Right to Refuse Care ** A 1990 Washington, D.C. case in which a cesarean section was performed over the objection of the pregnant woman (who was terminally ill and expected to die soon) and her parents, on the grounds that the fetus might be viable (the infant died). The appellate court, ruling after the fact, held that the wishes of the pregnant woman should have been determinative in such a situation except in very unusual circumstances. [Source: District of Columbia Court of Appeals, 573 A. 2d 1235 (1990).] ** On December 11, 1983, 25 yearold Missourian Nancy Cruzan was in a serious car accident, pronounced dead at the scene by police, then resuscitated by paramedics. Years later, Cruzan’s parents wanted to withdraw the artificial hydration and nutrition that kept their daughter alive in a persistent vegetative state. The facility caring for Cruzan insisted on a court order before doing so, and the case entered the legal system. The trial court ruled that tube feedings could be withheld, but the nursing facility appealed. The Missouri Supreme Court reversed the decision of the trial court and severely restricted family decisionmaking on behalf of incompetent patients. It required "clear and convincing evidence" of the patient’s wishes to refuse treatment, such as a living will. On June 25, 1990, the U.S. Supreme Court affirmed the right of the State of Missouri to demand clear and convincing evidence of a person’s expressed wishes made while competent. The majority opinion also held that competent patients have a "constitutionally protected liberty interest in refusing unwanted medical treatment" under the due process clause. The court stated, however, that incompetent patients need certain protection because they cannot exercise this right directly. Thus, states may establish procedural safeguards for incompetent patients. The individual’s durable right to refuse treatment, which they affirmed, must be balanced against relevant state interest in the preservation of life. After the Supreme Court ruling, the Cruzans petitioned the trial court in Missouri to rehear their request to discontinue tube feedings. New witnesses came forward. One of the women who had worked with Cruzan said that during one conversation, Cruzan had agreed that if she were a "vegetable," she would not want to be fed by force or kept alive by machines. Cruzan’s physician also changed his mind in favor of stopping the feedings. As a result, authorization was given to remove feedings and Cruzan died shortly thereafter. This case encouraged the development of advance directives that appoint a patient advocate or proxy. [Source: 497 U.S. 261 (1990); see also Supreme Court Collection.] ** This case illustrates the potential for conflicts between healthcare providers and parents regarding the treatment of severely compromised neonates, even when the parents have a sophisticated understanding of the medical circumstances. Dr. Messenger’s child was born prematurely at 25 weeks gestation. The child was placed on life support, against the parent’s wishes. Dr. Messenger himself removed lifesupport from the child, against the physician’s orders, and the child died. Dr. Messenger was subsequently charged and tried for murder in criminal court, from which he was acquitted by jury. To this day, there have been no criminal convictions of physicians involved in the removal of lifesupport. (See also, the BarberNejdl/Clarence Herbert case.) [Source: 15 T.M. Cooley L. Rev. 115
(1998).]