Yesterday, the Supreme Court of Connecticut ruled that the state could require a 17-year-old girl named Cassandra to continue chemotherapy treatment. Cassandra was diagnosed in September with a type of cancer called Hodgkin’s lymphoma. Experts in Cassandra’s case gave her a life expectancy of two years if she did not receive treatment but estimated her chances of survival at 85% if she received the treatment. Having received this advice, Cassandra and her mother do not want her to receive treatment, saying that she does not want to put poison into her body.
Doctors in Cassandra’s case reported her mother for neglect after there were missed doctors appointments as well as arguments with the doctors about her diagnosis. In November, the Department of Children and Families was awarded temporary custody of Cassandra. During the hearing, Cassandra swore under oath that she would undergo treatment, and the court then ordered her mother to provide her with medical care. Cassandra and her mother initially complied with the order, attending the first two chemotherapy treatments. However, after the first two treatments, Cassandra ran away from home to avoid further treatments. Another hearing was held after Cassandra returned home and refused further treatments. Based on testimony from Cassandra’s doctors at that hearing, the court removed Cassandra from her home and put her in the care of DCF. DCF was also given the authority to make all necessary medical decisions. Cassandra has been receiving chemotherapy since December under the supervision of DCF.
Cassandra and her mother appealed the court order, arguing that Cassandra’s constitutional rights were violated. They urged the court to adopt the “mature minor doctrine” under which the court must determine that a seventeen year old is not sufficiently mature enough to make medical decisions for herself before the court can force that seventeen year old to undergo treatment against her will.
Generally, a patient who is 18 years old or older has the right to refuse treatment, no matter how helpful that treatment might be. North Carolina statute allows a patient to recover medical malpractice damages in certain situations where a health care provider does not obtain the patient’s informed consent prior to rendering treatment. Specifically, G.S. 90-21.13 states that
(a) No recovery shall be allowed against any health care provider upon the grounds that the health care treatment was rendered without the informed consent of the patient or other person authorized to give consent for the patient where:
(1) The action of the health care provider in obtaining the consent of the patient or other person authorized to give consent for the patient was in accordance with the standards of practice among members of the same health care profession with similar training and experience situated in the same or similar communities; and
(2) A reasonable person, from the information provided by the health care provider under the circumstances, would have a general understanding of the procedures or treatments and of the usual and most frequent risks and hazards inherent in the proposed procedures or treatments which are recognized and followed by other health care providers engaged in the same field of practice in the same or similar communities; or
(3) A reasonable person, under all the surrounding circumstances, would have undergone such treatment or procedure had he been advised by the health care provider in accordance with the provisions of subdivisions (1) and (2) of this subsection.
In addition to the statutory provision for informed consent, there is also a common law doctrine of informed consent. The U.S. Supreme Court examined this doctrine and how it relates to a patient’s right to refuse medical treatment in the 1990 case, Cruzan v. Director, DMH. In Cruzan, the Court stated that “the common-law doctrine of informed consent is viewed as generally encompassing the right of a competent individual to refuse medical treatment” and “[t]he logical corollary of the doctrine of informed consent is that the patient generally possesses the right not to consent, that is, to refuse treatment.”
The Cruzan Court’s review of prior decisions noted that a competent person’s right to refuse medical treatment stems from the Due Process Clause in the Fourteenth Amendment which “provides that no State shall ‘deprive any person of life, liberty, or property, without due process of law.’” In examining a person’s rights under the Due Process Clause, courts must balance the person’s “liberty interests against the relevant state interests.” The relevant state interests in this situation is a state’s “interest in the protection and preservation of human life.” The Court assumed “that the United States Constitution would grant a competent person a constitutionally protected right to refuse lifesaving hydration and nutrition.”
Under the mature minor doctrine, a young person must demonstrate that he is sufficiently mature enough to make decisions regarding his medical care. Only a handful of states recognize the mature minor doctrine. One such state is Illinois, the Supreme Court of which issued an opinion the 1989 case, In re E.G. In that case, a 17-year-old girl with leukemia refused life-saving blood transfusions based on her membership in the Jehovah’s Witness faith. There were several witnesses at the hearing that testified to the girl’s maturity and sincerity in her faith. The Illinois Court sided with the girl and pointed to the “sliding scale of maturity” used in other areas of law with respect to juveniles. Similar to the balancing test laid out in Cruzan, under Illinois’ mature minor doctrine, a trial court must balance the interests of the state (preservation of life and protection of minors) against the evidence of the minor’s maturity. The more serious the medical issue, the greater the state’s protection interest.
News reports do not indicate that the Connecticut Court completely rejected the mature minor doctrine, only that it did not apply in this case. The Court pointed to the incident from November (where Cassandra swore she would undergo treatment and then ran away from home to avoid further treatments) as an indication of Cassandra’s lack of maturity. The Court also ruled that Cassandra had the chance to prove her maturity during the December hearing and failed to do so.