Peggy Wright

@PeggyWrightDR

MORRISTOWN - A 29-year-old Morris County woman who now weighs 65 pounds has dreamed of a thin body since she was a child and deliberately threw up a Cookie Monster Cupcake and compared the size of her thighs to the limbs of other girls in her preschool dance class.

The woman, identified in court papers as A.G., is the poignant subject of a legal decision slated to be given Monday by Superior Court Judge Paul Armstrong in Morristown. The issue is whether A.G. - who has worked as a barista and briefly attended film school in Manhattan - possesses the mental capacity to determine for herself that she doesn't want artificial nutrition or is mentally incapacitated and should be force-fed, even though the process could involve restraints that may break her bones.

"I think it's horrific," said A.G.'s treating psychiatrist, Dr. Joshua Braun, of the proposal to force-feed A.G., according to court papers.

Braun opined that it would be an assault on A.G. "to forcibly put an inanimate object into her three times a day against her will...because she's going to pull it, she's threatened that so I think it would have to be done under restraint where there is potential to break limbs and other sorts of things. I think this is cruel and torturous at this point."

Armstrong in the 1970's was at the forefront of medical bioethics when he represented Julia and Joseph Quinlan in their fight to disconnect a ventilator on their 21-year-old daughter, Karen Ann Quinlan, who was in a persistent vegetative state. The state Supreme Court ruled that Karen could be disconnected from life support. She survived, breathing on her own but comatose, for another nine years at Morris View Nursing Home in Morris Township.

The Quinlan decision led to multiple other right-to-die cases and the ability of competent individuals to prepare advance medical directives on whether they want various treatments and life-saving measures if they become incapacitated. Landmark cases, including those of Clare Conroy and Nancy Ellen Jobes, dealt with right-to-die decisions involving people in vegetative states or with life-threatening illnesses but in A.G.'s case, she is not terminally ill and is the architect of her physical condition.

Since January 2014, A.G. has been involuntarily committed to Greystone Park Psychiatric Hospital because she poses a danger to herself. Three months earlier, she was found passed out at a motel in Whippany, through an overdose of alcohol and an antidepressant. She was treated at both Morristown Medical Center and St. Clare's Hospital in Boonton and refused to seek treatment for her eating disorder, anorexia-binge purging type. After the hospitalizations, she was committed to Greystone.

A.G.'s circumstances were first brought to Superior Court this past June 20 when a state deputy attorney general, acting on behalf of the state Department of Human Services which operates Greystone, sought the appointment of a temporary guardian who could make medical decisions for A.G.

Superior Court Assignment Judge Stuart Minkowitz in June appointed attorney Susan Joseph to be temporary guardian and attorney Edward G. D'Alessandro Jr. to serve as A.G.'s lawyer. After meeting A.G., Joseph requested and received from the court in June an order that A.G. be fed through a tube. The intravenous Total Parental Nutrition program made A.G. gain 25 to 30 pounds but she suffered heart failure as a result of "re-feeding syndrome" from the treatment.

A.G. herself pulled out the tube and the TPN program was stopped.

Between June and November, Joseph and D'Alessandro, along with A.G.'s mother, several doctors and members of the bioethics committee at Morristown Medical Center have formed the conclusion that A.G. is competent and has knowingly chosen to reject force-feeding. She has been subsisting on diet soda and black coffee - which are delivered intravenously along with her antidepressants - and occasional bites of food like raisins, toast or cookies.

A.G. has stated, according to court papers, that she is prepared to die. But she also envisions getting her own apartment one day and living in the community. She believes that force-feeding is an effort to make her fat and that any weight above 70 is too much for her 5 foot, 6 inch frame, court papers state.

Joseph, who obtained the June court order for force-feeding, now wants Armstrong to amend that order to allow A.G. to enter palliative and then hospice care. If she changes her mind and opts for treatment and to be artificially fed, her wishes would be granted, according to court papers.

Deputy Attorney General Gene Rosenblum, who represents Greystone which is technically A.G.'s current home, said in court papers that A.G. is mentally ill and a court order approving the withdrawal of nutrition is tantamount to sanctioning A.G.'s passive suicide.

In making his ruling, Armstrong has to determine A.G.'s competence, consider the best interests of A.G, and weigh the state's interest in preserving life and policy against suicide versus A.G.'s right to self-determination.

Rosenblum noted that the state Supreme Court already has mapped out the boundaries of an individual's right to refuse treatment when terminally ill or facing a hopeless medical predicament - but that is not A.G., she said in court papers.

"A.G. wants her doctors to resist providing her nutrition; yet she requests, in the name of 'palliative care,' drugs to numb her anxiety and her pain, to ease the path to her own death," Rosenblum wrote.

In pushing for force-feeding, the state had hired Dr. Michael Pertschuk, a 30-year specialist in treating eating disorders. Pertschuk interviewed A.G. at Morristown Medical Center and testified at a hearing before Judge Armstrong on Nov. 4 that he believes A.G.'s depression and her prolonged malnutrition have skewed her thinking so that she is not making an informed decision to reject feeding. Pertschuk has proposed a three-prong approach to treating A.G. that includes force-feeding, increased family time with her parents and siblings and pets and possibly experimental treatment with Ketamine for her depression.

Several psychiatrists at Greystone have examined A.G. and concluded she lacks sufficient mental capacity to manage her affairs and makes poor judgments that endanger her health, including refusing treatment for injured hips, court records said.

A.G.'s prognosis is not hopeless, Rosenblum wrote, and the benefits to A.G. of force-feeding - restoration of health and renewed ability to enjoy life - "outweigh the temporary discomfort or even pain that A.G. will experience if treatment is imposed."

Rosenblum also said that guardian Susan Joseph's request to disallow force-feeding has not been supported by two independent, non-attending physicians as the law requires. Physicians and psychiatrists have opined on the best course for A.G. but they are familiar with her and not independent examiners of her competence, Rosenblum wrote.

During a hearing that Armstrong held on Nov. 4 to gather testimony and information for Monday's ruling, he heard from A.G.'s mother, who appeared anguished but accepting of her daughter's decision. A.G. had told her court-appointed attorney that her parents had shown her "unconditional love" throughout her life.

The mother had testified that she and her husband sought every available treatment they could for their daughter for more than 10 years. She said she accepts A.G.'s decision but will jump to help her again if asked.

"She hasn't been able to take the treatment and thrive," the mother said. "The thoughts of this whole process are running through her head and she has no peace. She never seems to have a moment where she's just relaxed. She's tormented."

Staff Writer Peggy Wright: 973-267-1142; pwright@GannettNJ.com.