## Facts

- A.C. (Angela Carder) was hospitalized at approximately 26 weeks’ gestation with terminal, metastatic cancer and was heavily sedated and intermittently communicative.
- Hospital officials sought emergency judicial authorization to perform a cesarean section, citing the state’s interest in a viable fetus.
- The trial court conducted an expedited bedside hearing, received conflicting evidence about A.C.’s wishes and the fetus’s survival prospects, and ordered the surgery after “balancing” maternal interests against fetal and state interests.
- The court found A.C. likely to die within days and that surgery might hasten her death but might improve fetal survival.
- After the order, A.C. had a lucid interval in which she briefly consented and then withdrew consent; the order was not changed and the cesarean proceeded.
- The infant died within hours; A.C. died two days later.
- Although the controversy was moot, the appellate court heard the case because similar emergencies were capable of repetition yet evading review.

## Issues

1. Whether a court may order a cesarean section over a pregnant patient’s refusal to protect a viable fetus.
2. What decision-making framework applies when the pregnant patient is incompetent or intermittently competent.
3. Whether the trial court erred by balancing fetal/state interests against the patient without first determining the patient’s competent choice or, if incompetent, her substituted judgment choice.

## Decision

- The en banc court reversed the trial court’s order authorizing the cesarean section.
- The court held that, as a general rule, a competent pregnant patient is the medical decision-maker and may accept or refuse treatment even if refusal risks fetal death.
- When the patient is incompetent, the court must apply substituted judgment to determine what the patient would have chosen based on her values and prior statements.
- The trial court erred by proceeding directly to an interests-balancing analysis without first determining A.C.’s competent decision or, if incompetent, her substituted-judgment decision.
- The court left open only a narrow, extremely rare possibility that extraordinary or compelling circumstances could justify overriding the patient’s wishes, and found such circumstances absent here.

## Legal Principles

- A competent person has a common-law right to bodily integrity and informed consent, including the right to refuse medical treatment.
- Pregnancy does not diminish a competent patient’s authority to decide medical treatment; fetal viability does not create a per se rule permitting compelled major surgery.
- For an incompetent patient, the proper inquiry is substituted judgment: the court must determine the patient’s likely choice from her prior statements, beliefs, and value system.
- State and fetal interests may not routinely override the patient’s decision; they may be considered only after the patient’s wishes are determined and only in extraordinary or compelling circumstances.
- Emergency decision-making must be patient-centered and evidence-driven; thin, ambiguous records of the patient’s wishes cannot justify compelled invasive procedures.

## Conclusion

The court held that a competent pregnant patient’s informed refusal generally controls medical treatment decisions, and that when competence is lacking, courts must determine the patient’s choice through substituted judgment rather than defaulting to a broad balancing in favor of fetal or state interests; the compelled cesarean order was therefore reversed.


In re A.C., 573 A.2d 1235 (D.C. 1990) (en banc)