Title: Betty Spahn v. Howard B. Eisenberg

State: wisconsin

Issuer: Wisconsin Supreme Court

Document:

SUPREME COURT OF WISCONSIN 
 
                                                              
 
Case No.: 
 
95-2719 
                                                              
 
Complete Title 
of Case: 
 
 
In the Matter of the Guardianship   
 
 
 
and Protective Placement of Edna M.F.:  
 
 
 
 
Betty Spahn, Guardian of Edna M.F. and 
 
 
 
Mark Wittman, Guardian Ad Litem for  
 
 
 
Edna M.F., 
 
 
 
 
Appellants,  
 
 
 
 
v.  
 
 
 
Howard B. Eisenberg,  
 
 
 
 
Respondent-Designate. 
 
 
 
________________________________________ 
 
 
 
 
 
 
 
ON BYPASS FROM THE COURT OF APPEALS 
 
 
 
 
 
                                                              
 
Opinion Filed:  
June 12, 1997 
Submitted on Briefs: 
 
Oral Argument:  
January 8, 1997 
                                                              
 
Source of APPEAL 
 
COURT: 
Circuit 
 
COUNTY: 
Wood 
 
JUDGE: 
 
DENNIS D. CONWAY 
 
                                                              
 
JUSTICES: 
 
 
Concurred: 
Abrahamson, C.J., concurs (opinion filed) 
 
 
 
Bablitch, J. concurs (opinion filed) 
 
 
 
Geske, J. concurs (opinion filed) 
 
 
 
Bradley, J. concurs (opinion filed) 
 
Dissented: 
 
 
Not Participating: 
 
                                                              
 
ATTORNEYS:  
For the appellant there were briefs (in the Court 
of Appeals & Supreme Court) by John R. Hutchinson and Wynia & 
Billings, 
S.C., 
Marshfield 
and 
oral 
argument 
by 
John 
R. 
Hutchinson. 
 
 
For the Guardian Ad Litem there was a brief (in the Supreme 
Court) by Mark J. Wittman and Zappen & Meissner, Marshfield and 
oral arugment by Mark J. Wittman. 
 
 
For the respondent-designate there was a brief and oral 
argument (in the Supreme Court) by Howard B. Eisenberg, Milwaukee.  
 
 
 
 
 
Amicus curiae brief was filed (in the Court of Appeals) by 
William P. Donaldson, Madison for the Board on Aging and Long Term 
Care of the State of Wisconsin. 
 
 
Amicus curiae brief was filed (in the Court of Appeals) by 
Betsy J. Abramson, Madison, for the Elder Law Center of the 
Coalition of Wisconsin Aging Groups. 
 
 
No.  95-2719 
 
 
1
 
NOTICE 
This opinion is subject to further editing 
and modification.  The final version will 
appear in the bound volume of the official 
reports. 
 
 
No. 95-2719 
 
STATE OF WISCONSIN               :        
        
 
 
 
 
IN SUPREME COURT 
 
 
IN THE MATTER OF THE GUARDIANSHIP AND 
PROTECTIVE PLACEMENT OF EDNA M.F.:  
BETTY SPAHN, GUARDIAN OF EDNA M.F., 
AND MARK WITTMAN, GUARDIAN AD LITEM 
FOR EDNA M.F.,  
 
          Appellants, 
 
 
v. 
 
HOWARD B. EISENBERG, 
 
 
Respondent-Designate. 
 
FILED 
 
JUN 12, 1997 
 
Marilyn L. Graves 
Clerk of Supreme Court 
Madison, WI 
 
 
 
 
Appeal from an order of the Circuit Court for Wood County, 
Dennis D. Conway, Judge.  Affirmed. 
¶1 
DONALD W. STEINMETZ, J.  Betty Spahn ("Spahn") seeks 
review of a decision by the Circuit Court for Wood County, Judge 
Dennis D. Conway, denying her request to withdraw artificial 
nutrition from her sister, Edna M.F.  The court held that it was 
without authority to grant Spahn's request because Edna is not 
in a persistent vegetative state.  This case presents this court 
with two issues:  
¶2 
1) Whether the guardian of an incompetent person who 
has not executed an advance directive and is not in a persistent 
vegetative state has the authority to direct withdrawal of life- 
sustaining medical treatment from the incompetent person; and 
 
 
No.  95-2719 
 
 
2
¶3 
2) Whether in this case, notwithstanding the fact that 
she is not in a persistent vegetative state, there is a clear 
statement evidenced in the record of Edna's desire to die rather 
than have extreme measures applied to sustain her life under 
circumstances such as these.  
¶4 
Relying on this court's previous decision in In re 
Guardianship of L.W., 167 Wis. 2d 53, 482 N.W.2d 60 (1992), we 
hold that a guardian may only direct the withdrawal of life-
sustaining medical treatment, including nutrition and hydration, 
if the incompetent ward is in a persistent vegetative state and 
the decision to withdraw is in the best interests of the ward.  
We further hold that in this case, where the only indication of 
Edna's desires was made at least 30 years ago and under 
different circumstances, there is not a clear statement of 
intent such that Edna's guardian may authorize the withholding 
of her nutrition.  
¶5 
Edna M.F. is a 71-year old woman who has been 
diagnosed with dementia of the Alzheimer's type.  She is 
bedridden, but her doctors have indicated that she responds to 
stimulation from voice and movement.  She also appears alert at 
times, with her eyes open, and she responds to mildly noxious 
stimuli.1  According to these doctors, her condition does not 
meet the definition of a persistent vegetative state.  In 1988, 
a permanent feeding tube was surgically inserted in Edna's body. 
 Edna currently breathes without a respirator, but she continues 
                     
1 In his testimony at trial, Dr. John Przybylinski, one of Edna 
M.F.'s doctors, described the mildly noxious stimuli as "either 
pinching her arm or her leg or rubbing her sternum." 
 
 
No.  95-2719 
 
 
3
to receive artificial nutrition and hydration.  Edna's condition 
is not likely to improve. 
¶6 
Edna's sister and court-appointed guardian, Betty 
Spahn, seeks permission to direct the withholding of Edna's 
nutrition, claiming that her sister would not want to live in 
this condition.  However, the only testimony presented at trial 
regarding Edna's views on the use of life-sustaining medical 
treatment involves a statement made in 1966 or 1967.  At that 
time, Spahn and Edna were having a conversation about their 
mother, who was recovering from depression, and Spahn's mother-
in-law, who was dying of cancer.  Spahn testified that during 
this conversation, Edna said to her: "I would rather die of 
cancer than lose my mind."  Spahn further testified that this 
was the only time that she and Edna discussed the subject and 
that Edna never said anything specifically about withholding or 
withdrawing life-sustaining medical treatment.        
¶7 
In October of 1994, the Ethics Committee at the 
Marshfield Nursing and Rehabilitation, the facility where Edna 
lives, met to discuss the issue of withholding artificial 
nutrition from Edna.  The committee approved the withholding of 
the nutrition if no family member objected.  However, one of 
Edna's nieces refused to sign a statement approving the 
withdrawal of nutrition. 
¶8 
On January 12, 1995, Spahn filed a petition in Wood 
County Circuit Court as guardian of an incompetent person, Edna 
M.F., asking the court to issue an order confirming Spahn's 
decision to withhold nutrition from Edna.  On January 13, 1995, 
the court appointed Mark Wittman ("Wittman") as the guardian ad 
 
 
No.  95-2719 
 
 
4
litem.  The court denied Spahn's petition.  The case is now 
before this court on a petition to bypass the court of appeals. 
 However, because both Spahn and Wittman are arguing to withhold 
nutrition, this court has appointed Attorney Howard Eisenberg as 
respondent-designate to argue for sustaining the life of Edna 
M.F. 
¶9 
The issue of the right to terminate life-sustaining 
medical treatment first came to the national forefront in the 
controversial case In re Quinlan, 355 A.2d 647 (N.J. 1976), 
cert. denied sub nom., 424 U.S. 922 (1976).  In Quinlan, Joseph 
Quinlan petitioned the court to be appointed guardian of his 21-
year old daughter, Karen.  Karen was in a chronic persistent 
vegetative state2 and her father sought the express power to 
authorize "the discontinuance of all extraordinary medical 
procedures now allegedly sustaining Karen's vital processes and 
hence her life. . . ."  Id. at 651.  Because Karen existed in a 
persistent vegetative state, and there was no hope of her ever 
recovering from this state, the court granted Joseph Quinlan's 
requests.  Id. at 671-72. 
¶10 Fourteen years later, the United States Supreme Court 
considered whether the state of Missouri could require clear and 
convincing 
evidence 
of 
an 
incompetent's 
wishes 
before 
authorizing the withdrawal of life-sustaining medical treatment, 
including nutrition and hydration, when the incompetent is in a 
                     
2 Dr. Fred Plum, the doctor who created the term, defined a 
person in a persistent vegetative state "as a subject who remains 
with the capacity to maintain the vegetative parts of 
neurological function but who . . . no longer has any cognitive 
function."  Quinlan, 355 A.2d at 654.  Cognitive function can be 
best understood as "either self-awareness or awareness of the 
surroundings in a learned manner."  See In re Jobes, 529 A.2d 
434, 438 (N.J. 1987).      
 
 
No.  95-2719 
 
 
5
persistent vegetative state.3  Cruzan v. Director, Missouri 
Department of Health, 497 U.S. 261 (1990).  In making its 
decision, the Court determined that the states have an interest 
in protecting the lives of their citizens and that that interest 
is demonstrated, among other ways, "by treating homicide as a 
serious crime."  Id. at 280.  On the other hand, the Court notes 
that "[i]t cannot be disputed that the Due Process Clause 
protects an interest in life as well as an interest in refusing 
life-sustaining medical treatment."  Id. at 281.  The Court 
concludes that the rights of the state and the individual must 
be balanced: "we 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."  Id.   
¶11 The Court upheld the decision of the Missouri Supreme 
Court to require that a guardian meet a "clear and convincing" 
standard before terminating an incompetent's life-sustaining 
medical treatment, including artificial nutrition and hydration.4 
 The Court explained that these life-and-death decisions have 
great consequences, and that an erroneous decision to terminate 
cannot be remedied: 
 
                     
3 The Court in Cruzan defined persistent vegetative state as "a 
condition in which a person exhibits motor reflexes but evinces 
no indications of significant cognitive function."  Cruzan v. 
Director, Missouri Department of Health, 497 U.S. 261,  266 
(1990).   
4 We note here that the Cruzan Court did not decide that the 
liberty interest in refusing life-sustaining medical treatment 
includes the right to refuse nutrition and hydration.  The Court 
merely assumed so for the purposes of ruling on the proper 
evidentiary standard in the case.   See In re Guardianship of 
L.W., 167 Wis. 2d 53, 71, 482 N.W.2d 60 (1992). 
 
 
No.  95-2719 
 
 
6
An erroneous decision not to terminate results in a 
maintenance of the status quo; the possibility of 
subsequent 
developments 
such 
as 
advancements 
in 
medical 
science, 
the 
discovery 
of 
new 
evidence 
regarding the patient's intent, changes in the law, or 
simply the unexpected death of the patient despite the 
administration of life-sustaining treatment at least 
create the potential that a wrong decision will 
eventually be corrected or its impact mitigated.  An 
erroneous decision to withdraw of life-sustaining 
treatment, however, is not susceptible to correction.  
Id. at 283-84.   
 
¶12 Two years after the Cruzan decision was rendered, this 
court was faced with a similar case, In re Guardianship of L.W., 
167 Wis. 2d 53, 482 N.W.2d 60 (1992).  In L.W., this court 
considered the issue of whether an incompetent individual in a 
persistent vegetative state has the right to refuse life-
sustaining medical treatment, including nutrition and hydration. 
 The court further considered whether a court-appointed guardian 
may exercise that right on behalf of the incompetent patient.  
This court began its analysis of the situation with an 
exploration of the possible constitutional rights implicated by 
these circumstances, and concluded "that an individual's right 
to refuse unwanted medical treatment emanates from the common 
law right of self-determination and informed consent, the 
personal liberties protected by the Fourteenth Amendment, and 
from the guarantee of liberty in Article I, section I of the 
Wisconsin Constitution."  Id. at 67. 
¶13 This court further concluded that the right to refuse 
unwanted treatment applies to both competent and incompetent 
individuals, and that the right of the incompetent to refuse may 
be exercised by his or her guardian.  Id. at 73, 76.  The court 
in L.W. then faced the choice of what standard the guardian 
should apply in determining whether to continue life-sustaining 
 
 
No.  95-2719 
 
 
7
medical treatment.  The guardian argued for a subjective test 
considering the ward's past values, wishes, and beliefs (the 
"substituted judgment" standard), and the guardian ad litem 
argued in favor of the standard upheld in Cruzan requiring 
"clear and convincing evidence" of the ward's desires.  Noting 
that this court has rejected the substituted judgment standard 
in the past5 and that the clear and convincing evidence standard 
would be too strict, this court concluded that an objective 
"best interests" standard was the appropriate standard to apply 
when 
deciding 
whether 
to 
withdraw 
life-sustaining medical 
treatment from an incompetent ward in a persistent vegetative 
state.  Id. at 76, 78, 81.  The only thing that matters in the 
decision-making process is what would be in the ward's best 
interests.  Of course, the court noted, if the wishes of the 
ward are clearly evidenced, then it is in the best interests of 
the ward to have his or her wishes honored.  Id. at 79-80.      
               
¶14 In sum, this court concluded in L.W. "that an 
incompetent individual in a persistent vegetative state has a 
constitutionally protected right to refuse unwanted medical 
treatment, including artificial nutrition and hydration," and 
that a guardian may consent to withholding or withdrawal of such 
treatment without prior approval of the courts if to do so is in 
                     
5 In the case of In re Guardianship of Pescinski, 67 Wis. 2d 4, 
7-8, 226 N.W.2d 180 (1975), this court held that a guardian must 
act under the "best interests" standard with respect to the ward, 
and the court explicitly declined to adopt the "substituted 
judgment" standard.  
In the case of In re Guardianship of Eberhardy, 102 Wis. 2d 539, 
307 N.W.2d 881 (1981), the court again chose to apply the "best 
interests" standard to the guardian-ward relationship.  See Id., 
at 566, 567.   
 
 
No.  95-2719 
 
 
8
the "best interests" of the ward.  Id. at 63.  However, this 
court stressed the fact that the opinion in L.W. "is limited in 
scope to persons in a persistent vegetative state."  Id. 
 ¶15 Spahn asks this court to extend L.W. beyond its 
current scope to include incompetent wards who are not in a 
persistent vegetative state.  Spahn notes that in L.W., this 
court concluded that the right to refuse unwanted medical 
treatment applies to competent and incompetent people alike, 
even if there has been no advance directive on the part of the 
incompetent ward.   
¶16 In the case In re Guardianship of Eberhardy, 102 Wis. 
2d 539, 307 N.W.2d 881 (1981), this court was faced with the 
request to authorize a guardian of an incompetent to consent to 
the sterilization of the incompetent, a mentally disabled woman. 
 The guardian argued that since the competent person has the 
right to sterilization, that right should not be withheld from 
the incompetent.  This court explained in Eberhardy that even 
though all citizens have the same constitutional rights, the 
United States Supreme Court has recognized that "the uninhibited 
exercise of those rights may be hedged about with restrictions 
that reflect the public policy of protecting persons of a 
distinct class."  Id. at 572.  For example, this court notes 
that the Supreme Court has recognized that the decision by a 
minor to have an abortion could be circumscribed by action 
requiring a showing of maturity or "best interests" to make a 
decision without parental involvement.  Id. at 572, citing 
Bellotti v. Baird, 443 U.S. 622 (1979).  Additionally, a state 
may require a physician to notify a minor's parents before 
 
 
No.  95-2719 
 
 
9
agreeing to perform an abortion.  Id. at 572-73, citing H.L. v. 
Matheson, 450 U.S. 398 (1981). 
¶17 The Eberhardy court proceeded to explain that the 
mentally disabled are a similar class to minors in that they are 
also subject to "special protections of the state" because many 
mentally disabled adults are "not competent to exercise a free 
choice."  Id. at 573.  The court explained that "[w]hile the 
Constitution would generally mandate a free choice for sui juris 
adults, a free choice is an empty option for those who cannot 
exercise it."  Id. 
¶18 This brings us to the situation at hand–-whether this 
court should allow surrogate decisionmakers to decide to 
withhold or withdraw life-sustaining medical treatment from an 
incompetent adult who is not in a persistent vegetative state.  
This 
court in Eberhardy 
said 
that 
for the 
purposes of 
sterilization, incompetent people are to be considered "a 
distinct class to whom the state owes a special concern."  Id. 
at 574.  So, although incompetent adults have the same 
constitutional rights as competent adults, they do not have the 
same ability to exercise those rights.  Someone must instead act 
in the best interests of that person to make a decision 
regarding 
whether 
to withhold or 
withdraw 
life-sustaining 
treatment.  However, if that person is not in a persistent 
vegetative state, this court has determined that, as a matter of 
law, it is not in the best interests of the ward to withdraw 
life-sustaining treatment, including a feeding tube, unless the 
ward has executed an advance directive or other statement 
clearly indicating his or her desires. 
 
 
No.  95-2719 
 
 
10
¶19 One of the main reasons that this court in L.W. 
limited the scope of its holdings is the fact that The American 
Academy of Neurology explains that people in a persistent 
vegetative state do not feel pain or discomfort.  L.W., 167 Wis. 
2d at 87, note 17.  In the case at bar, Edna M.F. is not in a 
persistent vegetative state and could therefore likely feel the 
pain and discomfort of starving to death.  Even a competent 
person cannot order "the withholding or withdrawal of any 
medication, life-sustaining procedure or feeding tube" if "the 
withholding or withdrawal will cause the declarant pain or 
reduce the declarant's comfort" unless the pain or discomfort 
can be alleviated through further medical means.  Wis. Stat. 
§ 154.03(1).  See also Wis. Stat. § 155.20(1).  In the case 
where withdrawal of life-sustaining medical treatment, including 
nutrition or hydration, will cause pain or discomfort, then, the 
competent and incompetent person have exactly the same rights.6 
¶20 This court has established a bright-line rule in L.W. 
that the guardian of an incompetent ward possesses the authority 
to direct withholding or withdrawal of life-sustaining medical 
treatment, including artificial nutrition and hydration, if it 
is in the best interests of the ward and the ward is in a 
persistent vegetative state.  Spahn now asks this court to 
extend the scope of L.W. to include those incompetent patients 
who are afflicted with incurable or irreversible conditions of 
health.  We decline to go down this slippery slope, for the 
                     
6 Of course, a competent and incompetent person always have the 
same rights.  See generally In re Guardianship of L.W., 167 Wis. 
2d 53, 73-74, 482 N.W.2d 60 (1992). 
 
 
No.  95-2719 
 
 
11
consequences and the confusion may be great.  One author 
explains as follows: 
 
 
While 
at 
first 
euthanasia 
may 
be 
institutionalized only for those in terrible pain, or 
those who are terminally ill, or those for whom it is 
otherwise appropriate, the pressure of the allocation 
of health care resources will inevitably enlarge the 
class for whom euthanasia is deemed appropriate.  
Every society has a group who are deemed to be 
socially unworthy and members of that group–-the 
uneducated, the unemployed, the disabled, for example–
-will become good candidates for euthanasia. 
Barry R. Furrow et al., Bioethics: Health Care Law and Ethics 
325 (1991).  This court has drawn a bright-line in L.W., and we 
will not venture down the slippery slope of extending it when 
there is insufficient evidence of the ward's desires. 
 
¶21 Even though Edna M.F. is not currently existing in a 
persistent vegetative state, if her guardian can demonstrate by 
a preponderance of the evidence a clear statement of Edna's 
desires in these circumstances, then it is in the best interests 
of Edna to honor those wishes.7  See L.W., 167 Wis. 2d at 79-80. 
 The reason this court requires a clear statement of the ward's 
desires is because of the interest of the state in preserving 
human life8 and the irreversible nature of the decision to 
withdraw nutrition from a person.  This court explained the 
                     
7 We stress that this right has been limited by the legislature 
in Wis. Stat. § 154.03(1), which does not permit withdrawal of 
life-sustaining medical treatment, including nutrition and 
hydration, if it would cause pain or discomfort unless the pain 
or discomfort can be alleviated through further medical means. 
8 This court has set out the four relevant state interests that 
must be considered in making decisions about medical treatment 
decisions for incompetent people.  These are 1) preserving life, 
2) safeguarding the integrity of the medical profession, 3) 
preventing suicide, and 4) protecting innocent third parties.  In 
re Guardianship of L.W., 167 Wis. 2d 53, 90.  Preserving life is 
the most significant state interest at issue here.  See id.    
 
 
No.  95-2719 
 
 
12
magnitude of this type of decision as compared to other, less 
permanent, decisions in Eberhardy: 
 
Importantly, however, most determinations made in the 
best interests of a child or an incompetent person are 
not irreversible; and although a wrong decision may be 
damaging indeed, there is an opportunity for a certain 
amount of empiricism in the correction of errors of 
discretion.  Errors of judgment or revisions of 
decisions by courts and social workers can, in part at 
least, be rectified when new facts or second thoughts 
prevail. . . .Sterilization as it is now understood by 
medical 
science 
is, 
however, 
substantially 
irreversible. 
 Eberhardy, 102 Wis. 2d at 567-68.  Like sterilization, the 
decision to withdraw life-sustaining medical treatment is also 
not reversible, because death is not reversible.  It is for this 
reason, then, that we require a guardian to show a clear 
statement of the ward's desires by a preponderance of the 
evidence. 
 
¶22 We now turn to the case at bar to determine whether 
there is sufficient evidence in the record to reflect a clear 
statement of desire by Edna M.F. while she was still competent. 
 The trial court did not make an explicit factual finding as to 
whether the guardian met this burden.  However, it did mention 
in its memorandum decision that none of the witnesses who 
presented letters and affidavits to the court ever discussed the 
matter with Edna M.F., and that the only testimony as to Edna's 
opinions 
on the situation 
dates 
back 
to 
1966 
or 
1967.  
Generally, findings of fact shall not be set aside unless they 
are clearly erroneous,  Wis. Stat. § 805.17(2), but in a 
situation where there are no explicit factual findings, "this 
court may affirm the judgment if '[a] perusal of the evidence 
shows that the court reached a result which the evidence would 
 
 
No.  95-2719 
 
 
13
sustain if specifically found.'" Grimh v. Western Fire Ins. Co., 
5 Wis. 2d 84, 89, 92 N.W.2d 259 (1958) (citations omitted).   
 
¶23 The record speaks very little to what Edna's desires 
would be under the current circumstances.  We know from the 
record that she was a vibrant woman, a gifted journalist, and a 
devout Roman Catholic.  We know that she was and is loved dearly 
by her family and friends, and that the majority of them feel 
that she "would not want to be kept alive" in this condition.  
We know that in 1966 or 1967 during a time of family crisis, she 
said that she "would rather die of cancer than lose [her] mind." 
 But we do not have any clear statement of what her desires 
would be today, under the current conditions.  Her friends and 
family never had any conversations with her about her feelings 
or opinions on the withdrawal of nutrition or hydration, and she 
did not execute any advance directives expressing her wishes 
while she was competent. 
¶24 There is a presumption that continuing life is in the 
best interests of the ward.  L.W., 167 Wis. 2d at 86.  The only 
evidence in the record of Edna's desires is the general 
statement she made to her sister in 1966 or 1967.  We understand 
how difficult Edna's illness has been on her loved ones, and we 
sympathize with their plight, but the evidence contained in the 
record is simply not sufficient to rebut the presumption that 
Edna would choose life.  A perusal of the record and the 
insufficiency of the evidence contained therein supports the 
result the trial court reached, even though there was no 
explicit factual finding by the trial court on this issue.   
 
 
No.  95-2719 
 
 
14
¶25 In conclusion, this court declines to extend the scope 
of L.W. beyond those incompetent wards who are currently in a 
persistent vegetative state; we will not apply L.W. to those 
with incurable or irreversible conditions.  As such, we re-
affirm the decision of this court in L.W. that the threshold at 
which this court will authorize the withholding or withdrawal of 
life-sustaining medical treatment is the point at which trained 
medical doctors diagnose a patient as being in a persistent 
vegetative state.   
¶26 Whether or not a patient is in a persistent vegetative 
state is a medical, not legal, determination.  If Edna M.F.'s 
doctors determine she is now in a persistent vegetative state 
and the guardian determines that it is in the best interest of 
Edna, she may be authorized to withhold nutrition and hydration. 
 As it now stands, however, the facts of this case do not 
support a finding that Edna M.F. is in a persistent vegetative 
state.  That is the rule of L.W. and we decline to extend that 
rule.     
¶27 Consequently, we hold that a guardian may only direct 
the withdrawal of life-sustaining medical treatment, including 
nutrition and hydration, if the incompetent ward is in a 
persistent vegetative state and the decision to withdraw is in 
the best interests of the ward.  We further hold that in this 
case, where the only indication of Edna's desires was made at 
least 30 years ago and under different circumstances, there is 
not a clear statement of intent such that Edna's guardian may 
authorize the withholding of her nutrition.  
 
 
No.  95-2719 
 
 
15
By the Court.— The decision of the Wood County Circuit 
Court is affirmed.   
 
 
         
 
            
    
 
 
 
 
No. 95-2719.ssa 
 
1
¶28 SHIRLEY S. ABRAHAMSON, CHIEF JUSTICE (concurring). I 
join in the mandate. I agree that In the Matter of Guardianship 
of L.W., 167 Wis. 2d 53, 482 N.W.2d 60 (1992), should not be 
extended to persons not in a persistent vegetative state.9  
¶29 I write separately because I believe (1) that the 
majority opinion's characterization of Ms. F.'s condition is 
incomplete; and (2) that further discussion of the application 
of L.W. to the present case is needed. 
I. 
¶30 I write first to explain my disagreement with the 
majority opinion's characterization of some parts of the record.  
¶31 The majority's discussion of Ms. F.'s condition does 
not do justice to the factual record. The majority describes Ms. 
F. as bedridden, responsive to stimulation and appearing alert 
at times. Majority op. at 2. While this description is true, it 
conveys an inaccurate picture of Ms. F.'s medical situation. Ms. 
                     
9 The guardian, the guardian ad litem, the two amici, and 
counsel appointed by this court to support the order of the 
circuit court agree that at the time of the hearing Ms. F. was 
not in a persistent vegetative state. The guardian and guardian 
ad litem would have preferred that the attending doctor opine 
that Ms. F. was in a persistent vegetative state because the 
guardian could then have directed the withdrawal of nutrition 
without 
authorization 
from 
the 
court 
if 
two 
independent 
physicians concurred in the diagnosis. Yet the guardian accepted 
the diagnosis of Ms. F.'s attending doctors at that time. 
 
Because of the attending doctor's diagnosis, the guardian, the 
guardian ad litem and the amici came to court to urge the court 
to authorize circuit courts to confirm a guardian's decision to 
direct withdrawal of nutrition from a person not in a persistent 
vegetative state. Thus counsel urge us to extend In the Matter of 
Guardianship of L.W., 167 Wis. 2d 53, 482 N.W.2d 60 (1992). 
Court-appointed counsel urges us to adhere to L.W.  
The amici curiae are the Elder Law Center of the Coalition of 
Wisconsin Aging Groups and the Board on Aging and Long Term Care 
of the State of Wisconsin. Each filed a brief. 
 
 
No. 95-2719.ssa 
 
2
F. breathes without assistance but in all other respects is 
dependent on others for her care and continued existence. Ms. 
F.'s muscles have deteriorated to the point where her limbs are 
contracted 
and 
immobile. 
She 
demonstrates 
no 
purposeful 
response, such as withdrawal, to tactile, aural or visual 
stimuli; she makes non-specific responses to pinching or tapping 
of the arm or sternum. There is also some testimony suggesting 
Ms. F. occasionally may track movements in the room with her 
eyes. 
¶32 Two attending physicians testified; only Dr. Erickson, 
however, was asked to opine on whether Ms. F. was in a 
persistent vegetative state at the time of his examination of 
her. Dr. Erickson testified as follows: 
 
The definition [of persistent vegetative state] as 
described in the journal of neurology in 1989, 
January, 1989, requires that there be no behavioral 
response whatsoever over an extended period of time, 
and that no voluntary action or behavior of any kind 
is present. As I testified before, Edna, in my 
opinion, 
has 
provided 
evidence 
of 
some 
minimal 
response to stimulation from her surrounding, and so 
in the strict definition, I would have to say that she 
approximates 
but 
does 
not 
entirely 
meet 
that 
definition of the persistent vegetative state. 
R. 19 at 33. 
¶33 The circuit court made the following finding of fact, 
in accord with the guardian's position and the evidence 
presented: "Edna M.F. is a 71 year old woman whose mental 
condition approximates but does not meet the clinical definition 
of persistent vegetative state." Given the record in this case 
 
 
No. 95-2719.ssa 
 
3
the circuit court's finding that Ms. F. is not in a persistent 
vegetative state is not clearly erroneous.10 
¶34 The other important factual question is whether Ms. F. 
made a clear expression of her wishes regarding life-sustaining 
medical treatment. I agree with the majority opinion that the 
record supports the finding that she did not and the circuit 
court's memorandum decision implies such a finding. That finding 
is not clearly erroneous. 
II. 
¶35 I have some concern about the majority opinion's 
characterization of several aspects of the L.W. decision. 
¶36 L.W. largely controls our decision in the present 
case. L.W. held that a guardian may consent to the withholding 
or withdrawal of life-sustaining medical treatment on behalf of 
one who was never competent, or a once competent person whose 
conduct was never of a kind from which one could draw a 
reasonable inference upon which to make a substituted judgment,11 
when: (1) the attending physician and independent physicians 
determine with reasonable medical certainty that the patient is 
                     
10 The majority opinion embellishes the record when it concludes 
that Ms. F. could "likely feel the pain and discomfort of 
starving to death." Majority op. at 10. Dr. Erickson testified 
that in his opinion Ms. F. was not experiencing any pain. R. 19 
at 34, 51-52. Dr. Przybylinski testified that he thought Ms. F. 
could experience pain but that a physician could not determine 
this fact. R. 19 at 63, 68-69. The circuit court made no finding, 
express or implied, regarding whether Ms. F. retains sufficient 
cortical function to feel pain. Retention of the feeding tube 
would enable the clinic staff to continue to provide Ms. F. with 
fluids and, if deemed necessary, with pain medication, while 
nutrition was withheld. 
11 I agree with the majority opinion that the ward in the present 
case had not made a clear expression, when competent, of her 
wishes with regard to life-sustaining medical treatment.  
 
 
No. 95-2719.ssa 
 
4
in a persistent vegetative state and has no reasonable chance of 
recovery to a cognitive and sentient life; and (2) the guardian 
determines in good faith that the withholding or withdrawal of 
treatment is in the ward's best interests. L.W., 167 Wis. 2d at 
84-85. 
¶37 I feel it necessary to state what I believe L.W. does 
and does not stand for and to offer further discussion of the 
application of L.W. to the facts of this case. 
¶38 First, L.W. held that a person's right to refuse life-
sustaining medical treatment includes the right to refuse the 
provision of nutrition and hydration. L.W., 167 Wis. 2d at 70-
73.12 It is therefore of no moment that the United States Supreme 
Court "merely assumed" this fact in Cruzan v. Director, Missouri 
Dep't of Health, 497 U.S. 261 (1990), as the majority opinion 
states. Majority op. at 6 n.4. There is no longer any doubt that 
the provision of nutrition and hydration by artificial means are 
forms of medical treatment in Wisconsin. 
                     
12 Despite the objection raised in the dissenting opinion in L.W., 
167 Wis. 2d at 99 (Steinmetz, J., dissenting), the court 
concluded its thorough consideration of the issue as follows: 
"Consistent with the implied holding of the United States Supreme 
Court, and the specific declaration of the Wisconsin legislature, 
we conclude that an individual's right to refuse unwanted life-
sustaining medical treatment extends to artificial nutrition and 
hydration." L.W., 167 Wis. 2d at 73. In response to the 
dissenting opinion the L.W. majority stated:  
The 
dissent 
asserts 
that 
this 
conclusion 
is 
'unwarranted and misconceived' because Cruzan did not 
decide the issue . . . . It is clear that we base our 
conclusion that artificial nutrition and hydration is 
medical treatment which may be refused primarily on 
the fact that it is indistinguishable from other forms 
of treatment and not on the ambivalence of the Cruzan 
majority. 
 
Id. at 73 n.7. 
 
 
No. 95-2719.ssa 
 
5
¶39 Second, L.W. held that a surrogate decision-maker must 
apply a best interests test to determine the propriety of 
withholding life-sustaining medical treatment to a person who 
was never competent or a person whose conduct while competent 
was never of a kind from which one could draw a reasonable 
inference upon which to make a substituted judgment. L.W. 167 
Wis. 2d at 75-76. L.W. did not establish whether a substituted 
judgment test or other test is appropriate to determine the 
propriety of withholding life-sustaining medical treatment from 
a person who gave indication while competent of his or her 
wishes regarding such treatment. Nor did L.W. address the proper 
test to be used when the incompetent person is not in a 
persistent vegetative state. L.W. was concerned with a person in 
a persistent vegetative state who by all indications had never 
been competent. There was, therefore, no basis on which a 
guardian or a court could make a substituted judgment and only 
under such circumstances did the court rule out a substituted 
judgment test. L.W. 167 Wis. 2d at 78-79 and n.11. It would be 
inaccurate to conclude that the substituted judgment test has 
been rejected in other circumstances. 
¶40 I take the majority opinion to imply that L.W. 
rejected the substituted judgment test for all persons in a 
persistent vegetative state:  
 
Noting that this court has rejected the substituted 
judgment 
standard 
in 
the 
past 
[citing 
In 
re 
Guardianship of Pescinski, 67 Wis. 2d 4, 7-8, 226 
N.W.2d 180 (1975)and In re Guardianship of Eberhardy, 
102 Wis. 2d 539, 566-67, 307 N.W.2d 881 (1981)] and 
that the clear and convincing evidence standard would 
be too strict, this court [in L.W.] concluded that an 
 
 
No. 95-2719.ssa 
 
6
objective 
"best 
interests" 
standard 
was 
the 
appropriate standard to apply when deciding whether to 
withdraw life-sustaining medical treatment from an 
incompetent ward in a persistent vegetative state. 
[L.W., 167 Wis. 2d] at 76, 78, 81. The only thing that 
matters in the decision-making process is what would 
be in the ward's best interests.  
Majority op. at 7-8. But the court in L.W., having considered 
the two cases cited by the majority opinion in the present case, 
Pescinski and Eberhardy, stated explicitly that substituted 
judgment may be the appropriate test in some circumstances: 
 
[N]either of these cases should be construed to mean 
that a surrogate decision maker could not make a 
substituted judgment or decision that was designed to 
carry out the wishes of the incompetent if the 
incompetent's wishes were knowable. . . . To hold that 
all substituted judgments are ipso facto rejected 
would probably constitute an unconstitutional holding 
for 
it 
would 
deprive 
an 
incompetent 
of 
the 
constitutional 
right 
of 
choicea 
right 
that 
is 
universally 
recognized 
when 
the 
choice 
is 
ascertainable. 
L.W., 167 Wis. 2d at 79 n.11. The court has no reason to address 
the appropriate test in the present case because according to 
the record Ms. F. was not in a persistent vegetative state and 
her wishes were not knowable. The majority opinion therefore 
should not be read to change or add to L.W.'s limited statement 
regarding the appropriate test for a court or guardian to apply 
in determining the propriety of withholding life-sustaining 
medical treatment.13 
                     
13 For discussions of the substituted judgment and best interests 
tests see John A. Robertson, Cruzan and the Constitutional Status 
of Nontreatment Decisions for Incompetent Patients, 25 Ga. L. 
Rev. 1139 (1991); Yale Kamisar, When is there a Constitutional 
"Right to Die"? When is there no Constitutional "Right to Live"?, 
25 Ga. L. Rev. 1203 (1991); John A. Robertson, Assessing Quality 
of Life: A Response to Professor Kamisar, 25 Ga. L. Rev. 1243 
(1991); Stewart G. Pollock, Life and Death Decisions: Who Makes 
Them and By What Standards?, 41 Rutgers L. Rev. 505 (1989); Nancy 
K. Rhoden, Litigating Life and Death, 102 Harv. L. Rev. 375, 380-
 
 
No. 95-2719.ssa 
 
7
¶41 Third, pursuant to L.W., the court's ruling today is 
limited to Ms. F.'s condition in the spring of 1995. The 
decision whether to seek additional diagnoses when this case is 
completed properly belongs to the guardian and not to the court. 
It is a fundamental premise of L.W. that ordinarily decisions to 
withhold or withdraw life-sustaining medical treatment of a ward 
are to be made by a guardian in conjunction with doctors and the 
family, not by the courts. As L.W. stated, courts are poorly 
equipped to handle these matters. L.W., 167 Wis. 2d at 92.  
¶42 If the guardian chooses to seek further diagnoses and 
if the doctors, applying current medical knowledge, determine 
that Ms. F. is at the time of examination in a persistent 
vegetative state, the guardian may consent to withdrawal of 
nutrition or the guardian may decide not to withdraw nutrition. 
In either event, no further circuit court proceeding is 
available or required unless an interested person objects to the 
withdrawal of nutrition. 
¶43 The diagnosis of a persistent vegetative state or its 
absence is made by qualified physicians using scientifically 
current information and standards. Guardians and doctors must be 
allowed to adopt the medical community's most advanced thinking 
on the subject.14 It is similarly important that physicians who 
                                                                  
419 (1988); Joanna K. Weinberg, Whose Right Is It Anyway? 
Individualism, Community, and the Right to Die: A Commentary on 
the New Jersey Experience, 40 Hastings L.J. 119 (1988); Rebecca 
Morgan, Florida Law and Feeding TubesThe Right of Removal, 17 
Stetson L. Rev. 109 (1987). 
14 Unlike the other concurring opinion I do not believe this court 
should determine the differences, if any, between the 1994 and 
earlier medical standards about persistent vegetative state and 
 
 
No. 95-2719.ssa 
 
8
are called upon to make the apparently difficult diagnosis of a 
persistent vegetative state be expert in this area of medicine. 
Court review of the guardian's determination is necessary only 
if a party in interest objects. L.W., 167 Wis. 2d at 92-93 and 
n.20. 
¶44 Fourth, the holding in L.W. should be understood to 
state the principle that the fact that the ward is in a 
persistent vegetative state is a significant legal threshold.  
¶45 Under L.W. the opinion of an attending physician is 
essential for the withdrawal of nutrition. Dr. Erickson, one of 
the attending physicians, was an internist, had extensive 
experience with older persons including treating Alzheimer's 
patients, and held a certificate of added qualifications in 
geriatrics. While the guardian and guardian ad litem believe 
that withdrawal of life-sustaining treatment for Ms. F. is 
appropriate, they relied on the diagnosis of Ms. F.'s attending 
physicians, as they were required to do under L.W.  
¶46 When the attending physician did not diagnose Ms. F. 
as in a persistent vegetative state, there was no point in 
consulting independent physicians. The issue of who should be 
the independent physicians to diagnose Ms. F.'s condition is 
thus not raised in this case and has not been briefed by the 
parties. Furthermore, L.W. does not address the difficult 
question of what procedure should be followed when there is 
disagreement among the consulted physicians whether the patient 
                                                                  
the appropriate medical diagnosis of persistent vegetative state 
without the assistance of experts' testimony and without briefing 
by the parties. 
 
 
No. 95-2719.ssa 
 
9
is in a persistent vegetative state. Again, this question is not 
raised or briefed in this case. 
¶47 To the extent it may be necessary or appropriate for 
the court to change, add to, or expand upon the standards set 
forth in L.W., the court should do so only with the benefit of 
full 
adversarial 
briefing 
in 
a 
case 
presenting 
a 
real 
controversy framed by adversarial parties. See, e.g., State v. 
Garfoot, 207 Wis. 2d 215, 239, 558 N.W.2d 626 (1997) (Bablitch, 
J., concurring). 
¶48 I view L.W. as the first step in addressing withdrawal 
of 
life-sustaining 
medical 
treatment 
from 
persons 
in 
a 
persistent vegetative state who have not clearly expressed their 
wishes. As is evident in this case, L.W. has not answered all 
the questions that will be raised in this complex and troubling 
area. I have tried to take care, however, not to use the present 
case as the vehicle to offer answers to unresolved complex 
questions that have been neither raised nor briefed. I am 
concerned that I not engage in appellate decision-making of the 
sort Attorney Bernard Witkin has characterized as "Have Opinion, 
Need Case." B.E. Witkin, Manual on Appellate Court Opinions § 86 
at 155 (1977). 
¶49 Fifth, L.W. commented favorably on the role of the 
health care provider's ethics committee.15 Hospital or nursing 
home ethics committees provide an important forum for careful 
                     
15 L.W., 167 Wis. 2d at 89. For a discussion of the role of ethics 
committees see Gregory A. Jaffe, Institutional Ethics Committees: 
Legitimate and Impartial Review of Ethical Health Care Decisions, 
10 J. Legal Medicine 393 (1989). 
 
 
No. 95-2719.ssa 
 
10
deliberation about the decision to withhold life-sustaining 
medical treatment. Based on the limited record before us, it 
appears that the committee reviewing the request by Ms. F.'s 
guardian did not function effectively. Had Ms. F. been in a 
persistent vegetative state and had an interested person 
objected to the withdrawal of nutrition, the circuit court 
stated that it would have been unable to give weight to the 
committee's 
purported 
determination 
that 
withholding 
of 
nutrition was the ethically proper course. The circuit court 
noted that no formal minutes or report of the meeting was 
produced 
at 
the 
hearing 
and 
that 
the 
committee 
members 
apparently functioned without either a shared body of rules or 
training in ethics. In fairness to the committee members in this 
case, it must be noted that the committee had only recently been 
formed and had deliberated in perhaps only one other case.  
¶50 The circuit court also seemed troubled, as am I, with 
the apparent focus of the ethics committee's investigation. The 
committee seemed to understand that its function was to reach a 
determination that would insulate the facility from legal 
liability rather than the determination that best comported with 
medical ethics.16 The focus of all participants in this fateful 
                     
16 The ethics committee apparently agreed with the decision to 
withhold nutrition from Ms. F. but would not agree to carry out 
this decision without written consent from all family members. It 
appears that all family members except for one niece of Ms. F. 
consented in writing. The niece was reported to have said that 
she did not object to withholding nutrition but that her 
religious views precluded her from consenting in writing.  
The circuit judge concluded his own lengthy questioning of one 
member of the ethics committee with the following: "[T]he way I 
understand it, what you really have is a liability problem, and 
that’s why you want everybody to consent, is that correct?" Dr. 
 
 
No. 95-2719.ssa 
 
11
and difficult process should be on the propriety of taking 
action which will lead to a person's death. The health care 
facility's liability concerns must not be allowed to interfere 
with the guardian's efforts to assure the exercise of the ward's 
right to be free of unwanted life-sustaining medical treatment 
when the guardian has determined, in consultation with the 
physicians, that the ward is in a persistent vegetative state 
and it is in the ward's best interests to withhold such 
treatment. 
¶51 For the foregoing reasons I write separately. 
                                                                  
Erickson answered: "That is correct." R. 19 at 47.  
 
 
No. 95-2719.jpg   
 
1
 
 
No. 95-2719.wab   
 
1
¶52 WILLIAM 
A. BABLITCH, J. 
(Concurring).  
The 
medical determination of the existence of a persistent 
vegetative state is, literally, one of life or death.  It 
is important the doctors get it right.  It is equally 
important that we get the law right.   
¶53 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.  
¶54 We further agree that if Ms. F. is diagnosed 
again and the doctors determine that she meets the current 
medical definition of persistent vegetative state, medical 
treatment may be withdrawn even if her physical condition 
has not changed from the time of the diagnosis rendered in 
this case. 
¶55 But then we part company. 
¶56 Regrettably, the majority and the concurring 
opinions fail to establish a significant safeguard designed 
to ensure the accuracy of that determination.  They would 
allow any person with a medical degree to make the critical 
diagnosis that drives the ultimate decision to withdraw or 
continue life sustaining medical treatment.  Furthermore, 
they insist on the presence of three  doctors only when the 
decision is to withdraw life sustaining medical support.  
Respectfully, I cannot join such a decision 
¶57 I would direct as a matter of law that anytime a 
guardian 
requests 
a 
diagnosis 
for 
the 
purpose 
of 
determining the presence or absence of a persistent 
 
 
No. 95-2719.wab   
 
2
vegetative state in order to ascertain whether life 
sustaining medical treatment 
can 
be 
withdrawn, three 
conditions must be met.  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.17  Third, I join with the concurring opinion that 
the 
doctors 
must 
rely 
on 
current 
medical 
authority 
generally 
accepted 
in 
that 
specialty. 
 
Inasmuch 
as 
Alzheimer’s is a neurological disease, I would direct that 
in the case of Ms. F. one of the independent doctors be a 
neurologist relying on current medical authority accepted 
in the field of neurological medicine. 
I. 
¶58 The majority and concurring opinions fail to 
require 
that 
one 
of 
the 
attending 
physicians 
be 
a 
specialist in the medical field relevant to the patient’s 
condition.   
¶59 This case amply demonstrates the need for such 
                     
17 Although these two issues were neither briefed nor argued 
by the parties, the posture in which this case comes to us 
does raise them.  It is obvious from this record that all 
parties agreed to a trial and appellate strategy of 
attempting to extend L. W..  Thus, none of the original 
parties were adversarial to each other, and none of them 
briefed nor argued these issues.  From their perspective, it 
was unnecessary.  Nonetheless, I would reach and decide 
them.  We have on occasion in the past ordered the parties 
to brief issues not presented in the briefs or arguments.  
We have, as we did in this very case, appointed counsel to 
advance opposing positions.  I would support similar action 
in this case.  The nature of these issues make it highly 
unlikely that this court will see them again for years, if 
ever. 
 
 
No. 95-2719.wab   
 
3
protection.  Neither of the two physicians who examined Ms. 
F. were neurologists.  The only doctor who was asked his 
opinion on whether Ms. F. was in a persistent vegetative 
testified she was not.  However, he testified that his 
diagnosis was based on a January 1989 article in the 
medical journal, Neurology.  The authority he relied on was 
arguably outdated.   
¶60 The entire 1989 Statement upon which the doctor 
relied covered two pages in that journal. In 1991, the 
Multi-Society Task Force on Persistent Vegetative State was 
created.18  The Task Force’s 1994 Statement, a far more 
exhaustive 
treatment 
of 
persistent 
vegetative 
state, 
summarizes current knowledge of the medical aspects of 
persistent vegetative state.19  The 1994 Statement explains, 
refines and substantially augments the 1989 definition of 
                     
18 The 1994 Statement, Medical Aspects of the Persistent 
Vegetative State, Parts I and II, 330 N.Engl. J. Med. (May 
26, 1994), was approved by the executive committee of each 
of the following medical societies: the American Academy of 
Neurology, the Child Neurology Society, the American 
Neurological Association, the American Association of 
Neurological Surgeons, and the American Academy of 
Pediatrics.  Two representatives from each of these 
societies were appointed to the Task Force, and an advisory 
panel of consultants was selected from the related fields of 
medicine, ethics, and law. 
19 The 1994 Statement speaks to the “vegetative state,” 
distinguishing between a “persistent vegetative state” and a 
“permanent vegetative state.”  It refers to the persistent 
vegetative state as a diagnosis, the permanent vegetative 
state as a prognosis, i.e., an irreversible persistent 
vegetative state.  L.W. used the term persistent vegetative 
state to refer to an irreversible condition.  Because the 
majority and concurring opinions continue to use the term 
“persistent” to categorize the irreversible condition, I do 
likewise. 
 
 
No. 95-2719.wab   
 
4
persistent vegetative state applied by Ms. F.’s doctor in 
his diagnosis. 
¶61  As 
more 
fully 
discussed 
below, 
the 
1994 
Statement appears to call into serious question the 
accuracy of the diagnosis made by Dr. Erickson.   
¶62 Unless this court directs that at least one of 
the doctors be a specialist current in his or her field, 
there is nothing to stop this from happening again.  The 
potential for serious error, as possibly occurred here 
where Ms. F. was diagnosed as not being in a persistent 
vegetative state, is patent.  The potential for serious 
error in cases involving a patient diagnosed as being in a 
persistent vegetative is equally apparent.   
¶63 In retrospect, L.W. should have insisted upon, 
rather than recommended, a specialist in the field.  It did 
not, and the majority and concurring opinions continue in 
that error.  In a justifiable desire to leave these 
decisions as much as reasonably possible to family members 
and their physicians and not the courts, the majority and 
concurring opinions abdicate too much.  They are willing to 
allow any person with a medical degree to diagnose the 
presence or absence of a persistent vegetative state. 
¶64 I am not. 
¶65 A diagnosis of the presence or absence of a 
persistent vegetative state drives the ultimate decision to 
withdraw or continue life sustaining medical treatment.  It 
is far too important and critical a decision to leave in 
 
 
No. 95-2719.wab   
 
5
the hands of anybody with a medical degree.  A level of 
expertise beyond a medical degree should be demanded.  
¶66 Other states and commentators have recognized 
this problem.  One legal scholar cites the risk of an 
erroneous medical diagnosis as one of the three major 
factors that contribute to the risk of an improper decision 
to 
continue 
or 
to 
withhold 
life 
sustaining 
medical 
treatment.  Linda C. Fentiman, Privacy and Personhood 
Revisited: A New Framework for Substitute Decision Making 
for the Incompetent, Incurably Ill Adult, 57 Geo. Wash. L. 
Rev. 801, 808 (March 1989).  Professor Fentiman notes that 
a 
number 
of 
courts 
have 
implicitly 
recognized 
this 
possibility of a mistaken diagnosis.  Id. at 809. 
¶67 The New Jersey Supreme Court, which set the stage 
for decision making analysis in these cases with the 
Quinlan decision, expressly recognized the risk of an 
erroneous diagnosis.  In re Jobes, 529 A.2d 434, 447-448 
(N.J. 1987).  To guard against the risk of such an error 
and to ensure the preservation of medical ethics, the 
surrogate decision maker must secure statements from “at 
least two independent physicians knowledgeable in neurology 
that the patient is in a persistent vegetative state.”  Id. 
at 448. 
¶68 Acknowledging that the prognosis determination is 
a medical one, the Washington Supreme Court held that even 
this 
prong 
of 
the 
life-sustaining 
medical 
treatment 
decision making process must incorporate safeguards to 
 
 
No. 95-2719.wab   
 
6
protect patients from an inaccurate diagnosis.  In re 
Colyer, 660 P.2d 738, 749 (1983)(requiring confirmation of 
the attending physician’s diagnosis by a prognosis board 
consisting 
of 
“no 
fewer 
than 
two 
physicians 
with 
qualifications 
relevant 
to 
the 
patient’s 
condition”).  
Accord 
In 
re 
Moorhouse, 
593 
A.2d 
1256 
(N.J. 
App. 
1991)(requiring that the attending physician’s diagnosis be 
confirmed by the hospital’s prognosis committee and at 
least 
two 
independent 
physicians 
knowledgeable 
in 
neurology); John F. Kennedy Memorial Hospital, Inc. v. 
Bludworth, 
452 
So.2d 
921, 
926 
(Fla. 
1984)(requiring 
certification that patient is in a permanent vegetative 
state by the primary treating physician and concurrence in 
the certification by “at least two other physicians with 
specialties relevant to the patient’s condition.”). 
¶69 The concurring opinion recognizes to some extent 
these problems by stating that “It is similarly important 
that physicians who are called upon to make the apparently 
difficult diagnosis of a persistent vegetative state be 
expert in this area of medicine.”  Concurrence at 8. 
¶70 It is more than “important.”  It is critical.  I 
would not recommend, I would direct.  The absence of this 
safeguard in the majority and concurring opinions charts a 
perilous course. 
¶71 Dr. Erickson, who is not a neurologist, relying 
on arguably outdated medical authority, diagnosed Ms. F. 
and testified that she approximates but does not meet the 
 
 
No. 95-2719.wab   
 
7
strict definition of persistent vegetative state. If he was 
in error, important constitutional rights were denied Ms. 
F.  This record raises serious concern in my mind that he 
may have been in error.  At the very least, his testimony 
did not indicate a knowledge of the 1994 Statement.  A 
neurologist might well have been aware.  It might have 
changed the diagnosis. 
¶72 Nevertheless, if there was an error made in the 
diagnosis of Ms. F., or others like her, it was an error 
made on the side of life.  It can be corrected.  Not so in 
the case of a diagnosis of a persistent vegetative state of 
a person who is in fact not in a persistent vegetative 
state.  Once medical treatment is withdrawn, life will 
cease:  misdiagnosis in that event cannot be corrected.  
Surely some minimum safeguards speaking to the expertise 
and knowledge of the doctors should be present.  The 
majority requires nothing other than a medical degree.   
¶73 I would require more. 
II. 
¶74 Unfortunately, 
the 
majority 
and 
concurring 
opinions require three doctors only when life sustaining 
support is to be withdrawn.  They are silent as to the 
threshold stage in any case involving these issues:  the 
decision of the guardian to seek a diagnosis.   
¶75 I would require three doctors anytime a guardian 
requests a diagnosis  for the purpose of determining the 
presence or absence of a persistent vegetative state.  The 
 
 
No. 95-2719.wab   
 
8
importance of that requirement is demonstrated by this 
case.  Once the attending physician determined that Ms. F. 
was close but not actually in a persistent vegetative 
state, the inquiry was ended.  But if Ms. F. was 
incorrectly diagnosed, as I believe is suggested in this 
record, important constitutional rights were denied her.  
¶76 We require three doctors when the decision to 
withdraw life support is made.  Is it not equally important 
to require the same number of doctors at the threshold 
inquiry which, in a case like this, is determinative of 
constitutional rights?   
¶77 I would require that once the guardian determines 
that the question of withdrawal of life sustaining medical 
support is presented, the attending physician and two 
independent doctors must be consulted. 
III. 
¶78 Fortunately, the concurring opinion recognizes 
the importance of using current medical authority, and 
directs that it be used.  Concurrence at 7 (“If the 
guardian chooses to seek further diagnoses and if the 
doctors, applying current medical knowledge, determine that 
Ms. F. is at the time of the examination in a persistent 
vegetative state, the guardian may consent to withdrawal of 
nutrition or the guardian may decide not to withdraw 
nutrition.”(emphasis added)).  Id. at 7-8 (“Qualified 
physicians make the diagnosis of a persistent vegetative 
state 
or 
its 
absence, 
using 
scientifically 
current 
 
 
No. 95-2719.wab   
 
9
information 
and 
information 
and 
standards.” 
(emphasis 
added)).  I join that part of the concurring opinion.  
Accordingly, that requirement has the support of a majority 
of this court. 
¶79 The importance of using current medical authority 
is amply demonstrated in this record.  Dr. Erickson, 
relying on a January, 1989, journal of neurology, testified 
that the standards expressed therein required “that there 
be no behavioral response whatsoever over an extended 
period of time.”  (emphasis added). Further, he testified 
that those 1989 standards required there be “no voluntary 
action or behavior of any kind [present].” (emphasis 
added).  Because there was “some minimal response to 
stimulation from her surroundings” the doctor concluded Ms. 
F. “approximates but does not entirely meet that definition 
of the persistent vegetative state.” 
¶80 This testimony was crucial.  No one disputed the 
doctor’s finding that Ms. F. was not in a persistent 
vegetative state.  The circuit court had no choice but to 
agree.  But current medical authority, the 1994 Statement, 
contradicts or at the very least calls into serious 
question Dr. Erickson’s conclusion.  It does not require 
“no behavioral response whatsoever” for the presence of a 
persistent 
vegetative 
state; 
rather, 
it 
requires 
no 
evidence of “sustained” behavior of that kind. 
¶81 In order to more fully understand why the 1994 
Statement seriously undercuts the doctor’s conclusion, it 
 
 
No. 95-2719.wab   
 
10
is necessary to first understand more completely the 
condition of Ms. F. with respect to her response to 
stimulation.20 
¶82 Although she appears to respond to voices or 
noises in her room, she makes no meaningful response to 
questions or commands.  R:19 at 24-25.21  Several medical 
professionals who had regular contact with Ms. F. described 
her condition.  Licensed practical nurse, Patricia Rohmeyer 
(Rohmeyer), has had regular contact with Ms. F. since 1986. 
 R:19 at 6.  Rohmeyer testified that she “[d]oes not 
respond most of the time when you speak to her, either by 
blinking her eyes or opening her eyes.”  R:19 at 7.  Edna 
F. does not respond when Rohmeyer places a finger in her 
hand and asks her to squeeze the finger.  R:19 at 8.  When 
asked whether Ms. F. looked toward a person who called her 
name, Rohmeyer responded that “[s]he wasn’t able to today.” 
 R:19 at 8.  She 
described Ms. 
F.’s 
condition 
as 
“progressive through the years.”  R:19 at 8. 
¶83 Spahn described her sister’s condition to the 
circuit court: “Sometimes I can get her to look at me. . . 
. Sometimes I can get her to look.  Not very often.  The 
last couple times I have been in I’ve gotten – I did get 
                     
20 I agree with the concurring opinion that the majority 
opinion does not convey an accurate picture of Ms. F.’s 
condition.   The facts recited in the concurring opinion 
together with the facts stated herein convey an accurate 
portrayal.  In addition, I note that Ms. F. has been in this 
condition since 1993, and her doctors testify she will not 
improve, she will only get worse. 
21 References are to pages and documents in the record. 
 
 
No. 95-2719.wab   
 
11
her to open her eyes, but not to look at me.”  R:19 at 75-
76. 
¶84 Even more telling was the testimony of Dr. 
Erickson.  He described Ms. F.’s condition on December 19, 
1994: 
 
She did respond to voice by opening her eyes, but 
did not respond to command. . . .  She opened her 
eyes and looked, but not in any meaningful way at 
me.  She simply appeared to respond to a voice or 
to a noise in the room.  I discussed with the 
nursing staff at that time, although I did not 
notice that she would occasionally track movement 
in the room.  The level of alertness that I found 
at that time in discussion with the nursing staff 
was consistent with what they had observed on a 
day to day basis. . . .  Periodically she would 
follow movement in the room, or she may respond 
to tactile stimulation or voice by opening her 
eyes.  But there was no meaningful response to 
command or attempts at communication. 
R:19 at 24-25.  
¶85 The record reveals that upon application of 
mildly noxious stimuli, Ms. F. might open her eyes or 
grimace but, her doctors say, she fails to make a 
consistent effort to withdraw from or to remove the 
stimulation.  R: 19 at 26, 65. 
¶86 Dr. Przyblinski described Ms. F.’s response to 
mildly 
noxious 
stimuli: 
 
“When 
I 
gave 
her 
tactile 
stimulation which I considered mildly noxious, either 
pinching her for arm [sic] or her leg or rubbing her 
sternum, she grimaced and she did make a moaning sound.  
She did not make any attempt to push my hand away or pull 
her arm or leg away, so I didn’t see anything that I would 
see as purposeful movement with that kind of stimulation.” 
 
 
No. 95-2719.wab   
 
12
 R:19 at 63. He further states that she is no longer aware 
of, nor can she interact in any purposeful manner, with her 
surroundings, or the people who are attending to her.  R:19 
at 64-65 (emphasis added). 
¶87 Dr. Erickson has never observed a consistent 
effort by Ms. F. to withdraw from noxious stimuli.  R:19 at 
25.  When he touches her face, or presses gently on her 
sternum, she might make a minimal response, i.e., a 
movement 
or 
facial 
expression, 
acknowledging 
the 
stimulation, but he has observed no consistent effort to 
withdraw or to remove the stimuli.  R:19 at 26. When 
doctors subject her to noxious stimuli, Ms. F.’s vital 
signs remain stable.  R:19 at 34.   
¶88 The 1994 Statement lists the following criteria 
according to which the vegetative state can be diagnosed: 
 
(1) 
no 
evidence 
of 
awareness 
of 
self 
or 
environment and an inability to interact with 
others; 
(2) 
no 
evidence 
of 
sustained, 
reproducible, purposeful, or voluntary behavioral 
responses 
to 
visual, 
auditory, 
tactile, 
or 
noxious stimuli; (3) no evidence of language 
comprehension or expression; (4) intermittent 
wakefulness manifested by the presence of sleep-
wake 
cycles; 
(5) 
sufficiently 
preserved 
hypothalamic and brain-stem autonomic functions 
to permit survival with medical and nursing care; 
(6) bowel and bladder incontinence; and (7) 
variably 
preserved 
cranial-nerve 
reflexes 
(pupillary, 
oculocephalic, corneal, vestibulo-
ocular, and gag) and spinal reflexes. 
¶89 Dr. 
Erickson 
testified 
that 
a 
persistent 
vegetative 
state 
required 
“no 
behavioral 
response 
whatsoever.”  As seen from the above 1994 Statement, that 
appears to be an incorrect conclusion:  “no evidence of 
 
 
No. 95-2719.wab   
 
13
sustained, reproducible, or voluntary behavioral responses 
to . . . stimuli.”  (emphasis added).  The 1994 Statement 
further cautions that motor or eye movements and facial 
expressions in response to various stimuli also occur in 
persons in an irreversible vegetative state.  These 
movements and expressions occur in stereotyped patterns 
that indicate reflexive 
responses 
integrated 
at 
deep 
subcortical levels, and are not indicative of learned 
voluntary acts.  The presence of these responses is 
consistent with complete unawareness.  The 1989 Statement 
does not discuss the subtle distinctions between the visual 
pursuit of a person who is aware of the surroundings and a 
person in a persistent vegetative state.  
¶90 Given that Dr. Erickson believed the existence of 
a persistent vegetative 
state required no 
behavioral 
response whatsoever, given that he testified Ms. F.’s 
responses were “minimal,” and given the above quoted texts 
from the 1994 Statement, I conclude a serious question 
exists as to the accuracy of his diagnosis.  If so, 
important constitutional rights have been denied Ms. F.  
The use of current medical authority might well have 
changed his diagnosis.  Fortunately, that is now the 
mandate of this court.  
¶91 In summation, I would hold that anytime a 
guardian 
requests 
a 
diagnosis 
for 
the 
purpose 
of 
determining the presence or absence of a persistent 
vegetative state to ascertain whether life sustaining 
 
 
No. 95-2719.wab   
 
14
medical treatment may be withdrawn, three conditions must 
be met: 1) the diagnosis must be made by the attending 
physician together with two independent doctors; 2) at 
least one of the independent doctors must be a specialist 
in the medical field relevant to the patient’s condition; 
and, 3) the diagnosis must rely on current medical 
authority generally accepted in that specialty.   
¶92 If 
indeed 
Ms. 
F.’s 
original 
diagnosis 
was 
incorrect, needless suffering has been endured by her 
family and loved ones as they have been forced to sit 
helplessly by watching this woman they love continue an 
emptiness that only the most literal would call life.  Had 
the procedures I recommend been utilized, this might have 
been avoided.  Fortunately, if error has been made it can 
be corrected.  All members of this court agree that she can 
be re-diagnosed.  If her attending physician and two 
independent doctors agree that she meets the current 
medical definition of persistent vegetative state, and no 
one objects, medical treatment may be withdrawn without 
further recourse to the courts.  This is so even if her 
physical condition has not changed from the time of the 
original diagnosis rendered in this case.   
¶93 Others may not be as fortunate.   
¶94 For the above stated reasons, I respectfully 
concur.22  
                     
22 I also agree with the concurring opinion with respect to 
its discussion of what L.W. does and does not stand for, 
specifically that the provision of nutrition and hydration 
 
 
No. 95-2719.wab   
 
15
                                                             
by artificial means are forms of medical treatment in 
Wisconsin, and that the substituted judgment test has not 
been rejected in Wisconsin in all circumstances. 
 
 
No. 95-2719.jpg   
 
1
 
 
¶95 JANINE P. GESKE, J.  (Concurring).   I join 
both the majority opinion authored by Justice Donald W. 
Steinmetz and the concurring opinion authored by Chief 
Justice Shirley S. Abrahamson.  
 
 
No. 95-2719.awb   
 
1
 
 
¶96 ANN WALSH BRADLEY, J. (Concurring).   I join 
both the majority opinion authored by Justice Donald W. 
Steinmetz and the concurring opinion authored by Chief 
Justice Shirley S. Abrahamson.