How old is old enough to refuse medical treatment?

[Malik Ambar]

So you would rather have them wait till the situation worsens, because beliefs ?

If that's the case, can't agree with you.

[TerraPrime]

So you would rather have them wait till the situation worsens, because beliefs ?

If that's the case, can't agree with you.

I'd rather them seek treatment now. But that's not my place to force them into it.

I mean, yes, I'd rather people not make stupid decisions concerning their lives, like smoking cigarettes, riding motorcycles without helmets, eating an unhealthy diet, going to Church, binge drinking, getting addicted to illegal drugs, or watching Fox News. But it's their lives to live. Making medical decisions concerning one's own health ought to be protected by a higher order of scrutiny with a deference to the individual's wishes than many of these other self-harming activities I listed.

[Larry of the Lawn]

Terra has quite convinced me. I think the state should have stayed out of this one.

[Aemon Stark]

"In general well tolerated" is not exactly a ringing endorsement. It's still a regiment of treatment that kills the cancer cells faster than it kills healthy cells, no?

So? It's outpatient chemo, there are lots of excellent antiemetics around for nausea, and side effects are well monitored. The major downside is that cytopenias may necessitate staying at home a lot - but for most patients this age that generally implies watching a lot of Netflix. I won't minimize the experience, but it's also not the worst thing ever even amongst chemotherapy protocols. Many, many lymphoma patients do very, very well. This is at all similar to, say, a young adult with an acute leukemia which has relapsed and is now facing second-line therapy or a stem cell transplant.

I've seen many Hodgkins and NHL patients and good outcomes are common - the statistics further demonstrate this. Is it fun? No - but this is a "good" malignant hematology diagnosis and there's really no debate about that.

As a further aside, chemotherapy has changed considerably over the last 10-20 years, and unfortunately the lay view of it tends to be based more on what is was like in 1985.

I would agree, if we limit our consideration only to the health outcome. But more is at stake here now, including autonomy, agency, and a patient's rights. Add to that the emotional distress the court compulsion is inflicting on Cassandra, to say nothing of the emotional distress on her mother, the balance does not tip in favor of compulsatory treatment, in my view.

The emotional distress on her mother is not in point of fact relevant to the legal question in this case. As for Cassandra, she remains a minor, and has not been determined to be a "mature minor". Now regardless of whether this seems "arbitrary", I'm not sure that this has any relevance to "autonomy, agency, (or) patient's rights". The question here is one of competence to make medical decisions, and if this is assumed for any adult, that is not the case for minors. That there is a somewhat arbitrary cutoff is rather irrelevant - laws are conventions by nature, and there will always be trade offs of this sort.

Patient autonomy is something to be respected - and I agree that there is much to be said for avoiding having to "force" a particular treatment on someone who is unwilling. In this case, however, there appears to be an ignorant parent influencing her child to forego literally life-saving therapy that, quite frankly, should not be given the connotation of being so horrible. Cassandra will finish her cycles soon enough in any case.

I have to say also that it's very difficult to administer IV chemotherapy to a patient that is truly unwilling. I can't even imagine that they'd hold her down (or sedate her!) to do it (essentially impossible anyway). So I think it's also debatable just how unwilling she is.

[TerraPrime]

So? It's outpatient chemo, there are lots of excellent antiemetics around for nausea, and side effects are well monitored. The major downside is that cytopenias may necessitate staying at home a lot - but for most patients this age that generally implies watching a lot of Netflix. I won't minimize the experience, but it's also not the worst thing ever even amongst chemotherapy protocols. Many, many lymphoma patients do very, very well. This is at all similar to, say, a young adult with an acute leukemia which has relapsed and is now facing second-line therapy or a stem cell transplant.

That's.... really neither here nor there. There will be guaranteed side effects, some of which may not be "the most" horrible and can be "managed." There is a not-100% guarantee of success from treatment. Patients should know this, and Cassandra does (or you think her docts failed to relate the benefits and risks to her?). She is choosing not to take it.

The emotional distress on her mother is not in point of fact relevant to the legal question in this case.

Sure. Ethically, though? Her mother's distress is NOT a factor at all?

And what of Cassandra's emotional distress?

The question here is one of competence to make medical decisions, and if this is assumed for any adult, that is not the case for minors. That there is a somewhat arbitrary cutoff is rather irrelevant - laws are conventions by nature, and there will always be trade offs of this sort.

I agree that there will be trade-offs and borderline cases like this will always seem wrong to one side or the other.

But right now I am just trying to wrap my head around what is the legal standard for not being competent to make medical decisions mean, vis a vis being determined to lack compentency to stand criminal trials or being forcibly committed to psychiatric observation, etc.

In general, our society has a tendency to over-value the attempts to keep someone alive. Terry Schiavo and the general opposition to assisted suicides are examples of this. I have found that a lot of people see the decision to end one's life as a de facto piece of evidence for insanity, mental illness, or just plain craziness, because they cannot fathom why anyone would want to die. So when I read that the court has ruled that Cassandra is not emotionally competent to make a decision to refuse treatment, I am highly skeptical of the standards used in that assessment.

Patient autonomy is something to be respected - and I agree that there is much to be said for avoiding having to "force" a particular treatment on someone who is unwilling. In this case, however, there appears to be an ignorant parent influencing her child to forego literally life-saving therapy that, quite frankly, should not be given the connotation of being so horrible.

Yes, patient autonomy is to be respected, except when that autonomy leads to an outcome that is disfavored by the mainstream. In that case, then we should ignore the patient's wishes, as well as her legal guardian's wishes, and forcibly commit her to a treatment she clearly does not want, while along the process, cause her tremendous emotional distress by separating her from her mother and making a legal ruling that declares her mother to be an incompetent parent, all culminating in consigning her to foster care facilities while she receives forced chemotherapy.

But hey, there's an 85% chance that she might have the lymphoma in remission soon. So.... yay?

I have to say also that it's very difficult to administer IV chemotherapy to a patient that is truly unwilling. I can't even imagine that they'd hold her down (or sedate her!) to do it (essentially impossible anyway). So I think it's also debatable just how unwilling she is.

This paragraph is obnoxious and offensive. I wish you would redact that from your post, because, to me, it reads like "oh, she must not have minded the rape that much because she didn't struggle a whole lot."

Cassandra wrote an OpEd piece declaring her wishes to not receive the treatment. She and her mother had fought the authorities, for months, on it. She ran away from home to try to avoid it.

When does "no" actually mean "no" here?

[Aemon Stark]

That's.... really neither here nor there. There will be guaranteed side effects, some of which may not be "the most" horrible and can be "managed." There is a not-100% guarantee of success from treatment. Patients should know this, and Cassandra does (or you think her docts failed to relate the benefits and risks to her?). She is choosing not to take it.

I am not privy to the details of the case nor the arguments presented. A lack of 100% efficacy is inherent to anything, but an 85% probability of cure in the face of a 100% chance of fairly imminent death represents a fairly clear balance of probabilities. Here we see an interview with the mother who says that she does not think her daughter will die without chemo, and that she wished to explore "alternative" therapies. It is hard to see this as an "informed" decision.

Sure. Ethically, though? Her mother's distress is NOT a factor at all?

And what of Cassandra's emotional distress?

It is very difficult to sort out the nature of this relationship in the absence of direct testimony from Cassandra. Once again, the question becomes whether she can be considered a mature minor.

I agree that there will be trade-offs and borderline cases like this will always seem wrong to one side or the other.

But right now I am just trying to wrap my head around what is the legal standard for not being competent to make medical decisions mean, vis a vis being determined to lack compentency to stand criminal trials or being forcibly committed to psychiatric observation, etc.

In general, our society has a tendency to over-value the attempts to keep someone alive. Terry Schiavo and the general opposition to assisted suicides are examples of this. I have found that a lot of people see the decision to end one's life as a de facto piece of evidence for insanity, mental illness, or just plain craziness, because they cannot fathom why anyone would want to die. So when I read that the court has ruled that Cassandra is not emotionally competent to make a decision to refuse treatment, I am highly skeptical of the standards used in that assessment.

Competency to make medical decisions is not the same as criminal responsibility and furthermore not the same as involuntary psychiatric admissions. In the latter case, generally a person must have a "mental disorder" and be at "imminent" risk of self-harm or harm to others. I am not sure what "society" you're thinking of, but I fail to see how this case relates to assisted suicide or Terri Schiavo. Of course, the former exists in the US in Oregon, and Terri Schiavo's husband was eventually successful in having her life-sustaining care withdrawn - the issue was that this contested by her family members. At the same time, she was incapable of expressing her own wishes.

Yes, patient autonomy is to be respected, except when that autonomy leads to an outcome that is disfavored by the mainstream. In that case, then we should ignore the patient's wishes, as well as her legal guardian's wishes, and forcibly commit her to a treatment she clearly does not want, while along the process, cause her tremendous emotional distress by separating her from her mother and making a legal ruling that declares her mother to be an incompetent parent, all culminating in consigning her to foster care facilities while she receives forced chemotherapy.

But hey, there's an 85% chance that she might have the lymphoma in remission soon. So.... yay?

There are plenty of children that undergo procedures and therapies that they cannot or do not give consent to. Imagine having to hold down an adult-size 12 year old with the cognitive ability of a 6 year old for an IV because he's too big for a mask induction but needs a general anaesthetic for his fillings.

I have read Cassandra's op-ed - did she actually write it? What does it mean in the context of a court case? What are we to make of her agreeing to chemo and claiming that she had no intention of going through with it? Or running away from home? What at the age of barely 17 does she have "bills to pay"? It is very difficult to make this out to be right or wrong on some general principle when we are not able to independently assess the details of the story or the people involved. I will say from experience that media stories about any kind of controversial medical issue or story rarely closely reflect the actual events.

This paragraph is obnoxious and offensive. I wish you would redact that from your post, because, to me, it reads like "oh, she must not have minded the rape that much because she didn't struggle a whole lot."

Cassandra wrote an OpEd piece declaring her wishes to not receive the treatment. She and her mother had fought the authorities, for months, on it. She ran away from home to try to avoid it.

When does "no" actually mean "no" here?

Likening insertion of a port-a-cath and chemotherapy to rape is the only offensive thing here.

Perhaps the most bizarre statement in this case is the mother's comment that her daughter said "years ago" (when she was 10?) that she would "never" want chemotherapy. Most adults have only the vaguest idea of what that entails - there are too many red flags in this story that speak to uncertain facts and a questionable parental influence that make it challenging to call this purely an issue of patient autonomy.