Mentally competent adults generally have a constitutional right to refuse medical treatment, even when they would likely to die as a result. But how are courts to determine whether the adult is mentally competent, especially when the refusal of treatment seems to be motivated by the person’s belief that God will save her and thus she won’t actually die? That’s the issue in In re Matter of J.M. (N.J. Super. Ct.), just released earlier this month. Here are some excerpts:

A patient has capacity to consent to medical treatment if she can reasonably understand her condition, the effect of the proposed treatment, and the risks of both undergoing and refusing the treatment. In re Conroy, 98 N.J. 321, 382 (1985). Of the three psychiatrists who testified, two of them determined J.M. lacked capacity to refuse dialysis. Dr. Psemar indicated J.M. does not acknowledge the risk of refusing dialysis. She demonstrated anxiety, depression, and an inability to problem-solve. Dr. Dealwis testified J.M. did not believe she would die if not treated, and therefore, was not making a reasoned decision to choose death over dialysis. They both believed that because she did not understand the likely consequences of refusing treatment, she lacked capacity to make decisions about her health. The dissenting psychiatrist, Dr. Scham, acknowledged that he is not an expert in competency evaluations and only does five to six of them every year. He said J.M.’s mental status is clear and she has adequate judgment, but he also acknowledged her views were inconsistent in that she accepted blood transfusions and resuscitation, but not dialysis. Dr. Scham believed that J.M. understood she would die without dialysis, yet he also testified J.M. stated “God would save her.” When J.M. herself testified, she asserted that she would not die without dialysis because Jesus would save her….

A competent patient is able to choose his course of treatment even if his medical decision may seem irrational or unsupported by medical evidence. [Footnote: New Jersey courts have ruled that a patient found to be competent and aware of the consequences of her decision may exercise her right to refuse treatment for any reason, including when treatment violates the tenets of her religion. Further, guardians of incompetent patients must consider the tenets of a patient’s religion when determining the proper course of treatment. J.M.’s refusal of treatment was not premised upon an established tenet of her religion precluding certain medical procedures, as evidenced by her consent to all other medical treatment and her pastor’s attempt to convince her to undergo dialysis. As a result, her belief that God would save her does not preclude her from being found incompetent, nor does the appointed guardian need to act on that professed belief.] If a patient is unable to understand the consequences of the decision, however, that patient is unable to give informed consent and is therefore incapacitated.

The Court found, by clear and convincing evidence, that J.M. does not have the capacity to make a decision regarding dialysis. She had no long-lasting psychiatric disability, but rather demonstrated a lack of understanding of the high risk of death without dialysis. She refused to acknowledge the risk inherent in her refusal of treatment and through her other medical choices had demonstrated an unequivocal desire to live.