01.21.15

WHEN MATURITY MATTERS: CASSANDRA’S CASE

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Image courtesy of the New York Times

Image courtesy of the New York Times


On January 8th, Connecticut’s Supreme Court ruled that a 17-year-old named Cassandra does not have the right to refuse cancer treatment that her doctors believe will save her life. Cassandra learned from the doctors at Connecticut Children’s Medical Center in Hartford that she had Hodgkin’s lymphoma, a form of cancer that is common in children, in September 2014. According to her doctors, Cassandra has an 85% chance of survival if she receives chemotherapy, but that she will not survive more than two years without it.
However, Cassandra has consistently expressed her desire to forego chemotherapy, voicing her concerns about the long-term effects of the treatment, including in an interview with a local Connecticut TV station. Her mother, Jackie Fortin, has supported Cassandra’s decision. After Cassandra missed several appointments for treatment, Connecticut’s Department of Children and Families (DCF) removed her from her mother’s care and put her into temporary state custody, where she began to receive chemotherapy.

The legal battle between Cassandra and her mother on one side and the state of Connecticut on the other reached the Connecticut Supreme Court in late December 2014. The Court ultimately found that the state of Connecticut did not violate Cassandra’s right to bodily integrity by forcing her to receive medical treatment against her will.
Were Cassandra an adult, she would have been able to refuse life-saving medical treatment by exercising her right to bodily integrity. But Cassandra does not turn 18 until September 2015 and, as a minor, she is presumed to lack the legal capacity necessary to make decisions about her medical care.
In the U.S., a parent’s right to the care and custody of a child includes making decisions for minor children on a wide range of issues, including what health care they will or will not receive. In order to be allowed to make their own decisions in such matters, minors in the U.S. must turn to emancipation rules or other legal standards that allow for discretionary assessments of decisional capacity.
Cassandra’s appeal to the Connecticut Supreme Court relied on the “mature minor doctrine”, which, in some states, permits adolescents who demonstrate sufficient maturity to consent to certain medical treatments. The mature minor doctrine can be traced to the 1986 House of Lords decision Gillick v. West Norfolk and Wisbech Area Health Authority. Gillick developed a test for legal competency that required a minor to show “sufficient understanding and intelligence to enable him or her to fully understand what is proposed”. States in the U.S. have adopted a similar standard for legal competency. Kansas, for example, defines maturity as having “the intellectual capacity, experience, and knowledge necessary to substantially understand the situation at hand and the consequences of the choices that can be made”.
Mature minor statutes account for the fact that childhood and adolescence are periods of gradual development. They allow for contextual factors to be weighed on a case-by-case basis. But the flexible nature of these statutes also has an important drawback, namely that the outcome of the assessment is often subject to discretion or bias of the service provider or judge.
The mature minor doctrine is flexible when it comes to the requisite level of maturity a minor is expected to exhibit in a given case. In the past, the majority of mature minor cases involved minors’ ability to consent to treatment, particularly sexual and reproductive health services. Far fewer cases have dealt with their ability to refuse treatment, including life-saving or life-sustaining care. It is still too early to tell whether service providers and judges will consistently require minors to exhibit a higher level of maturity under these circumstances, given the serious consequences of such decisions.

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The views reflected in this blog are those of the individual authors and do not necessarily represent those of the O’Neill Institute for National and Global Health Law or Georgetown University. This blog is solely informational in nature, and not intended as a substitute for competent legal advice from a licensed and retained attorney in your state or country.

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