New York Law Review

Tag: Right to Refuse Treatment

  • In the Matter of O’Connor, 72 N.Y.2d 517 (1988): Proof Required to Decline Life-Sustaining Treatment

    In the Matter of O’Connor, 72 N.Y.2d 517 (1988)

    To decline life-sustaining medical treatment, an incompetent patient’s prior expressed wishes must be proven by clear and convincing evidence that the patient held a firm and settled commitment to decline the treatment under circumstances similar to those presented.

    Summary

    This case concerns Mary O’Connor, an elderly, incompetent hospital patient who previously expressed a desire not to be kept alive by artificial means if she could not care for herself. When the hospital sought court authorization to insert a nasogastric tube for feeding, her daughters objected, citing her prior statements. The New York Court of Appeals reversed the lower courts’ denial of the hospital’s petition, holding that there was not clear and convincing proof of a firm and settled commitment by O’Connor to decline this type of medical assistance under the current circumstances. The court emphasized the need for unequivocal proof when terminating life support is at issue.

    Facts

    Mary O’Connor, a 77-year-old widow with a history of working in hospital administration, suffered several strokes that left her mentally incompetent and physically unable to care for herself. Prior to her incompetency, she made statements that she did not want to be a burden and would not want to be kept alive artificially if she could not care for herself. After being cared for at home by her daughters and eventually placed in a long-term care facility, she suffered another stroke rendering her unable to swallow. The hospital sought to insert a nasogastric tube for feeding after intravenous feeding proved inadequate, but her daughters objected, citing her prior wishes.

    Procedural History

    The hospital petitioned the trial court for authorization to insert a nasogastric tube. The trial court denied the petition, concluding it was contrary to O’Connor’s wishes. The Appellate Division affirmed. The New York Court of Appeals granted leave to appeal and issued a stay, allowing intravenous feeding to continue pending the appeal.

    Issue(s)

    Whether there was clear and convincing evidence that Mary O’Connor, while competent, made a firm and settled commitment to decline the insertion of a nasogastric tube for feeding under her current circumstances, where she is elderly, disabled, but not terminally ill, comatose, or in a vegetative state.

    Holding

    No, because the evidence presented did not meet the demanding standard of clear and convincing proof that Mrs. O’Connor had a firm and settled commitment to decline the nasogastric tube under these specific circumstances.

    Court’s Reasoning

    The court reaffirmed the common-law right to decline medical treatment, even life-saving treatment, absent an overriding state interest, citing Schloendorff v. Society of N. Y. Hosp. The court also referenced Matter of Storar and Matter of Eichner v. Dillon, emphasizing that a hospital must respect this right even when a patient becomes incompetent if, while competent, the patient expressed their wishes. The court stressed that the standard of proof required to decline life-sustaining treatment is “clear and convincing evidence,” because “nothing less than unequivocal proof will suffice when the decision to terminate life supports is at issue.” The court found that Mrs. O’Connor’s statements, while repeated over time, were general expressions of a desire not to be a burden and to avoid prolonged suffering, not a specific rejection of medical assistance for nutrition under her current condition. The court distinguished this situation from cases where the patient had a terminal illness or was in a coma or vegetative state. The court noted the importance of considering the circumstances in which the statements were made and comparing them with those presently prevailing. The court stated, “Every person has a right to life, and no one should be denied essential medical care unless the evidence clearly and convincingly shows that the patient intended to decline the treatment under some particular circumstances.” Even the daughters admitted they did not know what their mother would want under these circumstances. The court found that Mrs. O’Connor’s prior statements did not demonstrate a firm and settled commitment to decline medical assistance when her prognosis was uncertain, and her only change in condition was the loss of her gag reflex, requiring medical assistance to eat. The court also stated that waivers of constitutional rights are always carefully scrutinized by the courts, and no one’s request to have real or personal property pass to a specified person upon death can be enforced in court unless it is also expressly stated in a signed will.

  • Rivers v. Katz, 67 N.Y.2d 485 (1986): Involuntarily Committed Patients’ Right to Refuse Antipsychotic Medication

    Rivers v. Katz, 67 N.Y.2d 485 (1986)

    Involuntarily committed mental patients have a fundamental right under the New York State Constitution to refuse antipsychotic medication, which can only be overridden by a judicial determination of incapacity to make a reasoned decision, or in emergency situations under the state’s police power.

    Summary

    Rivers, Zatz, and Grassi, involuntarily committed patients, challenged the nonconsensual administration of antipsychotic drugs. The New York Court of Appeals held that involuntarily committed mental patients possess a fundamental right to refuse antipsychotic medication under the state constitution’s due process clause. This right is not absolute but can be overridden if the patient is deemed incapable of making a reasoned decision about treatment or if the State’s police power is implicated due to the patient’s dangerousness. The court mandated a judicial hearing to determine the patient’s capacity to make treatment decisions, placing the burden on the state to prove incapacity by clear and convincing evidence.

    Facts

    Mark Rivers, Florence Zatz, and Florence Grassi were involuntarily committed to Harlem Valley Psychiatric Center. Each had been deemed in need of involuntary care and treatment due to mental illness impairing their judgment. Rivers and Zatz were medicated with antipsychotic drugs after refusing treatment and undergoing administrative review where their objections were overruled. Grassi was similarly medicated after refusing and having her protest overruled. All three patients then initiated legal challenges to stop the forced medication.

    Procedural History

    Rivers and Zatz filed a declaratory judgment action, which was dismissed by Special Term, which was affirmed by the Appellate Division. Grassi filed an Article 78 proceeding, also dismissed for similar reasons. The Appellate Division consolidated the appeals and affirmed the lower court’s decisions. The New York Court of Appeals reversed, holding that the patients had a right to refuse medication under the state constitution.

    Issue(s)

    Whether involuntarily committed mental patients have a constitutional right to refuse antipsychotic medication, and if so, under what circumstances can that right be overridden?

    Holding

    Yes, involuntarily committed mental patients have a fundamental right to refuse antipsychotic medication because this right is coextensive with the patient’s liberty interest protected by the due process clause of the New York State Constitution. This right can be overridden only if the patient is judicially determined to lack the capacity to make a reasoned decision about treatment or if the State’s police power is implicated due to the patient’s dangerousness.

    Court’s Reasoning

    The court grounded its decision in the common-law right of individuals to control their medical treatment, a right that extends to mentally ill persons. It rejected the argument that involuntary commitment automatically implies incompetence to make treatment decisions. The court acknowledged that this right is not absolute and may yield to compelling state interests under the police power (e.g., imminent danger to self or others) or the parens patriae power (protecting those unable to care for themselves). However, the parens patriae power can only be invoked after a judicial determination that the patient lacks the capacity to make a reasoned treatment decision.

    The court emphasized the need for procedural safeguards, including a de novo judicial hearing with representation by counsel, where the State bears the burden of proving incapacity by clear and convincing evidence. If incapacity is established, the court must then determine whether the proposed treatment is narrowly tailored to the patient’s best interests, considering benefits, side effects, and less intrusive alternatives.

    The court found the existing administrative review procedures inadequate to protect patients’ due process rights, citing the lack of clear standards and criteria. It also emphasized that medical determinations must adhere to accepted professional judgment and standards.

    Quoting the Oklahoma Supreme Court, the court stated, “[i]f the law recognizes the right of an individual to make decisions about * * * life out of respect for the dignity and autonomy of the individual, that interest is no less significant when the individual is mentally or physically ill”.

    The court concluded that “neither mental illness nor institutionalization per se can stand as a justification for overriding an individual’s fundamental right to refuse antipsychotic medication on either police power or parens patriae grounds.”

  • Matter of Eichner, 52 N.Y.2d 363 (1981): Right of Competent Adults to Refuse Medical Treatment

    Matter of Eichner, 52 N.Y.2d 363 (1981)

    A competent adult has a common-law right to refuse medical treatment, even life-sustaining treatment, and this right can be exercised on their behalf if they have clearly and convincingly expressed their wishes prior to becoming incompetent.

    Summary

    These consolidated cases, Matter of Eichner and Matter of Storar, address the issue of whether life-sustaining medical treatment can be discontinued for incompetent patients. In Eichner, the court considered whether a religious brother’s prior statements about not wanting extraordinary life support should be honored. In Storar, the court examined whether blood transfusions should be continued for a profoundly retarded man with terminal cancer, against his mother’s wishes. The Court of Appeals held that Brother Fox’s prior expressed wishes should be respected, while John Storar’s lack of competency and the life-saving nature of the transfusions required that they continue.

    Facts

    In Eichner, Brother Fox, an 83-year-old member of a religious society, suffered cardiac arrest during hernia surgery, leaving him in a permanent vegetative state dependent on a respirator. Prior to the surgery, he had discussed the Karen Ann Quinlan case and stated he would not want “extraordinary business” done for him under similar circumstances. In Storar, John Storar, a 52-year-old profoundly retarded man with terminal bladder cancer, was receiving blood transfusions. His mother, his legal guardian, requested the transfusions be stopped because they caused him discomfort.

    Procedural History

    In Eichner, the Supreme Court granted the petition to remove the respirator, and the Appellate Division modified and affirmed, establishing procedures for such cases. In Storar, the Supreme Court denied the application to continue transfusions, and the Appellate Division affirmed. The Court of Appeals consolidated the appeals, but both patients died during the appeal process, rendering the specific controversies moot.

    Issue(s)

    1. Whether a competent adult has a right to decline medical treatment?

    2. Whether that right can be exercised by another on the patient’s behalf if the patient becomes incompetent?

    3. Whether blood transfusions can be discontinued for a profoundly retarded man with terminal cancer, when those transfusions are necessary to prolong his life?

    Holding

    1. Yes, because every person “of adult years and sound mind has a right to determine what should be done with his own body.”

    2. Yes, because when there is “clear and convincing proof” that a person, now incompetent, left instructions to terminate life-sustaining procedures when there is no hope of recovery, those instructions should be honored.

    3. No, because a parent may not deprive a child of lifesaving treatment, even if the child is an adult with profound retardation.

    Court’s Reasoning

    The Court reasoned that a competent adult’s right to refuse medical treatment is grounded in common law, as articulated in Schloendorff v. Society of N.Y. Hosp., noting that a surgeon who operates without consent commits assault. This right is not absolute, as the State has interests in protecting life, but there is no statute in New York that prohibits a patient from declining necessary medical treatment. When a patient is incompetent, the decision to discontinue treatment is more sensitive. If the patient had expressed their wishes prior to incompetency, those wishes should be honored, provided there is clear and convincing evidence of their intent. The court noted, “Clear and convincing proof should also be required in cases where it is claimed that a person, now incompetent, left instructions to terminate life sustaining procedures when there is no hope of recovery.” In Storar, the court emphasized that John Storar had never been competent, thus his mother’s wishes could not override the necessity of life-saving treatment. “A parent or guardian has a right to consent to medical treatment on behalf of an infant (Public Health Law, § 2504, subd 2). The parent, however, may not deprive a child of lifesaving treatment, however well intentioned”. The court distinguished the transfusions from the cancer itself: “the transfusions were analogous to food — they would not cure the cancer, but they could eliminate the risk of death from another treatable cause.”