An Argument Based on Liberty: The case of John F. Kennedy Memorial Hospital v. Heston

Using the excerpt provided below from John F. Kennedy Memorial Hospital v. Heston (New Jersey Supreme Court, 1971) and the philosophical concepts and theories from readings and class discussions:

(A) Argue in support of the position of the defendant/appellant/patient Heston (namely, that the lower court acted improperly in authorizing the blood transfusion)

(B) Argue in support of the position of the plaintiff/respondent/Kennedy Hospital (namely, that the lower court acted properly in authorizing the blood transfusion)

Demonstrate your understanding of the philosophical theories and concepts considered in class discussions and in the readings.

1. Delores Heston, age 22 and unmarried, was severely injured in an automobile accident.
2. She was taken to the plaintiff hospital where it was determined that she would expire unless operated upon for a ruptured spleen and that if operated upon she would expire unless whole blood was administered.
3. Miss Heston and her parents are Jehovah’s Witnesses and a tenet of their faith forbids blood transfusions.
4. Miss Heston insists she expressed her refusal to accept blood, but the evidence indicates she was in shock on admittance to the hospital and in the judgment of the attending physicians and nurses was then or soon became disoriented and incoherent.
5. Her mother remained stern in her opposition to a transfusion and signed a release of liability for the hospital and medical personnel.
6. Miss Heston did not execute a release; presumably she could not.
7. Her father could not be located.
   
   
8. Death being imminent, plaintiff [hospital] on notice to the mother made application at 1:30 a.m. to a judge of the Superior Court for the appointment of a guardian for Miss Heston with directions to consent to transfusions as needed to save her life.
9. At the hearing, the mother and her friends thought a certain doctor would pursue surgery without a transfusion, but the doctor, in response to the judge’s telephone call, declined the case.
10. The court appointed a guardian with authority to consent to blood transfusions “for the preservation of the life of Delores Heston.”
11. Surgery was performed at 4 a.m. the same morning.
12. Blood was administered.
13. Miss Heston survived.
    
    
14. Defendants [Heston] then moved to vacate the order.
15. Affidavits were submitted by both sides.
16. The trial court declined to vacate the order.
17. This appeal followed.
18. We certified it before argument in the Appellate Division.
    
    
19. The controversy is moot.
20. Miss Heston is well and no longer in plaintiff’s hospital.
21. The prospect of her return at some future day in like circumstances is too remote to warrant a declaratory judgment as between the parties.
22. Nonetheless, the public interest warrants a resolution of the cause, and for that reason we accept the issue.
    
    
23. It seems correct to say there is no constitutional right to choose to die.
24. Attempted suicide was a crime at common law and was held to be a crime under [New Jersey State statutes].
25. It is now denounced as a disorderly persons offense.
26. Ordinarily nothing would be gained by a prosecution, and hence the offense is rarely charged.
27. Nonetheless the Constitution does not deny the State an interest in the subject.
28. It is commonplace for the police and other citizens, often at great risk to themselves, to use force or stratagem to defeat efforts at suicide, and it could hardly be said that thus to save someone from himself violated a right of his under the Constitution subjecting the rescuer to civil or penal consequences.
    
    
29. Nor is the constitutional right established by adding that one’s religious faith ordains his death.
30. Religious beliefs are absolute, but conduct in pursuance of religious beliefs is not wholly immune from government restraint.
    
    
31. Complicating the subject of suicide is the difficulty of knowing whether a decision to die is firmly held.
32. Psychiatrists may find that beneath it all a person bent on self-destruction is hoping to be rescued, and most who are rescued do not repeat the attempt at least not at once.
33. Then, too, there is the question whether in any event the person was and continues to be competent (a difficult concept in this area) to choose to die.
34. And of course there is no opportunity for a trial of these questions in advance of intervention by the State or a citizen.
    
    
35. Appellant suggests there is a difference between passively submitting to death and actively seeking it.
36. The distinction may be merely verbal as it would be if an adult sought death by starvation instead of a drug.
37. If the State may interrupt one mode of self-destruction, it may with equal authority interfere with the other.
38. It is arguably different when an individual, overtaken with illness, decides to let it run a fatal course.
39. But unless the medical option itself is laden with the risk of death or of serious infirmity, the State’s interest in sustaining life in such circumstances is hardly distinguishable from its interest in the case of suicide.
    
    
40. Here we are not dealing with deadly options.
41. The risk of death or permanent injury because of a transfusion is not a serious factor indeed, Miss Heston did not resist a transfusion on that basis.
42. Nor did she wish to die.
43. She wanted to live, but her faith demanded that she refuse blood even at the price of her life.
44. The question is not whether the State could punish her for refusing a transfusion.
45. It may be granted that it would serve no State interest to deal criminally with one who resisted a transfusion on the basis of religious faith.
46. The question is whether the State may authorize force to prevent death or may tolerate the use of force by others to that end.
47. Indeed, the issue is not solely between the State and Miss Heston, for the controversy is also between Miss Heston and a hospital and staff who did not seek her out and upon whom the dictates of her faith will fall as burden.
    
    
48. Hospitals exist to aid the sick and the injured.
49. The medical and nursing professions are consecrated to preserving life.
50. That is their professional creed.
51. To them, a failure to use a simple, established procedure in the circumstances of this case would be malpractice, however the law may characterize that failure because of the patient’s private convictions.
52. A surgeon should not be asked to operate under the strain of knowing that a transfusion may not be administered even though medically required to save his patient.
53. This hospital and its staff should not be required to decide whether the patient is or continues to be competent to make a judgment upon the subject, or whether the release tendered by the patient or a member of his family will protect them from civil responsibility.
54. The hospital could hardly avoid the problem by compelling the removal of a dying patient, and Miss Heston’s family made no effort to take her elsewhere.
    
    
55. When the hospital and staff are thus involuntary hosts and their interests are pitted against the belief of the patient, we think it reasonable to resolve the problem by permitting the hospital and its staff to pursue their functions according to their professional standards.
56. The solution sides with life, the conservation of which is, we think, a matter of State interest.
57. A prior application to a court is appropriate if time permits it, although in the nature of the emergency the only question that can be explored satisfactorily is whether death will probably ensue if medical procedures are not followed.
58. If a court finds, as the trial court did, that death will likely follow unless a transfusion is administered, the hospital and the physicians should be permitted to follow that medical procedure.
    

(A) Arguing in support of the position of the defendant/appellant/patient Heston (namely, that the lower court acted improperly in authorizing the blood transfusion)

Delores Heston may argue that the lower court was violating her 1st constitutional right. In forcing the blood transfusion by the state, the state was violating her rights to exercise her beliefs as a Jehovah Witness. She would not be arguing from the position of the right to die, but from the position that man's intervention is in direct interference with God's will. Obviously, as a Jehovah Witness, her belief in receiving a blood transfusion is in violation of Natural Law. Her belief would be that God is the one who decides whether she is to live or die and that a blood transfusion would be interfering with God's will. She could then continue to argue that man cannot possibly understand the "Big Picture" that only God sees. Only God understands the big picture and if this is her time to die then let it be so. There may be reasons beyond man's limited understanding that her living may cause changes within the time continuum riff that were never intended by God. She may argue that because society is a system that continuing her life may create changes that are not understood by man and only understood by God.

         As an example if her life was extended by man's interference, she may become pregnant, give birth to a child and that child when it comes of age, assassinates the President of the United States. This particular President may have had the ultimate solution to world peace and that without this President the solution to world peace dies with him. This may sound like an implausible point of argumentation because we do not know what the future holds. One could argue that the possibility of raising a Presidential assassin is an extremely low possibility, but on the other hand, because man does not understand God's Work, this scenario is as likely as an infinite number of scenarios that could or would occur if man interfered with God's Will for Delores Heston to die.

         Delores Heston could further argue that there is still the possibility, as remote as man may think, that without the blood transfusion, God knew it was not her time to die and that by Divine Intervention she would survive and this was also God's Work. Delores could argue that God's intention was to have her pass through this traumatic experience in order receive a vision, an experience, a test of her faith in God, or to strengthen her in some way. God's intention may have been for her to have this experience in order to create some new knowledge of God that she would then deliver to others because of her near miss experience with death.

         Delores could also argue from the position of the "Harm Principle" as stated by John Stewart Mill. She could argue that the State did not have the right to enforce the issuing of a blood transfusion because she was in no way interfering with any other individual's rights. The only harm was to herself, but in this case it was clearly not Delores' will to die. Her concern still hangs on that of Natural Law. The position being that accepting the transfusion would be interference in God's Laws as she understands and practices them. In accepting the transfusion, she would be going against God's Will. From this point, she could argue that because she received the transfusion against her will, she will still be subject to God's Judgement at the time of her natural death and that the State's Law or Man's Law is only temporary. Man's Law is temporary in the sense that we are only held subject to it so long as we are alive. She could then argue that God's Law is eternal. When her natural death occurred that her soul would be subject to God's Law and because she accepted the transfusion, she had interfered with God's Will and would be subject to eternal damnation because of such interference.

(B) Arguing in support of the position of the plaintiff/respondent/Kennedy Hospital (namely, that the lower court acted properly in authorizing the blood transfusion)

         The court could argue from several positions that the lower court acted properly in authorizing the blood transfusion. Referring to John Stewart Mill's "Harm Principle," the court may argue that the State had the right to authorize the blood transfusion from the point that there was more than one person, Delores, that could be harmed by not administering the blood transfusion. Others in imminent position of harm were the Kennedy Hospital, the doctors and nurses and the staff of the hospital. The doctors and nurses have a professional creed to uphold which is the preservation of life. They are also subject to uphold a specified "standard of care" by the law and not adhering to that standard is a violation of the law. According to Mill, "Man is under a duty to perform certain tasks within the State. The main task here for the hospital is saving someone's life. Administering the blood transfusion in no way threatened anyone else's well-being; therefore, the State was in no way violating the principle of saving Delores' life because it would not interfere with anyone else's well being. From the viewpoint of the hospital staff it could be argued that Delores decision to not receive the transfusion does interfere with the well-being of others; that being the hospital staff. The staff could argue that there is "harm" involved, which is not physical as it would be for Delores, but psychological harm. The hospital staff obviously would live beyond the incident, but would always have to carry within their minds a nagging doubt as to whether they had done the right thing in giving way to Delores' convictions to not receive the blood transfusion. Henceforth, the Hospital staff could argue that they were being subjected to unnecessary psychological harm in giving way to Delores' religious conviction to not receive the blood transfusion.

         The court could also argue from the standpoint that not administering the blood transfusion would be in violation of the majorities belief that all life is sacred and that everything possible must be done in order to see to the continuation of life. This argument could be applied from Patrick Devlin's view of Legal Moralism. The argument could stand on the position that even though Delores' belief that administering the blood transfusion is in violation of God's Law, that her view is a minority view. The majority view of society and specifically, the view of the hospital staff hold an opposing view. The majority could be observed as being the hospital staff itself, and that conviction is that the staff must do all that it can do in order to uphold the "Standards of Care." The blood transfusion would be the required standard of care and that the majority also sees itself as upholding God's Will. The Hospital staff is performing God's Will by attempting to see to the continuance of life through collective knowledge that has been obtained though training and practice. The Hospital's view of God's Will could be that all life is sacred and that everything that is possible by human intervention is expected by God. Hence the hospital is also in the position of performing God's Will. Also from this Legal Morality position, by not performing the prescribed "standard of care" the Hospital is neglecting its duties to ensuring the continuation of life; therefore, it is morally unacceptable for the hospital staff to not administer the blood transfusion. By not administering the blood transfusion the hospital staff could argue that they had not done everything possible. The hospital staff could conceivably view themselves as the "murderers" because they willfully and consciously decided not to administer the blood transfusion knowing from past experience what the inevitable outcome would be. They could then further argue that at the time of their own natural deaths that they would have to face their God with "blood on their hands" for going against their own convictions that all life is sacred and should be spared at all costs. This argument would be from the position of Legal Moralism that states that the majority decides what is morally correct versus the minority.

         The higher court also cites on line 29 that, "Religious beliefs are absolute (observing the right established within the 1st Constitutional right to the freedom to practice one's religion), but conduct pursuance of religious beliefs is not wholly immune from government restraint." Hence, the higher court is pointing to the philosophy of Paternalism. In Paternalism the State has the right to interfere with the individuals rights from the standpoint that the State knows what is best for the individual and that sometimes the State must protect individuals from harming themselves. The fact is that receiving a blood transfusion is the accepted norm or the standard of care and that its refusal places the individual in a position of harming themselves, the State has the right to interfere and protect that individual from themselves. In lines 37 through 38, the position is a continuation of Paternalism.

"It is arguably different when an individual, overtaken with illness decides to let it run a fatal course. But unless the medical option itself is laden (i.e. "value laden"), with the risk of death or of serious infirmary, the State's interest in sustaining life in such circumstances is hardly distinguishable from its interest in the case of suicide."

         Here the State's Paternal interest is the continuation of life and the failure to enforce the transfusion is "murder" by the state in that it has not fulfilled its obligation to the safety of its citizens. There is another possibility that without the transfusion Delores may have survived the surgery required to save her life, but her functionality may have been substantially thereby possibly requiring 24/7 assisted care for the rest of her natural life because of her religious conviction which would then place an unnecessary burden on the State and its citizens due to Delores' moral convictions.

         In lines 45 through 47,

"The question is whether the State may authorize force to prevent death or tolerate the use of force by others to that end. Indeed, the issue is not solely between the State and Miss Heston, for the controversy is also between Miss Heston and a hospital and staff who did not seek her out and upon whom the dictates of her faith will fall as burden."

         This supports my position that the Hospital can argue from the point that the Legal Morality of the Hospital (the majority) supercedes the Legal Moralism of the minority (Delores). The higher court supports this position for it is the Hospital Staff who will endure the brunt of the suffering and harm and not Delores.

         In lines 48 through 50, "Hospitals exist to aid the sick and the injured. The medical and nursing professions are consecrated to preserving life. That is their professional creed." In essence the higher court is upholding the fact that the Hospitals staff morally believes that they are upholding God's will that all life is sacred and that its function is to see to the continuation of life. The higher court continues, "To them (the Hospital Staff), a failure to use a simple, established procedure in the circumstances of this case would be malpractice (i.e. not administering the "Standard of Care"), however the law may characterize that failure because of the patient's private convictions." Here the higher court is saying that because of Delores' religious beliefs it is likely that the hospital staff would not have been held liable for malpractice by not administering the transfusion. The higher court brings up the surgeon involved by stating, "a surgeon should not be asked to operate under the strain of knowing that a transfusion may not be administered even though medically required to save his patient." The higher court is know pointing to the "Harm Principle" citing that Delores' being operated on without a transfusion would cause unnecessary physical stress and psychological duress to the surgeon in performing the operation. The higher court is supporting my earlier point that Delores is not the only one in a position of harm due to the refusal of the blood transfusion.

         On line 53, the Higher court continues, "This hospital and its staff should not be required to decide whether the patient is or continues to be competent to make a judgement upon the subject, or whether the release tendered by the patient or a member of his family will protect them from civil responsibility." Here the higher court is saying that the Hospital is in a position of being damned if it does and damned if it doesn't by the law. The Hospital Staff does not have the ability to evaluate the mental state of Delores or her parents to the point of whether they understand the implications involved in administering the blood transfusion (i.e. they understand, but do they REALLY understand? Do they posses their full faculties to evaluate the situation at hand.) On line 54, "The hospital could hardly avoid the problem by compelling the removal of a dying patient, and Miss Heston's family made no effort to take her elsewhere," the hospital is under obligation by the law to accept anyone brought into the hospital to administer the "standard of care" regardless of circumstances. The other position here is that there was no legal document that had been created between Delores and her legal advisor stating that under no circumstances was she to receive a blood transfusion due to her moral convictions. Furthermore, if she was incapacitated or not in a mental state to make such a decision that there was a appointed ward of the estate given the legal power to make such decisions for Delores. The other point here the court makes is that her parents make no conscious decision to follow through with their religious beliefs by removing Delores from the hospital. This implies either that the parents did expect the hospital to do something to extend her chances for living or demonstrating that they did not possess their full mental capacities to make a life or death decision.

         In summing up the case, the higher court on line 53 through to 85 has this to say, "When the hospital and staff are thus involuntarily hosts and their interests are pitted against the belief of the patient, we think it reasonable to resolve the problem by permitting the hospital and its staff to pursue their functions according to their professional standards." The higher court is pinning its decision on Legal Morality and in Legal Morality it is the Morality of the Majority (The Hospital Staff) that will be upheld. On line 56, the court continues, "The solution sides with life, the conservation of which is, we think, a matter of State interest." This supports the positions that the court is siding with the "Harm Principle," that the greater harm is to that of the hospital staff and the citizens of the State. It is the Hospital Staff that will suffer unnecessary physiological suffering because of Delores' decision and that the citizen's of the state also stand to suffer if she was to live and require full time living assistance because of her religious beliefs. In addition also implied here is the Paternal Principle, that the State and its citizens know what is best for the individual. Lastly, it implies legal morality in the sense that the majority of the State's citizens choose life before death and any actions that see to its continuation at all costs.

         Last, the court cites on lines 57 through 58,

"A prior application to the court is appropriate if time permits it, although in the nature of the emergency the only question that can be explored satisfactorily is whether death will probably ensue if medical procedures are not followed. If a court finds, as the trial court did, that death will likely follow unless a transfusion is administered, the hospital and the physicians should be permitted to follow that medical procedure."

         Here the higher court is siding with the decision of the lower court that administering the transfusion was the correct thing to do subscribing to Legal Moralism theory in that, "the morality of the majority outweighs the morality of the minority."