Angela Carder Case

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I know I have mentioned things like this in previous posts, but I want your opinions on this case in particular. The beginning of this is background information, but I want to give an unabridged summary:


At age 13, Angela was diagnosed as suffering from a rare and fatal form of cancer. Despite the odds, she survived and was cured after years of aggressive and often experimental chemotherapy and radiation. Ten years later, however, she developed another form of cancer. She bravely fought for life again, returning to chemotherapy and radiation and resorting to multiple surgeries. Ultimately, she consented to a hemipelvectomy, the surgical removal of her left leg and hip. After more chemotherapy and radiation, there were no signs of cancer anywhere. In 1986, three years into remission and confident in her ability to rob the grim reaper, Angela married and became pregnant. Because of her disability, she was eventually referred to the High Risk Pregnancy Clinic at George Washington University Medical Center, where she was enthusiastically accepted as a teaching case.

According to her clinic obstetrician, Angela emphasized two points about her health care: she wanted to be watched closely for any signs of recurrence of cancer and, having struggled so long to survive, she wanted to be sure her own health was not compromised because of her pregnancy.

Unfortunately, during the 25th week of gestation, Angela was admitted to GWUMC and eventually diagnosed as having a lung tumor. Again, fighting to live, she wanted everything possible done to prolong her life. Surgery was ruled out, leaving chemotherapy and radiation as the only means of prolonging her life. Angela was informed that her baby was too small to be born, meaning too premature to have a good chance to survive, and that her doctors did not consider intervention on behalf of the fetus appropriate until 28 weeks. She was also informed of the added risks to the fetus from chemotherapy and radiation, but Angela still decided to institute aggressive treatment of her cancer. This course was so clearly understood that her attending obstetricians did not consider, much less attempt, intervention for the fetus later that night when Angela's condition rapidly deteriorated, depriving Angela and the fetus of substantial amounts of vital oxygen for many hours.

The next morning, events took an unexpected turn. The hospital's administrators (who were also its liability risk managers) learned of the decision not to attempt delivery of the fetus. The administrator questioned the right of anyone but a court to make decisions affecting a potentially viable fetus, particularly in light of the political controversy over fetal rights. Although the decision was supported by Angela's parents and husband and by the obstetrical department as a whole, as consistent with the wishes of their patient, and despite the advice of legal counsel that the doctors should exercise their best medical judgment under the circumstances (which was not to deliver the - extremely premature and highly compromised fetus), the hospital required a court to decide what should be done for the fetus. Technically, the hospital sought a declaratory judgment as to "what it should do in terms of the fetus, whether to intervene and save its life."

In response to the hospital's petition, a court hearing was hastily convened at the hospital, counsel was rounded up in the hallways of the courthouse and appointed to represent Angela, counsel for the fetus was also appointed, and hospital counsel appeared for GWUMC. The hospital summoned all the witnesses who would testify at the hearing. Angela's family was brought to the hearing just before the proceedings began, with only minutes to confer with Angela's counsel. Angela's long-term cancer specialist, who had been at GWUMC the day before to consult on her case, was not contacted at all.

At the hearing, family members, including Angela's husband, opposed Caesarean surgery because Angela was not expected to be able to survive it and because all agreed that Angela would have opposed it. The treating physicians also opposed intervention based on their understanding of Angela's wishes and the clinical status of Angela and the fetus. However, a neonatologist, who had no familiarity with Angela's medical status, also testified at the hearing that the fetus had at least a 60 percent chance of survival (just slightly less than a fetus from a healthy woman at that gestational age). (Other medical experts have since concluded that there was virtually no chance of survival and that the fetus was already brain dead)

At the hearing almost no attention was paid to what was clinically best for Angela or to what she would want since, according to the hospital, it was "the apparent desire of the patient and her family" that no intervention be done on behalf of the fetus. Instead, the hearing focused on whether to "rescue" the fetus. Balancing Angela Carder's life expectancy as a cancer-ridden patient against that of the fetus (based on the neonatologist's unduly optimistic guesswork), the court ordered the Caesarean. Despite the court's order, the obstetricians refused to carry it out. The hospital was then in the ironic position of being in contempt of an order that the hospital itself had sought. Reluctantly, a staff obstetrician agreed to perform the surgery.

Although assumed to be near death and unconscious, Angela was lucid and able to communicate when, after the court made its ruling, one of her obstetricians told her about the court's decision. When her doctor explained that she might die as a result of the ordered surgery and that he would not perform the surgery without her consent, she said repeatedly, "I don't want it done." However, this declaration did not sway the hospital to withdraw its petition or the court to amend its order. A three-judge appellate panel upheld the decision during an emergency telephone appeal. Minutes later, having just been told that she probably would not survive the surgery, the woman who had courageously cheated death for fourteen years was rolled into the operating room. The fetus died within two hours. Two days later, Angela Carder died, never having received the cancer treatment she requested.

Despite her death, the Estate of Angela Carder, administered by her parents, Daniel and Nettie Stoner, represented by the American Civil Liberties Union, pursued an appeal of the Caesarean section order to the entire Court of Appeals for the District of Columbia. The parties submitted legal arguments concerning the constitutional right to make health care decisions and the purported state interest in protecting a viable fetus. More than 120 civil rights groups, health care organizations and health care professionals, including the American Medical Association and the American College of Obstetricians and Gynecologists jointly filed amicus (friend of the court) briefs on behalf of Angela Carder, opposing the hospital's use of a court to resolve medical treatment issues.

At the same time, the ACLU, on behalf of Estate of Angela Carder, instituted an unprecedented civil action against the hospital for damages, claiming discriminatory treatment of her cancer and pregnancy, hospital negligence, medical malpractice, the lack of informed consent arising out of the treatment of Ms. Carder and the decision to require a court to determine the course of medical care (Stoners U. George Washington University Hospital, et al., Civil Action No. 88-0M33 (Sup. Ct. D.C.)).

On April 26, 1990 the D.C. Court of Appeals en banc in In Re A.C. vacated the court-ordered Caesarean and held that Angela Carder had the right to make health care decisions for herself and her fetus. Seven months later, but only days before the scheduled trial in the Stoner case, the hospital agreed to settle the claims in the civil action by the payment of an undisclosed sum of money to the Carder estate and the development and adoption of hospital policies which implement the Court of Appeals' decision protecting the rights of pregnant patients to make health care decisions.

According to GWUMC, it "learned a great deal from the Angela Carder case, from the court's findings and conclusions in In Re A.C. and from the subsequent lawsuit brought by [her] family... This case motivated the hospital to examine carefully this area of law and ethics to establish an effective institutional framework for responding to complex situations in the future and to prevent the unnecessary and sometimes detrimental resort to the courts to advise the hospital in a particular situation."