## Facts

- Larry James McAfee suffered a spinal-cord injury in a motorcycle accident that left him a ventilator-dependent quadriplegic.
- He was incapable of spontaneous respiration, and his condition had no prospect of improvement or medical remedy.
- McAfee was a competent adult, had been counseled about his decision, discussed it with his family, and his family supported him.
- He petitioned for a declaration permitting him to discontinue mechanical ventilation, with instructions that the ventilator not be restarted once disconnected.
- He devised a method to turn off the ventilator himself using a timer.
- Because disconnecting the ventilator would cause severe pain and distress, he requested sedation to alleviate suffering during the dying process.
- The trial court granted declaratory relief, ruling McAfee’s rights to privacy, liberty, and refusal of medical treatment outweighed the state’s interests, and further stated it could not order sedation but that providing it would not create civil or criminal liability.
- The State appealed.

## Issues

1. Whether a competent adult has a right to refuse continued life-sustaining mechanical ventilation when refusal will foreseeably result in death.
2. Whether the state’s interests in preserving life, preventing suicide, protecting medical professionalism, and protecting third parties outweigh that refusal right on these facts.
3. Whether, and to what extent, medical professionals may provide palliative sedation in connection with ventilator withdrawal without crossing into unlawful assistance in causing death.

## Decision

- The Supreme Court of Georgia affirmed declaratory relief recognizing McAfee’s right, as a competent adult, to refuse continued mechanical ventilation and to decline reinitiation after disconnection.
- The court applied a balancing test and concluded the identified state interests did not override McAfee’s decision under the circumstances presented.
- The court distinguished withdrawal of unwanted life-sustaining treatment from assisted suicide or active euthanasia, emphasizing the legal significance of patient refusal rather than an affirmative act to cause death.
- The court addressed sedation as part of permissible palliative care associated with treatment withdrawal, while limiting its reasoning to avoid judicial authorization of assisted suicide or creation of a compelled duty for physicians to participate.

## Legal Principles

- A competent adult patient may refuse medical treatment, including life-sustaining treatment, absent a sufficiently weighty conflicting state interest.
- Courts balance the patient’s refusal right against four state interests: preserving life, preventing suicide, maintaining the integrity of the medical profession, and protecting innocent third parties.
- Withdrawal of extraordinary life support at a competent patient’s request is treated as refusal of treatment, not as suicide, so long as others do not intentionally cause death by affirmative conduct.
- Palliative measures to relieve suffering in connection with lawful treatment withdrawal may be permissible, but courts must avoid framing relief as authorizing assisted suicide or imposing a mandatory obligation on clinicians.

## Conclusion

The court held that a competent, ventilator-dependent adult may lawfully discontinue mechanical ventilation and refuse its reinitiation when the state’s asserted interests do not outweigh the patient’s autonomy, while maintaining a doctrinal line between lawful treatment refusal with palliative care and unlawful assistance in causing death.


State v. McAfee, 259 Ga. 579, 385 S.E.2d 651 (Ga. 1989)