Court supports pregnant patients' right of refusal

Ruling further obfuscates already murky issues

A recent court case in Illinois gives much more support to the idea that a pregnant patient can refuse treatment, even if doing so clearly would threaten her fetus, making it an important addition to the case law you might consult in such a situation.

The ruling came from the Appellate Court of Illinois, reversing a trial order that had authorized the forcible transfusion of a Jehovah's Witness for the sake of her viable fetus.1 The court said that Illinois law did not "impose a legal obligation upon a pregnant woman to consent to an invasive medical procedure for the sake of her viable fetus."

The case arose in June 1996 when 26-year-old Darlene Brown underwent minor elective surgery during her 34th week of pregnancy to remove a cyst from her urethra. The surgery was performed at Ingalls Memorial Hospital in Harvey, IL. Doctors expected her to lose no more than 100 cc of blood, but she lost 1,500 cc and needed a transfusion two days after the surgery.

The patient had said nothing about being a Jehovah's Witness before the surgery, but she was awake during the procedure and refused the blood transfusion the doctors wanted at that time. Later, when the blood loss seemed to threaten the fetus and she still refused, the hospital obtained a court order for the transfusion. The transfusion took place, and both mother and baby fared well.

Now that the appeals court reversed the earlier decision, the attorney representing the mother says the decision represents a significant turn in case law that risk managers must note. Donald T. Ridley, JD, in Patterson, NY, tells Healthcare Risk Management the case is significant because it is a thorough, carefully considered ruling after the fact instead of a brief emergency order.

Two previous rulings, from Georgia and New Jersey, usually were the basis for deciding whether a provider could force a pregnant patient to accept treatment on behalf of the fetus. Both were brief emergency orders authorizing treatment.

"Now there's an appellate case saying otherwise, and this one is a 10-page-plus appellate decision with the weight of a very recent decision and a long, detailed analysis," Ridley says. "The New Jersey decision was not even a page long, and the Georgia decision is only two lines. So now you have two very brief opinions authorizing intervention vs. a much more lengthy opinion denying it."

The appellate decision from Illinois does not necessarily mean a health provider will be refused from now on when trying to force treatment on a pregnant patient, but Ridley says it makes the issue more debatable. Since the only two previous cases favored authorizing treatment, there was presumption that health providers would have a good chance of getting that response. That's not so certain now, he says.

"This decision brings pregnant women to the same status as other patients concerning blood transfusions and Jehovah's Witnesses," he says. "This one focused on blood transfusions, but I'd suspect you could apply the ruling to other types of intervention with pregnant patients."

Procedure was not invasive>

It is worth noting that the decision involved a procedure that was minimally invasive. The hospital argued that providing the transfusion wouldn't even require a needle prick because the patient already had an intravenous line in place for fluids. That was an important part of the argument because some previous decisions had dealt with forcing a cesarean on a woman but pointedly avoided the issue of blood transfusions because they are so much less invasive.

"We argued that the issue was the treatment per se, the infusion of other people's bodily fluids into her against her will," Ridley says. "They were splitting hairs over how it was delivered."

The issue still will be debated, but Ridley suggests that risk managers make sure the case is added to the list of precedents they consider when faced with a pregnant patient refusing treatment. The other rulings probably will carry more weight in New Jersey or Georgia; in Illinois, the recent appellate decision will have to be followed.

But in other states, the recent Illinois ruling provides the patient with a strong case precedent to counter hospitals' precedents for authorizing treatment.

Reference

1. In re Fetus Brown, No. 1-96-2316 (Ill. App. Ct. Dec. 31, 1997).