Right to refuse medical treatment

The right to refuse medical treatment is the legal and ethical principle that a patient may decline medical intervention, including treatment needed to sustain life. The book traces its recognition through landmark American cases and then sets that history against a crisis in which a do-not-resuscitate order was used to rank some patients last for evacuation. The contrast is consequential: a decision about whether to attempt resuscitation in cardiac arrest does not, by itself, mean that a patient has refused treatment or rescue in every other circumstance.

Legal Recognition of Refusal

In 1975, Karen Ann Quinlan’s parents asked doctors to remove her from a ventilator after she became comatose and was not expected to recover. The doctors refused, but the New Jersey Supreme Court held that life support could be withdrawn on the basis of Quinlan’s constitutional rights to privacy and liberty, exercised by her father. The respirator was turned off; Quinlan breathed independently and lived for another nine years. Her survival gave the case a result distinct from the legal principle it established: the right to refuse treatment did not depend on withdrawal immediately resulting in death.

Later state-court decisions connected refusal to privacy, liberty, self-determination, and informed consent. The account also notes that, for some Jehovah’s Witnesses, the right to refuse treatment had already been recognized through religious freedom. These grounds locate refusal not simply in a clinician’s assessment of what care is useful, but in a patient’s authority over whether care is accepted.

From Withdrawal to Advance Directives

The Clarence Herbert case marked a change in how courts treated the withdrawal of life support. In the 1980s, doctors caring for Herbert were charged with murder after stopping life support and intravenous fluids. They argued that the decision reflected his prior wishes and his family’s request not to keep him on machines. A California appeals court dismissed the case, reasoning that the burdens of continued treatment outweighed its benefits given Herbert’s virtually hopeless prospect of significant improvement. Drawing on a presidential ethics commission, it held that stopping treatment was not materially different from never starting it and did not, in those circumstances, amount to active euthanasia.

The court applied the same reasoning to an ordinary intravenous line and a ventilator, provided the treatment had been legitimately refused by the patient or a surrogate decision-maker. The decision bound only part of California, but the underlying distinction between withdrawing and withholding treatment had become broadly accepted by the time of Katrina. It made the validity of the refusal central: stopping treatment was not treated as equivalent to killing when the patient or authorized surrogate had declined it.

In 1990, the United States Supreme Court considered Nancy Cruzan, who had severe brain damage after a car accident and was being nourished through a feeding tube. By a five-to-four vote, the Court recognized that the liberty right included the right to refuse life-sustaining medical care and die. It also allowed states to require clear and convincing evidence of a patient’s wishes, rather than relying only on a judgment about the patient’s best interests. After acquaintances testified about what Cruzan would have wanted, a Missouri judge permitted her nutrition to be discontinued. The case encouraged wider use of living wills and advance directives, documents intended to record treatment preferences before a catastrophe made communication or decision-making difficult.

DNR Orders and the Meaning of Rescue

The distinction between refusal of a particular treatment and abandonment from care becomes urgent in the account of Memorial Medical Center. Before the evacuation, doctors made an exception to the protocol that otherwise prioritized the sickest patients and those dependent on machines: patients with DNR orders would be evacuated last. Four such patients were in the intensive care unit, including Helen Breckenridge and Jannie Burgess. The policy converted a designation concerning resuscitation into a criterion for evacuation priority, although the two decisions address different circumstances.

Burgess’s presence at Memorial carried an additional historical weight. She had entered nursing to support her children and had worked in several other jobs. As a light-brown-skinned Black woman in mid-twentieth-century New Orleans, she could care for patients in many private hospitals but could not receive care in them. Born only months after Memorial opened as Southern Baptist Hospital in 1926, she waited more than four decades before she could become a patient there. During the Katrina crisis, the DNR classification placed her among those to be evacuated last. Her history makes the apparent neutrality of a medical category harder to separate from the unequal access that had shaped her earlier life.

On another floor, a nurse challenged instructions to leave an oxygen-dependent, ninety-three-year-old DNR patient behind. The patient’s daughter had agreed to the order because she did not want resuscitation if her mother suffered cardiac arrest. Faced with the possibility that the order would mean her mother was simply not rescued, she told the nurse that this was not what she had intended. The nurse explained that the daughter could request discontinuation of the DNR order. The exchange exposes a crucial limit: an order against resuscitation is not automatically consent to withholding evacuation or all other care. In an emergency, however, the institutional decision to rank DNR patients last could make that distinction ineffective in practice.

Care, Crisis, and Institutional Contrast

The same crisis shows how care extended beyond procedures and formal directives. John Thiele’s reflection drew on the Golden Rule and a medical-school motto centered on comfort when cure was not possible; with almost no control over the situation, he understood offering comfort as an action still available to him. At LifeCare, Angela McManus cared for her mother, Wilda, through feeding-tube support and other demanding daily tasks, and eventually recruited a nurse to help clean and redress her. She also talked, sang, and prayed with her. Before the storm, staff had gathered while Wilda prayed in sessions they called church. These details do not settle questions of legal authority, but they show that care and human presence continued to matter even when treatment options and resources were constrained.

The account also contrasts Memorial’s evacuation with that of public Charity Hospital. Charity lost power, plumbing, communications, computers, and elevators, and had no helipad or corporate overseers to assist. It held approximately twice as many patients across two campuses, with fewer staff relative to patients, and completed transfers on September 2, a day after Memorial. Yet fewer than ten patients died there. The comparison does not establish that any single policy explains the difference; it places decisions about refusal and evacuation within a wider landscape of unequal resources and institutional capacity. The right to refuse treatment therefore appears alongside a separate obligation: a patient’s refusal of one intervention should not be casually transformed into a reason to deny other forms of aid.