Wisconsin Lawyer: Editorial: Withholding a Feeding Tube from a Nonvegetative Dementia Patient:

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May 05, 2010

Editorial: Withholding a Feeding Tube from a Nonvegetative Dementia Patient

Numerous unsettled and enormously divisive legal, ethical, and medical issues surround the withholding of a feeding tube from a conscious nonvegetative patient pursuant to a power of attorney for health care document. Because the average person might wrongly think that feeding tube decisions only come into play when a patient is a “vegetable” or in a coma, it is imperative that lawyers advise clients to clearly spell out in their powers of attorney for health care documents whether they are giving their agent authority to withhold a feeding tube in a situation in which the client is conscious.

Gary A. Magnarini

Overview of Law

The applicable POAHC statute, Wis. Stat. section 155.20(4), contains both permissive and mandatory terms and states in relevant part: “A health care agent may consent to the withholding or withdrawal of a feeding tube for the principal if the power of attorney for health care instrument so authorizes, unless the principal’s attending physician advises that, in his or her professional judgment, the withholding or withdrawal will cause the principal pain or reduce the principal’s comfort. ...” (emphasis added).

Based on Wisconsin’s paramount interest in preserving life and prohibiting euthanasia, however, Wisconsin appellate courts have never permitted a feeding tube to be withheld from a person who was not in a persistent vegetative state.⁴ Further, it has not been shown that the Wisconsin Legislature even intended section 155.20(4) to apply to nonvegetative persons.⁵ The amendment of other parts of chapter 155 without modification of section 155.20(4) may be an acceptance of the decisions limiting the withholding of feeding tubes to persons in a vegetative state.⁶

Feeding tube decisions also may have civil and criminal ramifications for a POAHC agent or a physician.⁷ An Alabama court found that a surrogate decisionmaker’s withdrawal of a feeding tube from a patient with dementia constituted criminally negligent homicide, because there was no statutory right to withdraw the tube.⁸

Ethical, Moral, and Religious Division

The decision to sustain life by means of artificial nutrition and hydration is a highly emotional issue that divides people worldwide.⁹ “Right to life” proponents may view the use of a feeding tube as a moral, ethical, or religious obligation. “Right to die” advocates believe that the freedom to die with dignity and without unwanted medical intervention is fundamental.¹⁰

The feeding tube issue received global attention in 2004 when Pope John Paul II announced that Catholics have a moral obligation to feed patients in a vegetative state.¹¹

Religious convictions can affect feeding tube decisions. In one case, a New York court found that an incompetent patient with dementia who was a devout Catholic had revoked her living will/power of attorney, thereby overriding any consent to withhold a feeding tube.¹² In another case involving a Jewish patient with Alzheimer’s disease, a New York court engaged in a lengthy discussion of Judaism and how “respectable authorities deem any active and deliberate hastening of death as sheer murder.”¹³

Medical Community Divided as Well

Medical experts have testified that the insertion of a feeding tube (also referred to as a percutaneous endoscopic gastrostomy or PEG tube) “is a simple surgical procedure that causes little risk, but is vitally necessary.”¹⁴ There is widespread use of feeding tubes with patients with dementia, a condition that affects the brain and causes a progressive loss of cognitive functions.¹⁵

But opinions are divided as to whether tube feeding is highly effective. One source states: “The largest observation reported to date, comprised of over 81,000 patients who received either [PEG] or surgical gastrostomy, documented a 1-month mortality of 24%. Median survival was just over 6 months; 1-year survival was 38%.”¹⁶

Court Decisions

The court decisions gaining the most media attention have involved the withdrawal of feeding tubes or other medical care from persons in a vegetative state.¹⁷

In In re Guardianship of L.W., the Wisconsin Supreme Court ruled that a guardian could consent to the withdrawal of artificial nutrition and hydration from an incompetent patient in a persistent vegetative state.¹⁸ But the court “stress[ed] that [its] opinion is limited in scope to persons in a persistent vegetative state” because such patients are “on a completely different footing than patients with other disabilities.”¹⁹

In situations in which an incompetent patient is conscious, however, courts have resolved the issue in a dramatically different fashion. In general, courts strictly require a surrogate decisionmaker to show “clear and convincing” evidence of the incompetent person’s desire to have a feeding tube withheld under the circumstances. If the patient’s desires are not clearly stated, courts deem the continuation of life to be in the patient’s best interests as a matter of law.²⁰

In Edna M.F., decided in 1997, the Wisconsin Supreme Court refused a guardian’s request to withhold a feeding tube from an incompetent patient with dementia who was not in a persistent vegetative state. The court broadly declared: “[T]he threshold at which this court will authorize the withholding or withdrawal of life-sustaining medical treatment is the point at which the trained medical doctors diagnose the patient as being in a persistent vegetative state.”²¹ A feeding tube can only be withheld if the guardian “can demonstrate by a preponderance of the evidence a clear statement of [the ward’s] desires in these circumstances.”²² The California Supreme Court has equated Edna M.F.’s “clear statement” requirement with the heightened “clear and convincing evidence” standards discussed in other cases.²³ Because the patient in Edna M.F. did not execute a POAHC, however, the Wisconsin Supreme Court did not fully examine section 155.20(4).

Terms of Statutorily Authorized POAHC

Mandatory Use of Feeding Tube. Under the statutory POAHC’s plain terms, an agent is prohibited from withholding a feeding tube if the patient’s physician advises this will cause the patient pain. If a patient with dementia is fully conscious, common sense might suggest that the patient would feel some pain or discomfort from dying as a result of starving and dehydration. That is what the court noted in Edna M.F.: “Edna M.F. is not in a persistent vegetative state and could therefore likely feel the pain and discomfort of starving to death.”²⁴

A critical problem arises, therefore, if the physician of a conscious dementia patient opines that starving to death will not cause the patient any pain or discomfort, thereby nullifying the POAHC agent’s statutory duty to insert a feeding tube. Because the patient’s life may ride on a single physician’s stated opinion, the agent in that instance should consider obtaining an independent opinion. In Edna M.F., Justice Bablitch objected to the lack of safeguards for ensuring the accuracy of the determination as to whether a patient is in a vegetative state and, as a matter of law, would require two independent medical opinions.²⁵ Other courts are in accord.²⁶

Gary A. Magnarini, Marquette 1988 cum laude; Cambridge Univ., England, LL.M. – international law, is a partner at Hicks, Porter, Ebenfeld & Stein P.A. in Miami, Fla., practicing primarily in civil appeals. He clerked for the late Chief Justice Nathan S. Heffernan of the Wisconsin Supreme Court.

If it is truly impossible to determine whether a conscious patient with dementia feels pain or discomfort in starving or dehydrating to death,²⁷ courts might rule that a POAHC agent is barred from withholding a feeding tube from a conscious patient in light of Wisconsin’s interest in preserving life.²⁸

Permissive Withholding of Feeding Tube. By marking “yes,” the principal intends to grant authority for withholding of a feeding tube under some sets of circumstances. The problem is that the general public appears to be unaware that dementia can cause a loss of the ability to swallow, and more importantly, that a person can be in such a condition and still be walking, talking, feeling, and smiling.²⁹ The average person might think that feeding tube decisions only come into play when the patient is a “vegetable” or in a coma.³⁰

Although a competent adult generally has the right to refuse medical treatment, when that person becomes incompetent and thereby falls under the state’s parens patriae protection, the whole issue is whether the person had shown a clear intent to refuse medical care under the particular circumstances at hand.³¹

On its face, a standard POAHC may fail to meet the “clear statement” test with regard to conscious patients. Various studies also cast doubt on whether advance directives are consistent with patients’ desires under particular health-care scenarios.³²

Because feeding tube decisions have irreversible consequences, Wisconsin courts will likely strictly apply Edna M.F.’s “clear statement” requirement to POAHC decisions.³³ Courts do not allow parol evidence to rewrite the terms of a POAHC document.³⁴

Thus, if a principal wants to give the agent authority to withhold a feeding tube in a situation in which the principal is conscious, the principal should clearly spell that out in the add-on “special provisions” section of the POAHC document.³⁵

Alternatively, POAHC instruments generally could be interpreted as granting the agent permissive authority to withhold a feeding tube from a conscious patient if the patient had made a clear statement of such intent outside the POAHC (either orally or in a separate document). Generalized statements regarding not wanting to be kept alive as a “vegetable” would undoubtedly not be deemed sufficient.³⁶ Nor would the courts likely accept an agent’s “gut feeling” prediction.³⁷

Moreover, according to Edna M.F., absent compliance with the “clear statement” requirement, “quality of life” assessments are irrelevant and the “presumption that continuing life is in the best interests of the [patient]” remains unrebutted.³⁸ In this regard, however, the following POAHC provision is problematic: “In the absence of a specific directive by the principal or if the principal’s desires are unknown, the health care agent shall, in good faith, act in the best interests of the principal.”³⁹ If the principal’s desires are “unknown,” then, logically, the “clear statement” requirement could not be met. Further, courts “have never decided it is in the best interests” of a nonvegetative person to withhold life-sustaining medical care.⁴⁰

On the other hand, if courts determined that a POAHC agent could withhold a feeding tube from a conscious dementia patient based on the agent’s “best interests” assessment, the agent would surely have to focus on the interests of patient herself and not on those of the agent, the hospital, or the attending physician. POAHC agents may be tempted to think of their own hardships. Agents may feel worn out and trapped by the responsibility of caring for the patient. More insidious self-interest, such as monetary gain, is also a possibility. In upholding liability for the withdrawal of a feeding tube, an Alabama court noted that the guardian was the sole beneficiary under the ward’s will as well as the beneficiary of various financial instruments.⁴¹

POAHC agents also may have to guard against any perceived pressure exerted by hospitals or physicians who might advocate against a feeding tube based on their own financial interests or subjective views. Enormous amounts of money are spent on end-of-life care and there is a constant threat of unreimbursed costs.⁴² Courts have rejected decisions to withdraw feeding tubes even in situations in which the patient’s physicians and the hospital ethics committee have unanimously voiced approval.⁴³

Civil, Criminal Liability

The Wisconsin Legislature has granted immunity for civil and criminal liability for POAHC participants for various enumerated actions.⁴⁴ But health-care facilities and providers may potentially still be exposed to liability for the following (nonlisted) acts: 1) representing that withholding a feeding tube will not cause a dementia patient pain or discomfort in starving or dehydrating to death; or 2) giving incorrect or insufficient information to the health-care agent, causing the agent to erroneously believe that he or she had the legal right to withhold a feeding tube or that it was in the best interests of a patient to do so.⁴⁵

POAHC agents have been granted broader immunity.⁴⁶ But agents are still on the hook for “bad faith” actions. An agent could be exposed to liability for withholding a feeding tube if the motivating factor was the agent’s self interests or if the agent knowingly ignored the patient’s stated desires. Even after a patient is deemed incapacitated the agent still has a duty to “try to discuss with [the patient] any specific proposed health care if [he or she is] able to communicate in any manner, including blinking [his or her] eyes.”⁴⁷

Although there are sound policy reasons not to make health-care agents and providers liable for every lapse in judgment, the decision to withhold a feeding tube under a POAHC should be governed by exacting standards and procedures. For those entrusted to protect the well-being of persons who are legally incompetent, whatever their age, the failure to act in good faith may have serious consequences.⁴⁸

Judicial Review Problems

The complex issues surrounding the withholding of a feeding tube may spring up in a heartbeat. When a patient with dementia loses the ability to swallow, death can come quickly, within a matter of days. Moreover, other parties and next-of-kin interested in ensuring that the patient’s wishes are honored or that the law is followed may be excluded from the decisionmaking process between the POAHC agent and health-care providers. If the agent or health-care professionals have acted in bad faith or simply misunderstood the law, there may be no time for anyone to present the dispute to a court.⁴⁹

Conclusion

Wisconsin lawyers need to make sure people know what they are doing when they sign a POAHC. The need to tube feed patients with dementia will only explode with the aging of the baby-boom generation.⁵⁰ In light of the case law, a principal would be well-served to clearly articulate in the special provisions section of the POAHC whether or not the agent is permitted to withhold a feeding tube if the principal is conscious. Until the legislature or courts clarify the law, lawyers should do everything possible to effectuate their clients’ informed wishes under a POAHC.

Endnotes

¹See Lenz v. L.E. Phillips Career Dev. Ctr. (In re Guardianship of L.W.), 167 Wis. 2d 53, 93-94, 482 N.W.2d 60 (1992).

²See Wis. Stat. ch. 155 (Power of Attorney for Health Care).

³Wis. Stat. § 155.30(3).

⁴See Edna M.F. v. Eisenberg, 210 Wis. 2d 557, 559-73, 563 N.W.2d 485 (1997); see also id. at 584 (Bablitch, J., concurring) (“The majority and the concurring opinions, and this writer, agree that if a person is not in a persistent vegetative state, medical treatment cannot be withdrawn.”); Montalvo v. Borkovec, 2002 WI App 147, ¶ 25, 256 Wis. 2d 472, 647 N.W.2d 413 (“In Wisconsin, the interest in preserving life is of paramount significance. ... In the absence of proof of a persistent vegetative state, our courts have never decided it is in the best interests of a patient to withhold or withdraw life-sustaining medical care.”).

⁵Cf. Conservatorship of Wendland, 28 P.3d 151, 167 (Cal. 2001) (“In amending section 2355 in 1999, neither the Legislature, nor the Law Revision Commission in its official report to the Legislature, alluded to the possibility that the statute might be invoked to justify withholding artificial nutrition and hydration from a conscious person.”).

⁶See Glinski v. Sheldon, 88 Wis. 2d 509, 519-520, 276 N.W.2d 815 (1979) (“[T]he legislature is presumed to enact statutory provisions with full knowledge of the existing laws, including the decisions of this court interpreting relevant statutes.”); see also DeHart v. Wisconsin Mut. Ins. Co., 2007 WI 91, ¶ 18, 302 Wis. 2d 564, 734 N.W.2d 394.

⁷Cf. Wis. Stat. § 155.50 (duties and immunities).

⁸See Files v. State, 826 So. 2d 906, 908-09 (Ala. Crim. App. 2001); see also Cruzan v. Director, Missouri Dep’t of Health, 497 U.S. 261, 296-97 (1990) (Scalia, J., concurring) (“A physician ... could be criminally liable for failure to provide care that could have extended the patient’s life, even if death was immediately caused by the underlying disease that the physician failed to treat.”); People v. Medlin, 100 Cal. Rpt. 3d 810, 819 (Ct. App. 2009) (finding reasonable cause that nurse and nursing director were criminally negligent for improper administration of feeding tube to semicomatose patient).

⁹See David E. Milkes, “‘Tube Feeding’ – Right or Wrong: The Medical, Legal and Ethical Issues,” at http://www.thedoctorwillseeyounow.com/articles/senior_living/peg_14 (last visited July 10, 2009).

¹⁰See generally William H. Colby, Society’s Challenge: Finding a Better Way to Die, 82 Wis. Law. (April 2009); Max Lapertosa, Preventing the “Right to Refuse” from Becoming a License to Kill: Adopting a Constitutional Minimum Standard for Approving Withdrawal of Life Support for Legally Incompetent Patients, 15 Temp. Pol. & Civ. Rts. L. Rev. 483 (2006); Robyn S. Shapiro, The Schiavo Case in Wisconsin, 78 Wis. Law. (June 2005).

¹¹See Richard Doerflinger, “Pope John Paul II Affirms Obligation to Feed Patients in ‘Vegetative’ State” (Apr. 26, 2004), at http://www.freerepublic.com/focus/fr/1124925.

¹²See Matter of Univ. Hosp. of the State Univ. of N.Y. Upstate Medical Univ., 754 N.Y.S.2d 153, 154 (Sup. Ct. 2002), app. dismissed, 775 N.Y.S.2d 750 (App. Div. 2004).

¹³See Borenstein v. Simonson, 797 N.Y.S.2d 818, 830-32 (Sup. Ct. 2005).

¹⁴Id. at 821.

¹⁵See Edel P. McNamara & Nicholas P. Kennedy, “Tube feeding patients with advanced dementia: an ethical dilemma,” Proceedings of the Nutrition Society 60, 180 (2001).

¹⁶See Thomas E. Finucane, “Tube Feeding in the Demented Elderly: A Review of the Evidence,” at http://www.medscape.com/viewarticle/420780 (last visited Apr. 6, 2009).

¹⁷See, e.g., Cruzan, 497 U.S. at 265-87; In re Guardianship of Schiavo, 851 So. 2d 182, 183-87 (Fla. App. 2003); Matter of Quinlan, 355 A.2d 647, 651-72 (N.J. 1976).

¹⁸167 Wis. 2d at 66.

¹⁹Id. at 63, 72 n.15.

²⁰See Conservatorship of Wendland, 28 P.3d at 153-75; In re Martin, 538 N.W.2d 399, 401-13 (Mich. 1995); Matter of Westchester County Medical Ctr., 531 N.E.2d 607, 608-16 (N.Y. 1988); see also Matter of Rick, 1996 WL 361526 *1-*2 (Del. Ch. June 10, 1996); Matter of Conroy, 486 A.2d 1209, 1216-44 (N.J. 1985); Matter of Clark, 510 A.2d 136, 137-46 (N.J. Sup. 1986).

²¹Edna M.F., 210 Wis. 2d. at 572-73.

²²Id. at 569.

²³See Conservatorship of Wendland, 28 P.3d at 172 (“About these three decisions one point deserves emphasis: In each case, the court required a clear statement by the patient of the intent to refuse life-sustaining treatment when a conservator or guardian proposed to withdraw treatment from a conscious conservatee or ward in order to effectuate the latter’s own right to refuse treatment.”).

²⁴See Edna M.F., 210 Wis. 2d at 568; see also Conservatorship of Wendland, 28 P.3d at 167 (conscious person may subjectively perceive effects of starvation and dehydration); cf. In re Guardianship of L.W., 167 Wis. 2d at 77 (Steinmetz, J., dissenting) (“[T]he majority offers no data suggesting that an individual in a persistent vegetative state will not experience discomfort or pain when his/her body is dehydrating or starving to death.”).

²⁵See Edna M.F., 210 Wis. 2d at 584-85 (Bablitch, J., concurring) (“First, the diagnosis must be made by the attending physician and two independent doctors. Second, at least one of the independent doctors must be a specialist in the medical field relevant to the patient’s condition. Third, ... the doctors must rely on current medical authority generally accepted in that specialty.”).

²⁶See Matter of Conroy, 486 A.2d at 1242 (“Two other physicians, unaffiliated with the nursing home and with the attending physician, should then be appointed to confirm the patient’s medical condition and prognosis.”).

²⁷Cf. Edna M.F., 210 Wis. 2d at 575 n.2 (Abrahamson, C.J., concurring) (noting doctor’s testimony that he felt dementia patient “could experience pain but that a physician could not determine this fact”).

²⁸See id. at 569; Montalvo, 256 Wis. 2d at 488.

²⁹Cf. Matter of Westchester County Medical Ctr., 531 N.E.2d at 615 (“Neither is [the patient] in a coma or a vegetative state. She is awake and conscious; she can feel pain, responds to simple commands, can carry on limited conversations, and is not experiencing any pain. She is simply an elderly person who as a result of several strokes suffered certain disabilities, including an inability to feed herself or eat in a normal manner.”).

³⁰Cf. In re Martin, 538 N.W.2d at 411 (while patient had expressed statement that “he did not want to live like a vegetable,” “virtually all the witnesses agreed that [patient] is not in a vegetative state and is not suffering from the type of incapacitation referenced in his expression of a desire not to continue life-sustaining medical treatment”); Conservatorship of Wendland, 28 P.3d at 173 (expressed desire “not to live like a ‘vegetable’” was insufficient evidence to withhold feeding tube).

³¹See Edna M.F., 210 Wis. 2d at 570-71 (“we do not have any clear statement of what her desires would be today, under the current conditions”); Conservatorship of Wendland, 28 P.3d at 173 (“The court finds that neither of these conversations reflect an exact ‘on all fours’ description of conservatee’s present medical condition.”); Matter of Westchester County Medical Ctr., 531 N.E.2d at 615 (“In sum, on this record, it cannot be said that Mrs. O’Conner elected to die under circumstances such as these.”).

³²See Leslie Pickering Francis, Decisionmaking at the End of Life: Patients with Alzheimer’s or Other Dementia, 35 Ga. L. Rev. 539, 570 (2001) (“If there is reason to doubt the meaning of patients’ prior statements, there may even be more reason to doubt the accuracy of surrogates’ predictions of what patients would choose.”).

³³See Edna M.F., 210 Wis. 2d at 570 (“the decision to withdraw life-sustaining medical treatment is also not reversible, because death is not reversible”); see also Losee v. Marine Bank, 2005 WI App 184, ¶ 16, 286 Wis. 2d 438, 703 N.W.2d 751 (powers of attorney-in-fact are strictly construed to only grant clearly specified powers).

³⁴See Praefke v. American Enter. Life Ins. Co., 2002 WI App 235, ¶¶ 14-20, 257 Wis. 2d 637, 655 N.W.2d 456 (barring extrinsic evidence of intent of dementia-affected principal under power-of-attorney document); see also Cruzan, 497 U.S. at 284 (“in most States, the parol evidence rule prevents the variation of the terms of a written contract by oral testimony”).

³⁵See Wis. Stat. § 155.30(3) (“The following are specific desires, provisions or limitations that I wish to state ....”).

³⁶See Conservatorship of Wendland, 28 P.3d at 173; Matter of Westchester County Med. Ctr., 531 N.E.2d at 615.

³⁷See Edna M.F., 210 Wis. 2d at 570-71 (rejecting sufficiency of testimony of majority of patient’s friends who felt that she “‘would not want to be kept alive’ in this condition”).

³⁸See id. at 571-72; see also Cruzan, 497 U.S. at 281 (“[W]e think a State may properly decline to make judgments about the ‘quality’ of life that a particular individual may enjoy, and simply assert an unqualified interest in the preservation of human life to be weighed against the constitutionally protected interests of the individual.”); cf. Borenstein, 797 N.Y.S.2d at 833 (“‘[W]hen the quality of life replaces the sanctity of life, society has done itself irreparable harm.’”).

³⁹See Wis. Stat. § 155.20(5) (emphasis added); see also Wis. Stat. § 155.30(1), (3).

⁴⁰See Montalvo, 2002 WI App 147, ¶ 25, 256 Wis. 2d 472.

⁴¹See Files, 826 So. 2d at 908.

⁴²See Adriana Ramirez Martinez, The Duty to Die: Deciding for Incompetent and Terminally Ill Elderly Patients in the United States and England, 76 Rev. Jur. U.P.R. 1251, 1252-1255 (2007); St. Francis Hospital & Health Centers, “Unpaid Costs and Services,” at http://www.stfrancishospitals.org (visited Sept. 28, 2009); see generally Maureen Kwiecinski, To Be or Not to Be, Should Doctors Decide? Ethical and Legal Aspects of Medical Futility Policies, 7 Marq. Elder’s Advisor 313 (2006).

⁴³See Conservatorship of Wendland, 28 P.3d at 155.

⁴⁴See Wis. Stat. § 155.50(1).

⁴⁵See Montalvo, 2002 WI App 147, ¶ 14, 256 Wis. 2d 472 (“‘[W]hat a physician must disclose is contingent upon what, under the circumstances of a given case, a reasonable person in the patient’s position would need to know in order to make an intelligent and informed decision.’”); see also Kathleen E. Wherthey, Cause of Action to Recover Damages for Health Care Provider’s Failure to Comply with Advance Directive, 16 Causes of Action 2d 83 (2008).

⁴⁶See Wis. Stat. § 155.50(3) (“No health care agent may be charged with a crime or held civilly liable for making a decision in good faith under a power of attorney for health care instrument that is in compliance with this chapter. ...”).

⁴⁷Wis. Stat. § 155.30(3).

⁴⁸See In re Interest of Hope, 278 Neb. 869, 892-95 (2009) (terminating parental rights in situation in which child’s feeding tube was disconnected and food withheld); see also “Untreated Diabetes Girl’s Mother Found Guilty of Reckless Homicide” (May 22, 2009), at http://calvininjax.wordpress.com/2009/05/22.

⁴⁹See Wis. Stat. § 155.60(4)(a) (“Any interested party may petition the court...to review whether the health care agent is performing his or her duties in accordance with the terms of the [POAHC] instrument....”).

⁵⁰See John Wallace, “Tube feeding in the elderly,” Bette Care Article of the Month 11/2008, at http://www.bettecare.com; “Report: Alzheimer’s cases to nearly double every 20 years,” at http://www.cnn.com/2009/HEALTH/09/21/alzheimers.disease.report/index.html.

Wisconsin Lawyer

Editorial: Withholding a Feeding Tube from a Nonvegetative Dementia Patient

Overview of Law

Ethical, Moral, and Religious Division

Medical Community Divided as Well

Court Decisions

Terms of Statutorily Authorized POAHC

Civil, Criminal Liability

Judicial Review Problems

Conclusion

Endnotes

May 01, 2010

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