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Competency to refuse lifesaving treatment: valuing the nonlogical aspects of a person's decisions.

When he was thirty-one years old, Kenneth Bergstedt filed his petition requesting confirmation of his "right to die."(2) Kenneth had been afflicted with quadriplegia as a result of a swimming accident twenty-one years earlier, and for his entire post-accident life he had been dependent on respirator support and the personal care of his father. Although Kenneth was not likely to die from his condition in the near future, his condition was irreversible and not likely to improve. Faced with the imminent death of his terminally ill father, Kenneth sought court assurance that he could have his respirator removed "by one who could also administer a sedative and thereby relieve the pain" that might otherwise precede his death. Kenneth also sought assurance that his actions would not be deemed suicide.(3) As a part of the petitioning process, Kenneth had been examined by a psychiatrist, who found that Kenneth was "competent and able to understand the nature and consequences of his decision."(4) Ultimately, Nevada's Supreme Court affirmed the district court's decision granting Kenneth's petition.(5) The supreme court ruled that competent adults irreversibly sustained by artificial life support and enduring physical and mental pain and suffering had the right to terminate treatment. Under such circumstances, the patient's right to refuse or terminate life-sustaining treatment would override competing state interests in preserving life;(6) and the exercise of the right would not be suicide.(7) A court decision recognizing a competent patient's right to terminate treatment from a life-sustaining respirator is not new or surprising.(8) Beginning with the Quinlan(9) decision in 1976, courts have accepted the principle that a patient retains the right to refuse treatment, even when halting that treatment would result in the patient's death. Equally unsurprising is a ruling that favors patient treatment choices over state interests in preserving life and preventing suicide. What is surprising about Bergstedt and similar decisions is the court's abandonment of antisuicide policies by finding that the decisions and acts of patients in Kenneth's position would not constitute suicide. It is true that earlier court opinions have held that deaths resulting from the refusal of life-sustaining treatments were not suicides.(10) Those earlier opinions, however, approved treatment refusal or removal when the patient's condition was terminal,(11) when the patient was in a persistent vegetative state,(12) or when the patient suffered such physical discomfort that prevention of suffering justified removal of the treatment.(13) In Bergstedt, the court recognized that Kenneth's suffering was predominately emotional, not physical.(14) Focusing solely on cognitive aspects of competency, the court then ruled that Kenneth's conduct was not suicide.(15) The Nevada Supreme Court's "no suicide" finding relieved it from addressing the tension inherent between the patient's right to determine treatment and the state's antisuicide policy, particularly when the patient's medical condition did not come within recognized exceptions to the antisuicide policy. The court's decision unnecessarily and unwisely ignored noncognitive elements of decisionmaking. In its analysis, merely understanding the nature and immediate consequences of the decision constituted competency. No inquiry into the patient's psychological condition and motivation was required. This article recommends that a competency determination should evaluate both cognitive and noncognitive motives of patients who refuse life-sustaining treatment. Specifically, this article argues that states have an antisuicide interest in preventing suicides caused by mental illnesses. Protection of that antisuicide interest also requires evaluation of the patient's psychological state and motives as a part of the competency determination for patients who refuse life-sustaining treatments. …