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Substituted Judgment, Best Interests, and the Need for Best Respect

Published online by Cambridge University Press:  29 July 2009

Susan R. Martyn
Susan R. Martyn
Affiliation:
Law and Values at the University of Toledo College of Law
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Extract

Perhaps the most troublesome medical decisionmaking cases facing state courts concern serious healthcare decisions involving patients with severe or profound retardation. The courts who face this issue encounter a difficult dilemma. A decision to terminate a medical treatment of a dependent, vulnerable person requires considerable solicitude. Allowing a helpless person to die sooner than is medically possible directly conflicts with that person's most basic right – the right to live. However, continuing treatment in the face of terminal illness may not only prolong but also increase intense mental and physical suffering. Perpetuating near torture in the name of protecting a person's life may be equally worrisome.

Type
Special Section: Ethical Decision Making and Persons with Mental Retardation
Information
Cambridge Quarterly of Healthcare Ethics , Volume 3 , Issue 2 , Spring 1994 , pp. 195 - 208
Copyright
Copyright © Cambridge University Press 1994

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References

Notes

1. Guardianship of Jane Doe. 583 N.E. 2d 1263, 1268–69 (Mass. 1992).Google Scholar

2. See note 1. Guardianship of Jane Doe. 1992:1265.Google Scholar

3. See note 1. Guardianship of fane Doe. 1992:1265Google Scholar Use of a nasogastric tube for more than 6 weeks is uncommon because nasal tubes irritate, cause bleeding, and increase the risk of pneumonia. Major, D. The medical procedures for providing food and water: indications and effects. In: Lynn, J, ed. By No Extraordinary Means: The Choice to Forgo Life-Sustaining Food and Water. Indianapolis: Indiana University Press, 1986:21,25.Google ScholarBerger, R, Adams, L. Critical care: nutritional support in the critical care setting (part 2). Chest 1989;96:372.CrossRefGoogle Scholar

4. See note 1. Guardianship of Jane Doe. 1992:1266. The court did not specify which condition they meant–the Canavan's disease, persistent vegetative state, or both.Google Scholar

5. See note 1. Guardianship of Jane Doe. 1992:1266–7.Google Scholar

6. See note 1. Guardianship of Jane Doe. 1992:1267.Google Scholar

7. See note 1. Guardianship of Jane Doe. 1992:1267.Google Scholar

8. Superintendent of Belchertown State Sch. v. Saikewicz. 370 N.E. 2d 417 (Mass. 1977).Google Scholar

9. See note 8. Superintendent of Belchertown State Sch. v. Saikewicz. 1977:427.Google Scholar

10. See note 1. Guardianship of Jane Doe. 1992:1267Google Scholar, citing Superintendent of Belchertown State Sch. v. Saikewicz (note 8). 1977:431. The court earlier described this process as “don[ning] the mental mantle of the incompetent.”Google Scholar

11. See note 1. Guardianship of Jane Doe. 1992:1267.Google Scholar

12. See note 1. Guardianship of Jane Doe. 1992:1273 (Nolan J, dissenting).Google Scholar

13. See note 1. Guardianship of Jane Doe. 1992:1267.Google Scholar

14. See note 1. Guardianship of Jane Doe. 1992:1268.Google Scholar

15. Burt, RA. Taking Care of Strangers. New York: Free Press, 1979:171–2.Google ScholarHarmon, L. Falling off the vine: legal fictions and the doctrine of substituted judgment. Yale Law Journal 1990; 100:1, 63–4.CrossRefGoogle ScholarPubMed

16. See note 1. Guardianship of Jane Doe. 1992:1268.Google Scholar

17. See note 1. Guardianship of Jane Doe. 1992:1268.Google Scholar

18. See note 1. Guardianship of Jane Doe. 1992:1269.Google Scholar

19. See note 1. Guardianship of Jane Doe. 1992:1268–9.Google Scholar

20. See note 1. Guardianship of Jane Doe. 1992:1268.Google Scholar

21. See note 1. Guardianship of Jane Doe. 1992:1269.Google Scholar

22. See note 1. Guardianship of Jane Doe. 1992:1269.Google Scholar

23. See note 1. Guardianship of Jane Doe. 1992:1269.Google Scholar

24. See note 1. Guardianship of Jane Doe. 1992:1268.Google Scholar

25. See note 1. Guardianship of Jane Doe. 1992:1269–70.Google Scholar

26. See note 1. Guardianship of Jane Doe. 1992:1269.Google Scholar

27. Recent public opinion polls indicate that at least 75% of all Americans would not want life-sustaining treatment if permanently unconscious. Rouse, R. Mrs. Wanglie and “doctor knows best” and making decisions for those who cannot decide for themselves: autonomy in two recent cases. Cambridge Quarterly of Healthcare Ethics 1992;1:165–6.CrossRefGoogle ScholarPubMedBlendon, RJ, Szalay, US, Knox, RA. Public opinion and health care: should physicians aid their patients in dying? Journal of the American Medical Association 1992;267:2658, 2660.CrossRefGoogle Scholar

28. See note 1. Guardianship of Jane Doe. 1992:1274.Google Scholar

29. See note 1. Guardianship of Jane Doe. 1992:1276 (O'Connor J, Lynch J, dissenting).Google Scholar

30. See note 15. Harman, . 1990;100:38–42.Google Scholar

31. Dresser, RS, Robertson, JA. Quality of life and non-treatment decisions for incompetent patients: a critique of the orthodox approach. Law Medicine and Health Care 1989; 17:234, 240.CrossRefGoogle ScholarPubMed

32. In re Guardianship of L. W. 482 N.W. 2d 60 (Wis. 1992).Google ScholarIn re Lawrance. 579 N.E. 2d 32 (Ind. 1991).Google ScholarIn re Conservatorship of Wanglie. No. PX 91–283 (Minn. Dist. Ct. Hennepin County July, 1991) (Belois J).Google ScholarConservatorship of Drabick. 245 Cal. Rptr. 840 (Cal. Ct. App. 1988) Rev. den. (1988).Google ScholarIn re Morrison. 253 Cal. Rptr. 530 (Cal. Ct. App. 1988).Google ScholarRasmussen v. Fleming. 741 P. 2d 674 (Ariz. 1987).Google ScholarFoody v. Manchester Memorial Hosp. 482 A. 2d 713 (Conn. Super. Ct. 1984).Google ScholarIn re Conservatorship of Torres. 357 N.W. 2d 332 (Minn. 1984).Google ScholarIn re L.H.R. 321 S.E. 2d 716 (Ga. 1984).Google ScholarIn re Guardianship of Hamlin. 689 P. 2d 1372 (Wash. 1984).Google ScholarIn re Peter. 529 A. 2d 434 (N.J. 1987).Google ScholarIn re Jobes. 529 A. 2d 434 (N.J. 1987).Google ScholarIn re Quintan. 355 A. 2d 647 (N.J. 1976)Google Scholar, cert. den. 429 U.S. 922 (1976). In re Estate of Greenspan. 558 N.E. 2d 1194 (111. 1990).Google ScholarMcConnell v. Beverly Enterprises. 553 A. 2d 596 (Conn. 1989).Google ScholarIn re Barry. 445 So. 2d 365 (Fla. Dist. Ct. App. 1984).Google Scholar

The President's Commission also recommends the best interests standard “[w]hen a patient's likely decision is unknown. …” President's Commission for the Study of Ethical Problems in Medicine and Biomedical and Behavioral Research. Deciding to Forego Life-Sustaining Treatment: A Report on the Ethical, Medical and Legal Issues in Treatment Decisions. Washington, DC: US Government Printing Office. 1983:136.Google Scholar

33. See note 1. Guardianship of Jane Doe. 1992:1268,1273Google Scholar (Nolan J, dissenting). Custody of a Minor (No. 1). 434 N.E. 2d 601 (Mass. App. Ct. 1982).Google ScholarCustody of a Minor (No. 3). 393 N.E. 2d 836 (Mass. App. Ct. 1978).Google ScholarCustody of a Minor. 379 N.E. 2d 1053 (Mass. App. Ct. 1978).Google Scholar

34. See note 33. Custody of a Minor. 1978:1063.Google Scholar

35. See note 33. Custody of a Minor. 1978:1063.Google Scholar

36. See note 33. Custody of a Minor. 1978:1064. Cf.Google ScholarCustody of a Minor (No. 1). 1982:604–5.Google Scholar

37. Cruzan v. Harmon. 760 S.W. 2d 408 (Mo. 1988)Google Scholar aff'd, 110 S. Ct. 2841 (1990). Matter of Westchester County Medical Center. 531 N.E. 2d 607 (N.Y. 1988).Google Scholar

38. See note 32. In re Guardianship of L.W. 1992.Google ScholarIn re Lawrance. 1991.Google ScholarIn re Conservatorship of Wanglie. 1991.Google ScholarConservatorship of Drabick. 1988.Google ScholarIn re Morrison. 1988.Google ScholarRasmussen v. Fleming. 1987.Google ScholarFoody v. Manchester Memorial Hosp. 1984.Google ScholarIn re Conservatorship of Torres. 1984.Google ScholarIn re L.H.R. 1984.Google ScholarIn re Guardianship of Hamlin. 1984.Google Scholar

Some academics suggest a third approach not yet explicitly adopted by any court: a persistent vegetative state (PVS) patient has minimal or no current interests and therefore may be allowed to die. See, e.g., Buchanan, A, Brock, DW. Deciding for Others: The Ethics of Surrogate Decision Making. New York: Cambridge University Press, 1989:126–32, 194–6.Google Scholar See note 31. Dresser, Robertson. 1989;17:241–2.Google Scholar

A few authors have carried this argument to its logical conclusion: PVS patients should be considered legally dead. See Shapiro, RS. The case of L. W.: an argument for a permanent vegetative state treatment statue. Ohio State Journal 1990;51:439, 447-8.Google ScholarSmith, DR. Legal recognition of neocortical death. Cornell Law Review 1986;71:850, 872.Google ScholarPubMed

39. See note 32. In re Peter. 1987.Google ScholarIn re Jobes. 1987.Google ScholarIn re Quintan. 1976.Google ScholarIn re Estate of Greenspan. 1990.Google ScholarMcConnell v. Beverly Enterprises. 1989.Google ScholarIn re Barry. 1984.Google Scholar

40. Brophy v. New England Sinai Hosp., Inc. 497 N.E. 2d 626, 631 note 78 (Mass. 1986).Google Scholar

41. See note 1. Guardianship of Jane Doe. 1992:1276 (O'Connor J, dissenting).Google Scholar

42. Truog, RD, Brett, AS, Frader, J. The problem with futility. New England Journal of Medicine 1992;362:1560.CrossRefGoogle Scholar

43. In re Guardianship of Grant. 747 P. 2d 445, 447 (Wash. 1987).Google Scholar See note 32. In re Guardianship of Hamlin. 1984:1374.Google ScholarIn re Storar. 420 N.E. 2d 64, 66 (N.Y. 1981).Google Scholar See also note 8. Superintendent of Belchertown State Sch. v. Saikewicz. 1977:420.Google Scholar

44. Bogdan, R, Taylor, SJ. Relationships with severely disabled people: the social construction of humanness. Social Problems 1989;36:139–41.CrossRefGoogle Scholar

45. See note 8. Superintendent of Belchertown State Sch. v. Saikewicz. 1977:420.Google Scholar

46. See note 32. In re Guardianship of L.W. 1992:71;Google Scholar and President's Commission. 1983:185.Google Scholar

47. See note 32. In re Conservatorship of Wanglie. 1991.Google Scholar

48. See note 40. Brophy v. New England Sinai Hosp., Inc. 1986:632.Google Scholar

49. See note 40. Brophy v. New England Sinai Hosp., Inc. 1986:632.Google Scholar See also note 37. Cruzan v. Harmon. 1990:411.Google Scholar

50. See note 1. Guardianship of Jane Doe. 1992:1266, 1268.Google Scholar

51. Random House Dictionary of the English Language. New York: Random House, 1983:1190.Google Scholar

52. Cohen, CB. ‘Quality of life’ and the analogy with the Nazis. Journal of Medicine and Philosophy 1983;8:113.CrossRefGoogle ScholarPubMed

53. See note 51. Random House Dictionary. 1983:1190.Google Scholar

54. See, e.g., articles collected by Schalock, RJ, ed. Quality of Life, Perspectives and Issues. American Association on Mental Retardation, 1990.Google Scholar

55. Brakel, S, Parry, J, Weiner, BA. The Mentally Disabled and the Law. Washington, DC: American Bar Foundation, 1985:17–8.Google Scholar

56. Kopelman, L. Respect and the retarded: issues of valuing and labeling. In: Kopelman, L, Moskop, JC, eds. Ethics and Mental Retardation. Norwell, Massachusetts: Kluwer, 1984:65, 70.CrossRefGoogle ScholarTaylor, SJ, Bogdan, R. Quality of life and the individual's perspective. In: Schalock, RJ, ed. Quality of Life, Perspectives and Issues. Washington, DC: American Association on Mental Retardation, 1990:39.Google Scholar

57. Edgerton, R. Quality of life from a longitudinal research perspective. In: Schalock, RJ, ed. Quality of Life, Perspectives and Issues. Washington, DC: American Association on Mental Retardation, 1990:158.Google ScholarLuckasson, R. A lawyer's perspective on quality of life. In: Schalock, RJ, ed. Quality of Life, Perspectives and Issues. Washington, DC: American Association on Mental Retardation, 1990:211–4.Google Scholar

58. See note 8. Superintendent of Belchertown State Sch. v. Saikewicz. 1977:428.Google Scholar

59. See note 1. Guardianship of Jane Doe. 1992:1268–9.Google Scholar

60. See Veatch, RM. The Foundations of Justice: Why the Retarded and the Rest of Us Have Claims to Equality. New York: Oxford University Press, 1986.Google Scholar

61. See note 1. Guardianship of fane Doe. 1992:1272 (Nolan, J, dissenting), 1276 (O'Connor, J, Lynch, J, dissenting).Google Scholar

62. See note 1. Guardianship of Jane Doe. 1992:1272, 1276.Google Scholar

63. See note 32. President's Commission. 1983:135.

64. Objective quality of life has been explicitly rejected by nearly every court that has mentioned it. See e.g. In re Conroy, 486 A. 2d 1209, 1232–3. (N.J. 1985).Google Scholar See note 8. Superintendent of Belchertown State Sch. v. Saikewicz. 1977:428, 432.Google Scholar See also note 43. In re Guardianship of Grant. 1987:457.Google Scholar

65. Three jurisdictions (Maryland, Washington, D.C., and Virginia) have passed legislation that requires hospitals to have ethics committees. Hoffmann, DE. Does legislating hospital ethics committees make a difference? A study of hospital ethics committees in Maryland, the District of Columbia, and Virginia. Law, Medicine and Health Care 1991; 19:105.CrossRefGoogle ScholarPubMed

66. See note 1. Guardianship of Jane Doe. 1992:1266.Google Scholar

67. See note 1. Guardianship of Jane Doe. 1992:1266.Google Scholar

68. See note 32. In re Lawrance. 1991:35Google Scholar; In re Estate of Greenspan. 1990:1196;Google ScholarMcConnell v. Beverly Enterprises. 1989:531;Google ScholarIn re Morrison. 1988:531;Google ScholarConservatorship of Drabick. 1988:841;Google ScholarIn re Peter. 1987:422;Google ScholarIn re Jobes. 1987:438–9Google Scholar; In re L.H.R. 1984:718Google Scholar; Foody v. Manchester Memorial Hosp. 1984:717;Google ScholarIn re Conservatorship of Torres. 1984:333Google Scholar; In re Barry. 1984:368Google Scholar; In re Quinlan. 1976:653–4.Google Scholar See also note 37. Cruzan v. Harman. 1990:2845.Google Scholar

69. See note 40. Brophy v. New England Sinai Hosp., Inc. 1986.Google Scholar

70. See note 40. Brophy v. New England Sinai Hosp., Inc. 1986:628–30.Google Scholar

71. See note 1. Guardianship of Jane Doe. 1992:1266.Google Scholar

72. See note 1. Guardianship of Jane Doe. 1992:1271 (citing Guardianship of Roe, 421 N.E. 2d 40 [1981]).Google Scholar

73. The clinical diagnosis of persistent vegetative state (PVS) varies according to the age of the patient and the underlying cause of the unconscious state. Experts agree, however, that a specified period of unconsciousness must be documented before PVS can be diagnosed. Council on Scientific Affairs and Council on Ethical and Judicial Affairs. Persistent vegetative state and the decision to withdraw or withhold life support. Journal of the American Medical Association 1990;263:426,427–8.CrossRefGoogle ScholarCranford, RE. The persistent vegetative state: the medical reality (getting the facts straight). Hastings Center Report 1988;18(02./03.):27, 29.CrossRefGoogle ScholarPlum, F. Permanent loss of consciousness: expert opinion and community standards (Dec. 22, 1981).Google Scholar In: President's Commission. Deciding to Forego Life-Sustaining Treatment: A Report on the Ethical, Medical and Legal Issues in Treatment Decisions. Washington, DC: US Government Printing Office. 1983:459–60.Google Scholar

74. See note 43. In re Guardianship of Grant. 1987:447–8. This is the only other case where a near persistent vegetative state was caused by degenerative disease rather than injury. The Washington court was careful to document the progress and extent of the degenerative process.Google Scholar

75. Thomasma, DC. Medical ethics and humanities: ethical judgments of quality of life in the care of the aged. Journal of the American Geriatrics Society 1984;32:525–6.CrossRefGoogle ScholarPubMed

76. Brody, H. Stories of Sickness. New Haven, Connecticut: Yale University Press, 1987.Google Scholar

77. Callahan, S. The role of emotion in ethical decision making. Hastings Center Report 1988;18(06./07.):9. See note 75.CrossRefGoogle ScholarThomasma, . 1984;32:713.Google Scholar

78. Greenawalt, K. Law and Objectivity. New York: Oxford University Press, 1992:157, 159.Google Scholar