*1 MATTER KATHLEEN FARRELL. IN THE OF Argued 1987. 198 6 Decided June November *5 argued Peter R. and F. the cause Strohm John Gelson for appellant, Strohm, (Rothstein, Peter R. Guardian ad litem Mandell, Gelson, attorneys). Strohm &
Joseph argued respondent, Purrazzella the cause for Francis Farrell.
John R. Heher submitted a brief on behalf of amicus curiae Jersey Hospital {Smith, Stratton, Wise, New Association H Brennan, attorneys; eher & Heher Wendy Mager, John and L. brief). on the Cohen,
Fenalla Rouse Elena N. members of the New bar, York and Jo Anne C. Adlerstein submitted a brief on Society Die, behalf of Right amicus curiae for the Inc. (Stem, Marcus, attorneys). Dubrow & opinion by Court was delivered
GARIBALDI, J. However, everyone. Death comes to society, our due to great knowledge advances in medical technology over the decades, last few death suddenly completely does not come or unexpectedly people. to most President’s Commission Study Ethical Problems in Medicine and Biomedical and Research, Deciding Behavioral Forego Life-Sustaining Report (1983)(hereinafter Treatment 15 President’s Commission Instead, ) people most who die are under the treatment professionals of health care physical who are able to continue beings existence for human physical “even when most of our capacities and mental irrevocably have been lost.” In re Con roy, (1985). N.J. While medical advances have possible made it to forestall and previous cure certain illnesses fatal, ly they prolonged considered also have the slow deteriora tion and patients. Sophisticated death of some Congress 1The Commission, President’s established by consisted of theologians ethicists, doctors, and others. See lawyers, § 42 U.S.C. 300v (1982). *6 possible people technology has made it to hold some on medical time, period of of death for an indeterminate threshold definition of death.” In re “obfuscatpng] the use of traditional Quinlan, Garger 10, 27, cert. denied sub nom. v. New N.J. 70 922, 319, (1976). Jersey, 429 97 S.Ct. L.Ed.2d 50 289 U.S. Questions thereby matters of choice rais of fate have become “moral, social, ing technological, philosophical, and profound legal questions involving interplay many disciplines.” of Conroy, supra, Perspectives see on J. 344; Matter N.J. 98 at Patient, Katz, Doctor and The Silent World of 9 W. New (1987). Eng.L.Rev. 1 re case, in this and are faced with such issues
We Jobes, (1987), Peter, (1987), and In re 108 N.J. 365 N.J. 394 appeals today. Specifically, these three concern also decided life-sustaining treatment from three women the withdrawal of suffering from and irreversible medical conditions. incurable residence, ages, places their and medical condi Because of tions, pattern of none of their cases falls within the factual decisions, Quinlan, supra, 10, N.J. or either of our seminal Farrell, thirty-seven- Conroy, supra, N.J. 321. Kathleen a terminally-ill patient suffering amyo from year-old, competent, (ALS), commonly as Lou Geh trophic lateral sclerosis known disease, sixty-five-year-old rig’s died at home. Hilda Peter is a state, vegetative nursing persistent in a home resident nursing in a Nancy thirty-one-year-old a home resident Jobes is Mrs. persistent vegetative state. Neither Ms. Peter nor Jobes variety expected year. to die of these cases within that call for deci illustrates the infinite number of situations life-sustaining recog treatment. sionmaking medical We about courts, nize, Conroy, and as have numerous other as we did questions must given the fundamental societal that be resolved, government Legislature proper is the branch of guidelines set in this area:2 Legislature 12, 2On November created the "New Commission Jersey Legal on and Ethical Problems in the of Health Care” to Delivery study technology. issues created the evolution of medical The Commission is by Legislature, Governor, scheduled to to the on December report public (codified 1988, and three thereafter. L. c. 363 every years N.J.S.A. 52:9Y-2). Meanwhile, numerous bills that deal more with termi specifically pending. E.g., Dignity nation of are treatment Death With Act, (1986) (introduced Russo); Right (1986) S. 846 Senator Die Act, S. 947 by (introduced Feldman); (1986) (introduced Right Senator to Die A. by Act, Bryant); Medical Power Act, Decision A. by Assemblyman Attorney (1986) (introduced Weidel). by Assemblyman The National Conference of Commissioners on Uniform States Laws has *7 recognizing "living submitted a uniform act proposed enforceability legislation, Rights wills" in certain limited situations. That model the Uniform Act, of the 111 has not been in New Terminally But formally adopted Jersey. thirty-eight states and the District of Columbia have enacted laws in this area. (1981); See Alabama Natural Act, §§ Death Ala. Code 22-8A-1-10 Alaska Act Relating Rights to the III, of the Alaska Stat. § 18.12.010-.100 Terminally (1986); Arizona Medical Act, Treatment Decision §§ Ariz.Rev.Stat.Ann. 36- (1985); Rights 3201-3210 Arkansas of the III or Terminally Permanently Act, 713; Unconscious 1987 Ark. Acts Act, California Natural Death Cal. Health (1976); & §§ Code 7185-7195 Safety Colorado Medical Treatment Decision Act, §§ 15-18-101-113; Colo.Rev.Stat. see also Colo.Rev.Stat. §§ 12-36-117 (1985) Dignity (1985); ; Connecticut Act, Death with Public Act No. 85-606 Dignity (1982); Delaware Death Act, 16, with Del. Code Ann. tit. §§ 2501-2509 District of Columbia Natural 1981, Death Act of D.C. Code Ann. §§ 6-2421- (1982); Prolonging 2430 Florida Act, Fla.Stat., Life Procedure 84-58, Chap. (1984); Georgia Living §§ 765.01-.15 Act, Wills Ga. Code Ann. §§ 31-32-1-12 (1984) Amended, 1987 Ga. Laws 488; Act, Hawaii 1986 Hawaii Sess. Laws 338 (1986) (1977); ; Act, Idaho Natural Death Idaho Code §§ 39-4501-4508 Illinois Living (Smith-Hurd 1984); Will Act, Ill.Ann.Stat. ch. 110 §§ 701-710 1/2 Living Life-Prolonging Indiana Wills and Procedures Act, Ind. Code 16-8-11 (1985) Life-Sustaining ; Iowa Act, Procedures Iowa Code ch. 144A.l-144A.11 (1985) (1987 amended, H.F. 360 Sess., 72d Iowa Gen. Kansas Assembly; (1979); Natural Act, Death Kan.Stat.Ann. §§ 65-28, 101-109 Louisiana Life- Sustaining (1984, 1985); Procedures Act, La.Rev.Stat. 40:1299.58.1-.10 amend. Living (1985); Maine Act, 22, Wills Me.Rev.Stat.Ann. tit. ch. 710a Maryland Life-Sustaining Act, Procedures Md. Health General Code Ann. §§ 5-601-614, Life-Sustaining (1985); 6, subtitle Procedures Natural Act, Death Mississippi (1984); Death-Prolonging Miss. Code Ann. 41-41-101-121 §§ Missouri Proce (1985); Living Act, dures §§ Mo.Rev.Stat. 459.010-459.055 Act, Montana Will (1985); Mont. §§ 50-9-101-104, 50-9-111, Code Ann. §§ 50-9-201-206 Ne Withholding Life-Sustaining vada Act, Procedures Nev.Rev.Stat. §§ 449.540- (1977); Living 690 New Act, Wills N.H.Rev.Stat.Ann. ch. 137H Hampshire
343 fraught Because the issue with all its ramifications is with and complexity the interests of the both civil and encompasses law, criminal, medical ethics and social it is not one which is well-suited for resolution in an morality, adversary judicial proceeding. It is the issue which is more addressed in type [of] suitably legislative finding where fact can be forum, less confined and the view of all interested institutions and can be and points disciplines presented synthe subject sized. In this manner can the be dealt with only comprehensively accommodated, the interests of all institutions and individuals be properly [Conroy, supra, Perlmutter, (quoting N.J. Satz v. 98 344-45, 379 2d 359, So. (Fla.1980), aff'g (Fla.Dist.Ct.App.1978)).] So. 360 362 2d 160 Barber, Cal.App.3d In re Accord 1006, 195 Cal. 1016-17, 147 Rptr. Wilmington 484, Severns v. Medi (Cal.Ct.App.1983); 488 Center, Eichner, cal In re 1334, (Del.1980); 421 2d A. 1346 52 363, 382, N.Y.2d N.Y.S.2d cert. 64, 74, 266, 276, 420 N.E.2d 438 denied, U.S. S.Ct. L.Ed.2d (1981); Hamlin, re 810, 821-22, Wash.2d 689 P.2d (1984).
Nevertheless, patients physicians and their families and are increasingly being complex faced with these difficult and deci- legislative guidelines sions without and under the threat of civil acts, liability. Legislature and criminal Until the it is to the public guidelines proce- courts that must for the look may dures under which medical treatment be patients’ rights withdrawn or withheld. Sensitive to self-determination, cognizant vulnerability but of the (1985); Right (1977); Act, §§ New Mexico to Die N.M.Stat.Ann. 24-7-1-11 *8 (1977, Right Act, North Carolina to Natural Death N.C.Gen.Stat. §§ 90-320-322 1983); 1979, 1981, Act, 63, amend. Oklahoma Natural Death Okla.Stat. tit. (1985); Oregon Rights §§ Act, 3101-3111 with to Terminal Illness Respect (1977, 1983); §§ Or.Rev.Stat. amend. South Carolina Death With 97.050-.090 (1986); Dignity Right Act, § S.C. Code Ann. 44-77-10-160 Tennessee to Natural (1983); Act, Texas Natural Death Act, §§ Death Tenn.Code Ann. 32-11-101-111 (1977, 1985); 4590h, 1979, 1983, Tex.Stat.Ann. art. amend. Utah Personal (1985); Living Act, Choice and Will Utah Code Ann. 75-2-1101-1118 Ver §§ mont Terminal Act, 18, §§ Care Document Vt.Stat.Ann. tit. 5251-5262 and tit. (1982); Virginia 13, § Act, Natural Death Va. Code §§ 54-325.8:1-13 (1983) Washington ; Act, Natural Death Wash.Rev.Code Ann. 70.122.010- §§ (1979); Virginia Act, 70.122.905 West Natural Death W.Va. Code 16 Art. Chap. (1984); seq. 154.01 et Act, 1-10 §§ §§ Wisconsin Natural Death Wisc. Stat. (1984) (1984). Wyoming Living ; Act, §§ Will 33-26-144-152 Wy.Stat.
sick, protect ap- to interests. strive all the relevant We we great humility, recognize proach this task with for we that “[t]o way keep person a under err either alive circumstances —to die, he have allowed to to under which would rather been or person cling he would have chosen to allow that die when deeply Conroy, supra, be unfortunate.” 98 N.J. at life—would 343. Quinlan today Conroy,
As in we do not determine life-sustaining medical treatment should be whether withdrawn cases, patients in rather any from these but define who may may a it made. make such decision and how be
I Although general competent that principle we stated the patients right life-sustaining have the to decline treat- informed Quinlan, supra, ment and Conroy, in both N.J. at incompe- an of those cases involved each 98 N.J. In patient. tent institutionalized this case we deal the first right competent, terminally-ill time with the of a adult life-sustaining respirator. living at home to a withdraw They married Farrell in 1969. Kathleen Francis had two illness, key- children. Prior to her Mrs. Farrell worked as a punch operator. began experience November she ALS, symptoms a associated with disorder of nervous system degeneration results in of the victim’s muscles. patient incapable a Although eventually it renders of move- ment, impair patient’s does not mental ALS faculties. disease is no cause of the is unknown and there available diagnosis, a treatment or cure. At the time victim’s life expectancy usually even with treatment is one to years. three ill, Farrell admitted to Philadel-
After she became Mrs. was tracheotomy phia hospital where she underwent a and was *9 respirator.3 In connected to a the autumn of she was hospital from the provide released because it could no further help for her condition. She returned home to live with her teenage their two husband and sons. Thereafter Mrs. Farrell paralyzed was and confined to bed in need of around-the-clock nursing expenses care. Insurance covered all the of this care. experimental
In November after an program that her failed, characterized as hope” husband “their last had Mrs. him that she Farrell told wanted to be disconnected from the respirator breathing. that sustained her Mr. Farrell told her doctor, Pino, John of her decision. The doctor advised Mrs. respirator Farrell that she would die if her were removed. Dr. arranged psychologist, Orost, Pino for a Dr. Jean to interview Dr. Mrs. Farrell. Orost determined that Mrs. Farrell was not clinically depressed psychiatric and needed no treatment. She informed, concluded that Mrs. Farrell voluntary, had made an competent respirator. decision to remove the Dr. Orost weekly continued to see Mrs. Farrell on a basis from the time of their first in January interview 1986 until her death the following June. 13, 1986, Chancery
On June Francis Farrell filed a Division complaint seeking appointment Special his as Medical Guardian specific authority respirator. his wife with to disconnect her sought declaratory judgment anyone He also that he and who disconnecting respirator assisted him in her would incur no civil liability. or criminal The trial court executed an Order to Show Cause, 16,1986, date, appoint- which set the return June as guardian ed' a ad litem for the children.
Part of the trial was conducted at the Farrells’ home in order testify. to enable Mrs. Farrell The court described Mrs. Farrell’s medical condition at the time of the trial as follows: noting 3It is worth that Mrs. Farrell refused to allow the insertion of a nasogastric tube and the nurses were instructed not to resuscitate her. No arising issues out of those directives are before the Court. *10 weighing fragile to than woman, Mrs. Farrell be a less very presently appears weighed has no In December 1982 she She control pounds. pounds. legs, her or incontinent as to and has arms, bowel, over feet is hands, difficulty swallowing in and such function. She has is fed liquids, with bladder difficulty juices, syringe a who to her needs hours a as fruit with nurses attend by taking She of solid foods mouth. She is able to is incapable any by open day. talking. During in her close her and can see but has eyes difficulty and at court took what she and her husband times said, a down testimony, reporter generally limited to her answers to Her answers were yes repeated questions. times her answer was and at an board was used be certain no, or alphabet her Her mouth tended fill with saliva and made answers understood. up her and days to understand at times. When children better were difficult her filled with and her husband assisted discussed with Mrs. tears Farrell, eyes moving blowing her is her or head, neck, her in nose. She incapable any reclining in a chair and can other of her On occasion she put part body. although has falls She television she stated she usually asleep. pain watch relieve it to some extent. back, her arms and but medication does re Farrell, supra, N.J.Super. [In 296-97.] trial, that she had discussed her At the Mrs. Farrell testified husband, respirator with her their two to withdraw the decision sons, sister, her Dr. Orost. parents, psychologist, her her and open upsetting, resulted These discussions had been but among parties. Farrell Mrs. had full communication all respira- a consequences of her decision with also discussed why asked tory specialist, Dr. Mrs. Farrell was Sollami. When respirator to let nature had to disconnect her she decided course, suffering.” responded, “I’m tired of its she take Farrell's decision was not the Dr. testified that Mrs. Orost opinion The doctor’s of mere whim or casual decision. result a having weekly she had with discussions been was based on Additionally, a prior six months. Board- Mrs. Farrell over the request Mrs. at the psychologist examined Farrell certified guardian. He that she attorney for the children’s testified to make the competent decision. was closing arguments the trial court After on June requested, stayed but granted relief that Mr. Farrell had all the day Peter pending appellate review. next his order children, Strohm, appeal guardian for the filed notice petitioned this court direct Appellate Division and with 25, 1986, Mr. filed a Farrell’s counsel certification. On June joining letter request memorandum in the guardian.4 granted We certification on June 1986. 104 N.J. 446. 29, 1986,
On June Mrs. Farrell died while still connected respirator. death, Despite her guardian both the ad litem and Mr. Farrell have urged us to address her case and guidelines might formulate patients, aid future their loved ones, physicians and their dealing with similar situations. importance Because of the extreme of the issue and the inevita bility arising future, of cases like this one in the see In re *11 supra, Conroy, 342, at N.J. agree 98 we to render a decision on the merits.
II case, In resolving this as well as the two other cases we Quinlan today, decide on principles we build established Conroy. Hence, by reaffirming we start well-recog right nized common-law “[ejvery self-determination that hu being man years of adult right and sound mind has a to determine what shall be done Schloendorff body____” with his own Society Hosp., New York 125, 129-30, 211 N.Y. 105 v. 92, N.E. (1914) (Cardozo, J.). In Conroy, we stated that 93 right person of a body to control his own is a basic “[t]he concept, long societal recognized in the common law.” 98 N.J. explained at 346. We that the doctrine of “informed consent” developed protect was right to to self-determination in Id. at 346-48. This doctrine matters of medical treatment. prescribes “duty physician of a patient to disclose to a information that will enable him to knowledgeably evaluate options upon available and the risks attendant each before subjecting patient that to a course of treatment.” Perna v. Pirozzi, 446, (1983) (citations omitted); Conroy, N.J. see 92 459 supra, 98 N.J. at 346. the'Right 4We as amici curiae of the permitted participation Society Die,
to Inc. and New Association. Jersey Hospital 348 technology advancing, doctrine of
As
has been
medical
Conroy
Thus,
developing.5
has been
we
informed consent
patient’s right
give
refusal
to
recognized the
to
an informed
logical
give
right
medical
as the
correlative
treatment
competent
person
“a
stated that
adult
informed consent. We
any
generally
right
has the
to decline to have
medical treatment
Conroy,
N.J. at 347.
initiated or continued.”
right
patient’s
refuse medical treat-
held that a
While we
personal injury
primarily
or death is
ment
at the risk of
even
law,
recognized
by the
we
it
also
protected
common
right
priva-
by the
and state constitutional
protected
federal
Quinlan,
supra, 70
N.J.
348;
at 38-42.
See id.
cy.
right
competent
upheld the
of a
Numerous other courts have
if that decision
refuse medical treatment even
will
Court,
See, e.g.,
Superior
Bouvia v.
or her
hasten his
death.
Cal.Rptr.
re
1127,
Cal.App.3d
(Cal.Ct.App.1986),
225
297
179
Court,
Bartling
Superior
(June
1986);
v.
5,
163
view denied
(Cal.Ct.App.1984); In
Cal.App.3d
Cal.Rptr. 220
re
Perlmutter, (D.C.1972);
Osborne, 294 A .2d372
Satz v.
So.
(Fla.1980);
(Fla.Dist.Ct.App.1978), aff'd,
2d 160
379 So.2d
Estate,
(1965);
re
Brooks’
Ill.2d
Nevertheless, life-sustaining right the to refuse medi The has is state at least four cal treatment not absolute. countervailing sustaining person’s in life: interests a potentially Schultz, A New Pro- generally Patient Choice: Consent to 5 See From Informed (1985) (describing of limits this the traditional Yale L.J. 219 Interest, 95 tected recognition doctrine, substantially expanded illustrating of thereby how Conroy freedom). common-law
349 preserving preventing safeguarding integrity the life, suicide, of the medical protecting innocent N.J. third 98 at [Conroy, supra, profession parties. Spring, (citing Satz v. 348-49 Perlmutter, In re 362 So.2d at supra, 380 162; (1980); Mass. 405 Commissioner N.E.2d Correction v. 629, 640, 115, 123 of (1979); 379 Mass. 399 N.E.2d Myers, Saikewicz v. Superin 255, 261, 452, 456 tendent Belchertown State 373 Mass. School, N.E.2d 370 728, 738, 417, 426 of (1977); (Minn.1984); In re N. 2d Torres, W. In re Wash. 339 99 332, Colyer, (1983); 2d P.2d 743 President’s Commission 114, 738, 660 supra, Report, “In re Right Storar: at The to Die and 31-32; 43 Note, Patients,” Incompetent (1982)).] U.Pitt.L.Rev. treatment, party When a declines medical we patient’s rights balance the common-law constitutional against case, four these state interests. this none of these interests, interpreted concert, Conroy, as we them in nor their outweighs rights privacy Kathleen Farrell’s and self-determi- nation. preserving in state’s interest life “an embraces preserving particular in patient,
interest the life of the and an preserving interest in of all sanctity the life.” Conroy, at Neither of interests compelling N.J. 349. those this Conroy, case. In we decided value of that the life is desecrated by “by not a decision to refuse medical treatment but competent being failure right to allow human choice.” (quoting Superintendent Id. at 350 Saikewicz v. Belcher Mass, School, supra, town State at at 426 N.E.2d (1977)). Thus, cases not protection that do involve the “[i]n potential actual or life of someone other than the decision- maker, preserving the state’s indirect and abstract interest in competent patient generally gives the life of toway patient’s stronger personal directing much interest Conroy, supra, course own life.” of his 350. N.J. rejec The next two state interests that we consider in cases, i.e., preventing safeguard tion-of-treatment suicide and ing integrity profession, medical are not threatened by Conroy, Mrs. Farrell’s decision. In we that the determined if preventing by, State’s interest suicide is not “motivated *13 350 Id. within,” preserving (citing life.
encompassed its interest in 2C:11-6.)6 explained that N.J.S.A. 30:4-26.3a N.J.S.A. We declining sustaining life medical not be viewed as an treatment may properly Refusing merely to commit suicide. medical intervention allows attempt to course; occur, to take its natural if death were it would be eventually disease underlying and not the result of a self-in- result, disease, of primarily injury. flicted at [Id. 350-51.] consistently agreed jurisdictions in other have that
Courts
life-supporting treatment does not amount
to an
of
refusal
See, e.g.,
v.
Bartling
Superior
attempt
to commit suicide.
Court,
Cal.Rptr.
195-97,
supra,
Cal.App.3d
at
209
at
163
225-26; Foody
Hosp., Conn.Supp.
v. Manchester Memorial
40
Perlmutter,
v.
___,
713,
Satz
127,
(Super.Ct.1984);
720
482 A.2d
England
v.
Brophy
New
Sinai
162-63;
supra,
362
2d at
So.
Mass,
supra,
In re
438,
638;
at
Hosp.,
at
N.E.2d
Eichner,
6,
supra, 52 N. Y.2d at 377-78
n.
Similarly, ethics no in this medical create tension case. Our finds of medical authorities them review well-established right support unanimous of a informed competent The such as Mrs. Farrell to decline medical treatment. expressly of has Jersey State Board Medical Examiners New accept “competent right to or refuse stated that adult has. “likely refusal to medical treatment” even when the is result Policy Jersey Statement the New State natural death.” to Board Medical Examiners On Decision Withhold or (July 1986). Withdraw Medical Treatment 1-2 New Jer- College sey Chapter Physicians of the American has similar- legal ly competent right concluded that “a individual has subjects who suicide” 6N.J.S.A. 30:4-26.3a commit attempts “[a]ny person suggests on-going behavior existence of when person’s hospitalization illness; "[a] mental 2C:11-6 who aids N.J.S.A. provides person purposely crime____” guilty to commit of a another suicide *14 people might ‘wrong’ make what some consider to be the Jersey treatment. New life-sustaining regard to decision” with College Physicians Chapter the American Executive of of Irreversibly on III Policy Council Statement Care Patients of (Oct. 1986); Report accord the Judicial Council of of Association, (1985); American Medical 253 J. A.M.A. 2424 Hospital Policy American Association Statement Patients’ of Options (Feb. 1985); Choices Treatment Angeles Los Coun- of Associations, Principles and Guidelines ty Medical Bar Concerning Foregoing Sustaining Treatment of Life (Jan. 1986); Adult Patients Resolution the Massachusetts Society (July 17, 1985). Medical explicitly The President’s Commission also concluded that the patients authority competent, informed to make health care encompasses prerogative forgo decisions for themselves to treatment and allow death to occur: should determine choice of a and informed voluntary competent patient just whether or not will be as such choices undertaken, therapy for other decisions about medical treatment. Health care basis provide should to enhance abilities to make institutions try patients’ professionals understanding of the available decisions on their own behalf and to promote main- treatment Health care serve best patients by options____ professionals sustaining recognizing taining that a in favor of while life, compe- presumption forego including tent are entitled to choose to those treatments, patients any that sustain life. Report, supra, Commission [.President’s at 3.] by medical
Health care standards are not undermined support right that we authorities that to self-determination recognize today. patients enjoy control over their Even as treatment, professionals health-care remain bound to medical specific ethical criteria. We realize that act consonance with may concepts of self-determi these criteria conflict with some conflict, patient right has no to nation. In the case of such a provider generally accepted to compel a health-care violate Report, President’s Commission professional standards. Cf. (“A obligation to professional at 44. health care has an among medically acceptable allow a to choose from one, however, reject options. options or to all No treatment ... would, obligation provide an in his or interventions has. judgment, countertherapeutic.”) her be competent patient refuse
When courts to allow a life-sustaining treatment, always decline it is almost because protecting parties the state’s interest innocent third who by patient’s example, would be harmed decision. “[F]or required competent undergo courts adults medical have *15 protect procedures against necessary public their will if to health, prevent or to the emotional and financial abandon ... patient’s Conroy, supra, ment of minor children.” 98 N.J. 353; see, e.g., Application at President & Directors of Georgetown 1000, (D.C.Cir.), College, 331 F.2d 1008 cert. de nied, 978, (1964)(order 1883, 377 746 84 S.Ct. 12 L.Ed.2d U.S. ing “responsibility transfusion because a mother’s to infant”); community for her Holmes v. to care Silver Cross 125, (N.D.Ill.1972) Hosp., (noting 130 that a father F.Supp. 340 undergo to if similarly can be forced a transfusion his refusal dependents); Kennedy would his F. Memorial devastate John Heston, (1971)(ordering Hosp. v. 58 576 transfusion N.J. blood woman). pregnant a for sons, teenage left
Although Mrs. Farrell
two
her case
behind
distinguishable
parent
in
manifestly
is
from those which a
could
accept
prospect
his or
be forced to
treatment because
her
recovery
good
parent’s
the secur
death threatened
was
ity
disregard
of a
or children.
Farrell did not
her
child
Mrs.
respirator.
interest when she decided to withdraw the
children’s
fact,
part
recognition
In
her
on her
that
she based
decision
already put
her medical condition had
them under extreme
Moreover,
care
in her
capacity
stress.
Mr. Farrell’s
to
for them
unquestioned.
absence
Therefore the state’s interest
parties
against
protecting innocent third
does not militate
Mrs.
Osborne, supra,
Farrell’s decision.
In re
294 A. 2d
374
See
right
(upholding patient’s
part
treatment in
refuse
because
children);
Estate,
patient
provided for his
re
had
In Brooks
cf.
369-70,
(upholding right
440
tect personal meet granted position relief. His was based on court report a he received from a ings with the children and on However, need not had interviewed them. we psychiatrist who close, testimony. the evidence reveals a rely on his Where Farrells, presume that when the loving family like the we decisions, they medical are concerned about parents make infra, N.J. See children’s interests. protect their will Yoder, U.S. v. also Wisconsin 355-356; see (1972) 1526, 1532, (upholding L.Ed.2d 213-14, S.Ct. primary making decisions that rights to assume role parents’ ad litem children). for the children guardian A affect their will therefore, family like the is, unnecessary in the case of Farrells. foregoing, hold that the state’s light all of the we *16 right to withdraw her outweigh Mrs. Farrell’s
interests did not v. Satz support conclusion in find direct for our respirator. We Perlmutter, Florida Su supra, 379 So.2d in which the suffering patient similarly competent held that a preme Court respirator. to discontinue his from ALS was entitled IV help in future heard this order Mindful that we case doctors, Farrell, families and we like Mrs. and their patients procedures analysis and set forth the summarize our herewith living competent patients who are applicable when that will be life-sustaining medical request the discontinuance of at home treatment.
First,
patient
is
it must be determined that
competent7
properly
prognosis,
informed
his or
about
her
available,
the alternative treatments
and the risk
involved
generally
life-sustaining
See
withdrawal of the
treatment.
Schultz, Yale L.J.
(discussing
at 233-48
how the
increasing legal recognition
patients’
choosing
interests in
among medical alternatives
should increase the amount of
them).
provide
medical information that doctors
Then it
patient
must be determined that
made his or her choice
voluntarily and without coercion. After
these assessments
made,
patient’s right
have been
to choose to disconnect the
life-sustaining apparatus
against
must be balanced
the four
potentially countervailing state interests discussed above. Gen
erally,
competent
patient’s
informed
“interest
in freedom
bodily integrity
from nonconsensual
invasion of her
would
Conroy, supra,
outweigh any
N.J. at 355.
state interest.”
competent patient’s right
A
to exercise his or her choice
vary depending
does not
to refuse
treatment
on
patient
is in a medical institution or at home.
whether
Many people
surroundings.
wish to die at home in familiar
cases,
And, many
hospitals discharge terminally-
or irreversi
Report, supra, President’s Commission
bly-ill patients.
home,
Accordingly,
especially
103.
medical care
increasing.
See Con
terminally
irreversibly
patients,
ill
is
Care,
gresswomen Discuss Home
Caring,
March
at 44.
development
hospice programs,
of this trend is the
Evidence
premised
always
which are
on the belief
home
almost
facilities,
place
to die
care
best
and that traditional medical
especially hospitals,
properly
often cannot
accommodate the
understanding
competent
the nature of his or her
A
has a clear
treatment,
proposed
prognosis,
and of the risks and benefits
illness and
judgments
capacity
about that information.
and has the
to reason and make
Federman,
Wanzer, Adelstein, Cranford,
Conroy,
(citing
supra,
[F]amilies ailing to the and involve It is who come hospital members. family they care and comfort. patients usually in the sick Competent themselves person’s decisionmaking. and counsel of members family solicit the advice actively of the medical staff about the patient’s ask members routinely questions Family prognosis; found asked more questions and one they frequently condition study act as fact, members, commonly than themselves did. Family patients looking comfort, care, out for their for in the advocates patients hospital, interests____ best Rules III: Proposed Treatment Critically [Newman, Refusals for Rights Annual 35 III N. Y.L.Sch. Human State, and the Physician Family, (1985).] Responsi- Moral Dyck, generally See Self-Determination (1987)(discussing family 53, Eng.L.Rev. 55-60 9 W. New bility, of the doctrine in the context in medical decisions involvement self-determination). private realm of traditionally respected “the The law has Prince v. Massachu state cannot enter.” family life which the 442, 645, 438, 158, 166, 88 L.Ed. setts, S.Ct. U.S. Cleveland, 431 City East (1944). generally Moore v. See 1935-38, 499-505, L.Ed.2d 97 S.Ct. U.S. regula governmental (1977) intrusive (explaining that 537-41 subject to as nuclear—is family as well tion —extended pre Accordingly, numerous statutes scrutiny). judicial strict will care for one care about and family members sume (intestate passes estate See, 3B:5-2-14 e.g., another. N.J.S.A. *18 heirs); (providing surviving spouses and N.J.S.A. 3B:12-25 spouse normally appointed heirs should be when an that or estate); guardian person for his or incompetent needs N.J. (“heirs” children, parents, siblings, grand- 3B:5-4 include S.A. relatives). parents and other respect and believe that this tradition of confi
We family ground approach should our to the treat dence in the not, patient remains at home or ment of the sick. Whether a therefore, patient the decision of the should be unencumbered Thus, patient’s family with the advice of the doctor. and the impose any not restrictions or burdens on the we do want competent patient’s right life-sustaining to have treatment with present if he drawn if he or she is at home that would not be or nursing hospital in a or home. she were Nevertheless, society must en we do realize that patient forgo life-sustaining sure that a who has decided to prognosis, competent; is informed about his or her treatment is available, involved; the medical alternatives and the risk and easily These issues are more resolved has not been coerced. home, nursing patient hospital, the is in a or other when institution, settings patient by because in those the is observed home, protect patient require people. more To the who is at we non-attending physicians patient the to con that two examine competent fully is informed his firm that he or she is and about available, prognosis, the alternatives the risks or her medical involved, likely if medical treatment is disconn outcome presumed competent. that two ected.8 Adults are We trust physicians’ competency suffi independent determinations preclude ciently presumption in this context to bolster any competency need for court action to establish patient. determining we establish for of a 8The hereby competency procedure life-sustaining forgo treatment is likewise has decided to at home who nursing homes. applicable patients hospitals judicial competent patient’s
Likewise review of a refus generally appropri al of medical treatment not Only circumstances, among ate. unusual such as a conflict among members, physicians, family or or between physicians family professionals, and the or other health care judicial would necessitate intervention. “In most circumstanc *19 es, patients presumed capable making are to be of decisions Report, President’s Commission su their own care.” about pra, necessity depart general at 44. see no to from this We competent patient rule a when refuses treat independent competency ment. The two confirmations that satisfy questions might require any we should that later arise propriety withholding about or withdrawal of treat Additionally, procedural requirement ment. this should serve patient in hasty to forestall medical decisions made while a an emotionally major state of a sudden illness or disturbed because id. at 45 catastrophe. (noting capacity See the incidental of a physician certify patient’s competency is called to a “to who incapacities protect the individual from harms that arise from self-determination”). that the value of themselves diminish expedited, judicial in this com No matter how intervention Thus, may long. it could plex and sensitive area take too rights protect. The mere infringe very that we want to intrusive, cumbersome, expensive pro prospect of a court period in ceeding during upsetting emotional and such an patient undoubtedly her ones of a and his or loved would lives deciding discontinue treatment. many persons deter from to family willing patient And if the or the were to submit even patient’s rights proceeding, likely it is would such a many by judicial deliberation. Too nevertheless be frustrated right reject treatment was patients died their have before See, e.g., Conroy, supra, 342; 98 N.J. at vindicated court. 221; Cal.Rptr. 189, Bartling, supra, Cal.App.3d 209 at 163 at Bludworth, 452 Kennedy Hosp. v. John F. Memorial So.2d Perlmutter, 359; supra, 379 v. So.2d 921, (Fla.1984); Satz 923 D’Alessandro, 368, (Fla.Dist.Ct.App.), v. 487 369 Corbett So.2d 358 L.H.R., In re Ga. (Fla.1986); 253 denied, 492 1331 So.2d
review 629, 631 n. Spring, re 380 Mass. In (1984); 439, 716 321 S.E.2d (1980); Sackiewicz, 115, 1 373 1, 118 n. 405 N.E.2d Mass, Storar, 422; 363, In re N.Y.2d 370 N.E.2d 734, at at 1, cert. 1, 266, N. Y.S.2d 64, n. 268 n. 420 N.E.2d 369 n. In re (1981); 70 L.Ed.2d 858, 102 S.Ct. denied, U.S. P.2d at 1374. Even Hamlin, supra, 102 Wash.2d extremely judicial system acted an this case—where days elapsed (only fourteen be efficient manner prompt and grant petition filing complaint and the of the tween the certification) in time. Mrs. Farrell unable to act were —we respirator. shackled to the died liability criminal Unfortunately, fears of civil and judicial or doctors to seek family members have often forced they help his or her effectuate intervention before compe many realize that treatment. We decision to withdraw separate physically like Mrs. Farrell are unable patients tent this, equipment. light we life-support from themselves in liability or will be specifically hold that no civil criminal *20 who, good in faith9 reliance on the by any person curred opinion, procedures in this withdraws established competent patient and request of an informed treatment at required independent medical examina undergone the who has above. tion described patient, guides today us is that the his general
The rule that ones, people her doctor are the most her and his or or loved And in the case of a properly involved in medical decisions. person patient, primarily who should competent adult it in or his competent person’s A interest her make the decision. any countervailing in- generally outweighs self-determination might requirements The set forth this terest the state have. obligation a to act in accordance 9In the case of health-care professional, good generally is a with medical component duty accepted practices faith. protect competent without un- opinion adequately or her restricting patient’s right to determine his own duly medical treatment.
Hence, competent patient like Kathleen that a we conclude life-supporting her treatment discon- Farrell can choose to have right remaining days of her Farrell’s to live the tinued. Mrs. outweighed any interests the state had life as she chose compelling accept her to treatment.
Accordingly, judgment of the trial court. we affirm CLIFFORD, Justices Chief Justice WILENTZ POLLOCK, opinion. HANDLER, join this STEIN concurring opinion separate filed a HANDLER has Justice join. and POLLOCK in which Justices CLIFFORD concurring opinion. separate has filed a Justice O’HERN HANDLER, J., concurring. My added reasoning and conclusion. join majority’s in the
I opinion presented in are concurring in Court’s reasons for Jobes, (1987). 108 N.J. in In re opinion separate my factual record that this case is the special significance of of affirm- degree confidence the soundness conveys high the medical treatment to discontinue ing Mrs. Farrell’s decision dignified death. natural and precluding her from a that was these circumstances her decision under confirmation of Our right her self-determination. have effectuated would opinion, right-to-die us, of a in the context presents This case expressed self-determination example of individual a clear with Mrs. patient. Because competent of a informed wish by directly her wishes express competent, she could Farrell was *21 her decision was confirm that questioned to she could be example of prototypical knowing. It is a voluntary and both conceptual self-determination, provides the which individual guide application foundation can principles that of similar to involving incompetent patients. treatment decisions This case by underscores contrast how much less certain we can be that treatment decisions incompetent patient made the name of an Jobes, right self-determination. See effectuate her 108 N.J. at 433-37 (Handler, J., concurring). We are thus cri- develop additional need to consider to the alerted incompe- for decision medical treatment inform the teria to patients. tent in many encompass This will cases objective bearing upon patient’s buttress, factors or, best interests to necessary, supplant, if a treatment decision based on the expressed incompetent earlier wishes or patient. views O’HERN, J., concurring.
“It has been said always lags law behind the most ‘[t]he thinking advanced every area. It must wait until the theolo gians and the moral leaders and events have created some ” Superintendent ground, common some consensus.’ Saikewicz, BelchertownState School v. 728, 736, 373 Mass. 370 N.E. (1977) (quoting 2d Burger, “The Law and Medical Advances,” Annals 7, 15, Med.Supp. Internal (1967)). Hence, In re Conroy, (1985), N.J. attempt did not guidelines “to set forth decision-making for respect with variety treatment of other situations that * * * * * * currently are not before us each case [because] poses unique its own difficulties.”
Consequently, Justice Schreiber counseled: We do not deem it advisable to all such resolve human dilemmas in attempt the context of this casé. It is in our to move preferable, view, and to slowly gain highly in this sensitive experience field. As we noted previously, Legislature is better than we to and frame a equipped develop comprehensive resolving these [Id. plan problems. 387-88.] possible It was not for the trial court in this case to move slowly. The ineluctable deterioration of Kathleen Farrell’s health suffering and the by unutterable occasioned the artificial *22 by the relief entered breathing warranted prolongation of her (Ch.Div.1986). N.J.Super. that court.
I moral, medical, that a or ethical consensus lack of There is no immi- death that physician, faced with inevitable patient and used, prolong need not support means spite of the life nent no human by of that means to suffering occasioned the use the circumstances, may permitted be In purpose. such life-sustaining apparatus, provided to choose to discontinue dying patient is contin- supportive care for the normal ued. thus: has been described process in this
The role of law through translates its values into which a society of the basic means Law is one general Using the rules embodied conduct. and them to human applies policies judiciously to regulations, decisions, society attempts and court statutes, degree be and to arbitrate values may pursued to which various balance failing justified goal serving to serve entails one fully situations in which foregoing law simulta- treatment, With another. respect (as of the value of self-determina- an allows such decisions expression neously (to well-being), safeguard and well-being), circumscribes the tion and practice (to government programs and advance and equity social institutions shapes self-determination). for the well-being Commission [President’s and to protect Research, and Behavioral in Medicine and Biomedical of Ethical Problems Study (1983) (hereinafter Deciding Forego Life-sustaining as Treatment cited Report).} President’s Commission Conroy, Legislature cre- response our decision to: ated a commission developing health and science a. the issues by rapidly Clarify posed
technology highlight most relevant for informed facts that to be appear making treatment; care and as it relates to their decision by persons jurisdictions handle deci- and other how New b. Gather data about Jersey making regarding treatment; of care and termination and refusal sion relating programs services to medical c. Assess the need for additional making; decision relating Suggest to medical treatment at in public policy d. improvements through government, and the level of State not levels, various exclusively including legislation; means various making guidance Through involved in deci- e. its offer people reports, grounds. though on moral [N.J.S.A. not choices dictate sions, particular 52:9Y-3.] report As we await the any that commission and additional legislative implementation, we must hope, continue to as this Quinlan, In re did in 70 N.J. cert. denied sub nom. Court Garger Jersey, v. New 429 U.S. S.Ct. 50 L.Ed.2d *23 (1976), case-by-case that the development opinions “might degree be serviceable to some ameliorating pro the problems fessional under discussion.” 70 N.J. at 49. Gradual ly, may develop such decisions lines of regarding consensus the upon moral and social values which future courts can draw. Baron, “Medicine Rights: and Human Emerging Substantive Standards and Procedural Protections for Medical Decision Q. Making within the American Family,” Fam.L. (1983). II developing In case-by-case analysis, that comment on certain might features of this parties case assist judicial in future proceedings.
Shared Decisionmaking The President’s Commission has stressed in chapter its on “The Elements of Decisionmaking” “patient Good that and provider continuing collaborate in a process intended to make decisions that patient’s will advance the interests both in health (and well-being generally) and in self-determination.” Presi- Report, dent’s Commission (footnote omitted). at 43 primary this case the provider care was personally opposed to the decision to life-support apparatus. withdraw the In his conscientious patient, however, concern for his placed he her in contact with a practicing psychologist who arranged for a respiratory specialist explain patient consequences his the turning respirator. off the
In effectuating patient’s right to exercise an informed procedures, consent to medical it would assist a court to know that primary provider care patient has counseled the with respect decision, to that which was done this case. The in this physician the role of the Commission stresses President’s decisionmaking process: dying most health care is to help by
The individual provider likely patients (while sustaining accepting prolonga- maintaining life that a predisposition patient). dying serve for a no worthwhile purpose particular tion of may regarding favoring health of life is of society’s expectation this Indeed, part a belief or value personal it is Commonly, by care supported professionals. recognition dying of the needs of for reassurance and by patients commitment (footnote omitted).] [Id. of their own lives. the worth about However, quite once it becomes clear that informed, deliberate, to fore- making voluntary decision an physician, go specific life-sustaining procedures, then the individuals, can along various other serve different with patient acquiescing in death. functions assist valued accept- overwhelming Farrell’s and so was Kathleen So clear relief was inevitability her death that ance her to that here. She did not believe others wished warranted trial court quite clear her discussions with the It was from die. inevitability of accept her own decision to this was *24 her. from the disease that afflicted death Sharing The Decisions Quinlan that there would hopes of the Court was One of the hospitals, process a to review develop, conjunction area with view, concept of the ethical decisions. In the Court’s medical committee, readily to those accessible which would be an ethics di- promising persons rendering patients, care to would be a Quinlan, re In study further of such issues. rection for panel the dual benefit supra, 70 N.J. at 49. Such a would have (com- diffusing professional responsibility for a decision the courts) and multi-judge parable, way, in a to the value of “In Id. viability process. at 50. insuring of the decisional the decision relationship momentous the real world and diverse knowl- contemplated, the value of additional views and Ibid. apparent.” edge is Conroy, of an supra, re N.J. in the context In
institutionalized, the involvement elderly person, we stated that independent physicians establishing for factual
of two basis decision, and the concurrence the ombudsman and members, family assure available would the correctness of the choice made. case, apart hospital setting,
In the context of from this might provided such a committee have aid and counsel to a family physician facing such a decision. The commence- life-supporting apparat- ment of the decision to discontinue the pa- us was first undertaken in November 1985. It was the a tient’s first discussion of such choice. I that the believe availability of panel ability such a review would reinforce the guardian present any ad litem to the court available medically acceptable might alternatives assist the court in making case, in this appears a decision. As noted it clear that disease, because of the nature of the there no were reasonable that would alternatives have ameliorated the condition of the patient. Dying
Care Patient life-supporting appa- Once a valid decision to discontinue made, implementa- ratus has been a court should its consider particular forgo tion. decision to treat- “[A] ground ments is not a all care—nor should care- withdraw givers it in way, especially treat this when care needed to patient’s comfort, dignity, ensure the and self-determination.” Report, President’s Commission at 90. In this case the suggested evidence that Kathleen Farrell die of would suffoca- tion a matter if respirator within of minutes disconnect- was ed. dying person Hence normal care due to a described Report the President’s Commission would of limited con- be *25 cern. noted,
As Kathleen attending physician personally Farrell’s opposed discontinuing respirator, was to the he but consci- entiously agreed patient. to remain in attendance to comfort his addition, Kathleen had the Farrell service of an around-the- cases, I a court will nursing In other believe that clock team. of commensurate the needs the assure that care want to care and nurture of the provided. will dying be living, of most than reflects one the funda- dying, no less the humanity. shared Provided aspects our mental suffering add and discomfort taken do not in fact means Conroy, patient, they did here and in dying as both caring support dying person should continue receive providers. health that Kath- repeat,
To case all evidence indicated this amyotrophic lateral would death from sclerosis leen Farrell’s needlessly prolonged physician that her her not be I therefore concur be in attendance. husband would judgment. WILENTZ, Justices Justice
For affirmance —Chief O’HERN, CLIFFORD, HANDLER, POLLOCK, GARIBALDI and STEIN—7. HANDLER, CLIFFORD,
Concurring in result—Justices and O’HERN—4. POLLOCK PETER, GUARDIAN, BY HILDA M. HER
IN THE MATTER OF EBERHARD JOHANNING. Argued 198 6 Decided June 1987. November