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The main ethical issue in this article resolves around whether an individual should be

forced against his/her will into receiving medical treatment.


In this article, Cassandra C., a 17-year-old in Connecticut with stage 3 Hodgkins
lymphoma disease, has been placed under temporary custody of the Connecticut
Department of Children and Families (DCF) for refusing chemotherapy. Having been granted
the authority by the state to make medical decisions on the behalf of Cassandra, DCF
subsequently forced Cassandra to undergo treatment, which consisted of her being strapped
on a bed and sedated. She was also separated from her mother (Fortin) and had her phone
confiscated, leaving communication between mother and daughter to supervised visitation.
Doctors advised that without medical aid, it is highly likely that Cassandra would die.
However, with medical aid, Cassandra has an 85% chance of survival. Cassandra however
has refused treatment, as she believes that chemotherapy would cause more harm than good
to her body. As Cassandra is still considered a minor, she has been deemed to be unaware of
the severity of her prognosis. Thus, granting her parents the legal authority to make health
care decisions on her behalf. Fortins decision was to respect Cassandras choice to refuse
treatment. However, the state has deemed such a decision to be of threat to Cassandras life.
As a result, the state has intervened, and forcibly administered treatment on Cassandra.
The relevant stakeholders to be discussed would be the state, Cassandra, her doctors,
Fortin and the public. In refusing treatment, it is highly likely that Cassandra would die. Thus,
by adopting the Kantian approach, we see that the state is acting from a moral duty to
protect and preserve the life of Cassandra. Thus by intervening, the state could be said to be
demonstrating benevolence by preventing Cassandra from committing suicide. In addition,
the states fulfills the principle of humanity, as they are not using Cassandra as a means to
test out a new medical treatment (end), but is instead using a medical treatment as a means
towards the goal of curing Cassandra. With regards to the principle of universality,
assuming that the state would only intervene with an individuals decision if it were either
against the notion of life preservation, or if both the individual and the parent is deemed to
be incapable of comprehending the effects of their decision, we can will it to become a
universal law. Having said that, the state finds itself in conflict with the principle of individual

autonomy or the freedom to act. Does this mean that the state is acting in an unethical
manner?
Comparing Cassandras case to a case where an individual is about to jump off a
building, should the state accept the individuals decision to commit suicide? Both cases
consist of life-threatening decisions, and in both cases, the state would intervene and
preserve the life of the individual. Unfortunately, at the same time, the state would also be
stripping him/her of autonomy. From the analogy, we see that the state ranks preservation of
life above autonomy of an individual. It is however a positive that the state demonstrates
ethical consistency in its decision making. In addition, if we focus solely on the intention of
the state, which is to preserve the life of Cassandra, then the action of the state is ethical,
despite any potential negative consequences of the states action. Nonetheless, as there
exist a conflict between the Kantian imperatives, I shall not be adopting the Kantian approach
to determine the morality of the states decision.
According to Nozicks Entitlement Theory, each individual is free to pursue his/her
own interests with minimum government intervention. In the context of Cassandras case, as
the impact of the states decision would be on her body, and that her interest lies in refusing
chemotherapy, she should be deemed to be acting ethically in her decision to refuse
treatment. Conversely, the state would be deemed to be acting unethically in their action of
denying Cassandra of her prerogative to act within her self-interest. The state would not fulfill
the principles of Just Original Acquisition and Transfer, and thus would have to rectify the
situation by returning Cassandra her autonomy.
From the perspective of Rawls Justice as Fairness, the state has breached the
principle of equal liberty by denying Cassandra her right to exercise free will. Thus, their
action of forcing Cassandra into undergoing medical treatment should be considered as
unethical.
With a utilitarian approach however, it is complicated, as it is difficult to quantify the
costs and benefits that Cassandra would incur. We have to compare the happiness that
Cassandra might experience after the treatment, against the pain that she incurs during the
treatment. In undergoing enforced treatment, Cassandra would have to suffer the

excruciating physical pains of chemotherapy, the emotional trauma of lost autonomy, and
the pains of separation from Fortin. In addition, she could also have to live with future
implications on her health. On the other hand, in receiving treatment, Cassandra has an 85%
chance of survival.
Conversely, by refusing treatment, Cassandra would receive the happiness of being the
author of her own life; yet suffer the deterioration of her health. As the treatment would
only last a maximum of 8 months (months remaining before Cassandra can legally refuse the
treatment), does the happiness of being alive necessarily outweighs the pain of the 8
months? Expert medical professionals have declared an 85% survival rate for Cassandra.
However, survival does not necessarily mean quality of life. After the treatment, Cassandra
could still live a life that is of pain and suffering. In addition, she would continue to live with
the emotional scars of the enforced treatment. However, from another perspective, if
Cassandra were to refuse treatment, the amount of happiness that she would incur, would be
limited by her remaining lifespan. On the other hand, if Cassandra was forcibly treated and
survives, even if she perceives the entire process as a suffering, she could still seek out new
pleasure through new experiences for the rest of her life. If Cassandra was forced to receive
chemotherapy, when the physical pains of treatment come, what can Cassandra use to
motivate her to endure the pain? Would the pain of chemotherapy increase exponentially,
given a mindset that believes that the pain of treatment was brought upon her and not
something that she has willed? It is probable that even though Cassandra would experience
deteriorating health from her refusal of treatment, she would still be experiencing less pain
than if she were receiving treatment. This stems from her ability to justify to herself that she
was the one who chose to be in this very situation.
Amongst the 5 major stakeholders that would be most directly affected by the states
decision, it can be said, to bring about greatest happiness would be to allow Cassandra to
refuse treatment. By allowing Cassandra to refuse treatment, only the state would not derive
happiness. Furthermore, Cassandra case is likely to be just one of the many cases that the
state has to deal with. In comparison, given that the impact of the decision on their personal
lives, and having fought long and hard for the basic rights of free will, it is highly probable

that both Cassandra and Fortin would derive great amounts of happiness from a positive
decision. Moreover, the public (parents of minors) would receive greater autonomy about
making decisions for their child. As parents are responsible for the well being of a child, it is
only sensible for them to have the freedom and flexibility to make such related decisions. For
doctors, they would be able to rely on their professional opinion while respecting the
decisions of their patients. As such, under utilitarianism, it would be considered unethical for
the state to enforce treatment on Cassandra.
By overruling both Cassandra and Fortins decisions, the state can be said to be
arrogantly assuming that it knows the true value of pain and happiness to Cassandra, even
more so than Cassandra herself, and Fortin, who has nurtured Cassandra since birth.
If rule utilitarianism were to be applied, it would mean that as a general rule, the state
would be ethical in making the final decision for all minors, and in overruling the decisions of
their parent/guardian, as long as it is deemed to be life threatening. The purpose of granting
parents the authority to make medical decisions on the behalf of a minor is due to the states
recognition of the maturity level of an individual at age 18 and beyond (adult), to make lifechanging decisions. Thus by overruling the minors parent, they are defeating the purpose of
the initial law. The state would also be assuming that the representative adult is insufficiently
mature, merely on the basis that the adult has chosen to respect the decision of the minor. A
decision that though poses a threat to her survival, a decision she willed.
Thus, for the reasons of uncertainty and difficulty in quantifying and qualifying
happiness, rule utilitarianism, the difficulty in distinguishing between lower and higher
pleasures, the potential inaccuracy in making adequate predictions of the consequences of
the intended actions, and the improbable feat of making interpersonal comparisons, we
notice that the employment of utilitarianism as a moral guideline is extremely subjective and
thus ineffective in determining the morality of the states decision. However, based on the
assumption that autonomy would bring about greatest happiness, utilitarianism does suggest
that states action in forcibly administering treatment on Cassandra should be deemed
unethical.

Assessing the impact of the states action on the stakeholders, it is clear that
Cassandra and her mother have been inflicted with the most pain. The pain can be
summarized by Fortins statement that the state has ripped apart a normal family and
turned their lives into a nightmare. This statement clearly articulates the tremendous
amount of distress that the state has placed upon Cassandra and Fortin. Similarly, the states
decision could also negatively affect the reputation of doctors, and the publics behaviour.
Instead of being viewed as people who bring hope and healing, doctors could now be
viewed as complicit of an overbearing state. For the general public, when illness befalls them,
instead of seeking treatment at clinics and hospitals, they could now think twice about
seeking diagnosis for fear that they too may be forced into receiving specific treatments
against their will. Overtime this could then lead to undesirable societal consequences such as
the seeking out of untested, unprofessional treatment.
An alternative action that the state could have taken would be to provide advise,
education or counseling to Cassandra. By assigning a social worker to Cassandra, trust could
be built and more could be understood of her decision making process. In doing so, the state
would be in a better position to achieve their well intention of life preservation. In other
words, the state should advice, present its stand and allow the individual to make the final
decision. As it is the individual, who would have to live with the consequences of the decision,
the individual should be the one making the final decision. However, should the state
overrule the individuals personal decision and get involved in the decision making process,
then the state should be prepared to take responsibility for the consequences that might
entail.
Thus considering the relevant ethical theories, it is unethical for the state to enforce
medical treatment.