A.C. (Angela Carter) Cesarean Section
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).]
Principles & Concepts: human dignity, autonomy, informed consent, substituted judgment, right to life.
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Adkins, Janet
Janet Adkins was Dr. Kevorkian’s first public assisted suicide. Adkins was newly diagnosed with Alzheimer’s Disease when Dr. Kevorkian assisted her in committing suicide in 1989. The case stimulated discussion on euthanasia and physician-assisted suicide. Dr. Kevorkian was charged with murder, but the Oakland County District Court dropped charges on December 13, 1990, after a two-day preliminary hearing. The court ruled that Kevorkian did not break any law by helping Adkins commit suicide because there is no Michigan law outlawing suicide or the medical assistance of it. Some of the more prominent issues in the case concerned whether Adkins was in fact giving informed consent; the fact that Dr. Kevorkian did not have an established professional relationship with her; the fact that she was not terminally ill; the whole issue of whether or not a person actually possesses the right to die; and discussions on the limits of autonomy. [Source: People v. Dr. Kevorkian, No. 90-20157 (52nd Dist. Ct. Mich. 1991); 534 N.W. 2d. 172 (1995).]
Principles & Concepts: respect for autonomy, common good, human rights, human dignity, professional integrity.
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Baby Doe, Baby Jane Doe, Baby Doe Regulations, and the 1983 Amendment to the Child Abuse Law
Two cases and two sets of regulations that engaged the public and professionals on the issues of what treatment should be provided for seriously ill/disabled newborns and if their parents should be allowed to decide whether treatment was not to be provided. To help enforce these regulations, "hot line" telephone numbers were set up around the country by the federal government to encourage anonymous reporting of suspicious abuse. These hotlines were soon discontinued, because they resulted in the frequent intrusion of federal investigators into hospitals and the interruption of the daily functioning of neonatal intensive care units. The Baby Doe regulations would undergo several revisions before finally be assumed under the Child Abuse Amendments of 1984, 42 U.S.C.A. § 5102. [Source: Selected Recent Court Decisions, 9 Am. J. L. and Med. 517, 1984.]
Principles & Concepts: informed consent, human dignity, right to life, benefit and burdens, proportionate/ disproportionate means, surrogate decision-making, best interests.
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Baby Fae
The case of Baby Fae raises important issues in the area of human experimentation. On October 26, 1984, Dr. Leonard Baily and the transplant team of Loma Linda University Medical Center in California removed the defective heart (hypoplastic left heart syndrome, in which the left side is much smaller than the right) of a five pound baby girl (known as Baby Fae). It was replaced with the heart of a baboon, a procedure known as xenotransplantation (cross-species transplantation). Twenty days later, on November 15th, the baby died of complications caused when her body began to reject the transplanted heart. Among the ethical issues raised by the Baby Fae case are the risk/benefit ratios for the human subject, experimentation and quality of informed consent and surrogate decision-making, exploration of other options, the introduction of expensive and untested technology, and the priorities and economics of medicine. Regarding other options, the doctors at Loma Linda never sought a human heart and the chances for a successful xenograft were very slim. [Source: Hubbard, LL. "The Baby Fae Case," Medicine & Law 6(5): 385-96, 1987.]
Principles & Concepts: beneficence, benefit and burdens, proportionate/ disproportionate means, best interests.
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Baby K
Baby K was born on October 13, 1992, with anencephaly, a condition involving absence of the cerebral and cerebellar portions of the brain, for which there is no curative or ameliorative treatment. Baby K was permanently unconscious, could not hear or see, and apparently could not feel pain, but did have sucking, swallowing and coughing reflexes (consistent with the condition of anencephaly). She had difficulty breathing at birth and was placed on a ventilator. Hospital personnel encouraged Ms. H, Baby K’s mother, to enter a DNR order and to discontinue ventilator treatment for Baby K. Ms. H refused to permit either. Baby K was eventually weaned from the ventilator and transferred to a nursing home, where she had several subsequent episodes of respiratory distress requiring rehospitalization and a tracheotomy. Ms. H continued to seek aggressive care for Baby K. The hospital filed suit in federal district court seeking a declaratory ruling and injunctive relief to the effect that its future refusal to provide Baby K with life-sustaining medical care (primarily the ventilator), would not violate the following laws: The Emergency Medical Treatment and Active Labor Act (EMTALA), the Rehabilitation Act of 1973 (the "Rehab Act"), the Americans with Disabilities Act (ADA), and the Child Abuse Amendments of 1984, and the Virginia Medicine Malpractice Act.
The court denied the hospital the relief it sought under EMTALA, the ADA and the Rehabilitation Act, and declined, for technical legal reasons, to make a ruling under the Child Abuse Amendments or the Malpractice Act. As to EMTALA, the court refused to recognize an exception to EMTALA’s plain requirement that a hospital provide stabilizing emergency medical treatment for an emergency medical condition based upon the hospital’s assertion that such stabilizing treatment is futile or "inhumane." The court noted that even if such an exception were available in the language of EMTALA, it would not apply in Baby K’s case because the use of a ventilator is not futile or inhumane in relieving Baby K’s acute respiratory distress, which is the condition for which she sought emergency medical treatment. The court also argued that withholding the ventilator from Baby K would violate both the Rehabilitation Act and the ADA. The hospital had admitted that the sole reason that it wanted to withhold the ventilator was because of Baby K’s "handicapping condition," her anencephaly. The language of these two statutes does not permit denial of ventilator services to a disabled child when those services would be given to other, non-disabled children.
Because of the nature of legal relief sought by the hospital in this case, the court was not asked to address directly the issues of whether or not ventilator care was "futile" for Baby K, or whether or not the hospital or treating physicians had the authority to stop providing care that they had determined was futile. Instead, the case supports the proposition that heath care providers who assume authority to discontinue treatment that they feel is futile when the patient or the patient’s surrogate desires such treatment, may face liability under EMTALA, the ADA and the Rehabilitation Act if the patient is in an emergency medical condition or is disabled. [Source: In the Matter of Baby K, 832 F.supp. 1022, E.D. Va. 1993.]
Principles &
Concepts: human dignity,
right to life, personhood,
right to health care,
professional & institutional
integrity, proportionate/
disproportionate means, principles
of integrity and totality, best
interests.
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Baby M
This case involved a custody dispute between a father and a mother. The father, William Stern, had contracted with the mother, Mary Beth Whitehead, to bear him a child through artificial insemination. The contract, in part, provided that she would receive a fee of $10,000 upon terminating her parental rights and giving up the child to him. A lower court held that the contract was enforceable and that the custody of the child, known as Baby M, should be awarded to Mr. Stern on the basis of the child’s best interests. Mrs. Whitehead appealed, asking the court to determine "surrogacy contracts" unenforceable and void, to reinstate her parental rights and to grant her custody of Baby M. The Supreme Court ruled: 1) that giving money to a woman to induce her to surrender her child for adoption was unconstitutional; 2) that the state’s adoption laws permit irrevocable surrender of a child only after birth; and 3) that the law requires proof of abandonment or unfitness prior to termination of parental rights or adoption without consent. [Source: In Re Baby M, 217 N.J. Super. 313 (1987).]
Principles & Concepts: beneficence, human dignity, respect for persons, common good, respect for autonomy, justice.
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Barber-Nejdl (Clarence Herbert)
Doctors Nejdl and Barber were charged with murder and conspiracy to commit murder following the death of Clarence Herbert. Herbert went into cardiac arrest following routine surgery. After being on a respirator for three days, the doctors concluded that Herbert would not recover consciousness. His family consented to removal of the respirator; Herbert continued to breathe on his own. After two more days, and with family consent, the patient’s intravenous lines providing nutrition and fluids were removed. The patient died several days later. Charges against Nejdl and Barber were eventually dismissed. The court stated that in the case of a "permanently unconscious patient," decisions should be based on whether potential benefits outweigh the expected burdens. The court also found that in the absence of legislation to the contrary, family members could act as appropriate surrogate decision-makers even if they are not legal guardians. [Source: 195 Cal. Rptr. 484 (1983).]
Principles & Concepts: substituted judgment, best interests, informed consent, proportionate/ disproportionate means.
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Bouvia, Elizabeth
Elizabeth Bouvia was an intelligent young woman living with severe quadriplegic cerebral palsy, very limited muscle control, and constant pain from arthritis and contractures. In 1985, after separation from her husband, Elizabeth voluntarily entered Riverside General Hospital in California as a psychiatric patient. She requested nursing care and pain medication as she ceased eating in order to starve herself. Her physicians refused to comply with her request. Bouvia asked that the court prevent the hospital from force feeding her or from discharging her. The court determined that she was competent and believed that her decision to end her life by refusing food and water was rational given her extreme difficulties. The court did not feel, however, that she had the right to end her life with the assistance of society. The court therefore denied Bouvia’s request to keep the hospital from discharging her or, if she remained a patient, from feeding her by force. The case is remarkable on many levels, but especially for the issue of pain management. Ultimately, a physician approached Elizabeth with the promise of providing aggressive pain management; Elizabeth accepted the physician’s care. This new option apparently altered her determination to end her life. [Source: 179 Cal. App. 3d. 1127 (1986), and 60 Minutes.]
Principles & Concepts: human dignity, autonomy, respect for autonomy, informed consent, beneficence, institutional & professional integrity, common good, justice.
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Brownfield v. Daniel Freeman Marina Hospital
In this 1989 federal appellate court case, the plaintiff was taken to Freeman Hospital’s emergency room after being raped. In response to the patient’s request for information about the morning-after pill, the hospital authorities refused to provide such information, believing that they could not, on the grounds that it was a Catholic hospital. Specifically, the hospital did not inform the patient that if she wanted such treatment it must be obtained within 72 hours to be effective. The court reasoned that a patient has the right to make her own decisions regarding treatment, and therefore, adequate disclosure of information must be provided so the patient can make an informed decision. The court concluded that a rape victim who is denied information about access to the morning-after pill may bring a medical malpractice action. This means that liability may arise if the patient can show: 1) that a skilled practitioner would have provided such information and access under similar circumstances; 2) that she would have elected such treatment; and 3) that "damages" (in this case, pregnancy) resulted from the failure to provide such information. In a footnote to its decision, the court indicated that "access" to such treatment could include transfer of the patient to another medical facility or another physician.
More critical for Catholic-sponsored hospitals, the court also reasoned that the morning-after pill constitutes the "prevention" rather the than "termination" of pregnancy. It therefore concluded that the conscience clause under the state’s abortion statute did not immunize the hospital from liability for failure to refuse to provide such information. However, since human life begins at conception (fertilization) and not merely after implantation of the embryo, the relevant moral question from the Catholic perspective is not whether or not there is a pregnancy, but whether or not there is another innocent human life to be respected (see Ethical and Religious Directives, n. 45). Those "contraceptive" measures that operate solely through the prevention of implantation are morally equivalent to abortions in Catholic moral theology, and are therefore impermissible under the Ethical and Religious Directives (both then and now). Nevertheless, the court did not accept this moral distinction as relevant for its ruling.
If Catholic hospitals face a similar situation, they may ethically,
in keeping with the principle of informed consent, include in their protocol for the care of rape victims a requirement that victims be informed that such procedures and drugs can be obtained through their private physicians or non-Catholic facilities, but that Catholic facilities do not use them because they risk causing abortion. The decision to be satisfied with the Catholic facility’s mode of care or to go elsewhere thus remains with the victim [Ashley, B. and K. O’Rourke, Ethics of Healthcare (St. Louis, MO: Catholic Health Association, 1986) 138].
Legal opinion obtained for the Catholic Health Association supports such an approach:
It seems rather clear that a decision, based on religious principle, to refrain from performing abortions and sterilizations falls on the "beliefs" side of the [belief-action] dichotomy. It would contravene the separations of Church and State for government to require Catholic health care institutions to violate its principles in favor of a physician or patient who believes otherwise [In Defense of Values (St. Louis, MO: Catholic Health Association, 1984), 15].
The court ruling itself stated that Catholic Hospitals have the responsibility "to provide information concerning, and access to, estrogen prophylaxis for rape victims." [Source: Second Appellate district, Brownsfield v. Daniel Freeman Marina Hospital, March 2, 1989.]
Having said all this, it must be stated that if, after appropriate testing, it can be established with reasonable or moral certitude that the patient has not already conceived, it would then be appropriate for the Catholic hospital to treat the patient with medications that would in these circumstances prevent ovulation, sperm capacitation, or fertilization (see Ethical and Religious Directives, n. 36). Under these strict parameters, so-called "emergency contraception" would be permissible. This is appropriate because rape is not an act of mutual conjugal love. Rather, it is an extremely violent act that should not be confused with the moral obligations attendant to the inherent meaning of conjugal love. Under other circumstances, some of those same medications might function as abortifacients, which then would not be permissible. [For further reading, see: Ashley, B. and Kevin O’Rourke, Healthcare Ethics: A Theological Analysis (Washington, DC: Georgetown University Press, 1997), 302-307.]
Principles & Concepts: religious freedom, autonomy, respect for autonomy, right to life, human dignity, informed consent, respect for persons, beneficence, institutional & professional integrity, justice.
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Conroy, Claire
Claire Conroy was an 84 year-old resident of a nursing home. She suffered severe dementia and had a nasogastric feeding tube because she could not take adequate nourishment orally. She was bedridden, unable to speak, incontinent and contracted into a semi-fetal position, with several decubiti and a gangrenous left leg. Although not in a persistent vegetative state, she interacted with her environment in limited ways. Her only relative was a nephew, who visited her regularly. He went to court as her legal guardian in January of 1983 to request that the feeding tube be removed because he believed she would not want it. The trial court permitted the tube to be withdrawn but the decision was stayed pending appeal. Ms. Conroy died while the case was under appeal. Despite her death, the appeals process continued because of the importance of the issues raised by the case. An appellate court reversed the trial court decision. The New Jersey Supreme Court ruled that tube feedings, like other life-sustaining treatments, may be withheld if they are against the patient’s wishes or best interests.
The court believed that incompetent patients in nursing homes needed more procedural safeguards. It rejected the traditional practice of joint decisions by physicians and families of incompetent patients. Instead, the court mandated the following procedure: 1) the patient must be judged incompetent to make treatment decisions, and a guardian must be appointed by the courts; 2) the state office of ombudsman must be notified of any intention to withdraw life-sustaining treatment, and the case must be treated as a possible case of "abuse;" and 3) the guardian, attending physician and ombudsman may agree to withhold or withdraw life-sustaining treatment if the subjective test, pure-objective test or limited objective test is satisfied. [Source: In Re Conroy, 486 A. 2d. 1209 (1985).] The ruling, like other State Supreme Court rulings, sets no precedence for other states, but has influenced the thinking of other State Supreme Courts.
Principles & Concepts: human dignity, informed consent, substituted judgment, best interests, beneficence, benefits and burdens, proportionate/ disproportionate means.
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Cruzan, Nancy
On December 11, 1983, 25 year-old 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 decision-making 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.]
Principles & Concepts: autonomy, informed consent, substituted judgment, beneficence, proportionate/ disproportionate means, right to life, respect for persons.
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Dax (Dax Cowart)
The case of Dax Cowart illustrates the complexity of issues such as autonomy, paternalism, and quality of life. As the result of a freak accident in the summer of 1973, 25 year-old Dax Cowart was badly burned over 65% of his body. Both eyes, both ears and both hands were damaged beyond repair. Large doses of narcotics were required for minimal pain relief. He pleaded with his caregivers to be allowed to die, and also stated several times that he wanted to kill himself. The physicians at Parkland Hospital in Texas turned to his mother to obtain consent for all his treatments, even though she was not appointed his legal guardian and even though Dax was determined by psychiatric evaluation to have full decision-making capacity. There was a constant struggle of will between Dax and his mother. Ultimately, he recovered from the burns, albeit severely mutilated. He successfully sued the oil company responsible for his burns, which left him financially secure. Later, he attended law school at Baylor University. He attempted suicide twice after his rehabilitation period. He eventually finished law school and married. He is now apparently happy but still believes the doctors were wrong to follow his mother’s wishes over his. The case advanced respect for patient autonomy all around the country.
Principles & Concepts: human dignity, respect for autonomy, informed consent, beneficence, proportionate/ disproportionate means.
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