Ordinary vs. Extraordinary Care
Discussion of the following cases is concerned only with whether or not the decisions are legal or illegal and not with their moral implications.
Determine whether the cases involve ordinary care or extraordinary care, and whether the decisions given would be legal or illegal:
- An infant is born with Down’s syndrome, indicating probable mental retardation. He needs very low-risk surgery for an easily correctable intestinal defect. If untreated the baby will not be able to retain food and will die. The parents refuse surgery, stating that the mental retardation will mean a less than meaningful life for the baby. Answer: This case involves ordinary care; illegal decision: Parents may not refuse ordinary care; the refusal of surgery would result in the proximate cause of death for the child they have a legal duty to protect. Courts, however, usually have ruled in favor of parents’ refusal.
- A seven-year-old girl, auto-accident victim with severe internal bleeding, needs an immediate blood transfusion to prevent death. Her parents refuse consent because blood transfusions are forbidden by their religion (Jehovah’s Witnesses). Answer: This case involves ordinary care; illegal decision: Parents may not invoke their right to free exercise of religion to refuse lifesaving care for their child, for that would be a violation of the child’s unalienable right to life, which takes precedence over all other fundamental rights.
- A baby is born with anencephaly (part or most of the brain matter absent), with a prognosis of living only a few weeks or months. A decision is made to withhold all nourishment by mouth or other means. Answer: Ordinary care; illegal decision: Ordinary care is mandatory for all patients regardless of prognosis. However, in practice, many children like this are starved.
- A 55-year-old man with severe circulatory problems has gangrene of the leg. Amputation is necessary to save his life. The man refuses consent. Answer: Ordinary care – with qualifications. This is one of those difficult cases that could be classified as extraordinary care if it would involve great psychological harm to the patient to be deprived of his leg. Morally he might feel free to refuse surgery but legally it would probably be ordinary care, which would be lifesaving, the usual course of treatment for gangrene and of minimal risk.
Legal decision: Competent adults have the legal right to refuse treatment under the right of bodily integrity and intangibility. It would not be classified as suicide since the patient did not have the intent to cause his own death, but did not want the consequences of loss of limb resulting from surgery.
- A 50-year-old woman is dying of cancer. She has only a few days to live. She has severe anemia due to the cancer. Even though a blood transfusion is the usual treatment for severe anemia, the decision is made not to give it. Answer: Extraordinary care: This is an example of a treatment that is ordinary care in most instances but becomes extraordinary care due to the circumstances of the particular case. The transfusion would not be effective against the advanced cancer and would be burdensome to the patient.
Legal decision: Extraordinary care is not obligatory.
- An 87-year-old incompetent woman with congestive heart and kidney failure has primary cancer of the intestine. Surgery is the usual treatment for such cancer, but the family and doctor decide against it. Answer: Extraordinary care: Because of the advanced age and serious medical condition of the patient, the surgery that might be considered ordinary care becomes extraordinary care because of its high risk under these circumstances. Legal decision: Extraordinary care is not obligatory.
- A 45-year-old man has a bleeding ulcer for which he needs a blood transfusion. He refuses treatment because of religious beliefs which forbid transfusions of blood. Answer: Ordinary care; legal decision: Competent adults have the right to refuse even lifesaving treatment involving ordinary care under the right of bodily integrity and intangibility. In addition, this patient also had the right to refuse under the free exercise of religious right.
- A baby is born with spina bifida (open spine with spinal cord exposed) and hydrocephalus (excessive fluid surrounding the brain). Immediate surgery is necessary to close the exposed spinal cord to prevent dangerous infection that could cause death and to install a shunt to drain the excess fluid in the brain to prevent brain damage. The parents refuse consent because the child may be physically handicapped, involving hardship for the child and parents. Answer: Ordinary care: Because of the recent advances in spina bifida surgery and medical care, what had been high-risk surgery at one time is no longer so risky.
The Spina Bifida Association of America filed an amicus curiae brief to the New York State Court of Appeals Oct. 28, 1983, in the Infant Jane Doe case. The brief states: “Nearly all patients who receive prompt and proper treatment now survive . . . have normal life spans. . . . Left untreated, many die or live with greatly impaired futures, facing physical disabilities far more severe than they would have experienced with proper treatment and mental disabilities [which] proper treatment would have spared them altogether.” Illegal decision because the surgery involves ordinary care.
- A baby is born with the same condition as above, spina bifida, but in addition the baby has no kidneys, a rare and fatal condition for which there is no treatment. No surgery was done for the spina bifida. Answer: Extraordinary care: Ordinary care (surgery for spina bifida) becomes extraordinary care because the fatal kidney condition makes surgery useless. The baby will die regardless of treatment.
Legal decision – useless treatment not required.
- 55-year-old man stabs himself in the chest in a suicide attempt. Emergency chest surgery is needed to save his life. The man refuses consent. Answer: Ordinary care; illegal decision: Even though he is a competent adult, surgery to treat his injuries may be done without his consent because they were incurred as a result of a suicide attempt.