UPDATE (April 28, 2015): After her request to refuse chemotherapy was denied in January, Cassandra was released from the hospital yesterday, the Associated Press reports. Doctors say her Hodgkin's lymphoma is in remission; she received 6 rounds of chemotherapy that will give her an 85% chance of survival.
Tomorrow the Connecticut Supreme Court will hear the case of a 17-year-old girl currently being held in a hospital and receiving chemotherapy against her will. The plaintiff, referred to in court papers as Cassandra, is asking for the chance to be considered mature enough to refuse lifesaving treatment, the Associated Press reports.
Cassandra was diagnosed with Hodgkin's lymphoma in September and doctors told her that her chances of survival with chemotherapy were 80 to 85%. Without the treatment, she would likely die within two years.
But the teen decided against chemotherapy, and her mother, who is her sole guardian, supported her decision. Before they could seek a second opinion, Cassandra's mother told the Hartford Courant, a doctor at Connecticut Children's Medical Center reported them to the state Department of Children and Families (DCF) as a possible case of parental medical neglect.
Court documents state that Cassandra's medical team became concerned when her mother repeatedly did not bring her in for appointments and criticized their diagnoses and methods of care.
The state intervened, and ordered that Cassandra follow her doctors' orders. After just two sessions of chemotherapy, however, Cassandra ran away from home. When she returned, she was removed from her mother's care and placed in state custody, and has been forced to undergo treatment from a guarded hospital room.
DCF has since issued a statement saying that, "[e]ven if the decision might result in criticism; we have an obligation to protect the life of the child when there is consensus among the medical experts that action is required."
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Attorneys representing Cassandra and her mother are asking the Connecticut Supreme Court to adopt a "mature minor" doctrine, which would allow the state to decide on a case-by-case basis whether people under the age of 18 should be allowed to make life-and-death decisions about their own bodies.
"The rights of adults to consent or refuse medical care has been considered fundamental in American law pretty much as long as we've been a nation," Cassandra's appellate attorney Joshua Michtom told Health. The mature minor doctrine, he says, extends that right to teenagers who are found to have the maturity and understanding to exercise it.
Similar laws have been adopted by several states—including Illinois, Maine, and Massachusetts—and rejected by one (Texas), according to a brief filed by the American Civil Liberties Union of Connecticut and reported by the AP.
"Our laws make all kinds of exceptions for people under 18," Michtom says. "They can donate blood, they can get contraception, they can get addiction treatment, all without parental consent. They can also be tried as adults for certain crimes. Our laws recognize that maturity doesn’t happen from one day to the next—it’s a developing faculty, and sometimes, 18 actually isn’t the magic number."
Cassandra and her attorneys hope the state Supreme Court sends this case back to juvenile court for a full hearing on the question of her maturity. There, Michtom says, she could present evidence to convince a judge that she is able to make this decision for herself.
Of course, such a decision would have implications beyond just Cassandra. "DCF, hospitals, parents, and teenagers would know where Connecticut law stands on their ability to consent to or refuse treatment," says Michtom. "Hopefully, that would mean that no teenager would ever again be removed from her home and forced to undergo treatment in a situation like this."
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A decision in Cassandra's favor could also affect teens who refuse medical care for other reasons, says Arthur Caplan, PhD, director of the division of medical ethics at NYU Langone Medical Center.
"There could be 17-year-olds who are anorexic and say they don't want to eat, or who are depressed and say they don't want help," he says, "and the state may then have to honor those kids, as well." A court would still, however, need to find that these individuals were mentally competent.
Cassandra has not given interviews since being put in state custody, and Michtom says most of her contact with the outside world has been through her lawyers. Her mother Jackie Fortin has told news outlets that their decision is not based on religion, and implied that Cassandra sees chemotherapy as toxic—not just for cancer, but for the rest of her body, as well. Fortin said in a Hartford Courant video that her daughter "may not be able to have children after this because it affects everything in your body."
Even if her opposition were of a religious nature, says Caplan, the state's decision would have likely been the same. Historically, it is illegal for families who don't believe in medical intervention to impose those beliefs onto their children in potentially lifesaving situations. (In a 1989 Illinois case, however, the mature minor doctrine was used to successfully argue for a 17-year-old Jehovah's Witness who refused blood transfusions.)
In this case, the court will want to figure out exactly why Cassandra is refusing treatment. "That's the real moral puzzle," says Caplan. "Obviously it's tough to go through this treatment, but most people would say it's worse to be dead. So they're going to try learn what else might be going on: Is the mother souring the daughter's opinions? Does the daughter have some other agenda? These are the important questions, not just how old she is."
Caplan thinks the court is likely to rule in the state's favor, since chemotherapy is a proven treatment that will almost certainly save Cassandra's life and because she could, one day, look back and be grateful. But even if the state does win, curing Cassandra won't necessarily be easy.
"It's not easy to give treatment to a 17-year-old who's physically fighting it," he says. "Getting the court order is helpful, but what you really want to do is change the patient's mind."
The state could attempt to do this by having Cassandra meet other young people who've gone through chemotherapy, or having her meet with a social worker or chaplain she can establish trust with, Caplan says. "Or they may even try a little negotiation: It wouldn't be ideal, but maybe they agree to treatments every two weeks instead of every week."
Connecticut Children's Medical Center, where Cassandra is being held, says it is working closely with DCF, as required by law. "Connecticut Children's is and always will be committed to providing all children with the highest quality and most appropriate care possible," the hospital's Corporate Communications Director Bob Fraleigh wrote in a statement obtained by Health.
Because of Health Insurance Portability and Accountability Act (HIPAA) guidelines and out of respect for Cassandra and her family, the hospital will not comment on specifics of her situation. "Later this week, the state Supreme Court will hear arguments concerning this very important case," Fraleigh's statement adds, "and we look forward to their involvement and guidance."