Opinion ID: 1143517
Heading Depth: 2
Heading Rank: 4

Heading: Common-Law Right

Text: The common law has long recognized an individual's right to be free from bodily invasion. Nearly a century ago the Supreme Court noted: 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. Union Pacific Railway Co. v. Botsford, 141 U.S. 250, 251, 11 S.Ct. 1000, 1001, 35 L.Ed. 734 (1891). Judge Cardozo, during his tenure as a member of New York's highest tribunal, succinctly captured the spirit of the Supreme Court's language when he wrote: Every human being of adult years and sound mind has a right to determine what shall be done with his own body; and a surgeon who performs an operation without his patient's consent commits an assault, for which he is liable in damages. Schloendorff v. Society of New York Hospital, 211 N.Y. 125, 129-30, 105 N.E. 92, 93 (1914). Protection of this common-law right to be free from nonconsensual bodily invasions is at the heart of what is known today as the doctrine of informed consent. Under this doctrine, the patient must have the capacity to reason and make judgments, the decision must be made voluntarily and without coercion, and the patient must have a clear understanding of the risks and benefits of the proposed treatment alternatives or nontreatment, along with a full understanding of the nature of the disease and the prognosis. Wanzer, et al., The Physician's Responsibility Toward Hopelessly Ill Patients, 310 New Eng.J.Med. 955, 957 (1984). Cf. Conroy, 98 N.J. at 346, 486 A.2d at 1222; Colyer, 99 Wash.2d at 121, 660 P.2d at 743. The purpose underlying the doctrine of informed consent is defeated somewhat if, after receiving all information necessary to make an informed decision, the patient is forced to choose only from alternative methods of treatment and precluded from foregoing all treatment whatsoever. We hold that the doctrine of informed consent  a doctrine borne of the common-law right to be free from nonconsensual physical invasions  permits an individual to refuse medical treatment. [11] STATE INTERESTS Whether emanating from constitutional penumbras or premised on common-law doctrine, the right to refuse medical treatment is not absolute. Courts have held that the right may be limited by the state's interest in preserving life, safeguarding the integrity of the medical profession, preventing suicide, and protecting innocent third parties. [12] A. Preserving life The state's interest in preserving life is the most significant interest asserted by the state. Conroy, 98 N.J. at 348, 486 A.2d at 1223; Colyer, 99 Wash.2d at 121, 660 P.2d at 743; Saikewicz, 373 Mass. at 740, 370 N.E.2d at 425. It embraces the separate but related concerns of preserving the life of a particular individual as well as preserving the sanctity of all life. Conroy, 98 N.J. at 348, 486 A.2d at 1223. Although the state's interest in preserving life is justifiably strong, we believe this interest necessarily weakens and must yield to the patient's interest where treatment at issue serves only to prolong a life inflicted with an incurable condition. Colyer, 99 Wash.2d at 122, 660 P.2d at 743. [13] Such is the case here. The chance that any medical treatment would have brought Rasmussen out of her chronic vegetative state and returned her to a cognitive state was minimal, if not nonexistent. Hospitalization or resuscitation would have only postponed Rasmussen's death rather than have improved her life. Based on these observations, we decline to hold that the state's interest in preserving life outweighed Rasmussen's right to refuse medical treatment. B. Safeguarding integrity of medical profession The state's interest in preserving the ethical integrity of the medical profession is not readily apparent here. No member of the medical community opposed the medical treatment decisions in this case. In fact, it was Rasmussen's physician who placed the DNR and DNH orders on her chart. Thus, no real conflict existed between the patient and the medical profession that would impugn the latter's ethical integrity. See Farrell, 212 N.J. Super. at 300, 514 A.2d at 1345. Even if a conflict had existed, however, we would have hesitated to find that Rasmussen's interest must yield to the state's interest. The medical profession itself now recognizes that it is no longer obligated to provide medical treatment in all situations. The American Medical Association, through its Council on Ethical and Judicial Affairs, issued the following statement dated March 15, 1986: Withholding or Withdrawing Life Prolonging Medical Treatment The social commitment of the physician is to sustain life and relieve suffering. Where the performance of one duty conflicts with the other, the choice of the patient, or his family or legal representative if the patient is incompetent to act in his own behalf, should prevail. In the absence of the patient's choice or an authorized proxy, the physician must act in the best interest of the patient. For humane reasons, with informed consent, a physician may do what is medically necessary to alleviate severe pain, or cease or omit treatment to permit a terminally ill patient whose death is imminent to die. However, he should not intentionally cause death. In deciding whether the administration of potentially life-prolonging medical treatment is in the best interest of the patient who is incompetent to act in his own behalf, the physician should determine what the possibility is for extending life under humane and comfortable conditions and what are the prior expressed wishes of the patient and attitudes of the family or those who have responsibility for the custody of the patient. Even if death is not imminent but a patient's coma is beyond doubt irreversible and there are adequate safeguards to confirm the accuracy of the diagnosis and with the concurrence of those who have responsibility for the care of the patient, it is not unethical to discontinue all means of life prolonging medical treatment. Life prolonging medical treatment includes medication and artificially or technologically supplied respiration, nutrition or hydration. In treating a terminally ill or irreversibly comatose patient, the physician should determine whether the benefits of treatment outweigh its burdens. At all times, the dignity of the patient should be maintained. (Emphasis added). [14] The emphasized language suggests that medical ethics would not be questioned if a DNR or DNH order were placed on the chart of a patient suffering from an irreversible coma. Rasmussen was not in a coma, but she was in an irreversible chronic vegetative state. We fail to see any material significance between the two physical conditions. [15] Therefore, the above statement issued by the AMA leads us to believe that this case does not bring into disrepute the ethical integrity of the medical profession. C. Preventing suicide Asserting the right to refuse medical treatment is not tantamount to committing suicide. Refusing medical intervention merely allows the disease to take its natural course; if death were eventually to occur, it would be the result, primarily, of the underlying disease, and not the result of a self-inflicted injury. Conroy, 98 N.J. at 351, 486 A.2d at 1224. See also Foody, 40 Conn.Sup. at 137, 482 A.2d at 720; Colyer, 99 Wash.2d at 121, 660 P.2d at 743; Saikewicz, 373 Mass. at 743 n. 11, 370 N.E.2d at 426 n. 11. Furthermore, Arizona's legislature has recognized that [t]he withholding or withdrawal of life-sustaining procedures from a qualified patient in accordance with [the MTDA] does not, for any purpose, constitute a suicide. A.R.S. § 36-3208. Although we have held that the MTDA is inapplicable in this case, it would be illogical indeed to suggest that the state's interest in preventing suicide magically disappears only when an individual becomes terminally ill and completes certain paperwork. Perhaps in some cases the state's interest in preventing suicide will limit an individual's ability to assert his or her right to refuse medical treatment. See, e.g., In re Caulk, 125 N.H. 226, 480 A.2d 93 (1984) (state could force-feed prisoner who was starving himself to death because he preferred death to life imprisonment). This is not such a case. [16] D. Protecting innocent third parties Rasmussen's decision to forego medical treatment will not adversely or directly affect the health, safety, or security of others. Rasmussen had no children, and her only immediate family, three siblings, resided in another state and had agreed to abide by the decision of the physician and guardian to terminate treatment. We find no interests of third parties in this case. [17] INCOMPETENCY AND THE RIGHT TO REFUSE MEDICAL TREATMENT Ordinarily, only the person whose common-law or constitutional rights are at issue may assert them. A competent person clearly has the ability to exercise the right to refuse medical treatment. So, too, does an incompetent individual who has made his or her medical desires known prior to becoming incompetent. See, e.g., §§ 36-3201 et seq. (MTDA). Unfortunately, this case involved an individual who was incompetent at the time medical treatment became an issue and who had not expressed her medical treatment desires prior to becoming incompetent. We are not the first tribunal to confront this problem. Other jurisdictions have unanimously concluded that the right to refuse medical treatment is not lost merely because the individual has become incompetent and has failed to preserve that right. [18] Reasons for this conclusion have been best articulated by the New York Supreme Court: We ... conclude that by standards of logic, morality and medicine the terminally ill should be treated equally, whether competent or incompetent. Can it be doubted that the value of human dignity extends to both? What possible societal policy objective is vindicated or furthered by treating the two groups of terminally ill differently? What is gained by granting such a fundamental right only to those who, though terminally ill, have not suffered brain damage and coma in the last stages of the dying process? The very notion raises the spectre of constitutional infirmity when measured against the Supreme Court's recognition that incompetents must be afforded all their due process rights; indeed any State scheme which irrationally denies to the terminally ill competent patient is plainly subject to constitutional attack. Eichner, 73 A.D.2d at 464-465, 426 N.Y.S.2d at 542-43 (emphasis in original; citations omitted). We conclude that Rasmussen's right to refuse medical treatment still existed despite her incompetency and her failure to articulate her medical treatment desires prior to becoming incompetent. Because she was incapable of exercising that right, however, we must determine who could exercise that right for her.