In the Matter of Nancy Ellen Jobes
In 1980 twenty-four-year-old Nancy Ellen Jobes was in a car accident. At the time, she was four-and-a-half months pregnant. Doctors who treated her determined that her fetus was dead. During the surgery to remove the fetus, Jobes suffered loss of oxygen and blood flow to the brain. Never regaining consciousness, she was moved to the Lincoln Park Nursing Home several months later.
The nursing home provided nourishment to Jobes through a jejunostomy tube (j-tube) inserted into the jejunum of her small intestine. Five years later, Jobes's husband, John H. Jobes, asked the nursing home to stop his wife's artificial feeding. The nursing home refused, citing moral considerations.
The trial court appointed a guardian ad litem, who, after reviewing the case, filed in favor of Mr. Jobes. The nursing home moved to appoint a "life advocate" (a person who would support retaining the feeding tube), which was turned down by the trial court. The Supreme Court of New Jersey heard the case (In the Matter of Nancy Ellen Jobes, 529 A.2d 434 [N.J. 1987]).
DIFFERING INTERPRETATIONS OF PERSISTENT VEGETATIVE STATE
Whether Jobes was in a PVS was hotly debated, revealing how different medical interpretations of the same patient's condition can produce different conclusions. After Mr. Jobes initiated the suit, his wife was transferred to Cornell Medical Center for four days of observation and testing. Dr. Fred Plum, a world-renowned neurologist who had coined the term "persistent vegetative state," and his associate Dr. David Levy concluded, after extensive examination and testing, that Jobes was indeed in a PVS and would never recover.
On the other hand, Drs. Maurice Victor and Allan Ropper testified for the nursing home. Having examined Jobes for about one-and-a-half hours, Dr. Victor reported that, although the patient was severely brain-damaged, he did not believe she was in a PVS. She had responded to his commands, such as to pick up her head or to stick out her tongue. However, he could not back up his testimony with any written record of his examination.
Dr. Ropper had also examined Jobes for about an hour and a half. He testified that some of the patient's motions, such as lifting an arm off the bed, excluded her from his definition of PVS. (His definition of PVS differed from Dr. Plum's in that it excluded patients who made reflexive responses to outside stimuli—a definition that would have also excluded Karen Quinlan.) Testimony from the nurses who had cared for Jobes over the past years was also contradictory, with some asserting she smiled or responded to their care and others saying they saw no cognitive responses.
The New Jersey Supreme Court concluded that the neurological experts, especially Drs. Plum and Levy, "offered sufficiently clear and convincing evidence to support the trial court's finding that Jobes is in an irreversibly vegetative state." However, the court could find no "clear and convincing" evidence that Jobes, if she were competent, would want the j-tube removed. Jobes's family and friends, including her minister, had testified that in general conversation she had mentioned that she would not want to be kept alive with artificial life supports. The court did not accept these past remarks as clear evidence of the patient's intent.
With no clear and convincing evidence of Jobes's beliefs about artificial feeding, the New Jersey Supreme Court turned to In re Quinlan for guidance. The court stated:
Our review of these cases and medical authorities confirms our conclusion that we should continue to defer, as we did in Quinlan, to family members' substituted judgments about medical treatment for irreversibly vegetative patients who did not clearly express their medical preferences while they were competent. Those decisions are best made because the family is best able to decide what the patient would want.
THE NURSING HOME'S RESPONSIBILITY
The New Jersey Supreme Court reversed the trial court decision that had allowed the nursing home to refuse to participate in the withdrawal of the feeding tube. The court noted, "Mrs. Jobes's family had no reason to believe that they were surrendering the right to choose among medical alternatives when they placed her in the nursing home." The court pointed out that it was not until 1985, five years after Jobes's admission to the Lincoln Park Nursing Home, and only after her family requested the removal of her feeding tube, that her family learned of the policy. The court ordered the nursing home to comply with the family's request.
Justice O'Hern dissented on both issues. He claimed that not all families may be as loving as Jobes's. He was concerned for other individuals whose family might not be so caring, but who would still have the authority to order the withdrawal of life-sustaining treatments. He also disagreed with the order given the nursing home to comply with the family's request to discontinue Jobes's feeding. "I believe a proper balance could be obtained by adhering to the procedure adopted [in] In re Quinlan, that would have allowed the nonconsenting physician not to participate in the life-terminating process."
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