Opinion ID: 2237971
Heading Depth: 2
Heading Rank: 2

Heading: Is a Court Proceeding Necessary?

Text: Having determined that the withdrawal of artificial nutrition and hydration is a health care decision within the scope of the HCCA, we turn now to Judge Barr's findings. We read the Lawrances' amended petition as a request for declaratory relief only. The family sought assurance that the decision to withdraw artificial nutrition and hydration fell within the scope of the HCCA, and that they could order such withdrawal, as Sue Ann's parents, under Indiana Code § 16-8-12-4. In ruling on the petition, however, the trial court issued both declaratory and injunctive relief. The court enjoined the State Board of Health, Manor House, successor nursing homes, hospitals, and health care providers, none of which were parties to the action. The HCCA, written for a society in which health care decisions are routinely made by families on advice of physicians, is designed to resolve health care decisions without a need for court proceedings. Thus, in § 16-8-12-4, the legislature establishes the desired priority for substitute decisionmakers. [7] See Model Act, 9 U.L.A. part 1 § 4, 462 (comment). In the case at bar, Sue Ann Lawrance was (1) incapable of consenting to her own health care, Ind. Code § 16-8-12-4(a); (2) had not appointed a health care representative herself under § 16-8-12-6, Ind. Code § 16-8-12-4(a); (3) had no guardian or appointed health care representative under § 16-8-12-7, Ind. Code § 16-8-12-4(a)(2)(A); and (4) had not disqualified her parents as decision makers under § 16-8-12-8, Ind. Code § 16-8-12-4(a)(2). In short, all of the conditions of Indiana Code § 16-8-12-4(a)(2) were met for a spouse, parent, adult child, or adult sibling to make a health care decision for Sue Ann Lawrance under the provisions of Indiana Code § 16-8-12-4. The HCCA mandates that such authorized decisionmakers shall act in good faith and in the best interest of the individual incapable of consenting. Ind. Code § 16-8-12-4(d). Court proceedings were not required for the Lawrances to make health care decisions for their daughter. Given the legislature's design that the HCCA operate without court intervention in instances where none of the interested participants disagree, we think that any future declaratory proceedings under § 16-8-12-4 would be inappropriate. [8] Decisions concerning withdrawal of treatment are not necessarily better decided by the courts. It would be hubris to think otherwise. Our desire to leave future health care decisions to patients, their families, and their physicians comports not only with the will of the General Assembly, but also with the decisions of other courts who have reached the same conclusion. See, e.g., In re Jobes, 108 N.J. at 428, 529 A.2d at 451 (Courts are not the proper place to resolve the agonizing personal problems that underlie these cases. Our legal system cannot replace the more intimate struggle that must be borne by the patient, those caring for the patient, and those who care about the patient.); Drabick v. Drabick, 200 Cal. App.3d at 198, 245 Cal. Rptr. at 847 ([C]ourts do not have a general commission to supervise medical treatment decisions. Patients make their own treatment decisions with the advice of their physicians. Family members, and sometimes other persons, participate when the patients cannot. Courts, on the other hand, become involved only when no one is available to make decisions for a patient or when there are disagreements.). Permitting most medical decisions to be made without court intervention does not irresponsibly place helpless patients in a position of unusual risk. Families called upon to act without coming to court do not operate without restraint. Neither health care providers nor families of patients are given unbridled discretion in treatment decisions. Numerous other safeguards serve to constrain health care decision making. We expect the first line of defense against abuses in withdrawal of treatment to be the ethical guidelines of the medical profession. Advances by medical ethics committees and ethics opinions issued by groups like the AMA keep pace with rapid progress in the field of medical technology; we perceive that medical ethics committees grow stronger every year and that ethics opinions grow increasingly sophisticated. [E]thics lies in the realm of practice as opposed to theory. That's well established from the time of Aristotle. And I think that's what we're talking about here. What does it mean to practice good medicine? Record at 315 (testimony of Dr. Greg Gramelspacher, medical ethicist). The history of respect for decisions of ethics committees in the withdrawal of treatment field, where reliance on court decisions would be unduly burdensome, has its origins as early as the first well known case in this area. See In re Quinlan, 70 N.J. 10, 355 A.2d 647 (1976). Health care providers involved in withdrawal of treatment decisions are also likely to act very conservatively in light of the external constraints on their professional conduct. Appellant, along with amici curiae Manor House at Riverview, the Indiana Health Care Association, and the Indiana State Board of Health, ably point out numerous state and federal regulations governing the health care profession. For example, Indiana Code §§ 16-10-4-1 to -27 (West 1991) establishes rules for the licensing of health facilities; Indiana Code §§ 16-10-4.1-1 to -4 (West Supp. 1990) requires compliance with federal medicaid regulations; and Indiana Administrative Code title 410, article 16.2 (1988 and Supp. 1991) establishes licensing and operational standards for health facilities. Additionally, Indiana Code § 35-46-1-4 (West 1986) establishes the neglect of a dependent as a felony; Indiana Code §§ 4-28-5-1 to -13 (West 1991) creates an adult protective services unit; and Indiana Code § 31-6-11-10 (West Supp. 1990) establishes a local child protection service by county. These constraints are hardly hypothetical, but they do attempt to sort out abuses from reasonable behavior. See Hall v. State (1986), Ind., 493 N.E.2d 433 (affirming reckless homicide conviction of parents who withheld medical treatment from son); Barber v. Superior Court, 147 Cal. App.3d 1006, 195 Cal. Rptr. 484 (1983) (dismissing indictment against physician); Altman, Jury Declines to Indict Doctor Who Said He Aided in a Suicide, N.Y. Times, July 27, 1991, § 1, at 1, col. 2. The existence of this great variety of safeguards does not leave patients or their representatives who refuse treatment including artificial nutrition and hydration unprotected from collateral consequences. The HCCA contains extensive immunity provisions for health care providers relying on decisionmakers whom they believe in good faith are authorized to consent to health care. Ind. Code § 16-8-12-9(a). This same code section seems to protect the decisionmakers as well. Ind. Code § 16-8-12-9(c). Numerous briefs submitted to this Court, however, highlight the great number of other constraints operating on health care providers. We expect that these constraints will serve to prevent hasty or inappropriate treatment decisions. We expect, for example, that in cases like the one at bar, in which the patient's physicians and family members unanimously agree to a course of action, the good faith requirement of the HCCA, Ind. Code § 16-8-12-9, will be met, and complete immunity will follow. In keeping with the design of an HCCA that usually works independently of the courts, this result, where appropriate, will attach despite the lack of a court proceeding. When a patient's health care provider or some family member disagrees with the course of action preferred by the patient's parents or other health care decisionmaker, Indiana Code § 16-8-12-7 provides a mechanism for challenges, regardless of whether the initial decision involves court action. Court action under this section is appropriate where an individual authorized to consent to health care is not reasonably available, declines to act, or is not acting in the best interest of the individual in need of health care. Ind. Code § 16-8-12-7(d)(3). The commentary of the uniform act from which Indiana adapted the HCCA indicates that resolving disputes is the very purpose of this section. Model Act, 9 U.L.A. part 1 § 4, p. 462 (comment) (suggesting objections to decisions be considered under section 7). Because the Lawrances were authorized to act and apparently willing to do so and because the physicians and family agreed with their decision, there was no basis for a proceeding under § 16-8-12-7. [9] Indeed, under these sorts of circumstances, there should be no withdrawal of treatment cases before an Indiana court under § 16-8-12-4 either.