Opinion ID: 1454631
Heading Depth: 1
Heading Rank: 6

Heading: the natural death act

Text: In 1979, the Washington State Legislature, recognizing that medical technology was capable of prolonging human life beyond the natural moment of death, enacted the Natural Death Act. The Natural Death Act permits the withdrawal of `[l]ife-sustaining procedure[s]' from qualified, terminally ill patients. `Life-sustaining procedure[s]' include: any medical or surgical procedure or intervention which utilizes mechanical or other artificial means to sustain, restore, or supplant a vital function, which, when applied to a qualified patient, would serve only to artificially prolong the moment of death and where, in the judgment of the attending physician, death is imminent whether or not such procedures are utilized. Life-sustaining procedure shall not include the administration of medication or the performance of any medical procedure deemed necessary to alleviate pain. RCW 70.122.020(4). A qualified patient is a competent, terminally ill patient or an incompetent, terminally ill patient having issued a directive, before becoming incompetent, which indicated a desire to forgo treatment. RCW 70.122.020(6). A patient is considered terminally ill if judged by two physicians to be afflicted with, an incurable condition caused by injury, disease, or illness, which, regardless of the application of life-sustaining procedures, would, within reasonable medical judgment, produce death.... RCW 70.122.020(7). In 1983, we affirmed the terminally ill patient's right to refuse medical treatment under the Natural Death Act. In re Colyer, 99 Wn.2d 114, 660 P.2d 738 (1983). In Colyer, we approved the removal of artificial life support from a terminally ill, incompetent patient. We based our decision on the constitutional right to privacy and the common law right to be free from bodily invasion. We rejected, however, the view that the right to refuse treatment was absolute. 99 Wn.2d at 122. Instead, we balanced the invasiveness of the treatment, the prognosis of the patient, and the presence of state interests that might outweigh the patient's right to refuse treatment. These state interests included: (1) the preservation of life; (2) the prevention of suicide; (3) maintaining the integrity of the medical profession, and (4) the protection of third party interests. I agreed with the majority's affirmation of the right to refuse treatment in Colyer. I disagreed, however, with the designated waiting period of only 25 days before life support could be removed. I believed this period was insufficient to ensure an accurate determination of the patient's chances for recovery. 99 Wn.2d at 146. In 1984, we affirmed and broadened the right to refuse treatment by allowing a guardian to refuse treatment on behalf of a terminally ill, incompetent person. In re Hamlin, 102 Wn.2d 810, 689 P.2d 1372 (1984). In Hamlin, I argued against the majority's analysis which circumvented the regular court appointed guardian proceedings and negated the safeguards inherent in the guardian statutes. In both Hamlin and Colyer, I dissented not from the basic right of a person, incompetent or not, to refuse medical treatment, but rather from the implementation of inadequate procedural safeguards for what is obviously a practice of grave consequence. Although these cases established the parameters and procedural requirements of the Natural Death Act, it was not until later that we addressed the nutrition and hydration removal issue. In 1987, this court held that the removal of nutrition and hydration did not fall within the meaning of life-sustaining treatment under the Natural Death Act. In re Grant, 109 Wn.2d 545, 747 P.2d 445, 757 P.2d 534 (1987). In Grant, only four justices concurred in the lead opinion. They held that an incompetent person's family had the right to remove nutrition and hydration. A majority of five justices, however, held that the removal of nutrition and hydration was euthanasia of a cruel nature, raised complex policy issues, and necessitated deferral to the Legislature. [10] Justice Andersen, with Justices Brachtenbach and Durham concurring, agreed that an incompetent person's family could make decisions regarding life support, but forcefully dissented from the lead opinion's subscription to the removal of nutrition and hydration: I disagree ... with the ... decision which allows the patient's life to be taken by withholding intravenous nutrition and hydration or, to use less polite phraseology, to let her die of thirst or starvation. Call it whatever the majority will, this is pure, unadorned euthanasia. 109 Wn.2d at 570. Justice Andersen noted that recent legislative attempts to authorize the removal of nutrition and hydration had failed. During the 1987 session, Engrossed Substitute Senate Bill 5401, which authorized the discontinuance of artificial nutrition and hydration, failed after heated debate. [11] 109 Wn.2d at 572. Justice Andersen emphasized the Legislature's superior ability to evaluate such far-reaching public policy issues and felt that the issue should be deferred until the Legislature resolved it. Justice Goodloe and I agreed that the right to face an inevitable and imminent death in a manner most consistent with our beliefs and with our dignity as humans is vital. 109 Wn.2d at 575. We dissented, however, from both the majority's holding authorizing the removal of nutrition and hydration, and its holding enabling an incompetent person's family to make such decisions on behalf of the patient. We believed that allowing the removal of nutrition and hydration flew in the face of both the Natural Death Act and natural law: This result is contrary to the legislative dictates of the NDA [Natural Death Act].... [T]he unfortunate result of the majority opinion is that the potential for abuse is increased.... [B]y authorizing the withholding of intravenous nutrition and hydration, the majority authorizes death by starvation and dehydration....[,] authorizes mercy killing, arguably of a cruel nature.... .... ... [and] fails to give appropriate weight to the State's interest in preserving life  whether that of the particular patient, or the sanctity of all human life in general. 109 Wn.2d at 576, 580. We noted recent legal and scholarly debate on the issue of nutrition and hydration removal. 109 Wn.2d at 579. We argued that the existence of both the right to withhold nutrition and hydration, and the right of a guardian to exercise this power on behalf of an incompetent patient, was a question best left to the Legislature. We recalled Engrossed Substitute Senate Bill 5401, which would have established these rights, and objected to the majority's circumventing a straightforward legislative failure, imposing its own morality on the public in extending a legislative act ... [and] establishing philosophical principles in the guise of constitutional interpretation. 109 Wn.2d at 579-80. Like Justice Andersen, we emphasized that the Legislature was the only appropriate lawmaking body. Thus in Grant, although seven justices held that an incompetent person's family should be allowed to make decisions regarding the removal of life support, a 5-justice majority qualified this holding and agreed that the removal of nutrition and hydration was a particularly cruel method of euthanasia, inapplicable under the Natural Death Act and meriting deferral to the Legislature for a proper evaluation of public policy. Other states have experienced difficulty resolving the issue of nutrition and hydration removal as well. A New York court declined to authorize the removal of nutrition and hydration, which it viewed as ordinary care of a passive and less intrusive nature, because it reasoned that death should occur naturally from the patient's own untreated illness, rather than any act of either commission or omission. [12] A Massachusetts court upheld a hospital's refusal to withdraw a persistently vegetative patient's artificial sustenance, but allowed the patient to move to an institution which would comply with his wishes. [13] Conversely, numerous state courts authorize the removal of nutrition and hydration. These courts contend that a right to refuse nutrition and hydration, like the right to refuse artificial ventilation, derives from the substantive due process right to privacy, as well as the common law right to be free from bodily intrusion. In re Grant, 109 Wn.2d 545, 562, 747 P.2d 445, 757 P.2d 534 (1987). The United States Supreme Court, however, doubts the validity of such a contention.