Case Name: In re Daniel Joseph FIORI, an Adjudged Incompetent. Appeal of PENNSYLVANIA ATTORNEY GENERAL
Court: Superior Court of Pennsylvania
Jurisdiction: Pennsylvania
Decision Date: 1995-01-17
Citations: 652 A.2d 1350
Docket Number: 
Parties: In re Daniel Joseph FIORI, an Adjudged Incompetent. Appeal of PENNSYLVANIA ATTORNEY GENERAL.
Judges: Before ROWLEY, President Judge, and CAVANAUGH, WIEAND, MeEWEN, CIRILLO, OLSZEWSKI, BECK, KELLY and POPOVICH, JJ.
Reporter: West's Atlantic Reporter, Second Series
Volume: 652
Pages: 1350–1381

Head Matter:
In re Daniel Joseph FIORI, an Adjudged Incompetent. Appeal of PENNSYLVANIA ATTORNEY GENERAL.
Superior Court of Pennsylvania.
Argued Sept. 30, 1994.
Filed Jan. 17, 1995.
Sue A. .Unger, Philadelphia, for appellant.
John N. Schaeffer, Doylestown, for Rosemary Sherman, participating party.
Robert B. Hoffman, Harrisburg, for ami-cus curiae PA Med. Soc.
Before ROWLEY, President Judge, and CAVANAUGH, WIEAND, MeEWEN, CIRILLO, OLSZEWSKI, BECK, KELLY and POPOVICH, JJ.

Opinion:
BECK, Judge.
This appeal requires that we decide whether life sustaining treatment in the form of a gastrostomy tube should be removed from a patient who for almost twenty years has been in a persistent vegetative state with no cognitive powers and no chance of recovery. We agree with the trial court that the life sustaining treatment should be terminated and, therefore, affirm the trial court.
We conclude that consent of a close family member along with approval of two qualified physicians is sufficient to terminate life sustaining treatment to a person in a long-term persistent vegetative state without court involvement. We further emphasize that our decision today is limited to the category of cases where the patient is in a persistent vegetative state with no cognitive power and no chance of recovery where such patient has not previously expressed a view as to whether life sustaining treatment should be terminated.
The facts giving rise to this case as well as all such termination of life sustaining treatment cases are tragic. Daniel Joseph Fiori, the patient whose future is at issue, is 43 years old. As a result of two successive incidents, one in 1972 when Mr. Fiori was twenty years old and one in 1976, Mr. Fiori was rendered comatose. Since 1976, Mr. Fiori has been in a neurologic condition known as a persistent vegetative state. In Cruzan v. Director, Missouri Dept. of Health, 497 U.S. 261, 110 S.Ct. 2841, 111 L.Ed.2d 224 (1990), the United States Supreme Court provided the following well-accepted description of a persistent vegetative state:
Vegetative state describes a body which is functioning entirely in terms of its internal controls. It maintains temperature. It maintains heart beat and pulmonary ventilation. It maintains digestive activity. It maintains reflex activity of muscles and nerves for low level conditioned responses. But there is no behavioral evidence of either self-awareness or awareness of the surroundings in a learned manner.
Id. at 267, n. 1, 110 S.Ct. at 2846, n. 1.
In other words, although Mr. Fiori's body is alive and may well stay alive for years, his cognitive function has been so thoroughly destroyed that he does not know he is alive. He feels no pain and he feels no pleasure. Thus, although he realizes no pain from the presence of the gastrostomy tube, he would equally realize no pain if it were withdrawn. There is no dispute in this case that this is Mr. Fiori's medical condition, and there is also no dispute that his condition will never improve.
Mr. Fiori has for years been a patient at the Mayo Nursing and Convalescent Center in Philadelphia and has received excellent care. Since he has no capacity for voluntary muscular movement, including swallowing, he is provided his medications, fluids and nutrition through a tube surgically inserted in his stomach called a gastrostomy tube. His mother, Rosemarie Sherman, who was appointed the guardian of Mr. Fiori's person by court order entered in 1980, has been devoted to him throughout his ordeal. She visits him several times every day, supervises his nursing care and personally provides him with the supplies necessary to insure that his care is the very best.
In February 1992, Mrs. Sherman determined that her son's treatment, i.e. the gas-trostomy tube, should be terminated. The nursing home refused to comply with her request without a court order and she filed a petition in the Court of Common Pleas for Bucks County requesting an order directing the nursing home to terminate the treatment. The Attorney General appeared in the proceeding and, pursuant to its request, an independent medical expert was appointed to examine Mr. Fiori. The trial court took testimony from Mrs. Sherman and from a neurologist who had examined Mr. Fiori. The court also considered the report of the independent medical expert. The evidence revealed that prior to Mr. Fiori's injuries he had never specifically commented on how he would wish to be treated if he were in a persistent vegetative state or otherwise rendered incompetent. However, his mother testified that based on her understanding of her son and his attitude toward life while he was competent her son would no longer wish to be kept alive in his present condition.
The trial court found that it had insufficient evidence to determine what Mr. Fiori's own decision concerning his treatment would be if he were competent. Thus, the court applied what it termed an "objective standard," which it described as follows:
If the exercise of the right [to self-determination] is to be maintained where no expression has been made by an incompetent patient as to treatment, it must take place within the context of an analysis which seeks to implement what is in that person's best interests by reference to objective soeietally shared criteria_ '[I]n assessing whether a procedure or course of treatment would be in a patient's best interests, the decision maker must taken into account such factors as the relief of suffering, the preservation or restoration of functioning, and the quality as well as extent of life sustained.'
Trial Court Op. at 8 (quoting Foody v. Manchester Memorial Hospital, 40 Conn.Sup. 127, 482 A.2d 713, 721 (Ct.1984).
Finding this standard satisfied, the trial court entered a Final Decree authorizing the discontinuance of the gastrostomy tube and all other life sustaining procedures.
The Attorney General appealed, and raises the following issues for our review:
1. Whether the orphans' court erred by failing to appoint a guardian ad litem to represent a comatose patient's interest in a proceeding to determine whether life support should be withdrawn?
2. Whether the orphans' court erred by authorizing a process which would result in the patient's death without requiring clear and convincing evidence that he would wish to have life sustaining medical treatment withdrawn?
We need not separately address the Attorney General's first issue. Since we ultimately hold that no legal proceedings are necessary in the great majority of cases involving the termination of life sustaining treatment to persons in Mr. Fiori's condition, and that no such proceeding was actually necessary in this case, obviously we see no need for the appointment of a guardian ad litem.
The Attorney General's basic legal position on the issue presented is that life sustaining treatment should not be terminated in the case of Mr. Fiori or any other person without clear and convincing evidence that termination of treatment would be the choice that person would make if he or she were competent. Moreover, the Attorney General would have this court require that the only evidence of the patient's wishes that will meet this evidentiary standard is a prior express statement by the patient. Finally, the Attorney General would require that a court proceeding be conducted in every such case so that the determination of whether the above-stated test had been met could be made by the court.
We cannot adopt the Attorney General's suggested approach to the crucially important issue presented by this case. At the outset, we note that the Attorney General frames the issue far too broadly. The discussion of this case should be limited to its facts, i.e., what standard should be applied in the case of a once competent adult who is now in a persistent vegetative state and who, when competent, had not directly expressed a view on whether he would want life sustaining treatment to be terminated under these circumstances, but who has a close relative who believes he would want his treatment terminated. The development of the law as to other types of cases should wait until another day. These cases arise from greatly differing factual scenarios. Termination of treatment issues arise in cases involving never competent adults, once competent and now incompetent and terminally ill adults, never competent children who have been severely impaired since birth, and adults like Mr. Fiori who, although once competent, no longer are and who, while not terminally ill, are in a persistent vegetative state. As to life sustaining measures, in some instances the patient will have clearly articulated his or her view; in others the patient will have expressed a view, but it has not been clearly articulated; and, in others, the patient will not have expressed any view. It is both inappropriate and inadvisable to attempt to deal with each of these possible scenarios outside of the specific matrix of facts and considerations each such case might present. See, e.g., Matter of Peter, 108 N.J. 365, 529 A.2d 419 (1987) (setting standards for terminating treatment of elderly nursing home patients in a persistent vegetative state and distinguishing such cases from those involving other types of patients in distinct medical situations); Matter of Conroy, 98 N.J. 321, 486 A.2d 1209 (1985) (distinguishing standards applicable to terminally ill elderly patient from that of younger persistent vegetative state patient).
The issue we are called upon to decide relates only to the termination of life sustaining treatment to a once competent, now incompetent, adult in a persistent vegetative state who has not clearly expressed a view on whether he would want life sustaining measures to continue, but whose close relative believes that he would now want his treatment terminated.
We begin our analysis of the issue with an examination of the underlying right we are called upon to protect — the right to self-determination in regard to the acceptance or rejection of life sustaining medical treatment. Although many different grounds for the existence of a right to self-determination may be asserted, there can be no doubt that such a right does exist. See In re Torres, 357 N.W.2d 332 (Minn.1984) (citing both constitutional and common law grounds for existence of right to self-determination); Foody v. Manchester Memorial Hospital, 40 Conn.Sup. 127, 482 A.2d 713 (1984) (same). Careful review of the Supreme Court's recent Cruzan decision reveals that eight of the nine justices found a federal Due Process liberty interest in refusing unwanted medical treatment. Cruzan, 497 U.S. at 278, 110 S.Ct. at 2851; at 287, 110 S.Ct. at 2856 (O'Connor, J., concurring); at 302, 110 S.Ct. at 2863-64 (Brennan, Marshall and Blackmun, JJ., dissenting); at 331, 110 S.Ct. at 2879 (Stevens, J., dissenting). See also Mack v. Mack, 329 Md. 188, 618 A.2d 744, 755-56 (1993) (noting Supreme Court justices' apparent acceptance of liberty interest in rejecting treatment).
Our own Supreme Court has recently commented on the constitutional right to privacy, specifically including the right to make important personal decisions, as follows:
There is no longer any question that the United States Constitution provides protection for an individual's right of privacy. At least two distinct types of privacy interests have been recognized. "One is the individual interest in avoiding disclosure of personal matters, and another is the interest in independence in making certain kinds of important decisions." This Court has recognized these same interests under the Pennsylvania Constitution.
Under the Pennsylvania Constitution, the right to be let alone has also been recognized. Similarly in Pennsylvania, this right is not absolute. However, Pennsylvania has not adopted a flexible approach in its state constitutional privacy analysis. Under the law of this Commonwealth only a compelling state interest will override one's privacy rights.
Stenger v. Lehigh Valley Hospital Center, 530 Pa. 426, 434, 437, 609 A.2d 796, 800, 802 (1992) (citations omitted). See also McCusker v. Workmen's Compensation Appeal Board, 536 Pa. 380, 639 A.2d 776 (1994) ("[cjentral to this aspect of the privacy right is the intrusion of government into the sphere of marriage and family life by prohibiting or criminalizing certain kinds of decisions").
The right to control and refuse medical treatment is also founded on the common law of this Commonwealth, which has long provided that other than in an emergency, medical treatment may not be given without the informed consent of the patient. See Moure v. Raeuchle, 529 Pa. 394, 404, 604 A.2d 1003, 1008 (1992) (citing, inter alia, Smith v. Yohe, 412 Pa. 94, 194 A.2d 167 (1963); Gray v. Grunnagle, 423 Pa. 144, 223 A.2d 663 (1966)). Provision of medical treatment that exceeds the scope of the patient's consent may be actionable in tort. Id. The physician may not "touch" the patient without his knowledgeable consent. This reflects the common law's rationale that the patient is free to accept or reject treatment.
Clearly, however, the right to self-determination as to one's own medical treatment is not absolute. The state has interests that are implicated in cases involving the termination of life sustaining treatment. These interests have classically been identified as consisting of the state's interests in the preservation of life, the prevention of suicide, the protection of third parties and the integrity of the medical profession. See, e.g., Superintendent of Belchertown State School v. Saikowicz, 373 Mass. 728, 370 N.E.2d 417 (1977); In re Torres, 357 N.W.2d 332 (Minn.1984); In re Colyer, 99 Wash.2d 114, 660 P.2d 738 (1983). As the trial court aptly found, in this case the state's interests in the prevention of suicide, the protection of third parties, and medical ethics are not implicated. Suicide is the volitional taking of one's own life, an act of which Mr. Fiori is not even capable. There are no third parties in need of protection as Mr. Fiori has no dependents. Lastly, the integrity of the medical profession is not in question. As the amicus brief filed by the Pennsylvania Medical Society indicates, the termination of Mr. Fiori's treatment presents no medical ethical problems. All doctors involved in evaluating Mr. Fiori concur that he is in a persistent vegetative state from which he will not recover. In such a case, amicus states:
. medical ethical principles support the withdrawal of life sustaining treatment, including the provision of nutrition and fluids, when, as here, there is no hope of recovery and the decision is made by an obviously concerned and well-informed surrogate decisionmaker exercising a choice based on the patient's preferences when they can be discerned or, if they cannot be determined, based on the patient's best interests.
Brief of The Pennsylvania Medical Society at p. 16. See also, e.g., In re Guardianship of Grant, 109 Wash.2d 545, 747 P.2d 445 (1987) (citing AMA Council on Ethical and Judicial Affairs, "Withholding or Withdrawing Life-Prolonging Medical Treatment," Mar. 15, 1986) (no medical ethical barrier to discontinuing life sustaining treatment to indisputably irreversibly comatose patient where all responsible for care of patient concur).
Thus, the only state interest with any pertinence to our inquiry is the general interest in the preservation of life. Although there is no doubt as to the validity of this interest, the real question is, what is the force or import of this interest in comparison to the right to self-determination?
It has generally been held, and appropriately so, that the state's interest in the preservation of life does not outweigh a competent individual's right to self-determination. As the New Jersey Supreme Court has stated:
In cases that do not involve the protection of the actual or potential life of someone other than the decisionmaker, the state's indirect and abstract interest in preserving the life of the competent patient generally gives way to the patient's much stronger personal interest in directing the course of his own life.
On balance, the right to self-determination ordinarily outweighs any countervailing state interests, and competent persons generally are permitted to refuse medical treatment, even at the risk of death.
Conroy, 98 N.J. at 350, 486 A.2d at 1223, 1225. Cf. In re Estate of Dorone, 517 Pa. 3, 534 A.2d 452 (1987) (blood transfusion given to patient in emergency life-threatening situation despite his previous declaration of religious objection to transfusions).
However, as the Conroy court continued, the situation changes when the right to self-determination of an incompetent person is at issue:
More difficult questions arise in the context of patients who are incompetent to make particular treatment decisions for themselves. Such patients are unable to exercise directly their own right to accept or refuse medical treatment. In attempting to exercise that right on their behalf, substitute decisionmakers must seek to respect simultaneously both aspects of the patient's right to self-determination — -the right to live, and the right, in some cases, to die of natural causes without medical intervention.
Id. at 356, 486 A.2d at 1227.
In every case where a court has been asked to permit the withdrawal of life sustaining treatment from a patient in a persistent vegetative state, the court has held that if it can be definitely determined that it would have been the patient's desire not to receive such treatment, then the patient's right to self-determination outweighs any state interest and the treatment may be withdrawn. See, e.g., Mack v. Mack, 329 Md. 188, 618 A.2d 744 (1993); Rasmussen by Mitchell v. Fleming, 154 Ariz. 207, 741 P.2d 674 (1987); McConnell v. Beverly Enterprises—Connecticut, Inc., 209 Conn. 692, 553 A.2d 596 (1989); In re Guardianship of Browning, 543 So.2d 258 (Fla.Dist.Ct.App.1989), aff'd, 568 So.2d 4 (Fla.1990); In re Estate of Longeway, 133 Ill.2d 33, 139 Ill.Dec. 780, 549 N.E.2d 292 (1989). Thus, the right to self-determination has uniformly been held to survive incompetency and, if the patient's own desires can be ascertained, the right outweighs any state interest, including the preservation of life.
However, the difficult question arises as to what to do in a case like this, and like so many others, where the patient while competent simply had never expressed a clear and specific preference as to whether he or she would wish to be kept alive for decades in a totally non-sapient state. With rare exceptions, courts confronted with such a situation have stated that under certain circumstances they would permit the decision as to whether life sustaining treatment should be terminated to be made through the exercise of "substituted judgment" by the patient's family or guardian. Matter of Jobes, 108 N.J. 394, 529 A.2d 434 (1987); Estate of Longeway, 133 Ill.2d 33, 139 Ill.Dec. 780, 549 N.E.2d 292 (1989); In re Rosebush, 195 Mich.App. 675, 491 N.W.2d 633 (1992); Conservatorship of Torres, 357 N.W.2d 332 (Minn.1984). The Supreme Court of New Jersey has perhaps most eloquently and clearly stated how the judgment of the surrogate decisionmaker is to be rendered, as follows:
where an incompetent's wishes are not clearly expressed, a surrogate decision-maker considers the patient's personal value system for guidance. The surrogate considers the patient's prior statements about and reactions to medical issues, all the facets of the patient's personality that the surrogate is familiar with — with, of course, particular reference to his or her relevant philosophical, theological, and ethical values — in order to extrapolate what course of medical treatment the patient would choose.
Matter of Jobes, 108 N.J. at 415, 529 A.2d at 444 (footnote omitted).
In addition, many of the courts considering this question have found that there is no need for a court to intervene in this decision-making process unless there is disagreement between the interested parties, who are usually identified as the medical professionals involved in treating and evaluating the patient and the patient's family or guardian. See, e.g., Jobes, supra; Rosebush, supra.
In contrast, the Attorney General would require judicial intervention in every case and would impose a standard of decision requiring clear and convincing evidence of a prior express statement by the patient that he or she would want treatment terminated under the circumstances presented. While the Attorney General purports to provide maximum protection to the patient's right to self-determination by imposing this standard, in fact adoption of such a standard will not achieve that objective. It must be recalled that under Pennsylvania law, clear and convincing evidence has been defined as evidence that is virtually indisputable. See Leonard Packel and Anne Poulin, Pennsylvania Evidence, § 303.2 (1987). If, for example, we were to apply the clear and convincing evidence test to a case like the instant one, it would be impossible for a court to approve the termination of life sustaining treatment to Mr. Fiori, even if those closest to him were convinced that is what he would want. Unless they could produce a written statement, or testify to an oral one, in which Mr. Fiori had said, "This is what I want," nothing could be done. His right to self-determination would not be protected, but rather might well be negated.
Furthermore, the time of the decision to withdraw life sustaining treatment is one fraught with pain and anxiety for those who love the patient. To compound the suffering with a court proceeding is insensitive and unnecessary. What special knowledge or insight does the court have in these painful and intimate situations? Is not the patient sufficiently protected by the surrogate's decision approved by two doctors? Unlike the Attorney General we find state involvement through the courts overly intrusive and viola-tive of the individual's right to privacy. The patient's rights are adequately represented by the surrogate, in this case, the mother. She is clearly qualified to exercise substituted judgment and can express what Mr. Fiori would want. His mother, who has given her son devoted care for almost two decades, who has taken all those years to consider what should be done, who has consulted her religious advisors and her own heart, is here to tell us that at this point in time, her son would say "enough is enough". All the doctors who have evaluated Mr. Fiori, including the independent physicians appointed by the trial court, agree as to his irreversible persistent vegetative state. No one disputes these facts. All the pertinent questions have been answered. The treatment should be terminated, and not because a court says so, but because Mr. Fiori's mother is able to express what her son would have wanted and two physicians attest to the fact that for the remainder of his life he would be in a persistent vegetative state.
In reaching this conclusion, we have relied heavily on the guidance provided by the opinions of the courts of many of our sister jurisdictions who have reached the same conclusion. In particular, we have relied on the carefully crafted opinion of the Supreme Court of New Jersey in Matter of Jobes, supra. Justice Garibaldi, writing for the Jobes majority, held that in the case of a once competent adult patient in a persistent vegetative state who had never expressed a specific view as to life sustaining treatment, the treatment could nevertheless be terminated under certain circumstances and in accordance with certain procedures.
First, Justice Garibaldi found that while the state has an undeniable interest in the preservation of life,
. those interests weaken and the individual's right to privacy becomes stronger "as the degree of bodily invasion [effected by the medical treatment at issue] increases and the prognosis [for recovery to a cognitive, sapient state] dims."
. [It is] difficult to conceive of a case in which the State could have an interest strong enough to subordinate a patient's right to choose not to be sustained in a persistent vegetative state."
Matter of Jobes, 108 N.J. at 413-14, 529 A.2d at 444 (citations omitted) (quoting Matter of Peter, 108 N.J. 365, 380, 529 A.2d 419, 427 (1987); In re Quinlan, 70 N.J. 10, 41, 355 A.2d 647, cert. denied sub nom. Garger v. N.J., 429 U.S. 922, 97 S.Ct. 319, 50 L.Ed.2d 289 (1976)).
The Jobes court appropriately concluded that the only way to fully effectuate the predominating right of the incompetent patient to determine his own course of treatment was to permit the exercise of substituted judgment on the patient's behalf. The substituted judgment would, of course, aim solely at determining what the patient would have chosen for himself based on prior expressions of view concerning medical issues by the patient, if any, and on the entire personality, philosophy and value system of the patient. Id. at 413-15, 529 A.2d at 444.
Of equal importance is the Jobes court's determination, with which we entirely agree, that the patient's family members, usually but not limited to the spouse, parent, adult child or sibling, are the appropriate parties to render the substituted judgment. Id. at 413-20, 529 A.2d at 444-47. The court so found for the following cogent reasons:
Almost invariably the patient's family has an intimate understanding of the patient's medical attitudes and general world view and therefore is in the best position to know the motives and considerations that would control the patient's medical decisions.
Family members are best qualified to make substituted judgments for incompetent patients not only because of then- peculiar grasp of the patient's approach to life, but also because of their special bonds with him or her.
"The importance of the family in medical treatment decisions is axiomatic.
The law has traditionally respected the private realm of family life which the state cannot enter.... We believe that this tradition of respect for and confidence in the family should ground our approach to the treatment of the sick."
Id. at 415-16, 529 A.2d at 445 (quoting, in part, In re Farrell, 108 N.J. 335, 355, 529 A.2d 404, 414 (1987)).
Finally, like the Jobes court, we too would require that treatment may not be terminated unless the surrogate decisionmaker has obtained written statements of two doctors qualified to evaluate the patient's condition certifying that the patient is in a persistent vegetative state without reasonable possibility of recovery. Id. at 420-23, 529 A.2d at 448. If the patient has an attending physician, that physician should also submit such a statement. Thus, the appropriate professionals will render the crucial decision as to the patient's medical condition.
Of course, there will be instances where there is no family member sufficiently close to the patient to render a judgment on his or her behalf, or the doctors involved in the patient's care perceive that the family members are not actually attempting to effectuate the patient's own choice, or there is a dispute among family members and no one has been designated as the decisionmaker in an advance directive. In such situations, treatment should not be terminated without the appointment of a guardian and the aid of the court.
If the foregoing procedures are followed, and none of the above-listed extraordinary circumstances exist, the approval of a court prior to termination of treatment is not required. In this, we merely confirm what we suspect has in fact been the practice followed by many families and doctors for years. These decisions have been made by families, in consultation with doctors and other advisors, in privacy and without governmental interference. See In re Estate of Longeway, 139 Ill.Dec. 780, 139 Ill.Dec. 780, 549 N.E.2d 292 (1989).
We agree with the numerous courts that have found that the judiciary simply has no role to play in a ease where there is a loving family, willing and able to assess what the patient would have decided as to his or her treatment, all necessary medical confirmations are in hand, and no one rightfully interested in the patient's treatment disputes the family's decision. See, e.g., Jobes, 108 N.J. at 415-20, 529 A.2d at 445-47; In re Rosebush, 195 Mich.App. 675, 491 N.W.2d 633 (1992); In re Guardianship of Grant, 109 Wash.2d 545, 747 P.2d 445, 456-57 (1987). Those who disagree with this view and who favor court intervention in every case often cite the need for the court to protect the patient. Underlying this rationale is the philosophy that only courts can provide the necessary safeguards to assure protection of life. This is a narrow and unhealthy view. It violates the essential and traditional respect for the family. It is yet another expansion of the idea that courts in our society are the repository of wisdom and the only institution available to protect human life and dignity. There is an unartieulated, underlying fear that without intervention by the court and perhaps a guardian ad litem that the parent or other relative might take action to end life for personal gain. While this fear may in rare cases have some foundation, it loses its force when the consent of two physicians is a necessary requirement before life sustaining treatment is terminated.
Moreover, such fears do not justify the invasion of the state into the private realm of the family where such important personal decisions should be made. The law of this Commonwealth has long respected the sanctity of the family and has sought to protect its privacy and preserve to it the right to govern itself as far as possible. Certainly this respect for the family should extend to the intensely private decision as to whether a family member who has been tragically re duced to a vegetative state would wish to continue to live in that state.
Prior to concluding, we need address one further point raised by the Attorney General and certain amicus curiae. The suggestion is made that the Commonwealth's new Advance Directive for Health Care Act, 20 Pa.C.S. § 5402 et seq. (1992), and certain recent amendments to our guardianship statute lend support, if not expressly then implicitly, to the position taken by the Attorney General. We, on the other hand, find nothing in either the guardianship statute or the Advance Directive for Health Care Act (the "Act") that reasonably could be construed as dictating a result in this case or even as providing a general standard to guide our decisionmaking. The Act is concerned only with the establishment of standards pursuant to which competent persons may execute valid and binding advance directives stating what they wish to be done regarding their medical treatment in the event that they in the future become incompetent and are in a terminal condition or are permanently unconscious. 20 Pa.C.S. § 5404, 5405.
In fact, we find clear indicia in the Act that the legislature intended not to establish standards for the termination of life sustaining treatment in any case, like the instant one, where an advance directive had not been executed by the patient. The Act provides that it "shall create no presumption concerning the intent of any person who has not executed a declaration to consent to the use or withholding of life sustaining procedures in the event of a terminal condition or a state of permanent unconsciousness." 20 Pa.C.S. § 5402(b). The Act also contains a limitation of scope provision stating that the Act "shall not impair or supersede any existing rights or responsibilities not addressed in this chapter." Id. at § 5412. Since the Act specifically does not address the rights of incompetent persons who never executed advance directives, presumably under section 5412 those persons' rights now are exactly what they were before the passage of the Act. It is our task in this case to state, for the first time, what those rights are. Accord DeGrella v. Elston, 858 S.W.2d 698 (Ky.1993) (similarly construing Kentucky "living will" statute using language like that in Pennsylvania Advance Directive Act to be a non-exclusive enactment that does not dictate a result in termination of life sustaining treatment cases where patient had not executed a living will).
Reference is also made to the guardianship statute, as amended in 1992. 20 Pa.C.S. § 5501 et seq. The Attorney General refers to those portions of the statute relating to determinations of incapacity and appointment of guardians and appears to find support for his approach to this case in the portion of the statute that requires that "clear and convincing evidence" of incapacity be presented before a person is adjudicated incapacitated and a guardian appointed.
Having thoroughly reviewed the guardianship statute, we find that it not only does not control this case but also that it provides no real guidance on the issue presented. The fact that the guardianship statute requires clear and convincing evidence of incapacity has no relevance to the standard of proof to be employed in deciding to terminate life sustaining treatment. Moreover, there is nothing in the guardianship statute to suggest that judicial approval is necessary to terminate life sustaining treatment. In fact, those subsections that list the powers and duties that may only be specifically granted to a guardian by a court order or that may never be granted to a guardian make no reference to the termination of life sustaining treatment. 20 Pa.C.S. § 5521(d) & (f). The statute simply does not address the issue presented in this case.
The trial court correctly decided that all life sustaining treatment presently being rendered to Mr. Fiori should be terminated. The order of the trial court is affirmed.
ROWLEY, President Judge, and WIEAND, CIRILLO, OLSZEWSKI, and KELLY, JJ., join this Opinion.
WIEAND, J., files a Concurring Opinion in which ROWLEY, President Judge, joins.
McEWEN and OLSZEWSKI, JJ., each file Concurring Statements.
POPOVICH, J., files a Concurring and Dissenting Opinion.
CAVANAUGH, J., files a Dissenting Opinion.
. Despite the fact that court involvement is not required in this category of case, we realize as a practical matter uncertainty may arise and the parties will seek court guidance. In such an event, we endorse the standard set forth in Judge Wieand's Concurring Opinion which provides a common sense and compassionate standard for the trial court to follow.
. Amicus curiae briefs were filed by The Pennsylvania Medical Society, The Pennsylvania Catholic Conference, The University of Pittsburgh Center for Medical Ethics, The University of Pennsylvania Medical Center, the Hospital Association of Pennsylvania and the Ethics and Advocacy Task Force of the Nursing Home Action Group. In cases such as this, which raise issues of broad social concern and implicate far more than purely legal considerations, the submissions of such amici are particularly helpful.
. The right to privacy is founded upon both state and federal constitutional guarantees. For purposes of the Pennsylvania Constitution the right to privacy is grounded in Article I, sections 1 & 8. We find that the right to self-determination as to decisions concerning medical treatment emanates from that aspect of the privacy right which guarantees Pennsylvania citizens the right to make important personal decisions.
. Two such exceptions are the courts of New York and Missouri, both of which appear not to permit the termination of life sustaining treatment except where it can be shown by clear and convincing evidence that such would have been the desire of the patient if he or she were competent. See Cruzan v. Harmon, 760 S.W.2d 408 (Mo.1988), aff'd sub nom. Cruzan v. Missouri Dept. of Health, 497 U.S. 261, 110 S.Ct. 2841, 111 L.Ed.2d 224 (1990); In re O'Connor, 72 N.Y.2d 517, 531 N.E.2d 607, 534 N.Y.S.2d 886 (1988).
In reviewing the decision of the Missouri Supreme Court in Cruzan, the United States Supreme Court held that a state may constitutionally impose a requirement of clear and convincing evidence of the patient's own previously expressed desire as to life sustaining treatment. However, the court did not hold that such a requirement was constitutionally mandated. Cruzan, 497 U.S. at 292, 110 S.Ct. at 2858-59. As Justice O'Connor opined in her concurring opinion in Cruzan:
Today's decision . does not preclude a future determination that the Constitution requires the States to implement the decisions of a patient's duly appointed surrogate. Nor does it prevent States from developing other approaches for protecting an incompetent individual's liberty interest in refusing treatment. . Today we decide only that one State's practice does not violate the Constitution; the more challenging task of crafting appropriate procedures for safeguarding incompetents' liberty interests is entrusted to the 'laboratory' of the States.... in the first instance.
Id.
Interestingly, in a more recently decided case, the Missouri Court of Appeals appeared to limit the Cruzan holding to a case involving the withholding of artificial hydration and nutrition. In In re Warren, 858 S.W.2d 263 (Mo.Ct.App.1993), the Court permitted the use of a substituted judgment or best interests standard in a case involving a severely ill elderly patient. Employing this standard, the court permitted the entry of a "Do Not Resuscitate" order on the patient's chart, finding that the patient would likely not survive resuscitation efforts in the event of cardiac arrest. Id. at 264-66.
. The Attorney General suggests that in fact Mrs. Sherman is an inappropriate decisionmaker because she may be motivated by a desire for personal financial gain. We, on the other hand, have no such concern because the trial court, who saw and heard Mrs. Sherman testify, adjudged her to be entirely sincere and acting in good faith.
. The dissent quite correctly points out that many of today's families are unstable. Because of this the dissent would require court intervention in every case. The majority would not. The majority is in total agreement with the dissent that where there is a question raised about the appropriateness of the relative making the substituted judgment or the motives of the relative, those cases must be adjudicated by the court. Most hospitals have ethics committees in which such questions would be addressed and the hospital itself would be in a position to seek court intervention. Of course, any of the patient's relatives and any doctor involved in the decision-making process would also be able to seek the aid of the court where necessary.
The holding of the majority does not require court intervention in the absence of such questions but does require it in those cases which are not free from doubt. The majority upholds strongly the sanctity and the privacy of the family and believes the law should cherish and safeguard family integrity. The wisdom and decency of a family faced with life and death decisions do not need to be tested in court.
. The only aspect of the Act that may be viewed as pertinent is the initial section where the legislature sets forth its general findings underlying the new statute, as follows:
The General Assembly finds that all competent adults have a qualified right to control decisions relating to their own medical care. This right is subject to certain interests of society, such as the maintenance of ethical standards in the medical profession and the preservation and protection of human life. Modern medical technological procedures make possible the prolongation of human life beyond natural limits. The application of some procedures to an individual suffering a difficult and uncomfortable process of dying may cause loss of patient dignity and secure only continuation of a precarious and burdensome prolongation of life.
20 Pa.C.S. § 5402(a).
These findings are pertinent insofar as they confirm what we already have concluded concerning the right to self-determination of medical treatment possessed by all competent adults, the state interests in medical ethics and preservation of life, and the effect of modern medical developments on the prolongation of human life. They do not otherwise assist our decisionmaking in this case.