Opinion ID: 2402992
Heading Depth: 2
Heading Rank: 4

Heading: Balancing the Patient's Rights and the State's Interest

Text: In casting the balance between the patient's common law right to refuse treatment/constitutional right to privacy and the state's interest in life, we acknowledge that the great majority of courts allow the termination of life-sustaining treatment. In doing so, these courts invariably find that the patient's right to refuse treatment outweighs the state's interest in preserving life. In some cases, that result is the product of a hopeless medical prognosis; in others, the court allows concerns with quality of life to discount the state's interest in life. Quinlan , of course, is the source in each instance. Although Quinlan dealt with a terminally-ill person, it did so in language sufficiently broad that courts cite it for much different purposes. On the one hand, Quinlan based its decision on Karen Quinlan's constitutional right to privacy. While recognizing that privacy rights must be balanced against the state's interest in life, the court found that Karen's treatment was so extraordinary and so invasive that the state's interest paled in comparison. Though unstated, one can properly assume from Quinlan that the state's interest might prevail were the patient undergoing ordinary medical treatment. This focus on the extraordinary/ordinary dichotomy provided a ready standard by which the patient's interest could be assessed in a constitutional sense against the state's interest in life. Since Quinlan , the medical profession moved to abandon any distinction between extraordinary and ordinary treatment in considering the propriety of withdrawing life-sustaining treatment. [16] Conroy , decided by the same court six years later, found distinctions focusing on the type of treatment unpersuasive. [W]hile the analysis may be useful in weighing the implications of the specific treatment for the patient, essentially it merely restates the question: whether the burdens of treatment so clearly outweigh its benefit to the patient that continued treatment would be inhumane. 486 A.2d at 1235. This change of focus by the medical community led courts away from constitutional foundations for decisions in this area. The erosion of distinctions based on treatment complicated constitutional analysis since there was no other readily apparent standard which courts could use to calibrate the burden of an individual's privacy right inflicted by particular kinds of treatment. Tribe, American Constitutional Law, 1365 (2d ed. 1988). Perhaps realizing the difficulty of applying a constitutional standard which relied too heavily on medical technology, several courts, led by Eichner, abandoned right to privacy reasoning, focusing instead on the common law right to refuse treatment. The common law right to refuse treatment is not absolute. It too must be balanced against the state's interest in life. From its early application in Quinlan and Eichner, both of which involved terminally-ill patients, courts have read the right in an everbroadening manner. Brophy led the way. There the court found that an incompetent patient's imputed desire to terminate treatment outweighed the state's interest despite the fact that the patient had a fairly long life expectancy if feeding continued. Bouvia and In re Farrell, 108 N.J. 335, 529 A.2d 404 (1987), took the next step; they found that the state's interest in preserving life is not compelling when a competent patient wishes to have life-sustaining treatment withdrawn. No longer relying on the nature of the treatment to provide a standard, courts began to focus on the patient's medical prognosis and the individual patient's assessment of the quality of her life in the face of that prognosis. And in the face of a prognosis which promised no reasonable hope of recovery and which the patient found undesirable, the patient's choice prevailed over the state's interest. Commentators do not find this analysis persuasive. Taken to its logical end, this standard ultimately makes prognosis irrelevant. This situation is conducive to a rhetorical justification of the casesauthorizing the patient's choice is merely allowing an inexorable dying process to continue. While this distinction is rhetorically convenient, it is not easily justifiable by principle: where the patient's right to refuse medical treatment is constant, the patient's condition and prognosis would no longer seem to be relevant. Tribe, American Constitutional Law at 1366. Once prognosis becomes irrelevant, and the patient's choice always more important than the state's interest, this standard leads to the judicial approval of suicide. Tribe, supra at 1367. This result can be obtained only if the state's interest in the preservation of life is substantially discounted. Yet courts manage to find the states' interests wanting and allow surrogates to choose the death of patients by invoking a nearly unbridled right to refuse treatment. For an explanation, we revert to Quinlan . Prior to Quinlan , the common law preferred to err on the side of life. Choices for incompetents were made to preserve life, not hasten death. [17] Quinlan changed the calculus. Moving from the common law's prejudice in favor of life, Quinlan subtly recast the state's interest in life as an interest in the quality of life (cognitive and sapient), struck a balance between quality of life and Karen Quinlan's right to privacy and permitted the termination of a life sustaining procedure. By the rhetorical device of replacing a concern for life with quality of life, the court managed to avoid affronting previously accepted norms in reaching its decision. Alexander, Death by Directive, 28 Santa Clara L.Rev 67, 82 (1988). As we previously stated, however, the state's interest is not in quality of life. The state's interest is an unqualified interest in life. In striking the balance between a patient's right to refuse treatment or her right to privacy and the state's interest in life, we may not arbitrarily discount either side of the equation to reach a result which we find desirable.