Toward a Consistent End-of-Life Ethic:
The “Right to Refuse” Care for Competent
and Incompetent Patients
I HAVE SUGGESTED that life is a fundamental good, that it should not be intentionally destroyed, and I have suggested, too, how that principle might apply to the assisted suicide and euthanasia debate. Before closing, however, one might reasonably ask what this inviolability-of-life principle might say about still other, far more common, yet often very difficult, end-of-life scenarios. Along the way, for example, we have discussed the decision to withdraw or reject life-sustaining care by competent patients; how, we might ask, does the inviolability-of-life principle apply in these important and everyday cases? Similarly, as I alluded to previously,1 courts have sought to give meaning to the right to refuse treatment even for patients who have never been capable of making treatment decisions for themselves (e.g., infants) and for those who have lost their ability to do so (e.g., Alzheimer's patients and victims, like Terry Schiavo, of accidents that have grievously impaired their mental faculties), often permitting a guardian to decide for the patient on a proxy basis. Indeed, most of the reported right to refuse treatment cases in America have arisen in just these circumstances. But the question how far guardians may go in refusing lifesustaining care for incompetent wards who have made no living will and given no oral directives is increasingly a source of litigation in American (and English) courts. When may guardians discontinue basic (e.g., food and water) treatment? On what authority may they act? How should their decisions be reviewed when under legal challenge? The case law, to date, has produced inconsistent and often underreasoned results in these important cases; before closing, I briefly outline some of the leading cases and suggest the beginnings of potential answers to each of these questions.