Opinion ID: 2233087
Heading Depth: 2
Heading Rank: 1

Heading: The nature of the right of any person, competent or incompetent, to decline potentially life-prolonging treatment.

Text: B. The legal standards that control the course of decision whether or not potentially life-prolonging, but not life-saving, treatment should be administered to a person who is not competent to make the choice. C. The procedures that must be followed in arriving at that decision. For reasons we develop in the body of this opinion, it becomes apparent that the questions to be discussed in the first two areas are closely interrelated. We take the view that the substantive rights of the competent and the incompetent person are the same in regard to the right to decline potentially life-prolonging treatment. The factors which distinguish the two types of persons are found only in the area of how the State should approach the preservation and implementation of the rights of an incompetent person and in the procedures necessary to that process of preservation and implementation. We treat the matter in the sequence above stated because we think it helpful to set forth our views on (A) what the rights of all persons in this area are and (B) the issue of how an incompetent person is to be afforded the status in law of a competent person with respect to such rights. Only then can we proceed to (C) the particular procedures to be followed to ensure the rights of the incompetent person. A. 1. It has been said that [t]he law always lags behind the most advanced thinking in every area. It must wait until the theologians and the moral leaders and events have created some common ground, some consensus. Burger, The Law and Medical Advances, 67 Annals Internal Med. Supp. 7, 15, 17 (1967), quoted in Elkinton, The Dying Patient, the Doctor, and the Law, 13 Vill. L. Rev. 740 (1968). We therefore think it advisable to consider the framework of medical ethics which influences a doctor's decision as to how to deal with the terminally ill patient. While these considerations are not controlling, they ought to be considered for the insights they give us. Advances in medical science have given doctors greater control over the time and nature of death. Chemotherapy is, as evident from our previous discussion, one of these advances. Prior to the development of such new techniques the physician perceived his duty as that of making every conceivable effort to prolong life. On the other hand, the context in which such an ethos prevailed did not provide the range of options available to the physician today in terms of taking steps to postpone death irrespective of the effect on the patient. With the development of the new techniques, serious questions as to what may constitute acting in the best interests of the patient have arisen. The nature of the choice has become more difficult because physicians have begun to realize that in many cases the effect of using extraordinary measures to prolong life is to only prolong suffering, isolate the family from their loved one at a time when they may be close at hand or result in economic ruin for the family. Lewis, Machine Medicine and Its Relation to the Fatally Ill, 206 J.A.M.A. 387 (1968). Recognition of these factors led the Supreme Court of New Jersey to observe that physicians distinguish between curing the ill and comforting and easing the dying; that they refuse to treat the curable as if they were dying or ought to die, and that they have sometimes refused to treat the hopeless and dying as if they were curable. In re Quinlan, 70 N.J. 10, 47 (1976). The essence of this distinction in defining the medical role is to draw the sometimes subtle distinction between those situations in which the withholding of extraordinary measures may be viewed as allowing the disease to take its natural course and those in which the same actions may be deemed to have been the cause of death. See Elkinton, supra at 743. Recent literature suggests that health care institutions are drawing such a distinction, at least with regard to respecting the decision of competent patients to refuse such measures. Rabkin, Gillerman & Rice, Orders Not to Resuscitate, 293 N.E.J. of Med. 364 (1976). Cf. Beecher, Ethical Problems Created by the Hopelessly Unconscious Patient, 278 N.E.J. of Med. 1425 (1968). The current state of medical ethics in this area is expressed by one commentator who states that: we should not use extraordinary means of prolonging life or its semblance when, after careful consideration, consultation and the application of the most well conceived therapy it becomes apparent that there is no hope for the recovery of the patient. Recovery should not be defined simply as the ability to remain alive; it should mean life without intolerable suffering. Lewis, supra. See Collins, Limits of Medical Responsibility in Prolonging Life, 206 J.A.M.A. 389 (1968); Williamson, Life or Death  Whose Decision? 197 J.A.M.A. 793 (1966). Our decision in this case is consistent with the current medical ethos in this area. 2. There is implicit recognition in the law of the Commonwealth, as elsewhere, that a person has a strong interest in being free from nonconsensual invasion of his bodily integrity. Thibault v. Lalumiere, 318 Mass. 72 (1945). Commonwealth v. Clark, 2 Met. 23 (1840). Union Pac. Ry. v. Botsford, 141 U.S. 250, 251 (1891). In short, the law recognizes the individual interest in preserving the inviolability of his person. Pratt v. Davis, 118 Ill. App. 161, 166 (1905), aff'd, 224 Ill. 300 (1906). One means by which the law has developed in a manner consistent with the protection of this interest is through the development of the doctrine of informed consent. While the doctrine to the extent it may justify recovery in tort for the breach of a physician's duty has not been formally recognized by this court, Schroeder v. Lawrence, 372 Mass. 1 (1977); see Baird v. Attorney Gen., 371 Mass. 741 (1977); Reddington v. Clayman, 334 Mass. 244 (1956); G.L.c. 112, § 12F, it is one of widespread recognition. Capron, Informed Consent in Catastrophic Disease Research and Treatment, 123 U. Pa. L. Rev. 340, 365 (1975); Cantor, A Patient's Decision to Decline Life-Saving Medical Treatment: Bodily Integrity Versus the Preservation of Life, 26 Rutgers L. Rev. 228, 236-238 (1973). W. Prosser, Torts § 18 (4th ed. 1971). As previously suggested, one of the foundations of the doctrine is that it protects the patient's status as a human being. Capron, supra at 366-367. Of even broader import, but arising from the same regard for human dignity and self-determination, is the unwritten constitutional right of privacy found in the penumbra of specific guaranties of the Bill of Rights. Griswold v. Connecticut, 381 U.S. 479, 484 (1965). As this constitutional guaranty reaches out to protect the freedom of a woman to terminate pregnancy under certain conditions, Roe v. Wade, 410 U.S. 113, 153 (1973), so it encompasses the right of a patient to preserve his or her right to privacy against unwanted infringements of bodily integrity in appropriate circumstances. In re Quinlan, supra at 38-39. In the case of a person incompetent to assert this constitutional right of privacy, it may be asserted by that person's guardian in conformance with the standards and procedures set forth in sections II (B) and II (C) of this opinion. See Quinlan at 39. 3. The question when the circumstances are appropriate for the exercise of this privacy right depends on the proper identification of State interests. It is not surprising that courts have, in the course of investigating State interests in various medical contexts and under various formulations of the individual rights involved, reached differing views on the nature and the extent of State interests. We have undertaken a survey of some of the leading cases to help in identifying the range of State interests potentially applicable to cases of medical intervention. In a number of cases, no applicable State interest, or combination of such interests, was found sufficient to outweigh the individual's interests in exercising the choice of refusing medical treatment. To this effect are Erickson v. Dilgard, 44 Misc.2d 27 (N.Y. Sup. Ct. 1962) (scheme of liberty puts highest priority on free individual choice); In re Estate of Brooks, 32 Ill.2d 361 (1965) (patient may elect to pursue religious beliefs by refusing life-saving blood transfusion provided the decision did not endanger public health, safety or morals); see In re Osborne, 294 A.2d 372 (D.C. Ct. App. 1972); Holmes v. Silver Cross Hosp., 340 F. Supp. 125 (D. Ill. 1972); Byrn, Compulsory Lifesaving Treatment for the Competent Adult, 44 Fordham L. Rev. 1 (1975). See also In re Guardianship of Pescinski, 67 Wis.2d 4 (1975). Subordination of State interests to individual interests has not been universal, however. In a leading case, Application of the President & Directors of Georgetown College, Inc., 331 F.2d 1000 (D.C. Cir.), cert. denied, 377 U.S. 978 (1964), a hospital sought permission to perform a blood transfusion necessary to save the patient's life where the person was unwilling to consent due to religious beliefs. The court held that it had the power to allow the action to be taken despite the previously expressed contrary sentiments of the patient. The court justified its decision by reasoning that its purpose was to protect three State interests, the protection of which was viewed as having greater import than the individual right: (1) the State interest in preventing suicide, (2) a parens patriae interest in protecting the patient's minor children from abandonment by their parent, and (3) the protection of the medical profession's desire to act affirmatively to save life without fear of civil liability. In John F. Kennedy Memorial Hosp. v. Heston, 58 N.J. 576 (1971), a case involving a fact situation similar to Georgetown, the New Jersey Supreme Court also allowed a transfusion. It based its decision on Georgetown, as well as its prior decisions. See Raleigh Fitkin-Paul Morgan Memorial Hosp. v. Anderson, 42 N.J. 421, cert. denied, 377 U.S. 985 (1964); [8] State v. Perricone, 37 N.J. 463, cert. denied, 371 U.S. 890 (1962). The New Jersey court held that the State's paramount interest in preserving life and the hospital's interest in fully caring for a patient under its custody and control outweighed the individual decision to decline the necessary measures. See United States v. George, 239 F. Supp. 752 (D. Conn. 1965); Long Island Jewish-Hillside Medical Center v. Levitt, 73 Misc.2d 395 (N.Y. Sup. Ct. 1973); In re Sampson, 65 Misc.2d 658 (Fam. Ct. 1970), aff'd 37 App. Div.2d 668 (1971), aff'd per curiam, 29 N.Y.2d 900 (1972); In re Weberlist, 79 Misc.2d 753 (N.Y. Sup. Ct. 1974); In re Karwath, 199 N.W.2d 147 (Iowa 1972). This survey of recent decisions involving the difficult question of the right of an individual to refuse medical intervention or treatment indicates that a relatively concise statement of countervailing State interests may be made. As distilled from the cases, the State has claimed interest in: (1) the preservation of life; (2) the protection of the interests of innocent third parties; (3) the prevention of suicide; and (4) maintaining the ethical integrity of the medical profession. It is clear that the most significant of the asserted State interests is that of the preservation of human life. Recognition of such an interest, however, does not necessarily resolve the problem where the affliction or disease clearly indicates that life will soon, and inevitably, be extinguished. The interest of the State in prolonging a life must be reconciled with the interest of an individual to reject the traumatic cost of that prolongation. There is a substantial distinction in the State's insistence that human life be saved where the affliction is curable, as opposed to the State interest where, as here, the issue is not whether, but when, for how long, and at what cost to the individual that life may be briefly extended. Even if we assume that the State has an additional interest in seeing to it that individual decisions on the prolongation of life do not in any way tend to cheapen the value which is placed in the concept of living, see Roe v. Wade, supra , we believe it is not inconsistent to recognize a right to decline medical treatment in a situation of incurable illness. The constitutional right to privacy, as we conceive it, is an expression of the sanctity of individual free choice and self-determination as fundamental constituents of life. The value of life as so perceived is lessened not by a decision to refuse treatment, but by the failure to allow a competent human being the right of choice. [9] A second interest of considerable magnitude, which the State may have some interest in asserting, is that of protecting third parties, particularly minor children, from the emotional and financial damage which may occur as a result of the decision of a competent adult to refuse life-saving or life-prolonging treatment. Thus, in Holmes v. Silver Cross Hosp., 340 F. Supp. 125 (D. Ill. 1972), the court held that, while the State's interest in preserving an individual's life was not sufficient, by itself, to outweigh the individual's interest in the exercise of free choice, the possible impact on minor children would be a factor which might have a critical effect on the outcome of the balancing process. Similarly, in the Georgetown case the court held that one of the interests requiring protection was that of the minor child in order to avoid the effect of abandonment on that child as a result of the parent's decision to refuse the necessary medical measures. See Byrn, supra at 33; United States v. George, supra . [10] We need not reach this aspect of claimed State interest as it is not in issue on the facts of this case. The last State interest requiring discussion [11] is that of the maintenance of the ethical integrity of the medical profession as well as allowing hospitals the full opportunity to care for people under their control. See Georgetown, supra; United States v. George, supra ; John F. Kennedy Memorial Hosp. v. Heston, supra . The force and impact of this interest is lessened by the prevailing medical ethical standards, see Byrn, supra at 31. Prevailing medical ethical practice does not, without exception, demand that all efforts toward life prolongation be made in all circumstances. Rather, as indicated in Quinlan, the prevailing ethical practice seems to be to recognize that the dying are more often in need of comfort than treatment. Recognition of the right to refuse necessary treatment in appropriate circumstances is consistent with existing medical mores; such a doctrine does not threaten either the integrity of the medical profession, the proper role of hospitals in caring for such patients or the State's interest in protecting the same. It is not necessary to deny a right of self-determination to a patient in order to recognize the interests of doctors, hospitals, and medical personnel in attendance on the patient. Also, if the doctrines of informed consent and right of privacy have as their foundations the right to bodily integrity, see Union Pac. Ry. v. Botsford, 141 U.S. 250 (1891), and control of one's own fate, then those rights are superior to the institutional considerations. [12] Applying the considerations discussed in this subsection to the decision made by the probate judge in the circumstances of the case before us, we are satisfied that his decision was consistent with a proper balancing of applicable State and individual interests. Two of the four categories of State interests that we have identified, the protection of third parties and the prevention of suicide, are inapplicable to this case. The third, involving the protection of the ethical integrity of the medical profession was satisfied on two grounds. The probate judge's decision was in accord with the testimony of the attending physicians of the patient. The decision is in accord with the generally accepted views of the medical profession, as set forth in this opinion. The fourth State interest  the preservation of life  has been viewed with proper regard for the heavy physical and emotional burdens on the patient if a vigorous regimen of drug therapy were to be imposed to effect a brief and uncertain delay in the natural process of death. To be balanced against these State interests was the individual's interest in the freedom to choose to reject, or refuse to consent to, intrusions of his bodily integrity and privacy. We cannot say that the facts of this case required a result contrary to that reached by the probate judge with regard to the right of any person, competent or incompetent, to be spared the deleterious consequences of life-prolonging treatment. We therefore turn to consider the unique considerations arising in this case by virtue of the patient's inability to appreciate his predicament and articulate his desires.