Stouffer v. Reid

DAVIS, Judge. J. Michael Stouffer, appellant, Commissioner of Correction, filed a Complaint for Declaratory Judgment and Application for Temporary Restraining Order and Preliminary and Permanent Injunction in the Circuit Court for Baltimore City against Troy Reid, appellee, an inmate in appellant’s custody. Appellant sought to compel appellee, over appellee’s objection, to submit to kidney dialysis and medical treatment. A hearing was held on May 1, 2008 before the circuit court (Nance, J.).

At the close of the hearing, the circuit court orally denied appellant’s complaint and, on May 6, 2008, filed a Declaratory Judgment, adjudging that appellee could refuse dialysis and medical treatment. Appellant appeals the circuit court’s ruling and presents one question for our review, which we have rephrased as follows: Did the circuit court err in determining that appellant was without legal authority to compel appellee to submit to medical treatment? For the reasons that follow, we answer appellant’s question in the negative. Accordingly, we affirm the judgment of the circuit court.

FACTUAL BACKGROUND In 1995, appellee was sentenced to a forty-year term of imprisonment. In July 2007, prison medical personnel diagnosed appellee with end-stage renal disease. Thereafter, appellee was prescribed kidney dialysis three times per week. Appellee objected to receiving dialysis and periodically refused to accept dialysis, sometimes going weeks at a time without receiving treatment.

In early April 2008, appellee again refused dialysis and, on April 11, 2008, appellant filed a Complaint for Declaratory Judgment and Application for ²⁷³ Temporary Restraining Order and Preliminary and Permanent Injunction in the Circuit Court for Baltimore City, seeking to compel appellee to submit to dialysis and medical treatment. 1 The circuit court granted appellee a temporary restraining order (TRO) on April 25, 2008, ordering appellee to submit to dialysis and medical treatment. At a hearing held on May 1, 2008, the trial judge, in an oral ruling from the bench, denied appellant’s request for a permanent injunction and declared that appellee had the right to refuse kidney dialysis and other medical treatment: [Appellant] is the head of the Department of Correction. He ... [has] the responsibility of maintaining the operation of the correctional institutions in the State of Maryland.... [Appellee] is an inmate within the Department of Correction ... [and is] a charge of [appellant]. [Appellant] has the responsibility of insuring [safety] ... and providing] proper medical treatment and care for ... inmates. The testimony submitted by [appellant] ... is that failure to abide by that medical treatment ... would negatively impact this inmate.

It would impact his heart, his heartbeat, the regularity of his heartbeat, that may cause a heart attack; is that it would cause fluid to build up in the body that is not being taken out of the body under normal means and that fluid may build up in his leg, in his face, in his lungs, and in his lungs could cause respiratory failure and that respiratory failure could lead to heart attack or death. [T]he inmate also has high blood pressure and that failure to receive the treatment in question may impact negatively to his high blood pressure. The impact could lead to the ²⁷⁴ heightening of his high blood pressure, that also could lead to stroke. Maryland is clear that a mentally competent adult may refuse medical care, even though the refusal may result in his or her death, and that unless there are compelling State interests which override the person’s interest in their body’s integrity, as the Mack [2] case says, is that the Court should recognize it. In this case ... [what appellant] is saying, [appellee], is that he recognizes that you are a competent individual and he recognizes that you have not been a troubling impact overall while in this facility.

That is clearly what is being said here is that you have not disrupted the system; is that it is, in fact, raising the question of concern (a) for your health and trying to make sure that you receive the medical treatment that he and the medical providers say are necessary. ... [I]t’s been determined by the doctors that you need this treatment. [M]y concern is as to whether or not the countervailing State interest in this case, as identified by the Court of Appeals, does apply. One of the countervailing factors is preserving your life. The other is around the safety and the safety of others and whether or not it’s there. Well, I’m not hearing that you’re doing this to cause [something to happen] and ... that it will simply pass____The Court’s question of [appellee] is is he trying to kill himself and he said, no, that’s not the case, and so prevention of suicide is not it.

The maintenance of ethical integrity of the medical profession or the medical treatment is the last point of the ²⁷⁵ balancing ... [and] the medical profession has made it clear is that they believe this is needed. I don’t like playing Russian roulette with anyone’s life.... However, on this date, the Court is satisfied that the inmate is aware that he has been advised that the medical treatment that’s being offered to him is appropriate and necessary, and that refusal to receive that medical treatment may be harmful to him. This Court believes that [appellee] is competent, but ill-informed in his own wisdom.

However, the Court denies the request at this time. The motion for permanent injunction is denied. In a written order issued on May 2, 2008, the trial court denied appellant’s request for a permanent injunction and issued a declaratory judgment on May 6, 2008, memorializing the May 1, 2008 oral ruling. The trial court based its declaratory judgment that “the state interests in forcing [appellee] to undergo dialysis does not outweigh [appellee’s] right to refuse medical care” on the following: (1) [Appellee] has been diagnosed with, among other medical conditions, end-stage kidney disease, for which he should receive dialysis three times a week. [Appellee] has refused this treatment.

(2) There has been no argument or suggestion that [appellee] is not a competent adult. (3) [Appellant], in his responsibility to oversee and maintain the proper medical care of prisoners, has petitioned this court requesting permanent injunctive relief. (4) Citing Mack v. Mack, supra, the court concluded that a patient has a right to refuse treatment, but this right is not absolute. This right must be balanced against the state interests of the preservation of life, protection of innocent ²⁷⁶ third parties interests, suicide prevention, and the maintenance of the ethical integrity of the medical profession.

(5) [Appellee] is not contemplating suicide, nor is there evidence that his refusal has caused any disruption in the operation of the prison system, nor is there any indication that he seeks to cause a disturbance. (6) [Appellant] showed proper concern for the negative impact [appellee’s] choice could have upon the prison community, but there has been no evidence presented that [appellee] has made any attempt to disrupt the order of the prison, nor is there any evidence suggesting the actions of [appellee] would cause disruption to the prison community, and no evidence has been presented showing that [appellee’s] choice has harmed the integrity of the medical profession. Appellant timely filed this appeal. On May 5, 2008, appellant filed an Emergency Motion for Injunctive Relief Pending Appeal, requesting a stay of his April 25, 2008 TRO.

On May 6, 2008, we stayed enforcement of the circuit court’s order pending the filing and consideration of appellee’s response to appellant’s motion. Appellee filed a Show Cause Order on July 7, 2008. On July 31, 2008, we denied appellant’s May 5 then emergency motion, but ordered that the stay remain in effect until August 15, 2008. On August 14, 2008, the Court of Appeals denied appellant’s petition for writ of certiorari and motion for injunction pending appeal.

Additional facts will be discussed as warranted, infra. LEGAL ANALYSIS I Appellant contends that the circuit court erred in determining that he could not compel appellee to submit to kidney dialysis and medical treatment. We disagree. Our review of the issue raised in this appeal is pursuant to Md. Rule 8 — 131(c): ²⁷⁷ (c) Action tried without a jury.

When an action has been tried without a jury, the appellate court will review the case on both the law and the evidence. It will not set aside the judgment of the trial court on the evidence unless clearly erroneous, and will give due regard to the opportunity of the trial court to judge the credibility of the witnesses. “The clearly erroneous standard does not apply to the circuit court’s legal conclusions, however, to which we accord no deference and which we review to determine whether they are legally correct.” Cattail Assocs. v. Sass, 170 Md.App. 474, 486 , 907 A.2d 828 (2006). We will “review the trial court’s application of the law to the facts on an abuse of discretion standard.” Porter v. Schaffer, 126 Md.App. 237, 259 , 728 A.2d 755 (1999). A. STATE INTERESTS The circuit court based its determinations on Mack, supra, 329 Md. 188 , 618 A.2d 744 , which addresses the qualified common law right of a competent adult to refuse medical care.

Following the reasoning of the Court of Appeals in Mack , we will “sketch the path of general reasoning from the basic right to the particular application” sought here by the parties. Id. at 210 , 618 A.2d 744 . The “doctrine of informed consent[,] as part of the common law, ... ‘follows logically from the universally recognized rule that a physician, treating a mentally competent adult under non-emergency circumstances, cannot properly undertake to perform surgery or administer other therapy without the prior consent of his patient.’ ” Id. (quoting Sard v. Hardy, 281 Md. 432, 438-39 , 379 A.2d 1014 (1977)). “ ‘The fountainhead of the doctrine ... is the patient’s right to exercise control over his own body, ... by deciding for himself whether or not to submit to the particular therapy.’ ” Id.

(quoting Sard, 281 Md. at 439 , 379 A.2d 1014 ). “A corollary to the doctrine is the patient’s right, in general, to refuse treatment and to withdraw consent to treatment once begun.” Id. (Emphasis added). ²⁷⁸ The right to refuse treatment is not absolute; rather, it is subject to “at least four countervailing State interests: (1) the preservation of life; (2) the protection of interests of innocent third parties; (3) the prevention of suicide; and (4) the maintenance of the ethical integrity of the medical profession.” Id. at 210, n. 7, 618 A.2d 744 (quoting Brophy v. New England Sinai Hosp., Inc., 497 N.E.2d 626, 634 (Mass.1986)). In Mack , the Court of Appeals went on to add: Some courts have held that a person’s right to refuse treatment is based on a federal or state constitutional right of privacy. See, e.g., Rasmussen v. Fleming, 154 Ariz. 207 , 741 P.2d 674, 682 (1987) (federal and state); Bouvia v. Superior Court, 179 Cal.App.3d 1127 , 225 Cal.Rptr. 297, 301 (1986) (federal and state); In re Severns, 425 A.2d 156, 158 (Del.Ch.1980) (federal); In re A.C., 573 A.2d 1235, 1244-47 (D.C.1990) (federal); In re Guardianship of Browning, 543 So.2d 258, 267 (Fla.Dist.Ct.App.1989) (state), aff'd, 568 So.2d 4 (Fla.1990); Brophy, 497 N.E.2d at 633 (federal); Superintendent of Belchertown State School v. Saikewicz, 373 Mass. 728 , 370 N.E.2d 417, 424 (1977) (federal).

Although the United States Supreme Court’s decision in Cruzan [v. Director, Missouri Dep’t of Health], 497 U.S. 261 , 110 S.Ct. 2841 , 111 L.Ed.2d 224 [ (1990) ], made no holding on the subject, all of the justices, save Justice Scalia, either flatly stated or strongly implied that a liberty interest under the Fourteenth Amendment gives rise to a constitutionally protected right to refuse life saving hydration and nutrition. See id. at 278 , 110 S.Ct. at 2851 , 111 L.Ed.2d at 241-42 ; id. at 287 , 110 S.Ct. at 2856 , 111 L.Ed.2d at 247-48 (O’Connor, J., concurring); id. at 304-05 , 110 S.Ct. at 2865 , 111 L.Ed.2d at 257 (Brennan, Marshall, and Blackmun, JJ., dissenting); id. at 331 , 110 S.Ct. at 2879 , 111 L.Ed.2d at 275 (Stevens, J., dissenting). Id. at 210-11, 618 A.2d 744 (internal citations omitted). As in the case sub judice, in Mack , there is no issue that turns on whether the right to refuse treatment is a constitutional or common-law right.

It is sufficient for present purposes to decide this case under the ²⁷⁹ Maryland common-law right of a competent adult to refuse treatment. For cases in which the court found no need to opine beyond a common-law analysis, see Barber v. Superior Court, 147 Cal.App.3d 1006 , 195 Cal.Rptr. 484 (1983); In re Estate of Longeway, 133 Ill.2d 33 , 139 Ill.Dec. 780 , 549 N.E.2d 292 (1989); In re Gardner, 534 A.2d 947 (Me.1987); In re Peter, 108 N.J. 365 , 529 A.2d 419 (1987); In re Conroy, 98 N.J. 321 , 486 A.2d 1209 (1985); In re Storar, 52 N.Y.2d 363 , 438 N.Y.S.2d 266 , 420 N.E.2d 64 , cert. denied sub nom. Storar v. Storar, 454 U.S. 858 , 102 S.Ct. 309 , 70 L.Ed.2d 153 (1981); In re Delio, 129 A.D.2d 1 , 516 N.Y.S.2d 677 (1987). Id. at 211, 618 A.2d 744 .

The principal pillar upon which appellant seeks to distinguish Mack is his claim that the Court of Appeals did not address the unique circumstances involved when the right to refuse medical treatment is being asserted by a prison inmate. Specifically, the circuit court failed to take into account the repercussions that arise in a prison environment when an inmate refuses medical treatment, particularly when that treatment is necessary to protect the inmate from serious bodily injury or death. The circuit court, appellant contends, failed to acknowledge the effect that appellee’s refusal to accept medical treatment has on the prison staff and inmate population. Appellant contends that, contrary to the circuit court’s findings, his position is supported by at least three of the four factors delineated in Mack : “preservation of life,” the “protection of interests of innocent third parties” and the “maintenance of the ethical integrity of the medical profession.” Id. at 210, n. 7 , 618 A.2d 744 . 3 i.

Preservation of Life Regarding the “preservation of life,” Dr. Tadesse Telda, a physician employed by the State’s prison medical contractor, ²⁸⁰ testified that, if appellee did not receive medical treatment and dialysis for his end-stage renal disease and related illnesses, appellee would suffer serious bodily injury or death. Appellant posits that appellee erroneously believes that he does not require dialysis or medical treatment and that he has been falsely diagnosed by his care providers. Appellee’s belief is expressed in the following colloquy: [APPELLEE]: Like I was saying, I don’t want to take dialysis. You know, they say after a few weeks of not taking it, I’ll go through all of these complications, but I haven’t been going through no complications, you know.

I mean, I have refused dialysis before for like months. The professionals, the doctors said I should have been dead, but I.wasn’t. So, I mean, my whole thing is that— THE COURT: Well, why do you think that that didn’t happen, that you didn’t die? [APPELLEE]: Because, obviously, they were wrong. You know, I think— THE COURT: You mean because in the past you didn’t die, they were wrong? [APPELLEE]: I think they were wrong because, for one, all of the complications that I’m supposed to go through, I don’t go through.

I mean, I think I was falsely diagnosed. THE COURT: You think you were falsely diagnosed? [APPELLEE]: Yes. THE COURT: You don’t think you have kidney disease? [APPELLEE]: Yes, I don’t think I have kidney disease. That appellee suffered from kidney disease was established beyond any doubt at the hearing and the trial judge expressly acknowledged that appellee’s failure to accept medical treatment was potentially life-threatening.

In light of the severity of appellee’s condition and his erroneous belief that he was falsely diagnosed, appellant asserts that the “preservation of life” factor supports the State’s interest in compelling appellee to undergo kidney dialysis and other related medical treatment. ²⁸¹ Appellee posits that, under Maryland’s Health Care Decisions Act, an individual who executes an advance directive regarding the withholding or withdrawal of health care has a statutory right to refuse medical care. Md.Code, Health-General (H.G.), § 5-602 (2005 Repl. Vol, 2008 Supp.). 4 See also Mack, 329 Md. at 210-11 , 618 A.2d 744 . This right overlies the common law right to refuse medical treatment and to withdraw consent to such treatment once begun.

Mack, 329 Md. at 210 , 618 A.2d 744 . A written advance directive is valid if signed by the declarant and subscribed by two witnesses. H.G. § 5-602(c)(l). An advance directive becomes effective when conditions specified in the directive are satisfied.

H.G. § 5-602(e)(l). On May 6, 2008, appellee executed a written advance directive stating his desire to refuse dialysis. The directive was signed by appellee, his attending physician and two witnesses. In his directive, appellee acknowledged that cessation of dialysis will result in his death and he took full responsibility for the consequences of his refusal of treatment.

The Maryland Attorney General has stated that individuals may use advance directives “to decide against the use of life-sustaining procedures under three circumstances: ‘terminal condition,’ ‘persistent vegetative state’ or ‘end-stage condition.’ ” 78 Md. Op. Att’y Gen. 208, 211 (June 1, 1993) (citation omitted) (emphasis added). Furthermore, the Maryland Attorney General has identified dialysis as an example of a life-sustaining procedure that may be declined. 79 Md. Op. Att’y Gen. 218 (May 3, 1994).

Appellee’s argument is flawed in that, although he suffers from an “end-stage” disease, his current condition does not effectuate his advance medical directive. H.G. § 5-601 (j) defines an “End-stage condition” as an advanced, progressive, irreversible condition caused by injury, disease or illness: ²⁸² (1) That has caused severe and permanent deterioration indicated by incompetency and complete physical dependence; and (2) For which, to a reasonable degree of medical certainty, treatment of the irreversible condition would be medically ineffective. The Maryland Attorney General has indicated that “end-stage condition” applies to individuals who have suffered severe and permanent generalized infirmity from an untreatable irreversible condition. 78 Md. Op. Att’y Gen. at 212-13.

Although “a patient in end-stage condition does not suffer a total loss of consciousness, ... the condition must have caused ‘severe and permanent deterioration.’ ” Id. Furthermore, the “hallmarks of this deterioration ... refers to the patient’s inability to understand or evaluate treatment issues.” Id. Appellee is a competent adult for whom medical treatment is effective. Furthermore, the evidence does not indicate that appellee suffers from a “permanent generalized infirmity” or that he cannot understand or evaluate treatment issues.

Appellee’s filing of an advanced medical directive, therefore, is ineffectual. 5 Notwithstanding his deficient advance medical directive, appellee contends that, when a competent adult refuses medical treatment, “the State’s interest in preserving the particular patient’s life will not override the individual’s decision.” Norwood Hosp. v. Munoz, 409 Mass. 116 , 564 N.E.2d 1017, 1023 (1991). Even in cases where a patient’s condition is curable, the State’s interest in preserving life is diminished “because the life that the [SJtate is seeking to protect in such a situation is the life of the same person who has competently decided to forgo the medical intervention.” Id. (internal citation omitted). See also In re Guardianship of Grant, 109 Wash.2d 545 , 747 P.2d 445, 451 (1987) (State’s interest in the preservation of life of inmate suffering from terminal illness can diminish in ²⁸³ cases where treatment is invasive and postpones death).

The State’s duty to preserve life must also “encompass a recognition of an individual’s right to avoid circumstances in which the individual himself would feel that efforts to sustain life demean or degrade his humanity.” Brophy, 497 N.E.2d at 635 . The circuit court found that appellee is a competent adult who, notwithstanding being “ill-informed in his own wisdom,” had expressly stated his desire to forego medical treatment that he finds objectionable. Although appellant advances a legitimate concern relating to the “preservation of life” factor, such an interest is not sufficient to overcome a competent adult’s choice to refuse medical treatment. Notably, appellee’s skepticism about his condition arises from the information that was provided to him from medical professionals that turned out to be inaccurate; namely, that he would immediately suffer severe symptoms if he discontinued dialysis, which subsequently did not happen when appellee ceased dialysis for weeks at a time.

We note the same concerns as the circuit court regarding appellee’s understanding as to the seriousness of his condition, but such concerns are insufficient for us to divest a competent adult of his right to refuse medical treatment. ii. Interests of Third Parties The second Mack factor relates to the protection of the interests of innocent third parties from the potential harm caused by appellee’s death. According to appellant, the Department of Corrections (DOC) confines 23,000 prison inmates and employs 6,500 individuals. Appellant asserts that inmates and employees bear the brunt of disruptions to the safety and security of the State’s prisons and that appellee’s refusal to accept medical treatment will result in such a disruption.

Consequently, appellant posits that the safety and “protection of the interests of innocent third parties” under Mack — here ²⁸⁴ the State’s inmates and employees — support compelling appellee to accept medical treatment. Appellant fails to provide any authority that would support an application of the “interests of innocent third parties” factor to the present circumstance. In determining whether a state has a compelling interest in protecting innocent third parties, a court typically considers “the interests of the patient’s dependents and family members.” McNabb v. Dep’t of Corr., 163 Wash.2d 393 , 180 P.3d 1257, 1266 (2008). “Generally, this concern [about protecting innocent third parties] arises when the refusal of medical treatment endangers public health or implicates the emotional or financial welfare of the patient’s minor children.” Thor v. Superior Court, 5 Cal.4th 725 , 21 Cal.Rptr.2d 357 , 855 P.2d 375, 387 (1993). See also Polk County