******************************************************

The ‘‘officially released’’ date that appears near the

beginning of each opinion is the date the opinion will

be published in the Connecticut Law Journal or the

date it was released as a slip opinion. The operative

date for the beginning of all time periods for filing

postopinion motions and petitions for certification is

the ‘‘officially released’’ date appearing in the opinion.

In no event will any such motions be accepted before

the ‘‘officially released’’ date.

All opinions are subject to modification and technical

correction prior to official publication in the Connecticut Reports and Connecticut Appellate Reports. In the

event of discrepancies between the electronic version

of an opinion and the print version appearing in the

Connecticut Law Journal and subsequently in the Connecticut Reports or Connecticut Appellate Reports, the

latest print version is to be considered authoritative.

The syllabus and procedural history accompanying

the opinion as it appears on the Commission on Official

Legal Publications Electronic Bulletin Board Service

and in the Connecticut Law Journal and bound volumes

of official reports are copyrighted by the Secretary of

the State, State of Connecticut, and may not be reproduced and distributed without the express written permission of the Commission on Official Legal

Publications, Judicial Branch, State of Connecticut.

******************************************************
IN RE CASSANDRA C.*

(SC 19426)

Rogers, C. J., and Palmer, Zarella, Eveleigh, McDonald, Espinosa and

Robinson, Js.

Argued January 8—officially released January 8, 2015**

Michael S. Taylor, assigned counsel, with whom was

James P. Sexton, assigned counsel, for the appellant

(respondent mother).

Joshua Michtom, assigned counsel, for the appellant

(minor child).

John E. Tucker, assistant attorney general, with

whom were Rosemarie T. Webber, assistant attorney

general, and, on the brief, George Jepsen, attorney general, and Benjamin Zivyon and Michael Besso, assistant attorneys general, for the appelllee (petitioner).

Daniel J. Krisch, Sandra Staub and David McGuire

filed a brief forthe American Civil Liberties Union Foundation of Connecticut as amicus curiae.
Opinion

ROGERS, C. J. This appeal raised the question of

whether Connecticut should recognize as a matter of

our common law the ‘‘mature minor’’ doctrine, which

allows a sufficiently mature minor to consent to or to

refuse medical treatment. The threshold issue that we

must resolve, however, is whether the trial court properly determined that Cassandra C., the minor daughter

of the respondent mother (mother), was not competent

to make her own medical decisions at the time of the

underlying events. After certain medical providers

reported to the Department of Children and Families

(department) that Cassandra and her mother,1 were

refusing to obtain appropriate medical treatment for

Cassandra, who had been diagnosed with Hodgkin’s

lymphoma, the petitioner, the Commissioner of Children and Families (commissioner), filed a neglect petition seeking an order of temporary custody of

Cassandra pursuant to General Statutes § 46b-129 (a)

and (b). The trial court, Westbrook, J., granted the order

placing Cassandra in the temporary custody of the

department and ordered that Cassandra be removed

from the residence where she lived with her mother

and be placed in her cousin’s home. After conducting

an evidentiary hearing, the trial court, Taylor, J., sustained the order of temporary custody and ordered that

Cassandra be placed back in her own home on the

condition the respondents allow the department to have

unfettered access to Cassandra and that the respondents cooperate with her medical care providers. Cassandra subsequently started chemotherapy, but ran

away from home before the treatment could be completed. The commissioner then filed a motion to reargue, for reconsideration, for clarification and to reopen

the evidence ‘‘in order to consider evidence regarding

[Cassandra’s] subsequent behaviors and whether she is

competent to make life/death decisions regarding her

medical care.’’ That motion was granted and an evidentiary hearing was held before the trial court, Quinn, J.

At the conclusion of the hearing, Judge Quinn ordered

that Cassandra remain in the custody and care of the

department and that she be removed from her home,

and authorized the department to make all medical

decisions for her. Thereafter, the respondents filed this

appeal2 claiming that Judge Quinn improperly had found

that Cassandra was not competent to make her own

medical decisions and had violated the respondents’

constitutional due process right to bodily and family

integrity. After hearing oral argument on an expedited

basis, this court affirmed Judge Quinn’s judgment from

the bench and indicated that a written decision would

be issued in due course. This is that written decision.

In sum, we conclude that the question of Cassandra’s

competence to make medical decisions was squarely

before Judge Quinn and that her finding that Cassandra
was not a mature minor was not clearly erroneous. We

further conclude that, because the evidence does not

support a finding that Cassandra was a mature minor

under any standard, this is not a proper case in which

to decide whether to adopt the mature minor doctrine.

Finally, because the respondents have not established

the factual predicate for their due process claims—that

they were deprived of a hearing at which to determine

Cassandra’s competence to refuse medical treatment—

we reject that claim.

The record reveals the following facts on which Judge

Quinn reasonably could have relied in determining that

Cassandra was not competent to make her own medical

decisions and procedural history. Cassandra was born

on September 30, 1997. From May, 2014 through July,

2014, when Cassandra was sixteen years old, she suffered from stomachaches, lower back pain, chest pain

and an enlarged and tender cervical gland. When antibiotic treatment failed to resolve her condition, her primary care physician, Hemant K. Panchal, referred

Cassandra to another physician, Henry M. Feder, an

infectious disease specialist. After an initial appointment on July 1, 2014, Feder attempted to follow up with

the respondents to determine whether the treatment

he had prescribed was effective, but Cassandra missed

two scheduled appointments. Feder finally saw Cassandra in early August, at which time he ordered a chest

X ray that revealed enlarged lymph nodes. At that point,

Feder suspected that Cassandra might have cancer and

he scheduled an appointment for a needle biopsy of

her enlarged cervical gland. Cassandra did not attend

the appointment, which concerned Feder. Feder scheduled a second appointment at which a needle biopsy

was taken that was suspicious for lymphoma.

At that point, Cassandra was referred to the cancer

and blood disorders services division of hematology

and oncology at the Connecticut Children’s Medical

Center (medical center) in Hartford. An appointment

was scheduled for September 4, 2014, but Cassandra

did not show up. Another appointment was scheduled

for September 9, at which Cassandra was examined by

Eileen Gillan, a physician with the Connecticut Children’s Specialty Group, who recommended that Cassandra undergo a biopsy procedure of an enlarged lymph

node. On September 12, 2014, Brendan Campbell, a

surgeon, performed an incisional biopsy on Cassandra’s

enlarged cervical gland. Pathological tests showed conclusively that Cassandra was suffering from Hodgkin’s

lymphoma, a type of cancer that is invariably fatal if

not treated, but that has a high probability of cure if

treated in a timely manner. Interrupting chemotherapy

treatment of the disease can lead to resistance of the

cancer to treatment. Delaying chemotherapy treatment

may increase the risk of a poor outcome and may

require radiation treatment, which has increased risks

of harmful side effects, especially for young women.3
On September 19, 2014, Gillan spoke by telephone

with Cassandra’s mother and informed her of the diagnosis. The mother was upset that Gillan had not called

her earlier and by what she perceived as Gillan’s attitude

when she ‘‘nonchalantly’’ stated that she had been

unsure how to break the bad news regarding Cassandra’s diagnosis to the respondents. Gillan recommended that Cassandra undergo further evaluations to

determine the stage of the cancer and to discuss treatment, but the mother refused.

At some point, Gillan asked her partner, Michael Isakoff, a pediatric oncologist, to take over Cassandra’s

treatment. Gillan told Isakoff that, on the basis of her

interactions with the mother, she believed that Isakoff

would be able to deal more effectively with her. Gillan

also told Isakoff that the mother had been angry and

hostile toward her and that the respondents were not

interested in getting treatment or tests to determine the

stage of the disease. Isakoff was able to schedule an

appointment with the respondents to discuss these

issues for October 7, 2014, but only Cassandra’s mother

and uncle attended that appointment. The mother was

upset because she had been expecting to meet with

Gillan. Isakoff explained the further testing and treatment that he recommended. When the mother

expressed great concern about giving Cassandra ‘‘poisons,’’ Isakoff acknowledged that the treatment had

some toxic side effects, but explained that chemotherapy was the only way to treat the disease and that

there were ways to reduce the toxicity. The mother

also complained about the mannerin which information

had been relayed to her and other ‘‘process’’ issues,

and was angry and hostile toward Isakoff. She further

indicated that she did not believe the diagnosis and

asked about getting a second opinion. Specifically, she

questioned why the biopsy report showed no signs of

the Epstein-Barr virus when, based on her research,

that virus is always present with Hodgkin’s lymphoma.

Isakoff repeatedly assured the mother that that was not

the case, but Isakoff was not convinced that she was

comfortable with his response. Toward the end of the

conversation, Isakoff told the mother bluntly that he

was very concerned about the amount of time that had

elapsed since the biopsy and that it was important for

Cassandra to start treatment within two weeks. He

asked the mother to contact him within two days to let

him know how she wanted to proceed. At that point,

the mother got up and walked out. On October 17, 2014,

Isakoff wrote a letter to Cassandra’s mother to express

his concerns about the ongoing delays in the evaluation

and treatment of Cassandra’s disease and asked her to

contact his office as soon as possible.

The respondents sought a second opinion about Cassandra’s diagnosis from Matthew Richardson, a pediatric oncologist at Baystate Medical Center in Springfield,
Massachusetts. Richardson examined Cassandra on

October 14, 2014, and, after reviewing the scans and

pathology reports from the medical center, agreed with

the diagnosis that Cassandra had Hodgkin’s lymphoma.

Richardson attempted to contact the respondents seven

times overtwo days and lefttelephone messages regarding his diagnosis and the urgency of the situation. The

mother finally returned his calls on October 20, 2014,

and Richardson told her that it was urgent that the

staging of Cassandra’s cancer be completed and that

treatment be started. The mother indicated that she had

not yet decided whether Richardson would be Cassandra’s treating physician. Two days later, the mother

called Richardson and indicated that she wanted Richardson to treat Cassandra.

On October 23, 2014, a PET scan was performed that

revealed extensive stage three lymphoma in Cassandra’s neck, chest and abdomen. That same day, Richardson telephoned the mother and left a message on her

telephone indicating that it was necessary to complete

the staging evaluation and to start treatment, and that

he was concerned that the period that had elapsed since

the biopsy was beginning to be outside the standard of

care. Richardson ultimately attempted to telephone the

mother six times between October 25 and October 27,

2014, but received no answer. The mother finally telephoned Richardson on October 30, 2014, and stated

that she had decided Cassandra would be receiving care

from another physician. When Richardson asked where

he should send Cassandra’s medical records, the

mother stated that she would pick them up. She also

indicated that she did not have time to discuss the

results of the PET scan and that Cassandra would not

be following through with the pretreatment tests that

had been scheduled.

Richardson spoke with Isakoff at some point and

indicated that he had concerns about the mother’s hostility and unwillingness to obtain treatment for Cassandra in a timely manner. In addition, Richardson told

Isakoff that the respondents were seeking to have a

second biopsy performed. Isakoff believed that a second biopsy was medically inappropriate because, even

if it was negative, it would not invalidate the results of

the first biopsy, and the biopsy procedure involves risk.

Meanwhile, on October 2, 2014, Feder had reported

his concerns about the respondents’ apparent unwillingness to obtain treatment for Cassandra’s disease to

the department. At that point, Margaret Nardelli, an

investigator for the department, contacted the mother

to discuss the referral. The mother indicated that she

was not willing to meet with the department and that

she was meeting Cassandra’s needs. She also stated that

she was obtaining a second opinion about Cassandra’s

condition. When Nardelli tried to follow up, the mother

did not return her telephone calls. Finally, on October
21, 2014, Nardelli left a note at the respondents’ residence. At that point, the mother called Nardelli. She

was very upset and was yelling and swearing. The

mother told Nardelli that she was not allowed to go to

her home ever again, that Cassandra’s needs were being

met, and that she did not have to tell Nardelli anything or

do anything that the department requested. The mother

also told Nardelli that Cassandra felt fine and that she,

the mother, did not think that Cassandra had cancer.

Nardelli responded that if the mother did not want to

meet with the department, Nardelli would speak with

an attorney for the department about ways to ensure

that Cassandra’s needs were being met. The mother

said that she did not care what the department did and

hung up the telephone.

During Nardelli’s investigation of the case, Richardson called her and indicated that he was concerned

that the respondents were not moving quickly enough

to obtain treatment for Cassandra’s disease and that

they were consistently not keeping medical appointments. Panchal also called Nardelli and stated that the

respondents were not keeping scheduled appointments.

In addition, Panchal reported that the mother had told

him that he would no longer be Cassandra’s physician

and had demanded her medical records.

On the basis of this information, the department

became concerned that the mother was not following

through in a timely manner to obtain treatment for

Cassandra’s life threatening illness. The department

also became concerned about the mother’s ‘‘anxiety’’

and that the mother did not always remember information that previously had been provided to her. Although

the mother eventually attended scheduled meetings

with the department, she continued to question Cassandra’s diagnosis and to demand further assessments that

Cassandra’s medical providers had found to be inappropriate. On the basis of these concerns, the commissioner filed a neglect petition alleging that the mother

had ‘‘failed to meet the medical needs’’ of Cassandra

and sought an ex parte order of temporary custody

pursuant to § 46b-129 (b). The trial court, Westbrook,

J., found that there was reason to believe that Cassandra was in immediate physical danger and granted an

ex parte order of temporary custody on October 31,

2014. Immediately thereafter, the department brought

Cassandra to the emergency room at the medical center

for an evaluation. At that time, Cassandra was ‘‘very

fearful’’ of staying in the hospital and of waking up with

‘‘tubes sticking out of her.’’ She also expressed concerns

about not wanting to anger her mother, who, she said,

was very distrustful of physicians. Pursuant to Judge

Westbrook’s order, Cassandra was removed from her

home and placed in the home of a cousin pending a

hearing.

A preliminary hearing on the commissioner’s request
for an order of temporary custody was held on November 6, 2014, at which time Judge Westbrook ordered

a guardian ad litem for Cassandra and scheduled an

evidentiary hearing for November 12. At that evidentiary hearing, which took place before Judge Taylor,

Nardelli, Feder, Campbell and Isakoff testified as to

the foregoing facts. Cassandra’s guardian ad litem, Jon

David Anthony Reducha, testified that Cassandra had

told him the previous day that she was willing to be

treated for her disease, but that she would refuse treatment if she were not allowed to go home. Reducha

acknowledged that Cassandra’s decision to refuse treatment for her life threatening disease if she were not

allowed to go home was not a rational decision. It was

Reducha’s understanding that Cassandra initially had

resisted treatment because she was doing her own

research and she needed time to absorb the information. Reducha believed that it would be in Cassandra’s

best interest to be allowed to go home so that she would

agree to treatment.

Cassandra also testified at the November 12, 2014

hearing. Before she testified, her attorney requested the

court’s permission for her to testify from where she

was sitting in the courtroom instead of from the witness

stand, because she was nervous. When the trial court

denied the request, the attorney requested permission

to stand close to Cassandra ‘‘to give her a little comfort

and moral support.’’ The court also denied that request.

Cassandra testified that her mother had told her many

times that she did not want to lose a child and that

she wanted her to undergo chemotherapy. Cassandra

initially did not want to undergo chemotherapy because

of ‘‘everything that happens when you go through

chemo.’’ After her best friend told Cassandra that she

did not want to lose her and would ‘‘drag [her] to the

hospital and make [her] do it,’’ however, Cassandra

changed her mind. Because the treatment was going to

be very difficult, Cassandra wanted to be at home while

she was undergoing chemotherapy. If she were not

allowed to go home, she would refuse treatment. When

told thatthe department was concerned that, if she were

allowed to go home, she would still refuse treatment,

Cassandra stated that ‘‘[i]f you let me go home today,

I would start chemo tomorrow.’’

Cassandra’s mother testified at the hearing that she

had wanted to obtain a second opinion about Cassandra’s condition because she had ‘‘a right to a second

opinion’’ and the first diagnosis was serious. When the

respondents went to Richardson, the mother asked him

not to contact Isakoff because she wanted a ‘‘second

opinion, not a second agreement . . . .’’ She was upset

when she found out that Richardson had spoken to

Isakoff. After she discontinued Cassandra’s treatment

with Isakoff, the mother decided not to comply with

the department’s request to ‘‘keep in touch’’ because

she ‘‘was doing what [she] was supposed to be doing.’’
The mother testified that, although she continued to

believe that she had a right to a second and even a

third opinion about Cassandra’s diagnosis, she believed

that Cassandra had cancer and that she would die without treatment. She further testified that she ‘‘[a]bsolutely’’ agreed that Cassandra should be treated as soon

as possible.

On November 14, 2014, Judge Taylor issued an order

sustaining Judge Westbrook’s order of temporary custody. The court ordered that Cassandra be placed back

in her home with her mother subject to certain conditions, including that the mother allow the department

unfettered access to Cassandra and her home, that she

cooperate with Cassandra’s medical providers and that

she keep all medical appointments and appointments

with the department. The court also ordered that Isakoff

would serve as Cassandra’s treating physician and that

treatment was required to begin within seventy-two

hours after Cassandra returned home. In addition, the

court ordered that Cassandra remain within the state

for the duration of this case and that she not leave her

home for more than twelve hours without the prior

authorization of the department or the court.

On November 17 and 18, 2014, Cassandra underwent

her first two chemotherapy treatments. Her mother did

not attend the second treatment. After the second treatment, Isakoff observed bruising around the site of the

intravenous infusion. At that point, he told Cassandra

that, because her veins were fragile, she would have to

have a ‘‘port-a-cath’’4

surgically placed. Isakoff arranged

for a surgeon to perform the procedure the next morning so that Cassandra could receive her scheduled treatment later that day. When a department employee

arrived at the respondents’ home on the morning of

November 19, 2014, to transport Cassandra to her third

chemotherapy treatment, Cassandra was not there. Her

mother indicated that she did not know Cassandra’s

whereabouts. She made no efforts to find Cassandra

and did not notify the police. The mother told the

department that Cassandra would not be coming home.

During the next several days, the department went to

the respondents’ home on a daily basis to search for

Cassandra, and also went to the home of one of Cassandra’s friends and to her workplace. The department

also issued a ‘‘silver alert’’5 and searched online social

media in an attempt to locate Cassandra. Several days

after she disappeared, Cassandra’s attorney called the

department and stated that she wanted to return home.

Cassandra returned to her home on November 24,

2014, and, the next day, the department brought her to

the medical center for an evaluation by Isakoff. Nardelli

and two other department employees attended the

meeting. Cassandra told Isakoff that she was adamant

that she would not return for further chemotherapy.

She stated that she did not feel sick and that when she
started to feel sick she might reconsider her decision,

but that she would not be treated at the medical center

because she did not trust the physicians there. Isakoff

told Cassandra that there was a danger that the cancer

would become resistant if she interrupted the chemotherapy treatment. Cassandra then told Isakoff that she

had never intended to start chemotherapy and that she

had stated that she would do so in order to get the

department and the court to agree to allow her to go

home. She also stated that she was going to be eighteen

years old soon, at which point she would not be in the

position of being forced into treatment.

On December 1, 2014, the commissioner filed in the

trial court a motion forreargument and reconsideration,

for clarification and to reopen evidence. The commissioner requested that the trial court conduct a hearing

‘‘to consider evidence regarding [Cassandra’s] subsequent behaviors and whether she is competent to make

life/death decisions regarding her medical care.’’ An

evidentiary hearing for that purpose was held before

Judge Quinn on December 9, 2014.6

Isakoff testified at

the hearing that he did not believe that Cassandra was

competent to make the decision to refuse chemotherapy treatment for her disease. Indeed, he testified that,

if an adult were to make that decision, it would lead him

to question that person’s competence. Isakoff believed

that it was unreasonable for Cassandra to subject herself to chemotherapy in order to be allowed to return

home, especially if she intended to worsen her own

prognosis by interrupting the treatment, but to refuse

further chemotherapy to cure her fatal disease. He further testified that if Cassandra did not start chemotherapy within two weeks of the hearing, there would be

a much higher probability that Cassandra would have

to undergo radiation therapy. Isakoff also did not

believe that Cassandra’s mother was competent to

make decisions regarding Cassandra’s medical care.

Although he understood the mother’s concerns about

putting ‘‘poisons’’ in Cassandra’s body, the chemotherapy treatment provided Cassandra with her only chance

of survival. Isakoff further testified that the mother’s

doubts about the diagnosis also were unreasonable, as

the diagnosis had been repeatedly confirmed.

Cassandra’s mother testified that she believed that

Cassandra had cancer, that she believed that Cassandra

needed chemotherapy, that she wanted Cassandra to

have chemotherapy and that she had told Cassandra to

undergo chemotherapy. She also testified, however,

that she believed that it was Cassandra’s ‘‘right as a

human being’’ to refuse treatment and ‘‘to choose if she

wants poisons that are going to affect her the rest of

her life . . . .’’ When asked whether she knew that

Cassandra would die without treatment, the mother

stated, ‘‘[t]hat’s what they say, but there’s no guarantee

with treatment of cancer . . . .’’
At the conclusion of the hearing, Judge Quinn found

that Cassandra’s mother did not believe that Cassandra

had Hodgkin’s lymphoma or that she needed chemotherapy in order to have a chance to survive. Judge

Quinn ordered that Cassandra remain in the custody

of the department, that she be removed from her home

and that the department make medical treatment decisions for her.

On December 17, 2014, the respondents filed in this

court a joint motion for the emergency exercise of the

court’s supervisory power over the trial court. The

respondents represented in their motion that Cassandra

had been transferred to the medical center on December 9, 2014, and had not been permitted to leave since

that time. They further represented that they had been

informed that, on December 18, 2014, Cassandra’s treatment would begin with the surgical placement of the

port-a-cath and that chemotherapy would immediately

follow. The respondents indicated that they had petitioned the trial court for an injunction against the treatment until they could file in this court an application to

file an expedited appealfrom Judge Quinn’s December 9

ruling pursuant to General Statutes § 52-265a, and that

Judge Taylor had denied the petition. They contended

that Cassandra had a right to refuse treatment under

the mature minor doctrine and requested that this court

enjoin the treatment until further order of this court.

This court treated the respondents’ motion as a motion

for review of a denial of an emergency motion for a

stay and, after the commissioner filed an expedited

response to the motion pursuant to this court’s order,

denied the motion. The respondents then filed an application for certification to appeal to this court from

both Judge Taylor’s November 14, 2014 ruling and from

Judge Quinn’s December 9, 2014 ruling, pursuant to

§ 52-265a. They also filed an appeal in the Appellate

Court. The Chief Justice denied the respondents’ application pursuant to § 52-265a, but we ordered that the

respondents’ appeal to the Appellate Court be transferred to this court and that it be heard on an expedited basis.7

Thereafter, the commissioner filed a motion for an

expedited articulation in which it requested that Judge

Quinn articulate the basis for her December 9, 2014

ruling. Specifically, the commissioner requested that

Judge Quinn specify: ‘‘(a) [t]he extent to which the trial

court credited the testimony of . . . Isakoff in which

[he] indicated that Cassandra did not have the capacity

to make sound medical decisions concerning her cancer

treatment, and (b) [t]o the extent that [Cassandra] and

[her] mother have raised the ‘mature minor doctrine’

on appeal, whether the trial court made a finding that

the minor child was a mature minor.’’ Judge Quinn

issued an articulation in which she stated in response

to part (a) of the request that she had credited Isakoff’s
testimony that Cassandra did not have the capacity to

make sound medical decisions concerning her cancer

treatment based on ‘‘[Cassandra’s] apparent willingness

to undergo treatment [during the November 12, 2014

hearing before Judge Taylor] while secretly knowing

she would not, the consequences of such behavior on

the efficacy of the future treatment, and the totality of

all the facts she knew . . . .’’ Judge Quinn also stated

that she had observed Cassandra’s behavior at trial and

‘‘saw how closely she followed her mother’s testimony

and hung on her every word.’’ Judge Quinn then

observed that the mother ‘‘did not appear to be in support of the chemotherapy and that Cassandra is concerned about going against what her mother would like

to see happen.’’ She further observed that ‘‘[t]he record

is replete with [the] mother’s arguments with physicians

about the diagnosis, her seeking three separate opinions

about the diagnosis, attempting to change pediatricians

and delaying follow-up appointments and needed treatment.’’ Judge Quinn concluded that the ‘‘mother has

engaged in a passive refusal to follow reasonable medical advice for her mortally ill child.’’ She further concluded that Cassandra ‘‘does not possess the necessary

level of maturity orindependence to make life and death

decisions about her own medical care, as demonstrated

both by her conduct and her behavior subsequent to

the initial court order,’’ and that Cassandra was ‘‘overshadowed by the strong negative opinions her mother

holds about her cancer diagnosis and treatment, including chemotherapy.’’ In response to part (b) of the

requested articulation, Judge Quinn stated that Isakoff’s

‘‘thoughtful assessment of [Cassandra’s] capacity, the

court’s own observations of the parties and the witnesses, the observations of the [department’s] investigations worker, and Cassandra’s own actions all support

the conclusion that she is an immature seventeen year

old.’’ Accordingly, she concluded that ‘‘Cassandra is

not a mature minor. She is as yet incapable of acting

independently concerning her own life threatening medical condition. And time is running out for the recommended course of treatment to have a positive outcome

for her future.’’8

The respondents contend on appeal that this court

should adopt the mature minor doctrine, under which

a sufficiently mature minor may be deemed competent

to make important medical decisions on his or her own.

They further contend that Judge Quinn’s finding that

Cassandra was not a mature minor and competent to

make her own medical decisions was not supported by

any evidence because that issue was not before the

court at the December 9, 2014 hearing. Finally, they

contend that removing Cassandra from her home and

subjecting her to treatment against her will without a

hearing to determine whether she was mature enough to

make medical decisions for herself violated her liberty

interest in bodily integrity under the due process provi-
sions of the fifth amendment to the United States constitution and article first, §§ 8, 9 and 10, of the Connecticut

constitution, violated the respondents’ fundamental

right to family integrity, and deprived the mother of her

constitutionally protected interest in the care, custody

and control of Cassandra.9 We conclude that the question of Cassandra’s competence to make medical decisions was squarely before Judge Quinn and that her

finding that Cassandra was not a mature minor was not

clearly erroneous. We further conclude that, because

the evidence does not support a finding that Cassandra

was a mature minor under any standard, this is not a

proper case in which to decide whether to adopt the

mature minor doctrine. Finally, because the respondents have not established the factual predicate for

their due process claim—that they were deprived of a

hearing at which to determine Cassandra’s competence

to refuse medical treatment—we reject that claim.

We begin our analysis by setting forth the standard

of review. Whether Cassandra is a mature minor and,

as such, competent to make her own medical decisions

is a question of fact. Belcher v. Charleston Area Medical

Center, 188 W. Va. 105, 116, 422 S.E.2d 827 (1992)

(‘‘[w]hether a child is a mature minor is a question of

fact’’). Accordingly, Judge Quinn’s finding that she was

not mature is subject to review for clear error. American Car Rental, Inc. v. Commissioner of Consumer

Protection, 273 Conn. 296, 309, 869 A.2d 1198 (2005).

Whether the respondents’ constitutional due process

rights were violated is a question of law over which

ourreview is plenary. Commissioner of Environmental

Protection v. Farricielli, 307 Conn. 787, 819, 59 A.3d

789 (2013) (‘‘[w]hether [a party] was deprived of his

due process rights is a question of law, to which we

grant plenary review’’ [internal quotation marks

omitted]).

We next review the governing legal principles. This

court previously has not had the opportunity to address

directly the question of whether and, if so, under what

circumstances minors may be competent to make their

own medical decisions. The United States Supreme

Court has recognized, however, that ‘‘[m]ost children,

even in adolescence, simply are not able to make sound

judgments concerning many decisions, including their

need for medical care or treatment. Parents can and

must make those judgments.’’ Parham v. J. R., 442

U.S. 584, 603, 99 S. Ct. 2493, 61 L. Ed. 2d 101 (1979).

Accordingly, ‘‘[a]t common law, minors generally were

considered to lack the legal capacity to give valid consent to medical treatment or services, and consequently

a parent, guardian, or other legally authorized person

generally was required to provide the requisite consent.

In the absence of an emergency, a physician who provided medical care to a minor without such parental

or other legally authorized consent could be sued for

battery.’’ American Academy of Pediatrics v. Lungren,
16 Cal. 4th 307, 314–15, 940 P.2d 797, 66 Cal. Rptr. 210

(1997); see also id., 315 (‘‘[t]he requirement that medical

care be provided to a minor only with the consent of

the minor’s parent or guardian remains the general rule,

both in California and throughout the United States’’).

Although this general common-law principle has not

been expressly recognized by this court, it has been

implicitly recognized by our legislature. For example,

pursuant to General Statutes § 46b-150d, ‘‘a minor10

[who] is emancipated . . . (1) . . . may consent to

medical, dental or psychiatric care, without parental

consent, knowledge or liability . . . .’’ (Emphasis

added; footnote added.) Thus, under the ‘‘tenet of statutory construction referred to as expressio unius est

exclusio alterius, which may be translated as the

expression of one thing is the exclusion of another’’;

(internal quotation marks omitted) Felician Sisters of

St. Francis of Connecticut, Inc. v. Historic District

Commission, 284 Conn. 838, 851, 937 A.2d 39 (2008);

it is implicit that unemancipated minors do not have this

ability. Similarly, other statutes providing that under

specific, narrowly limited circumstances, minors may

make medical decisions clearly imply legislative recognition of the common-law principle that they generally

are not competent to do so.11 We conclude, therefore,

that the general rule in this state is that minors are

presumed to be incompetent to make medical decisions.12 A number of courts have concluded, however,

that there is an exception to this general common-law

principle for mature minors. See In re E.G., 133 Ill. 2d

98, 111, 549 N.E.2d 322 (1989) (‘‘[i]f the evidence is

clear and convincing that the minor is mature enough

to appreciate the consequences of her actions, and that

the minor is mature enough to exercise the judgment

of an adult, then the mature minor doctrine affords her

the common law right to consent to or refuse medical

treatment’’); In re Swan, 569 A.2d 1202, 1205 (Me. 1990)

(minor has capacity to consent to withholding of medical treatment when ‘‘the minor has the ability of the

average person to understand and weigh the risks and

benefits’’ and ‘‘if he is capable of appreciating the

nature, extent, and probable consequences of the conduct consented to’’ [internal quotation marks omitted]);

Cardwell v. Bechtol, 724 S.W.2d 739, 748 (Tenn. 1987)

(‘‘Whether a minor has the capacity to consent to medical treatment depends upon the age, ability, experience,

education, training, and degree of maturity or judgment

obtained by the minor, as well as upon the conduct

and demeanor of the minor at the time of the incident

involved. Moreover, the totality of the circumstances,

the nature of the treatment and its risks or probable

consequences, and the minor’s ability to appreciate the

risks and consequences are to be considered.’’); Belcher

v. Charleston Area Medical Center, supra, 188 W. Va.

116 (‘‘[W]e hold that, except in very extreme cases, a

physician has no legal right to perform a procedure
upon, or administer or withhold treatment from a . . .

child withoutthe consent ofthe child’s parents or guardian, unless the child is a mature minor, in which case

the child’s consent would be required. Whether a child

is a mature minor is a question of fact. Whether the

child has the capacity to consent depends upon the age,

ability, experience, education, training, and degree of

maturity or judgment obtained by the child, as well as

upon the conduct and demeanor of the child at the time

of the procedure or treatment. The factual determination would also involve whether the minor has the

capacity to appreciate the nature, risks, and consequences of the medical procedure to be performed, or

the treatment to be administered or withheld.’’); see

also In the Matter of Rena, 46 Mass. App. 335, 337, 705

N.E.2d 1155 (1999) (court may ‘‘consider the maturity

of the child to make an informed choice’’ when

determining whether refusal of medical treatment is in

child’s best interest).

With these principles in mind, we turn to the respondents’ claims in the present case that Judge Quinn could

not have determined that Cassandra was not a mature

minor because that issue was not before her at the

December 9, 2014 hearing and, even if the issue was

before Judge Quinn, her finding that Cassandra was not

a mature minor was not supported by the evidence. We

disagree. For purposes of the mature minor doctrine,

a mature minor is a minor who is competent to make

medical decisions. As we have explained, the very reason that the commissioner asked for the December 9,

2014 hearing was to determine Cassandra’s competence

to refuse chemotherapy treatment for her cancer.

Accordingly, the issue of whether Cassandra was sufficiently mature to make this decision despite the fact

that she was a minor was squarely before the court.

Under the authority previously set forth, there is a legal

presumption that Cassandra was not competent to

make the life or death decision whether to undergo

chemotherapy treatment for her cancer because she

was a minor, and the burden was therefore on the

respondents to establish that she was sufficiently

mature to do so. Because the respondents failed to

produce any evidence on that factual issue, despite

being on notice that that was the purpose of the hearing,

there was no basis for Judge Quinn to find that Cassandra was a mature minor under any standard.13 Accordingly, we conclude that her finding that Cassandra was

not competent to make her own medical decisions was

not clearly erroneous.

Moreover, although the burden was not on the department to show that Cassandra was not a mature minor,

there was ample evidence to support Judge Quinn’s

express factual findings that Cassandra was not yet

fully separated from or independent of her mother, that

she was prone to engage in compulsive and risky

actions, that she was unable or unwilling to speak her
true mind to those in authority, and that she was reluctant to hold opinions that her mother did not share.

Specifically, there was evidence: that Cassandra was

extremely nervous and timid during the hearing before

Judge Taylor, and that she was fearful during the medical evaluation at the medical center emergency room

that followed the hearing; that the reasons that Cassandra did not want to undergo chemotherapy were that

she was afraid of seeing ‘‘tubes sticking out of her’’ and

that she did not yet feel sick, even though she had been

told repeatedly that she would die without the treatment

and that delaying treatment until she felt sick could

have very serious consequences, potentially including

her death; that Cassandra was very emotionally dependent on her mother, and was heavily influenced by her

mother’s distrust of physicians and other persons in

positions of authority; that the respondents were influenced by their independent research into Hodgkin’s

lymphoma and its medical treatments, even after

numerous physicians contradicted that research;14 that

Cassandra had intentionally misrepresented her intentions to Judge Taylor and the department when she

stated that she was willing to undergo treatment; and

that Cassandra intentionally violated Judge Taylor’s

order and placed her own health at serious risk when

she interrupted chemotherapy and ran away from

home. In turn, Judge Quinn’s factual findings amply

support her ultimate determination that Cassandra was

not a mature seventeen year old and, therefore, was

not competent to make her own medical decisions.

The respondents claim, however, that Judge Quinn

improperly relied on Isakoff’s testimony that Cassandra

was not competent to make the decision rejecting treatment because that testimony was based on the ‘‘impossible position that an individual is proved incompetent

to refuse medical care simply by the factthat she refuses

medical care.’’ The respondents concede that ‘‘[t]here

is no dispute that Cassandra’s refusal of treatment, if

permitted, would be deleterious to her health,’’ and they

have pointed to no possible benefit that would have

been gained if she had been permitted to refuse or

delay treatment. Thus, they are effectively claiming that

Cassandra had a right to reject lifesaving medical treatment for any reason or for no reason, and her assertion

of this right had no bearing on the question of whether

she was a mature minor. We disagree. Even if we were

to assume that adults have the unfettered right to refuse

lifesaving medical treatment, an issue that we need not

address here, the law is clear that a seventeen year old

does not have thatright but, to the contrary, is presumed

to be incompetent to do so, at least in the absence of

proof of maturity. We conclude that it was well within

Judge Quinn’s discretion to credit Isakoff’s eminently

sensible opinion that Cassandra’s assertion of her purported ‘‘right’’ to refuse the only treatment that could

save her life for no reason except that it was her right
to do so, did not constitute evidence of maturity, but

its opposite.15 Accordingly, we conclude that the record

amply supports Judge Quinn’s ultimate finding that Cassandra was not a mature seventeen year old, and, therefore, was not competent to refuse a course of medical

treatment that would provide her with her only chance

of survival.16 Thus, there is no need for us to reach the

question of whether we should adopt the mature minor

doctrine because, even if we were inclined to do so,

the doctrine would not apply to Cassandra.

We further conclude that the respondent’s constitutional rights were not violated. Even if we were to

assume that the mature minor doctrine applies, because

the respondents were on notice that the purpose of the

December 9, 2014 hearing before Judge Quinn was to

determine Cassandra’s competence to refuse lifesaving

medical treatment and they had an opportunity to present evidence on that question, they have failed to establish the factual predicate of their claim that they were

deprived of their constitutional due process rights to a

hearing at which they could establish that Cassandra

was a mature minor before she could be removed from

the care and custody of her mother and subjected to

forced medical treatment.17 Although the respondents

contend that the December 9, 2014 hearing did not

comply with constitutional due process requirements

because there was no expert testimony regarding Cassandra’s decision-making capacity, the burden was on

them to prove that Cassandra was competent. They

make no claim that they were prohibited from presenting such evidence.18 Accordingly, even if we were

to assume that the respondents had a constitutional

right to present expert testimony, they were not

deprived of that right.

The judgment is affirmed.

In this opinion the other justices concurred.

* In accordance with the spirit and intent of General Statutes § 46b-142

(b) and Practice Book § 79a-12, the names of the parties involved in this

appeal are not disclosed. The records and papers of this case shall be open

for inspection only to persons having a proper interest therein and upon

order of the Appellate Court.

** January 8, 2015, the date that the order was issued in this case, is the

operative date for all substantive and procedural purposes.

1 For purposes of convenience, references herein to both the mother and

Cassandra jointly are to the respondents.

2 The respondents appealed from the judgment of the trial court to the

Appellate Court, and we transferred the appeal to this court pursuant to

General Statutes § 51-199 (c) and Practice Book § 65-1.

3 Matthew Richardson, a pediatric oncologist from whom the respondents

subsequently sought a second opinion, explained in a report that if treatment

is delayed, the cancer can spread to other lymph nodes and other parts of

the body. As the affected lymph nodes continue to grow, they can compress

vital structures such as veins and airways, which can be fatal. In addition,

the larger the affected lymph nodes are when chemotherapy starts, the

greater is the risk of a condition known as tumor lysis syndrome, which

can result in heart arrhythmias and kidney failure.

4 A ‘‘port-a-cath’’ is ‘‘[a] central venous catheter . . . that goes into a vein

in [the patient’s] chest . . . .’’ United States National Library of Medicine,

‘‘MedlinePlus, Central Venous Catheters—Ports,’’ available at http://

www.nlm.nih.gov/medlineplus/ency/patientinstructions/000491.htm (last
visited April 10, 2015).

5

‘‘The Silver Alert system . . . [is] an emergency notification system for

law enforcement agencies to broadcast local, regional, or statewide public

alerts via radio, television and electronic highway signs. The Silver Alert

system mandates that law enforcement immediately begin searching for

missing individuals who are ages [sixty-five] or older, or ages [eighteen]

and over if mentally impaired. Once the police receive a missing person’s

report and a description of the missing person, the information is broadcast

via radio, television, and electronic highway signs through the Emergency

Alert System . . . . The plan alerts the public as quickly as possible to the

disappearance so everyone may assist in the search for the safe return of

the individual.’’ State of Connecticut, Department on Aging, ‘‘Connecticut

Silver Alert System—An ElderlyAnd Or Mental Impairment Locator System,’’

(last modified on December 5, 2011), available at http://www.ct.gov/agingservices/cwp/view.asp?Q=442724&A=2513 (last visited April 10, 2015).

6 A transcript of the November 12, 2014 hearing was introduced as an

exhibit at the December 9, 2014 hearing before Judge Quinn. Although the

exhibits that had been introduced at the November 12 hearing were not

introduced as exhibits at the December 9 hearing, they were part of the

court file that was before Judge Quinn.

7 We also granted permission to the American Civil Liberties Union Foundation of Connecticut to file an amicus curiae brief in support of the respondents’ position.

8 The respondents filed a motion for review of Judge Quinn’s articulation,

claiming that the issue of whether Cassandra is a mature minor had not been

raised at the hearing before Judge Quinn. They claimed that the articulation

should be disregarded. This court granted the motion but denied the

requested relief.

9 The respondents point out that they did not expressly rely on the mature

minor doctrine at the December 9, 2014 hearing before Judge Quinn and

that their constitutional claims are also unpreserved. Accordingly, they seek

review of their claims pursuant to State v. Golding, 213 Conn. 233, 239–40,

567 A.2d 823 (1989). Because the respondents were on notice that the issue

of Cassandra’s competence to make medical decisions would be addressed

at the evidentiary hearing before Judge Quinn, we conclude that the issue

of whether Cassandra was sufficiently mature to make medical decisions

was not unpreserved. Rather, the respondents failed to present evidence

on the issue. Because the respondents had a hearing on the issue, there is,

as we discuss more fully later in this opinion, no basis for their constitutional claims.

10 ‘‘Except as otherwise provided by statute, on and after October 1, 1972,

the terms ‘minor’, ‘infant’ and ‘infancy’ shall be deemed to refer to a person

under the age of eighteen years and any person eighteen years of age or

over shall be an adult for all purposes whatsoever and have the same legal

capacity, rights, powers, privileges, duties, liabilities and responsibilities as

persons heretofore had at twenty-one years of age, and ‘age of majority’

shall be deemed to be eighteen years.’’ General Statutes § 1-1d.

11 See General Statutes § 17a-688 (d) (minor may consent to treatment for

drug and alcohol addiction); General Statutes § 19a-216 (a) (minor may

obtain treatment for venereal disease without parental consent); General

Statutes § 19a-285 (a) (minor may consent to medical treatment of minor’s

child); General Statutes § 19a-592 (a) (minor may be treated for human

immunodeficiency virus infection without parental consent if notification of

parent willresult in treatment being denied orif minor willrefuse treatment if

parents are notified); General Statutes § 19a-601 (minor may have abortion

without parental consent).

12 We emphasize that we merely conclude that, by enacting statutes providing that minors may consent to medical treatment only in certain limited

circumstances, the legislature has implicitly recognized the common-law

rule that minors are presumed to be incompetent to make medical decisions.

We leave for another day the question of whether the legislature intended

that this would be a conclusive presumption in the absence of a statutory

exception and, therefore, the courts are precluded from allowing minors to

rebut the presumption under the mature minor doctrine. Accordingly, we

need not address the amicus’ argument that, because many statutes treat

sixteen and seventeen years olds in the same manner as adults, minors of

that age are entitled to a hearing on the question of whether they are

sufficiently mature to make medical decisions.

13 Cassandra testified at the November 12, 2014 hearing that she has

worked since she was fourteen years old and pays some of her own bills.
This evidence has little bearing on her competence to make life and death

medical decisions on her own. In addition, Cassandra’s mother testified at

the December 9, 2014 hearing that Cassandra was a ‘‘very bright, intelligent

girl’’ who ‘‘can make her own decisions.’’ This conclusory statement also

provides little support for the respondents’ position. Although Cassandra

may be intelligent, intelligence, in and of itself, is not evidence of maturity,

and she provided no reasoned argument for refusing chemotherapy

treatment.

14 The mother’s testimony that Cassandra did not want to put ‘‘poisons’’

in her body that could affect her for the rest of her life did not justify

Cassandra’s decision in any rational way. There was ample evidence that

Cassandra would die within a relatively short period of time if she did not

receive chemotherapy and that there was a high probability of cure if she

received treatment. Even if the chemotherapy will have some long-term side

effects, there was no evidence presented that there is a significant risk that

those side effects will be worse than certain death in the near future.

15 We emphasize that we do not suggest that the refusal of lifesaving

medical treatment is unreasonable, per se. Such a decision may well be

justified by, for example, deeply held religious convictions, advanced age,

a small chance of long-term survival or the significant likelihood of a poor

quality of life. The respondents in the present case, however, have presented

no plausible justification for Cassandra’s refusal to be treated. They have

merely made the bare assertion that it is her ‘‘right’’ to refuse treatment,

for any reason or for no reason.

The respondents suggest that Isakoff was not competent to evaluate

whether Cassandra was sufficiently mature to make her own medical decisions because he was not a psychiatrist or psychologist. We disagree. Isakoff

is a board certified pediatrician and has worked for more than nine years

at the medical center, which specializes in treating children. In addition, he

has taken courses in psychology and has had psychological training in

helping families and patients to cope with a serious diagnosis. Even if we

were to assume that the question of whether a minor is sufficiently mature

to make medical decisions is a question that requires some specialized

knowledge, and is not within the knowledge and experience of an ordinary

person—a question that we do not decide here—we conclude that the issue

is within the knowledge of an experienced pediatrician with psychological

training who has treated the particular minor in question. See Belcher v.

Charleston Area Medical Center, supra, 188 W. Va. 115 (treating physician

must exercise best medical judgment as to whether minor patient is sufficiently mature to be able to consent to treatment).

16 We cast no aspersions on Cassandra. It is perfectly understandable that

a seventeen year old who is confronted with a devastating medical diagnosis

would be confused and anxious, would depend heavily on a parent for

guidance and emotional support, would have some fear and distrust of

medical providers, and would go through a period of denial. These natural

emotions, however, do not evince maturity. Indeed, the fact that children

and adolescents are more prone to such emotions than adults and more

easily swayed by them when making important decisions is the very reason

for the common-law rule that minors generally are not competent to make

medical decisions.

17 The respondents characterized Cassandra’s right not to be subjected to

unwanted medical treatment and their right to family integrity as substantive

due process rights in their brief to this court. At oral argument, however,

the mother conceded that the respondents are raising a procedural due

process claim that they were entitled to a hearing on the question of whether

Cassandra was a mature minor.

18 The respondents contend that Cassandra did not know that she was

entitled to present expert testimony on the issue of her competence to make

medical decisions at the December 9, 2014 hearing because this court has

not yet adopted the mature minor doctrine. The mere fact that this court

has not yet adopted the doctrine, however, would not have prevented Judge

Quinn from applying it for the first time if she had been asked to do so,

had determined that the doctrine is consistent with the public policy of this

state and had found Cassandra to be a mature minor.