Opinion ID: 2237971
Heading Depth: 2
Heading Rank: 1

Heading: Does the Health Care Consent Act Apply?

Text: Judge Barr found that Sue Ann's parents had authority to withdraw Sue Ann's nutrition and hydration under Indiana Code § 16-8-12-4, part of Indiana's Health Care Consent Act. The first step in assessing the validity of the trial court's order must therefore be determining whether the HCCA properly applies to decisions to withdraw artificially provided nutrition and hydration. The HCCA applies to health care decisions. As defined in the act, `[h]ealth care' means any care, treatment, service, or procedure to maintain, diagnose, or treat an individual's physical or mental condition. The term includes admission to a health care facility. Ind. Code § 16-8-12-1(2). This definition does not expressly include or exclude artificial nutrition and hydration decisions from the HCCA. Appellant contends that the HCCA does not apply to the Lawrances' decision. He relies on Indiana Code § 16-8-12-11 which provides: This chapter does not affect Indiana law concerning an individual's authorization to make a health care decision for the individual or another individual, or to provide, withdraw, or withhold medical care necessary to prolong or sustain life. Ind. Code § 16-8-12-11(a) (emphasis added). Our objective in statutory construction is to determine and effect the intent of the legislature. Thompson v. Thompson (1972), 259 Ind. 266, 286 N.E.2d 657. We examine a statute as a whole, giving common and ordinary meaning to the words used. Foremost Life Ins. v. Department of Ins. (1980), 274 Ind. 181, 409 N.E.2d 1092. We take the use of the word affect in § 16-8-12-11(a) to indicate the legislature's intent that the HCCA be a procedural statute. The comments to the uniform act on which the HCCA is based indicate that this is its purpose. See Unif. Law Commissioners' Model Health-Care Consent Act, 9 U.L.A. part 1, 453 (1988) [hereinafter Model Act ] (prefatory note) (This Act is procedural in nature and is purposefully narrow in scope.); id. at § 11, 472 (comment) (Nothing in this Act changes existing law [regarding termination of treatment].); Eads v. J & J Sales (1971), 257 Ind. 485, 491, 275 N.E.2d 802, 806 (permissible to consider the notes of the Commissioners of Uniform Laws when construing a uniform statute); Brief of Amicus Curiae Indiana Civil Liberties Union at 23 n. 7. The HCCA was hardly enacted in a legal vacuum. In recognition of existing law, the act is designed to establish procedures for health care decision making without altering the substantive rights of patients and their families. In this sense, the HCCA does not affect substantive Indiana law on withdrawal of treatment. We cannot accept appellant's reading of Indiana Code § 16-8-12-11(a) that the HCCA does not apply to decisions about nutrition and hydration. Regarding the HCCA as procedural, we are led to examine the substantive laws of the state, that is, the legal landscape in which the act was written. The HCCA was written in a culture in which families typically make health care decisions when patients cannot. Indiana common law and statutory law both describe an environment in which patient decision making is a central tenet. Indiana's common law doctrine of informed consent recognizes the right of the patient to intelligently reject or accept treatment. Revord v. Russell (1980), Ind. App., 401 N.E.2d 763, 767. Perhaps the strongest explanation of the basis for this rule is contained in Payne v. Marion General Hospital (1990), Ind. App., 549 N.E.2d 1043, 1046, trans. denied : The patient's right of self-determination is the sine qua non of the physician's duty to obtain informed consent. As Justice (then Judge) Cardozo said: `Every human being of adult years and sound mind has a right to determine what shall be done with his own body... .' Schloendorff v. Society of New York Hospital (1914), 211 N.Y. 125, 129, 105 N.E. 92, 93. This common law has evolved in a legal culture governed by the Indiana Constitution, which begins by declaring that the liberty of our citizens is inalienable. Ind. Const. art. I, § 1. The debates of our constitutional convention suggest that those who wrote the constitution believed that liberty included the opportunity to manage one's own life except in those areas yielded up to the body politic. [3] Like the common law and our constitution, Indiana's statutes reflect a commitment to patient self-determination. The Living Will Act, though inapplicable to the case at bar, declares that [c]ompetent adults have the right to control the decisions relating to their own medical care, including the decision to have medical or surgical means or procedures calculated to prolong their lives provided, withheld, or withdrawn. Ind. Code § 16-8-11-1 (West Supp. 1990). The new Powers of Attorney Act, by allowing patients to designate individuals to consent to or refuse their own health care, also demonstrates respect for patient autonomy. Ind. Code § 30-5-5-16(b)(2) (Burns Supp. 1991). This policy is also evident in the HCCA, which allows patients to select individuals to consent to their health care. Ind. Code § 16-8-12-6; Ind. Code § 16-8-12-8; Model Act, 9 U.L.A. part 1 § 6, 465 (comment) (The decision to allow the transfer of authority rests on the principle of the basic human need of self determination and individual autonomy.). Respect for patient autonomy does not end when the patient becomes incompetent. In our society, health care decision making for patients typically transfers upon incompetence to the patient's family. Our common human experience informs us that family members are generally most concerned with the welfare of a patient. It is they who provide for the patient's comfort, care, and best interests, and they who treat the patient as a person, rather than a symbol of a cause. In re Jobes, 108 N.J. 394, 416, 529 A.2d 434, 445 (1987) (citations omitted). Even when they have not left formal advance directives or expressed particular opinions about life-sustaining medical treatment, most Americans want the decisions about their care, upon their incapacity, to be made for them by family and physician, rather than by strangers or by government. This preference is reflected in the HCCA's default provision, which says the patient's close family may make health care decisions when no other health care representative or guardian has been designated for the patient. Ind. Code § 16-8-12-4. This right to consent to the patient's course of treatment necessarily includes the right to refuse a course of treatment. Determining the existence of a substantive right of a patient or her representative to refuse life-sustaining medical treatment does not dispose of the issue at hand. Only if artificially provided nutrition and hydration falls within the definition of such treatment do the procedures of the HCCA properly apply to the Lawrances' petition. We conclude that the administration of artificial nutrition and hydration (most people call it tube-feeding) is medical treatment which can be refused. Three sources inform our understanding: the view of the Indiana medical community; Indiana statutory law, including the HCCA; and persuasive authority from numerous courts across the country. We often rely on the medical community for accepted definitions of concepts commonly applied in that discipline. On this subject, the Indiana State Medical Association, a state affiliate of the American Medical Association (AMA), explains: The clear weight of medical opinion recognizes that artificially provided nutrition and hydration constitute medical treatment. For example, the AMA's Ethical Opinion 2.20 ... expressly defines the artificial provision of nutrition and hydration as medical treatment that may be withdrawn from a person in a persistent vegetative state. The AMA's position is consistent with other prominent organizations and commissions, including the President's Commission for the Study of Ethical Problems in Medicine and Behavioral Research, the Hastings Center, and the American Academy of Neurology. Brief of Amicus Curiae Indiana State Medical Ass'n at 9; see also AMA Council on Ethical and Judicial Affairs, Current Opinions 13 (1989). The very broad scope which the legislature gave the HCCA also persuades us that its procedures may be applied to decisions concerning artificial nutrition and hydration (even if the act itself did not affect existing substantive authority). [4] The HCCA defines health care as any care, treatment, service, or procedure... . Ind. Code § 16-8-12-1(2). The legislature did not even limit the term treatment to medical treatment. Read through the lens of the medical community's view, even a limitation to medical treatment would include nutrition and hydration decisions. We conclude that artificial nutrition and hydration is health care within § 16-8-12-1(2). [5] This conclusion is consistent with the apparently widespread view of courts that there is no objective distinction between withdrawal or withholding of artificial feeding and any other medical treatment. In re Peter, 108 N.J. 365, 382, 529 A.2d 419, 428 (1987) (footnote omitted). See, e.g., In re Conroy, 98 N.J. 321, 372-73, 486 A.2d 1209, 1236 (1985) (Once one enters the realm of complex, high-technology medical care, it is hard to shed the `emotional symbolism' of food. However, artificial feedings such as nasogastric tubes, gastrostomies, and intravenous infusions are significantly different from bottle-feeding or spoonfeeding... .) (citation omitted); Gray v. Romeo, 697 F. Supp. 580, 587 (D.R.I. 1988); Drabick v. Drabick, 200 Cal. App.3d 185, 195, 245 Cal. Rptr. 840, 846 n. 9 (Cal.Ct.App. 1988), cert. denied, 488 U.S. 958, 109 S.Ct. 399, 102 L.Ed.2d 387 (citing numerous courts in agreement). We recognize that categorizing artificial nutrition and hydration as medical treatment does not necessarily mean that many citizens would consider such procedures to be the same as, say, invasive surgery. Some family members who would refuse permission for extraordinary surgery might feel compelled to continue tube-feeding. Still, artificial nutrition and hydration can be successfully provided only by trained professionals working in a controlled environment. [6] In sum, we conclude that artificial nutrition and hydration is treatment that a competent patient can accept or refuse, that the family of an incompetent patient can accept or refuse it on behalf of the patient, and that the procedures of the HCCA apply to such decisions.