In re A.C.
573 A.2d 1235 (1990)
Rule of Law:
A competent pregnant woman has the right to decide the course of medical treatment for herself and her viable fetus, and if she is incompetent, her decision must be ascertained through the procedure of substituted judgment, which prioritizes her wishes and values, unless truly extraordinary and compelling state interests outweigh them.
Facts:
- A.C. was diagnosed with cancer at age 13, undergoing multiple surgeries, radiation, and chemotherapy over the years.
- At age 27, during a period of remission, A.C. married and became pregnant, later being referred to a high-risk pregnancy clinic.
- When A.C. was approximately 25 weeks pregnant, an X-ray revealed an inoperable tumor nearly filling her right lung, and she was admitted to George Washington University Hospital.
- A.C.'s medical team informed her that her illness was terminal, and she initially agreed to palliative treatment to extend her life until at least 28 weeks of pregnancy, knowing it posed some risk to the fetus.
- As A.C.'s condition worsened, she was intubated to assist her breathing and was heavily sedated, making meaningful conversation difficult.
- At 26 and a half weeks pregnant, medical testimony indicated the fetus was viable with a 50-60% chance of survival if delivered by C-section and less than a 20% risk of impairment, but delaying delivery would lessen its chances.
- A.C.'s mother opposed a C-section, stating A.C. wanted to 'live long enough to hold that baby', and medical staff had previously concluded they 'should abide by the wishes of the family'.
- After the trial court's initial order for a C-section was communicated to her, A.C. appeared to consent verbally, but moments later, while still sedated but more alert, she clearly mouthed 'I don't want it done. I don't want it done.'
Procedural Posture:
- George Washington University Hospital petitioned the emergency judge in chambers for declaratory relief regarding how it should treat its patient, A.C.
- The trial court held a hearing at the hospital, appointed counsel for A.C. and the fetus, and allowed the District of Columbia to intervene.
- The trial court found A.C. would probably die within 24-48 hours, the fetus was 26.5 weeks viable with 50-60% survival chance by C-section, and the state had an interest in protecting potential human life.
- The trial court found it did not clearly know A.C.'s present views and ordered that a caesarean section be performed.
- Counsel for A.C. immediately sought a stay of the trial court's order in the District of Columbia Court of Appeals (motions division).
- A hastily assembled division of three judges of the D.C. Court of Appeals unanimously denied the stay.
- The caesarean section was performed.
- A few months later, the District of Columbia Court of Appeals ordered the case heard en banc and vacated the opinion of the motions division.
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Issue:
Does a pregnant woman, even if near death, have the right to decide the course of medical treatment for herself and her viable fetus, and if she is incompetent, must her decision be ascertained through the procedure of substituted judgment rather than by a court balancing her interests against the state's interest in the fetus's life?
Opinions:
Majority - Associate Judge Terry
Yes, in virtually all cases, the decision about medical treatment for a pregnant woman and her viable fetus must be made by the pregnant woman herself. If she is incompetent, her decision must be determined through the procedure of 'substituted judgment.' The court affirms the fundamental right to bodily integrity and informed consent or refusal, rooted in common law and constitutional principles, which protects individuals from unwanted medical intrusions. This right applies equally to competent and incompetent patients, and its exercise is not extinguished by illness or proximity to death. The court cited cases like McFall v. Shimp, where an individual could not be compelled to donate bone marrow for another, to underscore that a fetus's rights cannot supersede the mother's bodily autonomy. For an incompetent patient, the court's duty is to act as a surrogate, discerning what that individual would have chosen if competent. This 'substituted judgment' inquiry is primarily subjective, considering the patient's previously expressed wishes (written or oral), past medical decisions, value system, goals, and desires. In the context of pregnancy, relevant factors may also include the mother's prognosis, fetal viability, and her likely interest in the child's well-being. The trial court erred by failing to definitively determine A.C.'s competency or, if incompetent, to apply the substituted judgment procedure. Instead, the trial court balanced A.C.'s interests against the state's interest in potential life, which was an improper step without first determining A.C.'s wishes. The court noted that court-ordered interventions can erode trust between patients and physicians and often suffer from severe procedural shortcomings due to time constraints. While the court does not entirely foreclose the theoretical possibility of a compelling state interest overriding a patient's wishes, it states that such cases would be 'extremely rare and truly exceptional,' and this case was not one of them.
Concurring in part and dissenting in part - Associate Judge Belson
Associate Judge Belson agrees with the majority's framework that courts should first assess a mother's competency and then apply substituted judgment, and that a competent pregnant woman's wishes should ordinarily be respected. However, he dissents from the majority's conclusion that the trial court committed reversible error. Justice Belson believes the trial judge implicitly found A.C. incompetent, given the medical testimony about her heavy sedation and inability to communicate. He also argues that the trial judge's failure to apply 'substituted judgment' sua sponte was not 'plain error' because, as the majority acknowledges, there was no reported opinion applying that procedure to such a unique case involving an incompetent pregnant patient. Justice Belson further disagrees with the majority's 'very limited view' of the circumstances under which a compelling state interest might override a patient's wishes. He contends that the state's interest in preserving human life and the viable unborn child's interest in survival are entitled to 'substantial weight.' Citing Roe v. Wade, he notes the state's compelling interest in potential human life at the point of viability. He also highlights tort law's recognition of a viable unborn child as a 'person' with legal rights (Bonbrest and Greater Southeast Hospital). Justice Belson supports a balancing test, citing Jefferson v. Griffin Spalding County Hospital Authority, which weighed the mother's religious rights against the unborn child's right to live and ruled for the child. He argues that a woman who carries a child to viability enters a unique category, as the viable unborn child is entirely dependent on her and literally 'captive within the mother’s body.' Therefore, in rare cases of conflict, the viable unborn child's vital needs, combined with the state's interest, should be able to override the mother's decision, especially if her wishes are equivocal, as he believes A.C.'s were. He fears the majority's opinion could diminish the rights of unborn children in future cases like In re Madyun, which he believes was correctly decided.
Analysis:
This case significantly reinforces the principle of bodily autonomy and informed consent for pregnant women, even when a viable fetus is involved, setting a high bar for judicial override. It clarifies and mandates the application of the 'substituted judgment' standard for incompetent patients in the context of pregnancy, emphasizing that a court must prioritize the patient's actual or extrapolated wishes and values. The ruling highlights critical procedural shortcomings inherent in emergency medical interventions and signals a strong judicial reluctance to compel invasive medical procedures against a patient's will, which could have far-reaching implications for cases involving maternal-fetal conflict.
