Crozer-Keystone Health System

Can a patient refuse medical treatment based on his/her religious beliefs? The law of Pennsylvania determines the answer to such a question through an individual analysis dependent on whether the individual refusing treatment is competent, incompetent, or a minor and the situation is emergent or non emergent. Courts generally do not make a distinction between the reasons for refusing medical care, but lump all reasons into simply the right to refuse treatment. This topic relates to such instances where Jehovah's Witnesses refuse blood transfusions, Christian Scientists refuse any form of medical care, or fundamentalist Christians rely solely on faith healing rather than seeking professional medical treatment.[1]

Basic Right

The right to refuse medical treatment is rooted in common law.[2] This right, sometimes referred to as the “right to die,” was examined by the Supreme Court in the landmark case Cruzan v. Director, Missouri Department of Health.[3] The Court upheld the legal standard that competent persons have the right to refuse medical treatment under the Due Process Clause, and incompetent persons must show by “clear and convincing evidence” they wish to refuse medical treatment.[4]

The Patient Self-Determination Act further codifies this decision.[5] This Act requires health care providers to advise patient’s of their decision-making rights and determine whether that person has any advance life directives or Durable Power of Attorney. Religious views should be inquired to during patient admission, and patients should be advised on the health care providers position regarding treatment of such patients.[6]

If a patient has been informed about the need for treatment and understands the need for it and the risks forgoing such treatment they may refuse the treatment if they desire, for whatever reason.[7] The right to refuse treatment by competent adults has been rooted in the Constitution under the First Amendment and an individual’s right to privacy. Where the refusal is informed, and the person is conscious of the consequences, the court may not intervene even if the decision seems unwise, foolish or irrational to an outside observer.[8]

One Pennsylvania court determined that a woman had the right to refuse a recommended surgery for detection of breast cancer where there were no minor or unborn children and no clear and present danger to public health, welfare or morals.[9] There was no indication the patient was in critical condition or was in the final hours of her life.[10]

There may be instances where a State interest overrides a competent person’s informed decision to refuse medical treatment. The four state interests in Pennsylvania are 1) protection of third parties; 2) protection of the ethical integrity of the medical profession; 3) preservation of life; and 4) prevention of suicide.[11] The following will provide further elaboration on each interest.

With the first interest, protection of third parties, courts will determine whether the surviving children and spouse will be left emotionally and financially bereft if the refusal of medical treatment was honored.[12] Protection of medical integrity (the second state interest), does not include overriding the self-determination of a patient, because to do so would negate the meaning of the patient’s informed consent.[13] The third state interest, in preserving life, is not referring to the patient’s own life, but injury to state citizens from third parties.[14] The state’s interest is low where the decision of the patient does not injure others or impact the public.[15] The forth state interest, prevention of suicide, does not include the refusal of medical treatment; refusal of treatment would allow the underlying disease or injury to take its natural course as opposed to a suicide which is a self-inflicted injury.[16]

The law makes no distinction between emergency and non-emergency situations when it comes to the decision of competent adults refusing medical treatment. “Absent evidence of overarching state interests, the patient’s clear and unequivocal wishes should generally be respected.”[17] One example of an overarching state interest occurred in a New Jersey case where the court granted the hospital authority to administer blood transfusions to a woman who was pregnant as it was necessary to save her life and the life of her child.[18]

A health care provider cannot generally be held to have violated legal or professional responsibilities when the refusal of medical treatment by a competent adult patient is honored.[19] Civil liability can be imposed on those who perform medical treatment on patients without their consent and in opposition of a competent person’s wishes, even though such treatment may be necessary to sustain life.[20]

When a person is deemed incompetent a guardian is sometimes appointed to act on behalf of the incompetent person. This guardian is to assert the rights and best interests of the incapacitated person and maintain their express wishes and preferences when possible.[21] Therefore, if a now incompetent person once wished to refuse medical treatment due to religious beliefs (when they were competent), they should be allowed to do so if it involves a non-emergency situation.[22] Just like competent individuals in non-emergency situations the law favors personal autonomy.

Although a person generally has the right to refuse treatment, if there is an emergency situation, the consent is considered implied if the patient is unable or not competent to consent.[23] In such emergency cases, the court may appoint a temporary guardian (including a hospital administrator, guardian, or the court) via an ex-parte hearing, who may then consent to the procedure.[24]

The Pennsylvania Superior Court examined one case where a 22-year-old Jehovah Witness was in a car accident, and now required a blood transfusion, although an identification card refusing blood transfusions and his parent’s objections to the transfusion stood in the way of performing the necessary care.[25] The court concluded that the ID card was not determinative by itself and the parent’s objections could only be one piece of evidence in the evaluation.[26] The Pennsylvania court established a high standard for ID cards to constitute a proper refusal.[27]

Pennsylvania seems to lean in favor of providing emergency care to the fullest extent when an emergency arises. Pennsylvania courts are insisting on a “nearly impossible standard of proof of the unconscious patient’s intentions.”[28] Basically without the express refusal from the patient themselves, there is no telling whether when faced with a possible death situation their beliefs would trump any medical recommendation for the preservation of life.

The state does not have an interest outweighing the parent’s religious beliefs when the child’s life is not immediately threatened.[29] The Supreme Court of Pennsylvania examined this situation with a minor who had curvature of the spine causing him to be unable to stand and leaving open the possibility he would become bed-ridden if nothing were done.[30] The court reasoned that since the child’s condition posed no danger to his life and no substantial threat to society, the state could not intervene in the mother’s decision to refuse a blood transfusion for her son based on the Jehovah Witness religion.[31]

The Supreme Court concluded the opinion by stating it believed the child should be heard in regards to his wishes regarding medical treatment.[32] This case implies in dicta that a minor-patient can override a parental decision to refuse non-emergency treatment on religious grounds. This will most likely need to be examined case-by-case.

A different situation arises where the minor in is need of emergency care and the parents refuse to give consent based on their religious views. The United States Supreme Court has held parents may martyr themselves, but they are not free “to make martyrs of their children.”[33] The theory behind state intervention is that a child lacks capacity to make informed judgments regarding their own medical treatment and if the parents refuse to do so, the state must save the child’s health or life[34].

The Pennsylvania Supreme Court has even held the religious parents of a minor child criminally liable for the refusal to medically treat her.[35] The court reasoned, “the right to practice religion freely does not include liberty to expose the community or the child to communicable disease or the latter ill health or death.”[36]

Pennsylvania has parens patriae[37]power to protect those too incompetent to protect themselves, regardless of the existence of a mature minor doctrine.[38] This power is “not nullified merely because the parent grounds his claim to control the child’s course of conduct on religion.”[39]

Conclusion

In any of the above situations a health care provider is free to obtain a court order denying the patient the right to refuse medical treatment. Health care providers are at a low liability risk where a competent adult has made an “informed refusal, which is properly documented including execution from the patient releasing liability regarding all parties involved.”[40] When a competent adult patient does refuse, to avoid liability under patient abandonment claims the health care providers must try to treat the patients in other ways in which the patient consents.[41]

Incompetent patients are still entitled to personal autonomy and the right to refuse non-emergency medical treatment. In certain emergency situations the court may order medical treatment after appointing a guardian to make a decision for the incompetent patient in a way the patient would have desired.

Minors are under the control of the state in emergency situations, when the patient refuses medical needed treatment, since they cannot consent or refuse treatment due to age based incapacity.

Patients should be asked from the beginning their religious beliefs and how it will affect their treatment. Such questions and answers should be documented from the beginning, which should include the caregivers discussion regarding the consequences of any refusal. If the health care provider seeks a court order, the parents, spouses, or next of kin should be notified so they have an opportunity to appear before the court.[42]

[1] Hammer, Richard, The Right to Refuse Medical Treatment, http://www.churchlawtoday.com/private/library/pcl/p18f.htm.

[2] Union Pacific Railway Co. v. Botsford, 141 U.S. 250 (1891) (“no right is held more sacred, or more carefully guarded, by the common law, than the right of every individual to the possession and control of his own person…”).

[3] Cruzan v. Director, Missouri Department of Health, 497 U.S. 261 (1990).

[4] Id.

[5] The Patient Self-Determination Act is part of the Omnibus Budget Reconciliation Act of 1990, Pub.L. No. 101-508 §§ 4206, 4751, codified at 42 U.S.C.A. §§ 1395cc(a)(1)(Q), 1395mm(c)(8), 1395cc(f); 42 U.S.C.A. §§ 1396a(a)(57), (58), 1396a(w).

[6] ECRI Institute, Refusal of Blood Transfusions on Religious Grounds, https://members2.ecri.org/Components/HRC/Pages/SpecClin3.aspx (January 1, 1996) (some hospital’s own mission may be based on religious values that conflict with the patients’).

[7] Id. at 2.

[8] In re Yetter, 62 Pa D & C2d 619, (1973).

[9] Id. at 623; see also, In re Melideo, 390 N.Y.S.2d 523 (1976) (where patient’s refusal was upheld as there was evidence that the patient was fully competent, was not pregnant, and had no children).

[10] Id. at 624.

[11] In re Duran, 769 A.2d 497 (2001) (where Maria Duran, a Jehovah Witness, refused blood transfusions during her liver transplant, and expressed her intent clearly prior to her surgery).

[12] Id. at 503; see also, In re Yetter, 62 Pa D & C2d 619, (1973) (the court indicated the state may interfere where refusing medical treatment would affect a minor or unborn child).

[13] Id. at 504.

[14] Id. at 504, quoting Fosmire v. Nicoleau, 75 N.Y.S.2d 281 (1990).

[15] Id.

[16] Duran, at 504.

[17] Id. at 507. (Duran’s situation can be considered an emergency as she was undergoing a liver transplant where her body rejected the first liver and now was rejecting a second attempt at the transplant. Doctors projected that her only chance at survival would be to receive a blood transfusion).

[18] Raleigh Fitkin-Paul Morgan Memorial Hospital v. Anderson, 201 A.2d 537 (1964) (the court reasoned the welfare of the child and mother were so intertwined and inseparable that it would have been impracticable to attempt to distinguish between them).

[19] 93 A.L.R. 3d 67, §3[b]

[20] Id.

[21] 20 Pa. C.S.A. §5521(a)

[22] e.g., In re Duran, 769 A.2d 497 (2001) (prior refusal upheld where Duran was competent when she expressed her refusal to family and medical personnel, but later became incompetent).

[23] ECRI, at 3.

[24] See, In re Dorone, 502 A.2d 1271 (1985); see also, In re Melideo, 390 N.Y.S.2d 523 (1976).

[25] Dorone, at 1273, 1276 (doctor testified the boy had “an acute subdural hematoma” and that “without surgery, death [was] imminent”).

[26] Dorone, at 1278-79. (“There was no time for research and reflection. Death could have mooted the case in a matter of minutes, if action were not taken to preserve the status quo”).

[27] Dorone, at 1278 (some factors the court wanted to consider were: how recently the card had been executed, the circumstances surrounding its execution, whether the signing was independent or as part of a statement of unity with other members of the congregation, whether the purpose of the card had been contemplated as in relation to a death situation, and if anything had intervened since the execution of the card to cast doubt on the patient’s religious convictions).

[28] ECRI, at 3.

[29] In re Green, 292 A.2d 387 (1972).

[30] Id. at 388.

[31] Id. at 389.

[32] In re Green, 307 A.2d 279 (Pa. 1973) (on appeal from the remand decision it was determined the child did not want the surgery, even though his decision was not based on religion).

[33] Prince v. Massachusetts, 321 U.S. 158 (1944).

[34] ECRI, at 4.

[35] Pennsylvania v. Nixon, 761 A.2d 1151 (2000).

[36] Id. at 1153.

[37] Black’s Law Dictionary (8^th ed. 2004), parens patriae - the state regarded as a sovereign; the state in its capacity as provider of protection to those unable to care for themselves

[38] Id. at 1155. (the mature minor doctrine is not codified by Pennsylvania, but a similar statute appears at 35 P.S. §10101 regarding certain minor’s ability to consent to medical procedures based on their status, although this court concluded the statute does not apply to life and death situations)

[39] Prince, at 166.

[40] ECRI, at 5.

[41] Id. at 4.

[42] Id. at 5. (in California, a hospital and surgeon were successfully sued for damages by the parents of a Jehovah Witness who received a transfusion; one factor in the analysis was the fact neither the surgeon nor the hospital informed the parents of their intentions to seek a court order).

Is Religion Grounds to Refuse Medical Treatment?September 2009

Basic Right

Conclusion

Is Religion Grounds to Refuse Medical Treatment?
September 2009