Opinion ID: 1938095
Heading Depth: 2
Heading Rank: 1

Heading: Informed Consent and Bodily Integrity

Text: A number of learned articles have been written about the propriety or impropriety of court-ordered caesarean sections. E.g., Johnsen, The Creation of Fetal Rights: Conflicts with Women's Constitutional Rights to Liberty, Privacy, and Equal Protection, 95 YALE L.J. 599 (1986); Kolder, Gallagher & Parsons, Court-Ordered Obstetrical Interventions, 316 NEW ENG. J. MED. 1192 (1987) (hereafter Obstetrical Interventions ); Rhoden, The Judge in the Delivery Room: The Emergence of Court-Ordered Caesareans, 74 CAL.L.REV. 1951 (1986); Robertson, Procreative Liberty and the Control of Conception, Pregnancy, and Childbirth, 69 VA.L.REV. 405 (1983). Commentators have also considered how medical decisions for incompetent persons which may involve some detriment or harm to them should be made. E.g., Pollock, Life and Death Decisions: Who Makes Them and by What Standards?, 41 RUTGERS L.REV. 505, 518-540 (1989); Robertson, Organ Donations by Incompetents and the Substituted Judgment Doctrine, 76 COLUM.L.REV. 48 (1976). These and other articles demonstrate the complexity of medical intervention cases, which become more complex with the steady advance of medical technology. From a recent national survey, it appears that over the five years preceding the survey there were thirty-six attempts to override maternal refusals of proposed medical treatment, and that in fifteen instances where court orders were sought to authorize caesarean interventions, thirteen such orders were granted. Obstetrical Interventions, supra, 316 NEW ENG. J. MED. at 1192-1193. Compare Goldberg, Medical Choices During Pregnancy: Whose Decision Is It Anyway?, 41 RUTGERS L.REV. 591, 609 (1989) (finding twelve such cases). Nevertheless, there is only one published decision from an appellate court that deals with the question of when, or even whether, a court may order a caesarean section: Jefferson v. Griffin Spalding County Hospital Authority, 247 Ga. 86, 274 S.E.2d 457 (1981). Jefferson is of limited relevance, if any at all, to the present case. In Jefferson there was a competent refusal by the mother to undergo the proposed surgery, but the evidence showed that performance of the caesarean was in the medical interests of both the mother and the fetus. [7] In the instant case, by contrast, the evidence is unclear as to whether A.C. was competent when she mouthed her apparent refusal of the caesarean (I don't want it done), and it was generally assumed that while the surgery would most likely be highly beneficial to the fetus, it would be dangerous for the mother. Thus there was no clear maternal-fetal conflict in this case arising from a competent decision by the mother to forego a procedure for the benefit of the fetus. The procedure may well have been against A.C.'s medical interest, but if she was competent and given the choice, she may well have consented to an operation of significant risk to herself in order to maximize her fetus' chance for survival. From the evidence, however, we simply cannot tell whether she would have consented or not. Thus our analysis of this case begins with the tenet common to all medical treatment cases: that any person has the right to make an informed choice, if competent to do so, to accept or forego medical treatment. The doctrine of informed consent, based on this principle and rooted in the concept of bodily integrity, is ingrained in our common law. See Crain v. Allison, 443 A.2d 558, 561-562 (D.C.1982); Canterbury v. Spence, 150 U.S.App.D.C. 263, 271, 464 F.2d 772, 780, cert. denied, 409 U.S. 1064, 93 S.Ct. 560, 34 L.Ed.2d 518 (1972); Schloendorff v. Society of New York Hospital, 211 N.Y. 125, 127, 105 N.E. 92, 93 (1914). Under the doctrine of informed consent, a physician must inform the patient, at a minimum, of the nature of the proposed treatment, any alternative treatment procedures, and the nature and degree of risks and benefits inherent in undergoing and in abstaining from the proposed treatment. Crain v. Allison, supra, 443 A.2d at 562 (footnote omitted). To protect the right of every person to bodily integrity, courts uniformly hold that a surgeon who performs an operation without the patient's consent may be guilty of a battery, Canterbury v. Spence, supra, 150 U.S.App.D.C. at 274, 464 F.2d at 783, or that if the surgeon obtains an insufficiently informed consent, he or she may be liable for negligence. Crain v. Allison, supra, 443 A.2d at 561-562. Furthermore, the right to informed consent also encompasses a right to informed refusal. In re Conroy, 98 N.J. 321, 336, 486 A.2d 1209, 1222 (1985) (citation omitted). In the same vein, courts do not compel one person to permit a significant intrusion upon his or her bodily integrity for the benefit of another person's health. See, e.g., Bonner v. Moran, 75 U.S.App.D.C. 156, 157, 126 F.2d 121, 122 (1941) (parental consent required for skin graft from fifteen-year-old for benefit of cousin who had been severely burned); McFall v. Shimp, 10 Pa.D. & C.3d 90 (Allegheny County Ct. 1978). In McFall the court refused to order Shimp to donate bone marrow which was necessary to save the life of his cousin, McFall: The common law has consistently held to a rule which provides that one human being is under no legal compulsion to give aid or to take action to save another human being or to rescue .... For our law to compel defendant to submit to an intrusion of his body would change every concept and principle upon which our society is founded. To do so would defeat the sanctity of the individual, and would impose a rule which would know no limits, and one could not imagine where the line would be drawn. Id. at 91 (emphasis in original). Even though Shimp's refusal would mean death for McFall, the court would not order Shimp to allow his body to be invaded. It has been suggested that fetal cases are different because a woman who has chosen to lend her body to bring [a] child into the world has an enhanced duty to assure the welfare of the fetus, sufficient even to require her to undergo caesarean surgery. Robertson, Procreative Liberty, supra, 69 VA.L.REV. at 456. Surely, however, a fetus cannot have rights in this respect superior to those of a person who has already been born. [8] Courts have generally held that a patient is competent to make his or her own medical choices when that patient is capable of the informed exercise of a choice, and that entails an opportunity to evaluate knowledgeably the options available and the risks attendant upon each. Canterbury v. Spence, supra, 150 U.S.App.D.C. at 271, 464 F.2d at 780. Thus competency in a case such as this turns on the patient's ability to function as a decision-maker, acting in accordance with her preferences and values. United States v. Charters, 829 F.2d 479, 495-497 & nn. 23-26 (4th Cir. 1987) (competency to make treatment decisions depends on whether the patient is able to make a rational choice based on reason), on rehearing en banc, 863 F.2d 302 (1988); In re Farrell, 108 N.J. 335, 354 & n. 7, 529 A.2d 404, 413 & n. 7 (1987) (A competent patient has a clear understanding of the nature of his or her illness and prognosis, and of the risks and benefits of the proposed treatment, and has the capacity to reason and make judgments about that information (citations omitted)); accord, PRESIDENT'S COMMISSION FOR THE STUDY OF ETHICAL PROBLEMS IN MEDICINE AND BIOMEDICAL AND BEHAVIORAL RESEARCH, DECIDING TO FOREGO LIFE-SUSTAINING TREATMENT 123 (1983) (hereafter 1983 PRESIDENT'S COMMISSION REPORT); 1 PRESIDENT'S COMMISSION FOR THE STUDY OF ETHICAL PROBLEMS IN MEDICINE AND BIOMEDICAL AND BEHAVIORAL RESEARCH, MAKING HEALTH CARE DECISIONS 171-172 (1982) (hereafter 1982 PRESIDENT'S COMMISSION REPORT). This court has recognized as well that, above and beyond common law protections, the right to accept or forego medical treatment is of constitutional magnitude. See In re Bryant, 542 A.2d 1216, 1218 (D.C. 1988); In re Boyd, 403 A.2d 744, 748 (D.C. 1979); In re Osborne, 294 A.2d 372 (D.C. 1972). Other courts also have found a basis in the Constitution for refusing medical treatment. E.g., United States v. Charters, supra, 829 F.2d at 491 & nn. 18-19 ([t]he right to be free of unwanted physical invasions is constitutionally protected); Bee v. Greaves, 744 F.2d 1387, 1392-1393 (10th Cir.1984) (same), cert. denied, 469 U.S. 1214, 105 S.Ct. 1187, 84 L.Ed.2d 334 (1985); Tune v. Walter Reed Army Medical Hospital, 602 F.Supp. 1452, 1456 (D.D. C.1985) (competent patient has right to order removal of life-sustaining medical systems); Rasmussen ex rel. Mitchell v. Fleming, 154 Ariz. 207, 215, 741 P.2d 674, 681-682 (1987) (constitutional right of privacy encompasses the right to refuse life-sustaining care); see also John F. Kennedy Memorial Hospital, Inc. v. Bludworth, 452 So.2d 921, 923-926 (Fla.1984) (incompetent persons have the right to discontinue life-sustaining care); Superintendent of Belchertown State School v. Saikewicz, 373 Mass. 728, 739, 370 N.E.2d 417, 426 (1977) (incompetent person may decline medical treatment for incurable illness); In re Conroy, supra, 98 N.J. at 336-37, 486 A.2d at 1222-1223, 1229 (competent persons have constitutional right to refuse medical treatment, and persons who become incompetent retain that right). Decisions of the Supreme Court, while not explicitly recognizing a right to bodily integrity, seem to assume that individuals have the right, depending on the circumstances, to accept or refuse medical treatment or other bodily invasion. See, e.g., Winston v. Lee, 470 U.S. 753, 105 S.Ct. 1611, 84 L.Ed.2d 662 (1985); Schmerber v. California, 384 U.S. 757, 86 S.Ct. 1826, 16 L.Ed.2d 908 (1966); Rochin v. California, supra note 8; cf. Union Pacific Ry. v. Botsford, 141 U.S. 250, 251, 11 S.Ct. 1000, 1001, 35 L.Ed. 734 (1891) (No right is held more sacred, or is more carefully guarded, by the common law, than the right of every individual to the possession and control of his own person, free from all restraint or interference of others, unless by clear and unquestionable authority of law (emphasis added)). In Winston v. Lee, supra , a robbery suspect challenged the state's right to compel him to submit to surgery for the removal of a bullet which was lodged in a muscle in his chest. The Court noted that the proposed surgery, which would require a general anesthetic, would be an `extensive' intrusion on respondent's personal privacy and bodily integrity and a virtually total divestment of respondent's ordinary control over surgical probing beneath his skin, 470 U.S. at 764-765, 105 S.Ct. at 1619 (citation omitted), and held that, without the patient-suspect's consent, the surgery was constitutionally impermissible. Nevertheless, even in recognizing a right to refuse medical treatment or state-imposed surgery, neither Winston nor any other Supreme Court decision holds that this right of refusal is absolute. Rather, in discussing the constitutional reasonableness of surgical intrusions beneath the skin, the Court said in Winston that the Fourth Amendment neither forbids nor permits all such intrusions.... Id. at 760, 105 S.Ct. at 1616 (citing Schmerber v. California, supra ); see also Jacobson v. Massachusetts, 197 U.S. 11, 25 S.Ct. 358, 49 L.Ed. 643 (1905) (upholding compulsory smallpox vaccinations over religious objections). [9] This court and others, while recognizing the right to accept or reject medical treatment, have consistently held that the right is not absolute. E.g., In re Boyd, supra, 403 A.2d at 749-750; In re Osborne, supra, 294 A.2d at 374; In re President & Directors of Georgetown College, Inc., 118 U.S.App.D.C. 80, 331 F.2d 1000, cert. denied, 377 U.S. 978, 84 S.Ct. 1883, 12 L.Ed.2d 746 (1964); Rasmussen ex rel. Mitchell v. Fleming, supra, 154 Ariz. at 216, 741 P.2d at 683; In re Conroy, supra, 98 N.J. at 337, 486 A.2d at 1223; cf. Hughes v. United States, 429 A.2d 1339 (D.C.1981) (upholding as reasonable a minor surgical intrusion to remove bullets from a criminal suspect); [10] United States v. Crowder, 177 U.S.App.D.C. 165, 543 F.2d 312 (1976) (same), cert. denied, 429 U.S. 1062, 97 S.Ct. 788, 50 L.Ed.2d 779 (1977). [11] In some cases, especially those involving life-or-death situations or incompetent patients, the courts have recognized four countervailing interests that may involve the state as parens patriae: preserving life, preventing suicide, maintaining the ethical integrity of the medical profession, and protecting third parties. See, e.g., In re Boyd, supra, 403 A.2d at 748 n. 9; Brophy v. New England Sinai Hospital, Inc., 398 Mass. 417, 431-433, 497 N.E.2d 626, 634 (1986); Saikewicz, supra, 373 Mass. at 737, 370 N.E.2d at 425; In re Farrell, supra, 108 N.J. at 350, 529 A.2d at 410-411. Neither the prevention of suicide [12] nor the integrity of the medical profession [13] has any bearing on this case. Further, the state's interest in preserving life must be truly compelling to justify overriding a competent person's right to refuse medical treatment. In re Osborne, supra, 294 A.2d at 374-375; Tune v. Walter Reed Army Medical Hospital, supra, 602 F.Supp. at 1455-1456. This is equally true for incompetent patients, who have just as much right as competent patients to have their decisions made while competent respected, even in a substituted judgment framework. See In re Boyd, supra, 403 A.2d at 750; John F. Kennedy Memorial Hospital, Inc. v. Bludworth, supra, 452 So.2d at 923-924; Saikewicz, supra, 373 Mass. at 739, 370 N.E.2d at 427-428; In re Conroy, supra, 98 N.J. at 343, 486 A.2d at 1229. In those rare cases in which a patient's right to decide her own course of treatment has been judicially overridden, courts have usually acted to vindicate the state's interest in protecting third parties, even if in fetal state. See Jefferson v. Griffin Spalding County Hospital Authority, supra (ordering that caesarean section be performed on a woman in her thirty-ninth week of pregnancy to save both the mother and the fetus); Raleigh Fitkin-Paul Morgan Memorial Hospital v. Anderson, 42 N.J. 421, 201 A.2d 537 (ordering blood transfusions over the objection of a Jehovah's Witness, in her thirty-second week of pregnancy, to save her life and that of the fetus), cert. denied, 377 U.S. 985, 84 S.Ct. 1894, 12 L.Ed.2d 1032 (1964); In re Jamaica Hospital, 128 Misc.2d 1006, 491 N.Y. S.2d 898 (Sup.Ct.1985) (ordering the transfusion of blood to a Jehovah's Witness eighteen weeks pregnant, who objected on religious grounds, and finding that the state's interest in the not-yet-viable fetus outweighed the patient's interests); Crouse Irving Memorial Hospital, Inc. v. Paddock, 127 Misc.2d 101, 485 N.Y.S.2d 443 (Sup.Ct.1985) (ordering transfusions as necessary over religious objections to save the mother and a fetus that was to be prematurely delivered); cf. In re President & Directors of Georgetown College, Inc., supra, 118 U.S.App.D.C. at 88, 331 F.2d at 1008 (ordering a transfusion, inter alia, because of a mother's parental duty to her living minor children). But see Taft v. Taft, 388 Mass. 331, 446 N.E.2d 395 (1983) (vacating an order which required a woman in her fourth month of pregnancy to undergo a purse-string operation, on the ground that there were no compelling circumstances to justify overriding her religious objections and her constitutional right of privacy). What we distill from the cases discussed in this section is that every person has the right, under the common law and the Constitution, to accept or refuse medical treatment. [14] This right of bodily integrity belongs equally to persons who are competent and persons who are not. Further, it matters not what the quality of a patient's life may be; the right of bodily integrity is not extinguished simply because someone is ill, or even at death's door. To protect that right against intrusion by others  family members, doctors, hospitals, or anyone else, however well-intentioned  we hold that a court must determine the patient's wishes by any means available, and must abide by those wishes unless there are truly extraordinary or compelling reasons to override them. In re Osborne, supra . When the patient is incompetent, or when the court is unable to determine competency, the substituted judgment procedure must be followed. From the record before us, we simply cannot tell whether A.C. was ever competent, after being sedated, to make an informed decision one way or the other regarding the proposed caesarean section. The trial court never made any finding about A.C.'s competency to decide. Undoubtedly, during most of the proceedings below, A.C. was incompetent to make a treatment decision; that is, she was unable to give an informed consent based on her assessment of the risks and benefits of the contemplated surgery. The court knew from the evidence that A.C. was sedated and unconscious, and thus it could reasonably have found her incompetent to render an informed consent; however, it made no such finding. On the other hand, there was no clear evidence that A.C. was competent to render an informed consent after the trial court's initial order was communicated to her. We think it is incumbent on any trial judge in a case like this, unless it is impossible to do so, to ascertain whether a patient is competent to make her own medical decisions. Whenever possible, the judge should personally attempt to speak with the patient and ascertain her wishes directly, rather than relying exclusively on hearsay evidence, even from doctors. [15] See In re Osborne, supra, 294 A.2d at 374; In re President & Directors of Georgetown College, Inc., supra, 118 U.S.App.D.C. at 87, 331 F.2d at 1007. It is improper to presume that a patient is incompetent. United States v. Charters, supra, 829 F.2d at 495. We have no reason to believe that, if competent, A.C. would or would not have refused consent to a caesarean. We hold, however, that without a competent refusal from A.C. to go forward with the surgery, and without a finding through substituted judgment that A.C. would not have consented to the surgery, it was error for the trial court to proceed to a balancing analysis, weighing the rights of A.C. against the interests of the state. There are two additional arguments against overriding A.C.'s objections to caesarean surgery. First, as the American Public Health Association cogently states in its amicus curiae brief: Rather than protecting the health of women and children, court-ordered caesareans erode the element of trust that permits a pregnant woman to communicate to her physician  without fear of reprisal  all information relevant to her proper diagnosis and treatment. An even more serious consequence of court-ordered intervention is that it drives women at high risk of complications during pregnancy and childbirth out of the health care system to avoid coerced treatment. [16] Second, and even more compellingly, any judicial proceeding in a case such as this will ordinarily take place  like the one before us here  under time constraints so pressing that it is difficult or impossible for the mother to communicate adequately with counsel, or for counsel to organize an effective factual and legal presentation in defense of her liberty and privacy interests and bodily integrity. Any intrusion implicating such basic values ought not to be lightly undertaken when the mother not only is precluded from conducting pre-trial discovery (to which she would be entitled as a matter of course in any controversy over even a modest amount of money) but also is in no position to prepare meaningfully for trial. As one commentator has noted: The procedural shortcomings rampant in these cases are not mere technical deficiencies. They undermine the authority of the decisions themselves, posing serious questions as to whether judges can, in the absence of genuine notice, adequate representation, explicit standards of proof, and right of appeal, realistically frame principled and useful legal responses to the dilemmas with which they are being confronted. Certainly courts dealing with other kinds of medical decision-making conflicts have insisted both upon much more rigorous procedural standards and upon significantly more information. Gallagher, Prenatal Invasions and Interventions: What's Wrong with Fetal Rights, 10 HARV.WOMEN'S L.J. 9, 49 (1987). In this case A.C.'s court-appointed attorney was unable even to meet with his client before the hearing. By the time the case was heard, A.C.'s condition did not allow her to be present, nor was it reasonably possible for the judge to hear from her directly. The factual record, moreover, was significantly flawed because A.C.'s medical records were not before the court and because Dr. Jeffrey Moscow, the physician who had been treating A.C. for many years, was not even contacted and hence did not testify. [17] Finally, the time for legal preparation was so minimal that neither the court nor counsel mentioned the doctrine of substituted judgment, which  with benefit of briefs, oral arguments, and above all, time  we now deem critical to the outcome of this case. We cannot be at all certain that the trial judge would have reached the same decision if the testimony of Dr. Moscow and the abundant legal scholarship filed in this court had been meaningfully available to him, and if there had been enough time for him to consider and reflect on these matters as a judge optimally should do. [18]