Substituted Judgment Guidelines for Withdrawal of Life-Sustaining Treatment in Persistent Vegetative State: IN RE JOBES

Substituted Judgment Guidelines for Withdrawal of Life-Sustaining Treatment in Persistent Vegetative State: IN RE JOBES

Introduction

The landmark decision in In the Matter of Nancy Ellen Jobes, 108 N.J. 394 (1987), rendered by the Supreme Court of New Jersey, addresses the complex and sensitive issue of withdrawing life-sustaining medical treatment from an individual in a persistent vegetative state (PVS). This case builds upon previous precedents, notably IN RE QUINLAN and In re Conroy, to establish clear guidelines and procedures for surrogate decision-making in situations where a patient cannot express their medical preferences.

Summary of the Judgment

Nancy Ellen Jobes, a 31-year-old woman, sustained irreversible brain damage resulting in a persistent vegetative state following a surgical complication. Her husband and parents sought to withdraw her jejunostomy tube (j-tube), which provided her with nutrition and hydration. The nursing home refused on moral grounds, prompting John H. Jobes, III, to petition the court for authorization to remove the j-tube. The Superior Court found that there was clear and convincing evidence that Mrs. Jobes would not have wanted to continue artificial feeding under her current condition. The Supreme Court of New Jersey affirmed this decision, establishing guidelines for surrogate decision-making in non-elderly PVS patients without clear prior expressions of their medical wishes.

Analysis

Precedents Cited

The judgment extensively references several key cases and reports that have shaped the legal landscape surrounding end-of-life decisions:

  • IN RE QUINLAN, 70 N.J. 10 (1976): Established the right to privacy and the adoption of the substituted judgment standard for withdrawing life-sustaining treatment.
  • In re Conroy, 98 N.J. 321 (1985): Further refined the standards for assessing evidence of a patient's wishes and emphasized a clear and convincing evidence standard.
  • In re Peter, 108 N.J. 365 (1987): Set forth guidelines for withdrawing life-sustaining treatment from elderly patients in PVS, which this case builds upon for non-elderly patients.
  • President's Commission Report on Deciding to Forego Life-Sustaining Treatment (1983): Provided ethical frameworks guiding medical and legal professionals in end-of-life care decisions.

These precedents collectively underscore the importance of patient autonomy, the role of surrogate decision-makers, and the necessity for clear evidence when determining the withdrawal of life-sustaining treatments.

Legal Reasoning

The Court's primary legal reasoning centers on the principle of self-determination, emphasizing that an incompetent patient's right to refuse or accept life-sustaining treatment should be respected and executed by surrogate decision-makers based on substituted judgment. The judgment delineates:

  • The surrogate's role in determining the patient's wishes when the patient lacks capacity.
  • The requirement of clear and convincing evidence to support the conclusion that the patient would have desired the withdrawal of treatment.
  • The necessity of obtaining confirmation from at least two independent neurologists regarding the patient's PVS status and prognosis.
  • The affirmation that institutions like nursing homes cannot unilaterally deny the withdrawal of life-sustaining treatment without infringing upon the patient's rights.

By emphasizing the family's intimate knowledge of the patient's values and beliefs, the Court reinforced the substituted judgment standard as the most appropriate method for surrogate decision-making in the absence of explicit directives from the patient.

Impact

The decision in IN RE JOBES has profound implications for future cases involving the withdrawal of life-sustaining treatment:

  • Expanded Guidelines: Extends the substituted judgment framework to non-elderly patients in PVS, ensuring consistent application across different patient demographics.
  • Institutional Responsibilities: Mandates that nursing homes and similar institutions comply with the withdrawal of treatment requests, preventing arbitrary denial of patient rights.
  • Medical Confirmations: Introduces the necessity for multiple independent medical confirmations, enhancing the reliability of PVS diagnoses and protecting against premature or unwarranted treatment termination.
  • Legal Precedent: Strengthens the legal foundation for patient autonomy in medical decision-making, influencing legislations and policies in New Jersey and potentially other jurisdictions.
  • Public and Ethical Discourse: Stimulates ongoing discussions about ethical standards, surrogate roles, and the balance between individual rights and institutional policies in end-of-life care.

Complex Concepts Simplified

Persistent Vegetative State (PVS)

A PVS is a condition in which a patient has lost cognitive functions and awareness of the environment but maintains automatic bodily functions such as breathing, circulation, and digestion. Unlike brain death, PVS patients retain some brain activity related to these basic functions.

Substituted Judgment

This legal doctrine allows a surrogate decision-maker, typically a family member, to make medical decisions on behalf of an incompetent patient based on what the patient would have wanted if they were competent. It aims to honor the patient's autonomy and prior expressed wishes.

Clear and Convincing Evidence

A high standard of proof required in legal proceedings, higher than preponderance of the evidence but lower than beyond a reasonable doubt. In the context of withdrawing life-sustaining treatment, it necessitates strong, credible, and unambiguous evidence that the patient would have desired the withdrawal.

Jejunostomy Tube (j-tube)

A medical device inserted through the abdominal wall into the jejunum (part of the small intestine) to provide nutrition and hydration directly, bypassing the stomach and esophagus.

Guardian ad Litem

A guardian appointed by the court to represent the best interests of an incompetent person in legal proceedings, ensuring that the individual's rights and welfare are adequately protected.

Conclusion

The Supreme Court of New Jersey’s decision in IN RE JOBES solidifies the substituted judgment standard as the cornerstone for surrogate decision-making in the withdrawal of life-sustaining treatment for patients in a persistent vegetative state without clear prior directives. By mandating robust medical verification and affirming the role of family as surrogate decision-makers, the Court ensures that patients' autonomy and dignity are upheld while providing necessary safeguards against potential abuses.

This judgment not only advances legal clarity in end-of-life decisions but also fosters ethical integrity in medical practice by balancing respect for individual autonomy with institutional responsibilities. As society continues to grapple with the complexities of medical ethics and patient rights, IN RE JOBES serves as a pivotal reference point for protecting vulnerable patients and guiding compassionate, informed medical and legal practices.

Case Details

Year: 1987
Court: Supreme Court of New Jersey.

Judge(s)

The opinion of the Court was delivered by GARIBALDI, J. HANDLER, J., concurring.[fn1] [fn1] This concurring opinion applies as well to In re Farrell,108 N.J. 335 (1987) and In re Peter, 108 N.J. 365 (1987). POLLOCK, J., concurring. O'HERN, J., dissenting.

Attorney(S)

Raymond M. Tierney, Jr., argued the cause for appellant Lincoln Park Nursing and Convalescent Home ( Shanley Fisher and Traynor Hogan, attorneys; Raymond M. Tierney, Richard E. Brennan, Richard J. Traynor, Vincent J. Infinito and Lisa M. Goldman, on the briefs). Alfred A. Slocum, Public Advocate, argued the cause for appellant pro se ( Alfred A. Slocum, attorney; Denise L. Sanders, Assistant Deputy Public Advocate, on the briefs). Richard Kahn, guardian ad litem of Nancy Ellen Jobes, argued the cause for respondent pro se ( Richard Kahn, attorney; Richard Kahn and Lauren V. Kessler, on the brief). Paul W. Armstrong argued the cause for respondent John H. Jobes, III ( Paul W. Armstrong, attorney; Paul W. Armstrong and Edward J. O'Donnell, on the brief). Steele R. Chadwell, General Counsel, argued the cause for amicus curiae Office of the Ombudsman for Institutionalized Elderly of the State of New Jersey ( Steele R. Chadwell, attorney; James E. Madden and Louis G. Karagias, on the brief). Richard P. Maggi submitted a brief on behalf of amici curiae Board of Directors of the United Handicapped Federation and the Association for Retarded Citizens/Minnesota ( McDermott, McGee Ruprecht, attorneys). Charles C. Deubel, III, submitted a brief on behalf of amicus curiae Concern for Dying. Charles J. Farley, Jr., submitted a brief on behalf of amicus curiae National Association of Prolife Nurses ( Farley Farley, attorneys). William F. Bolan, Jr., submitted a brief on behalf of amicus curiae New Jersey Catholic Conference. William I. Strasser submitted a brief on behalf of amicus curiae New Jersey Chapter of American College of Physicians ( Donohue, Donohue, Costenbader Strasser, attorneys). John R. Heher submitted a brief on behalf of amicus curiae New Jersey Hospital Association ( Smith, Stratton, Wise, Heher Brennan, attorneys; John R. Heher and Wendy L. Mager, on the brief). Anne M. Perone submitted a brief on behalf of amicus curiae New Jersey Right to Life Committee, Inc. Fennella Rouse and Elena N. Cohen, members of the New York bar, and Jo Anne C. Adlerstein submitted a brief on behalf of amicus curiae Society for the Right to Die, Inc. ( Stern, Dubrow Marcus, attorneys).

Comments