Should a 17-year-old be allowed to choose death?

Cassandra C., pictured here with her mother Jackie Fortin, is being forced by the state of Connecticut to undergo chemo against her will. But the odds are pretty high that it would save her life. (Photo: CBSTV) 

Does a 17-year old have the right to not only make choices in regards to her own medical treatment, but to do so in a way almost guaranteed to end in death?

This is the question that was just decided in Connecticut, where the state has taken custody of a 17-year old resident who is refusing chemotherapy treatment for her Hodgkin lymphoma.

The young woman, identified in court documents as Cassandra C., will turn 18 in September of 2015. Cassandra’s mother, Jackie Fortin, explained her daughter’s decision to local reporters, saying, “She has always — even years ago — said that if ever she had cancer … she would not put poison into her body.” Attorneys for the family have also made clear that Cassandra is not refusing treatment based on religious reasons and the family has also made clear that Cassandra has their full support.

The Connecticut Supreme Court ruled that state officials are not violating the young woman’s rights by forcing her to receive the chemotherapy treatment she does not want to receive.

A synopsis of the case by Fox news. 

A public defender with the state represented Cassandra and filed an emergency appeal with the Connecticut Supreme Court to determine whether Cassandra should be allowed to make her own decisions about her body, medical treatment, and, essentially, right to die, according to the “mature minor doctrine” recognized by six other states plus the District of Columbia that allow 16- and 17-year old minors to be assessed to prove they are mentally mature enough to make their own medical decisions.

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“Give us the chance to prove that she has the maturity to do this,” Joshua Mitchum, Cassandra’s attorney, said in a statement about their now-failed appeal. “One has a right to bodily integrity. It doesn’t matter if it’s harmful. An adult’s right to refuse care is without limitation, provided they’re not incompetent.”

The American Civil Liberties Union (ACLU) also filed an amicus brief in this case, supporting Cassandra’s decision and the mature minor doctrine, stating that “The appeal … involves a grave threat to one of our most basic civil liberties: the right to bodily integrity.”

Connecticut’s Department of Children and Families (DCF) argued otherwise — and won. In an earlier statement, the DCF said “When experts, such as the several physicians involved in this case, tell us with certainty that a child will die as a result of leaving a decision up to a parent, then the department has a responsibility to take action.”

Jackie Fortin and her daughter, Cassandra. 

However, a 17-year old is not a 5-year old, raising questions on whether an almost-arbitrary numerical cut-off is appropriate in determining whether an individual of sound mind has not only the ability but the right to make decisions in regards to her own body and life.

While both sides took clearly divided stands on whether a 17-year old should be able to choose to die, “this is a really complex case,” notes Art Markman, PhD, a psychologist with the University of Texas.

While many kinds of cancers have a low success rate in terms of chemotherapy treatment, Hodgkin lymphoma such as Cassandra’s is successfully treated with chemo 85 percent of the time when caught and treated early on, as would be the case in Cassandra’s treatment.

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“Hodgkin lymphoma is a very treatable cancer,” says Rohan Ramakrishna, MD, a neurosurgeon and surgical neurooncologist at Weill Cornell Medical College and New York Presbyterian Hospital. He notes that “to not want to pursue any therapy at all” isn’t necessarily a “rational” choice given the success rates of treatment with this type of cancer. “It would be one thing if someone has recurrent cancer, isn’t responding to chemotherapy,” says Ramakrishna, but as this is not the situation in Cassandra’s case, “to not want to pursue any therapy” is an unusual choice within the norms of “American-style medicine.”

“On the other hand,” Ramakrishna adds, “Everyone is very individual in terms of what their own understanding is of their own disease…and what their values are when it comes to life and end-to-life, and so if you are thoughtful about it, there really is no difference between being seventeen and eighteen….People make very rational, self-informed decisions when they’re very young, and then there are people who are much older who make really irrational decisions, and everything in between.”

The psychological state of teens is notoriously “short-term focused” when it comes to their decision making,” says Markman. “A teen may also be so focused on the negatives associated with treatment, that it is important to get them to consider the long-term benefits of treatment — this is particularly true for cancers that are highly treatable.”

It is also important to remember, as Markman notes, that “[i]n the US, we tend to focus on longevity rather than quality of life, and so we often question people’s decisions to forego treatment even if that will ultimately give them a better quality of life.” Agrees Ramakrishna, “Certain people value — or don’t value — their quality of life and want no quality of life diminishment that would be brought on by aggressive therapy….They just want to spend their days without the side effects of therapy, but with pain control, etc.”

Markman says that in his opinion, “teens should engage with parents and other adults in helping them to make these complex decisions. After all, many adults look back on things they did as teens and realize that with the benefit of adult perspective, many of the choices they made as a teen were things they would have done differently.”

However, he points out that individual feelings in regards to whether the state or Cassandra should ultimately be the decision-maker in this case are rooted in a “tendency of people in this culture to want to take any means to avoid death, without necessarily thinking about the costs of the treatment to the living.”

“When you’re a patient in this situation,” Ramakrishna notes, “You’re never really fully informed — you can’t possibly be as informed as your physician or your oncologist who has maybe been doing this for thirty years. I think that being informed as a patient is very difficult, in the larger sense.” The question, then, is whether “in the smaller sense, are you aware of the fact that your disease has reasonably good treatment options and are your refusing them” for personal reasons.

Cassandra’s case is starkly reminiscent of the recent coverage around the death of Brittany Maynard, the 29-year old death-with-dignity advocate who moved to Oregon after being diagnosed with a fatal brain tumor so that she would be able to legally, medically end her life on her own terms.

"I’m not killing myself,” Maynard had told NBC News during an interview on October 9, about a month before ending her own life. “Cancer is killing me. I am choosing to go in a way that is less suffering and less pain. Not everybody has to agree that it’s the right thing, because they don’t have to do it. And it’s an option that for me has provided a lot of relief…The thought that I can spare myself the physical and emotional lengthy pain of that, as well as my family, is a huge relief."

The quality of life issues in Maynard and Cassandra’s case are notably different, however, as Maynard had been diagnosed with an incurable and fatal tumor, whereas Cassandra’s prognosis is seemingly excellent should she receive chemotherapy treatment.

And yet, both Maynard and Cassandra are alike in the fact that they are both clearly not children, but women making decisions on their own terms, based on their own personal values and points-of-view in regards to medicine, life, and death.

“If she’s fully adult enough in the next twelve months when she turns eighteen,” Ramakrishna says regarding Cassandra’s case, “it’s not like some great chunk of new maturity is going to be gained” before then. “Forcing someone who is of sound mental ability to accept treatment that he or she doesn’t want, doesn’t make sense in terms of a civil liberty and autonomy point of view.”

WHAT DO YOU THINK: Should Cassandra be allowed to choose her fate, or is did the the Connecticut Supreme Court make the right decision? Leave a comment and tell us.