Superintendent of Belchertown State School et al v. Joseph Saikewicz
Joseph Saikewicz was a mentally incompetent resident of the Belchertown State School of the Massachusetts Department of Mental Health. In April 1976 Saikewicz was diagnosed with acute myeloblastic monocytic leukemia. He was sixty-seven years old but had the mental age of about two years and eight months. The superintendent of the mental institution petitioned the court for a guardian ad litem (a temporary guardian for the duration of the trial). The court-appointed guardian recommended that it would be in the patient's best interests that he not undergo chemotherapy.
In May 1976 the probate judge ordered nontreatment of the disease based in part on findings of medical experts who indicated that chemotherapy might produce remission of leukemia in 30 to 50% of the cases. If remission occurred, it would last between two and thirteen months. Chemotherapy, however, would make Saikewicz suffer adverse side effects that he would not understand. Without chemotherapy, the patient might live for several weeks or months, but would die without the pain or discomfort associated with chemotherapy.
In fact, Saikewicz died on September 4, 1976, from pneumonia, a complication of the leukemia. Nevertheless, his case was heard by the Supreme Court of Massachusetts in order to establish a precedent on the question of substituted judgment (Superintendent of Belchertown State School et al v. Joseph Saikewicz, Mass., 370 N.E.2d 417, 1977).
The court agreed that extraordinary measures should not be used if the patient would not recover from the disease. The court also ruled that a person has a right to the preservation of his or her bodily integrity and can refuse medical invasion. The Massachusetts Supreme Court turned to Quinlan for support of its right of privacy argument.
THE RIGHTS OF AN INCOMPETENT PATIENT
Once the right to refuse treatment had been established, the court declared that everyone, including an incompetent person, has the right of choice:
To presume that the incompetent person must always be subjected to what many rational and intelligent persons may decline is to downgrade the status of the incompetent person by placing a lesser value on his intrinsic human worth and vitality.
Referring to Quinlan, the Saikewicz court recommended that the patient not receive the treatment most people with leukemia would choose. (Unlike some later courts, the Quinlan court accepted the premise that a vegetative patient would not want to remain "alive.") The Saikewicz court believed that the "substituted judgment" standard would best preserve respect for the integrity and autonomy of the patient. In other words, the decision maker—in this case, the court—would put itself in Saikewicz's position and make the treatment decision the patient most likely would make were he competent. The court believed Saikewicz would have refused treatment.
In evaluating the role of the hospital and the guardian in the decision-making process, the Saikewicz court rejected the Quinlan court's recommendation that an ethics committee should be the source of the decision. The court instead concluded:
We do not view the judicial resolution of this most difficult and awesome question—whether potentially life-prolonging treatment should be withheld from a person incapable of making his own decision—as constituting a "gratuitous encroachment" on the domain of medical expertise. Rather, such questions of life and death seem to us to require the process of detached but passionate investigation and decision that forms the ideal on which the judicial branch of government was created.
The Case of John Storar
John Storar, a fifty-two-year-old mentally retarded man with a mental age of about eighteen months, was diagnosed with terminal cancer. His mother, Dorothy Storar, petitioned the court to discontinue blood transfusions that were delaying her son's death, which would probably occur within three to six months.
At the time of the hearing, Storar required two units of blood every week or two. He found the transfusions disagreeable and had to be given a sedative before the procedure. He also had to be restrained during the transfusions. Without the blood transfusions, however, there would be insufficient oxygen in his blood, causing his heart to beat faster and his respiratory rate to increase. After transfusions, the doctor reported, Storar had more energy and was able to resume most of his normal activities.
The probate court granted Mrs. Storar the right to terminate the treatments, but the order was stayed and treatment continued pending the appeal to the New York Appellate Division (or appellate court) (Charles S. Soper, as Director of Newark Developmental Center et al v. Dorothy Storar, N.Y., 420 N.E.2d 64, 1981). Storar died before the case could be heard, rendering the decision moot, but because the issue was considered to be of public importance, the appellate court proceeded to hear the case.
The appellate court agreed with the probate court that a guardian can make medical decisions for an incompetent patient. However, the parent/guardian "may not deprive a child of life-saving treatment." In this case there were two threats to Storar's life—the incurable cancer and the loss of blood that could be remedied with transfusions. Because the transfusions did not, in the eyes of the majority opinion written by Judge Wachtler, cause much pain, the appellate court overturned the probate court's ruling.
Judge Jones, dissenting from the determination, believed the treatments did not serve Storar's best interests. They did not relieve his pain and, in fact, caused him additional pain. Since the blood transfusions would not cure his cancer, they could be considered extraordinary treatments. Finally, the judge reasoned that Storar's mother had cared for him for a long time and knew best how he felt, and therefore the court should respect her decision.
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