New Jersey has long been a national leader in recognizing a person's right to decide what medical treatment they do and do not want. That right includes the ability to refuse life-sustaining treatment, even when refusing treatment may result in death. Although these cases often arise in heartbreaking circumstances, the legal principle is straightforward: medical treatment generally requires the patient's consent.
The right to refuse treatment is rooted in both personal autonomy and constitutional principles. New Jersey courts have recognized that competent adults have a fundamental right to make decisions about their own medical care, including the decision to decline treatment. The New Jersey Legislature later incorporated those principles into the New Jersey Advance Directives for Health Care Act, which expressly recognizes an individual's right to accept, reject, or discontinue medical treatment and to appoint another person to make decisions when the individual can no longer do so.
The Constitutional Basis for the Right to Refuse Treatment
New Jersey's modern law on refusing life-sustaining treatment began with the 1976 case of In re Quinlan. In that case, twenty-one-year-old Karen Ann Quinlan suffered severe brain damage and entered a persistent vegetative state. Her father sought authority to remove her from a ventilator after physicians concluded there was no realistic hope of recovery. The New Jersey Supreme Court held that an individual's constitutional right of privacy included the right to decline extraordinary life-sustaining treatment and that a guardian could assert that right for an incompetent patient under appropriate circumstances.
The United States Supreme Court later reached a similar conclusion in Cruzan v. Director, Missouri Department of Health. Nancy Cruzan was left in a persistent vegetative state following an automobile accident. The Court recognized that competent individuals have a constitutionally protected liberty interest under the Due Process Clause to refuse unwanted medical treatment. However, the Court also held that states may require reliable evidence of an incompetent patient's wishes before life-sustaining treatment is withdrawn. The decision helped spur the widespread use of living wills and health care powers of attorney across the country.
Conroy: Extending the Right Beyond Ventilators
In 1985 the New Jersey Supreme Court significantly expanded these principles in In re Conroy. Claire Conroy was an elderly nursing home resident suffering from severe, irreversible physical and cognitive impairments. The dispute involved whether artificial nutrition and hydration delivered through a feeding tube could be withdrawn.
The Court held that artificially provided nutrition and hydration constitute medical treatment and may be withdrawn under appropriate circumstances. More importantly, the Court established several decision-making standards for incompetent patients who had not left clear instructions. These standards focused on determining what the patient would have wanted and, in some circumstances, whether the burdens of treatment so outweighed its benefits that continuing treatment would be inappropriate even without clear evidence of the patient's wishes.
Today, Conroy remains one of New Jersey's most important end-of-life cases because it emphasized that the goal is not what family members, judges, or physicians want, but what the patient would have chosen.
Jobes: The Importance of Family and Substituted Judgment
In Matter of Jobes, the New Jersey Supreme Court addressed the case of a young woman who had remained in a persistent vegetative state for years following surgical complications. Her husband and family sought withdrawal of artificial nutrition and hydration.
The Court reaffirmed that the right to refuse life-sustaining treatment extends to incompetent patients. It also emphasized the role of close family members in applying a substituted judgment analysis, meaning an effort to determine what the patient would have chosen if able to decide. The Court ultimately allowed withdrawal of the feeding tube based upon evidence concerning the patient's values and wishes. Together, Quinlan, Conroy, and Jobes firmly established New Jersey's recognition of patient autonomy, even after a person loses decision-making capacity.
The Difference Between a Guardian and a Health Care Agent
Many people assume that a family member automatically gains authority to make medical decisions. That is not always true.
A person may designate a health care representative through an advance directive or medical power of attorney. Once the individual loses capacity, the representative gains legal authority to make health care decisions, including decisions about life-sustaining treatment, subject to the terms of the directive and the patient's known wishes. New Jersey law directs the representative to follow the patient's instructions whenever known.
A guardian, by contrast, receives authority from a court. Guardianship becomes necessary when a person has lost capacity and did not execute valid planning documents. If you would like to learn more about guardianship proceedings, see my articles on New Jersey guardianship, contested guardianship hearings, and who makes medical decisions in New Jersey.
Even a guardian's authority is not unlimited. A guardian is not free to substitute the guardian's personal beliefs for the ward's wishes. Instead, the guardian must attempt to make the decision the ward would have made based on the ward's values, statements, religious beliefs, and prior directives. The courts repeatedly emphasize that the patient's autonomy remains the central concern.
Must a Guardian or Agent Follow an Advance Directive?
Generally, yes.
Under New Jersey law, an advance directive is designed to preserve the patient's voice after incapacity occurs. A health care representative is expected to make decisions in accordance with the patient's instructions and known wishes. Only when the patient's preferences are unknown should the representative turn to a best-interests analysis.
Likewise, a guardian ordinarily must honor a valid advance directive. A court-appointed guardian does not gain the authority to rewrite the ward's prior decisions. The advance directive remains powerful evidence of the patient's wishes and usually controls medical decision-making.
There is one important qualification. New Jersey law provides that if an incapacitated patient clearly expresses a contemporaneous desire to receive life-sustaining treatment, that expressed wish can take precedence over an earlier contrary instruction in an advance directive.
Why Advance Directives Matter
The lesson from Quinlan, Conroy, Jobes, and Cruzan is that New Jersey law places tremendous importance on an individual's own choices. When a person's wishes are clearly documented, courts, physicians, guardians, and family members are far more likely to reach decisions consistent with those wishes.
An advance directive allows you to state what treatments you would accept or refuse and designate a trusted person to speak on your behalf. Without those documents, loved ones may face uncertainty, family disputes, guardianship proceedings, or court involvement at a time that is already emotionally difficult.
New Jersey law recognizes that the decision to undergo or refuse medical treatment belongs first and foremost to the individual. The best way to ensure your voice is heard is to make your wishes known before a crisis occurs.