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The Right to Refuse Medical Treatment

§ 13.09
Key point 13-09. Competent adults have the right to refuse medical treatment on the basis of their religious beliefs, including potentially life-saving treatment. However, they do not have the right to withhold life-saving medical treatment from their minor children.

Several courts have dealt with the right of an individual to refuse medical treatment on religious grounds. Such cases often involve treatment that is apparently necessary to save the diseased or injured person's life. In a majority of cases, courts have upheld the right of an adult to refuse potentially life-saving medical treatment on religious grounds, unless the individual is (1) mentally incompetent, (2) the parent and sole provider of young children, or (3) a pregnant woman. The majority rule was well-summarized by a New York court:

As a general rule, every human being of adult years and sound mind has a right to determine what shall be done with his own body and cannot be subjected to medical treatment without his consent. Specifically, where there is no compelling state interest which justifies overriding an adult patient's decision not to receive blood transfusions because of religious beliefs, such transfusions should not be ordered. Such an order would constitute a violation of the First Amendment's freedom of exercise clause.
However, judicial power to order compulsory medical treatment over an adult patient's objection exists in some situations. It may be the duty of the court to assume the responsibility of guardianship for a patient who is not compos mentis [mentally competent] to the extent of authorizing treatment necessary to save his life even though the medical treatment authorized may be contrary to the patient's religious beliefs. Furthermore, the state's interest, as parens patriae [i.e., protector of its citizens] in the welfare of children may justify compulsory medical care where necessary to save the life of the mother of young children or of a pregnant woman.[81] In re Melidio, 390 N.Y.S.2d 523, 524 (1976). Accord Holmes v. Silver Cross Hospital, 340 F. Supp. 125 (N.D. Ill. 1972); Montgomery v. Board of Retirement, 109 Cal. Rptr. 181 (1973); In re Osborne, 294 A.2d 372 (D.C. App. 1972); People v. Duncan, 205 N.E.2d 443 (Ill. 1965).

Such cases generally involve Jehovah's Witnesses who refuse potentially life-saving blood transfusions, Christian Scientists who refuse any form of medical care, or fundamentalist Christians who rely solely on faith healing. The result generally is the same in all three cases: the courts will honor the individual's desire to refuse medical treatment so long as he or she is mentally competent, even if such a decision will result in what otherwise would have been a preventable death. As the Ohio Supreme Court observed in a case involving a fundamentalist Christian's refusal to receive life-saving medical treatment on the basis of his reliance on prayer, "the state may not compel a legally competent adult to submit to medical treatment which would violate that individual's religious beliefs even though the treatment is arguably life-extending." This is so no matter how "unwise, foolish, or ridiculous" those beliefs may seem to others.[82] In re Milton, 505 N.E.2d 255 (Ohio 1987).

While some courts have limited a competent adult's right to refuse potentially life-saving medical treatment when the individual is a parent of minor children, other courts have rejected such a limitation.

Example

The Florida Supreme Court ruled that a civil court could not force a mother to receive a life-saving blood transfusion against her will and contrary to her religious beliefs.[83] Public Health Trust v. Wons, 541 So.2d 96 (Fla. 1989). See also In re Dubreuil, 603 So.2d 538 (Fla. App.1992). The woman entered a public hospital suffering from "dysfunctional uterine bleeding," and was informed by doctors that she would die if she did not receive a blood transfusion. The woman, a practicing Jehovah's Witness and mother of two minor children, refused the transfusion on the ground that it would violate her religious beliefs (she was competent at the time of her decision). The hospital asked a civil court to force the woman to undergo a blood transfusion. The court granted the hospital's request and ordered the woman to undergo a transfusion (she was by then unconscious) on the ground that "minor children have a right to be reared by two loving parents, a right which overrides the mother's right of free exercise [of religion] and privacy." Upon regaining consciousness, the woman appealed the court's order to a state appeals court, which ruled in favor of the woman. The hospital appealed the case to the state supreme court, which also ruled in favor of the woman. The court cited four factors to consider in deciding whether or not a patient's constitutional right to religious freedom outweighs the state's interest in requiring potentially life-saving medical treatment: "(1) preservation of life, (2) protection of innocent third parties, (3) prevention of suicide, and (4) maintenance of the ethical integrity of the medical profession." The court disagreed with the hospital's claim that the state's interest in maintaining a home with two parents for minor children outweighed any constitutional right of the mother to terminate her life by refusing medical treatment. It concluded, "[This case involves] a delicate balancing analysis in which the courts weigh, on the one hand, the patient's constitutional right of privacy and right to practice one's religion, as against certain basic societal interests. Obviously, there are no preordained answers to such problematic questions and the results reached in these cases are highly debatable. Running through all of these decisions, however, is the courts' deeply imbedded belief, rooted in our constitutional traditions, that an individual has a fundamental right to be left alone so that he is free to lead his private life according to his own beliefs free from unreasonable governmental interference. Surely nothing, in the last analysis, is more private or more sacred than one's religion or view of life, and here the courts, quite properly, have given great deference to the individual's right to make decisions vitally affecting his private life according to his own conscience. It is difficult to overstate this right because it is, without exaggeration, the very bedrock on which this country was founded."

The courts have consistently held that life-saving medical treatment can be administered to a minor child despite his or her parents' refusal to consent to such treatment on religious grounds, unless the treatment itself poses a significant danger to the child. One court observed:

[P]arents … have a perfect right to worship as they please and believe what they please. They enjoy complete freedom of religion. The parents also have the right to use all lawful means to vindicate this right. … But this right of theirs ends where somebody else's right begins. Their child is a human being in his own right with a soul and body of his own. He has rights of his own — the right to live and grow up and live without disfigurement. The child is a citizen of the State. While he "belongs" to his parents, he belongs also to his State. Their rights in him entail many duties. Likewise, the fact the child belongs to the State imposes upon the State many duties. Chief among them is the duty to protect his right to live and to grow up with a sound mind in a sound body. … When a religious doctrine espoused by the parents threatens to defeat or curtail such a right of their child, the State's duty to step in and preserve the child's right is immediately operative.[84] In re Clark, 185 N.E.2d 128, 132 (Ill. 1962). Accord In re Karwath, 199 N.W.2d 147 (Iowa 1972); Muhlenberg Hospital v. Patterson, 320 A.2d 518 (N.J. 1974); In re Sampson, 317 N.Y.S.2d 641 (1970); Matter of Hamilton, 657 S.W.2d 425 (Tenn. App. 1983) ("[w]here a child is dying with cancer and experiencing pain which will surely become more excruciating as the disease progresses … we believe is one of those times when humane considerations and life-saving attempts outweigh unlimited practices of religious belief").

Another court has observed that "it does not follow that parents who wish to be martyrs for their religious beliefs have a right to impose such martyrdom upon their offspring. …"[85] Muhlenberg Hospital v. Patterson, 320 A.2d 518, 521 (N.J. 1974). When a minor child's life is not in danger, some courts have permitted the child's parents to refuse consent to medical treatment on religious grounds. The Supreme Court of Pennsylvania has held, "We are of the opinion that as between a parent and the state, the state does not have an interest of sufficient magnitude outweighing a parent's religious beliefs when the child's life is not immediately imperiled by his physical condition."[86] In re Green, 292 A.2d 387, 392 (Pa. 1972). Other courts have reached the opposite conclusion.[87] See, e.g., In re Sampson, 317 N.Y.S.2d 641 (1970).

Some parents have been prosecuted for manslaughter (or other crimes) when their minor child dies because the parents refused life-saving medical treatment and relied exclusively on divine healing.

Case studies

The California Supreme Court ruled that a mother could be prosecuted for manslaughter when her child died of meningitis after being treated by prayer instead of medical therapy.[88] Walker v. Superior Court, 253 Cal. Rptr. 1 (Cal. 1988). Accord People in Interest of D.L.E., 645 P.2d 271 (Colo. 1982). The victim was a 4-year-old girl who fell ill with flu-like symptoms and a stiff neck. Consistent with the tenets of her religion, the child's mother chose to treat the illness with prayer rather than medical care. Members of the mother's church prayed with the child on two occasions. Nevertheless, the child lost weight, grew disoriented and irritable, and her breathing became heavy and irregular. She died of acute meningitis 17 days after her symptoms first appeared. The child's mother was charged with involuntary manslaughter, and she moved to dismiss the prosecution on the ground that her conduct was protected by law. Specifically, the mother argued that involuntary manslaughter is defined as the unlawful killing of a human being without malice "in the commission of an unlawful act … or without due caution or circumspection," and that her child had not died "in the commission of an unlawful act." She pointed out that the only "unlawful act" for which she could have been charged was the criminal neglect of a child, and that California law exempted "treatment by spiritual means through prayer alone" from the definition of criminal neglect. The state supreme court rejected the mother's arguments, concluding that she could be prosecuted for involuntary manslaughter. The court reasoned that the exemption of "treatment by spiritual means by prayer alone" from the definition of criminal neglect did not necessarily exempt such treatment from the crime of manslaughter. The court also rejected the mother's claim that her actions were protected by the constitutional guaranty of religious freedom. It observed that the mother's constitutional rights were outweighed by a "compelling state interest" of "unparalleled significance" —the protection of children. It further noted that "parents may be free to become martyrs themselves … but it does not follow that they are free … to make martyrs of their children."
A parent was prosecuted for manslaughter when his 5-week-old daughter died from bronchial pneumonia. The parent lived with his wife and 9 children in a small cabin in the mountains. He had been on a "walk of faith," which he described as a total reliance on God for all needs and for healing in times of illness or injury. One of the tenets of his church was healing of the sick through prayer. When the baby developed cold symptoms, her parents and another church member anointed the baby with oil, laid their hands on her head, and prayed for her healing. The next day, the baby's symptoms worsened. Because the mother was exhausted from caring for several sick children, and because the family's wood-burning stove seemed to aggravate the baby's condition, the baby was moved to a neighbor's home. The neighbor (who was a nurse) informed the parents that the baby might be suffering from pneumonia, and she urged them to take the baby to a hospital at once. The father declined, stating that "we can't, this is our walk and this is our life." The next morning, the baby seemed better. Later in the day, however, the symptoms worsened again, and the baby died that evening. An autopsy revealed that the baby had died from "acute necrotizing bronchial pneumonia." The father was later prosecuted for child abuse resulting in death. At the trial, a pediatrician testified that the baby would have survived had she received proper medical care. The father was convicted, and he was sentenced to 6 years of probation. On appeal, the Colorado Supreme Court reversed the father's conviction on the basis of a technicality, and sent the case back to the trial court for another trial.[89] Lybarger v. People, 807 P.2d 570 (Colo. 1991). The court noted that state law provided a defense to child abuse in cases of "treatment by spiritual means," and that the trial court had improperly let the jury decide if this defense were available rather than compelling the prosecutor to establish the crime, and the unavailability of the "treatment by spiritual means" defense, with evidence "beyond a reasonable doubt." The court cautioned that the "treatment by spiritual means" defense to child abuse was not available under state law when a child is suffering from a condition that would create a danger to the child's life if left untreated.
A Pennsylvania court upheld the criminal convictions of two parents for criminal neglect of their 2-year-old son because of their reliance on prayer and divine healing rather than medical care for a life-threatening medical condition. The parents insisted that they did not commit criminal neglect. To the contrary, they prayed for their son and had him anointed. The court rejected the parents' defense. It observed: "Regardless of the label attached to their course of conduct, their failure to seek medical care constituted a breach of their duties as parents. The law imposes an affirmative duty on parents to seek medical help when the life of a child is threatened, regardless, and in fact despite, their religious beliefs. … Every parent … has a duty of care to their child, at the very least, to avert the child's untimely death. … The validity and sincerity of the religious beliefs of [the parents] were not relevant to the issues presented. They had no choice but to seek help, despite their religious beliefs, when they were faced with a condition which threatened their child's life."[90] Commonwealth v. Foster, 764 A.2d 1076 (Pa. App. 2000).
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