Not too long ago, the Connecticut Supreme Court ruled on a case called in re Cassanda C. The case dealt with a mature minor; someone not quite 18, but close, and whether they are entitled to make their own medical decisions. If any reader has teenage children, you will readily appreciate they can be headstrong.
The name Cassandra goes back to Greek mythology. In an effort to seduce her, Apollo gave Cassandra the power of prophecy. When she rebuffed Apollo’s advances, he spat into her mouth and inflicted a curse where nobody would believe her prophecies. Modernly, Cassandra refers to someone whose accurate prophecies of disaster are disregarded.
But, I digress.
Historically, children have been considered legally incompetent to make medical decisions. Such decisions are made by the child’s parent, guardian, or court. There are exceptions. For example, a child does not need parental consent to receive treatment for a venereal disease or treatment regarding pregnancy. If a child has been emancipated by the courts, they do not need parental consent for medical treatment. The modern view in many states is that a child may make medical decisions if the child understands the information provided and if the child has an appropriate level of maturity.
Let’s see this play out in the real world.
Cassandra was a 17 year old minor in Connecticut. She lived with her mother. Her father was not meaningfully involved with her life. Her mother delayed approval of treatment for Cassandra’s diagnosis of non-Hodgkins lymphoma to the extent that it endangered her life. (After Cassandra developed a mass on the right side of her neck, the mother repeatedly failed to bring her to medical appointments concerning the diagnosis of the mass, repeatedly fought with her doctors over the accuracy of their eventual diagnosis, and repeatedly argued with the doctors over how they communicated Cassandra’s diagnosis to her.)
She was placed under the care of a state appointed guardian. Cassandra refused treatment believing it would be traumatic and unnecessary. She did not want to endure side effects of chemotherapy. She discussed the treatment options with her doctor and agreed to undergo therapy as long as she could remain at home.
She received two treatments. Bruising appeared around the treatment area. Her doctors recommended a port-a-cath as the best way to continue treatments. The next day, when a state health employee went to take Cassandra to get the procedure done, she was gone. She had returned home after several days and refused to receive further treatment. She said she did not trust her doctors; she would soon be 18 and she should not be forced to undergo treatment against her wishes.
The commissioner for the Department of Children and Families filed for a re-hearing. The lower court held that because of Cassandra’s behavior, her mother’s viewpoint on the diagnosis, and the likelihood the cancer would worsen, the state could take physical custody and force her to undergo treatment.
This worked its way up to the Connecticut Supreme Court quickly. The issue whether a minor could be considered a mature minor had not been addressed previously by that court.
It held that the common law assumes that a minor is incompetent to make medical decisions until the child has shown the ability to make reasoned decisions and act independently. The court bases its analysis on the minor’s conduct, ability to act and live independently from parental aid, ability to reason in a mature manner, and understanding of their current situation.
Here, the Connecticut Supreme Court held that Cassandra’s dependence on her mother, her behavior, and her lack of honesty with the lower court and healthcare providers showed she lacked the level of maturity needed to meet a mature minor standard. She was removed from her mother’s custody and forced to undergo treatments.
Dealing with teenagers can sometimes be difficult. There is no difference between the cognitive faculties of a patient who is 17 years old and 364 days and one who just celebrated her 18th birthday. The court suggested in a roundabout way – if you want to be treated like an adult, act like one.
What do you think?
Well at last a thoughtful and well reasoned decision. The so called medical ethicists will be all over this one though. They detest reason.
I think this is a tough one -in that we don’t know from the description what her likelihood of success is with chemo. If it is 90% chance of remission or cure that is one thing, what it is 10% — Should someone, including a minor be forced to undergo treatment with lots of side effects and a chance of permanent damage from it if they only have a 10% chance? Probably not, but if they have a 90% chance, that is a whole different picture. These things are just not cut and dry. Hopefully the court had all this data.
As I understand it, and the way the case is presented, the mother brainwashed the child into believing that the lymphoma was not treatable, and that the only solution was to surrender to death.
That is a faulty assumption. The unfortunate part is that this delayed treatment for the girl when should could have and should have been treated at a much earlier stage by any reasonable prudent parent.
This parent was not reasonable or prudent.
The courts were correct in that the child should be removed from custody and placed into state ordered custody.
Okay so that is step one.
Step two is a completely separate question. Should the patient as a minor have the right to refuse treatment. Well first, the minor was brainwashed by the mother. So on that basis alone she cannot make a competent prudent decision about her own care, because she feels that death is inevitable. What was done to educate the minor and have her talk to other lymphoma survivors her age? Probably nothing. Would education have worked? Unknown as the patient was not given that chance and had been previously brainwashed.
The court’s decision is likely correct, in the sense that she was not making rational decisions on the basis of her mother’s brainwashing.
But change the case to a child that has been through multiple rounds of surgery and chemo without success and all of a sudden if she states that she wants no more treatment due to the pain and the failure rates, then that would be a different situation.
Star Trek IV posed another medical dilemma for Dr. McCoy who agreed to withdraw treatment for his father who was dying of some rare disease. But a short time after a cure was found for the father’s disease. If Dr. McCoy had not withdrawn treatment his father would have lived to receive treatment that would have cured him, from the new miracle cure that came along after his death. And he had to live with that choice for the rest of his life.
These questions are never easy and require the assistance of a hospital ethics committee, social worker etc. to help support the patient and the family.
“The Apple doesn’t fall far from the tree.”
That said, the only argument the state should respect for refusing treatment would be one made on religious grounds. If a Jehovah’s Witness could refuse a lifesaving blood transfusion for a child, another could refuse chemo based on their religious belief that the afterlife is eternal. I suspect this family had too few neurons, and too many morons. Thank you.
First, there should be a “Like” button for the comments. I’d have given EasyE a thumb’s up.
I’m a medical malpractice claim manager in her last class for a Master’s in Jurisprudence in Health Care, and as it happens, this week’s topic is Treatment Decisions for Children and Adolescents, a component of which was the mature minor doctrine. The thing that struck me in reading about Cassandra C. is the fact that, if one considers her mother to be a point of reference, Cassandra may never have the maturity to consent to treatment at any age. And yet, like so many legal rights afforded to “adults” in this country, an arbitrary age is set after which one may drive, get married, drink alcohol — even if one has more morons than neurons.
This issue is easier solved in the state of Alabama, where medical competence is assumed when the patient is 14, regardless of what his/her parents think. Agree with previous comments that communication to the patient by the medical professionals is critical here.