Opinion ID: 2402992
Heading Depth: 2
Heading Rank: 1

Heading: Guardianship Issues

Text: Nancy is incompetent; she cannot make informed choices concerning her medical treatment. We therefore do not decide any issue in this case relating to the authority of competent persons to suspend life-sustaining treatment in the face of terminal illness or otherwise. Our focus here is expressly limited to those instances in which the person receiving the life-sustaining treatment is unable to render a decision by reason of incompetency. Section 475.120.3, RSMo 1986, provides that the guardian of an incapacitated ward shall provide for the ward's care, treatment, habilitation, education, support and maintenance and has the power to: (2) Assure that the ward receives medical care and other services that are needed; (3) Promote and protect the care, comfort, safety, health, and welfare of the ward; (4) Provide required consents on behalf of the ward; .... The statute makes no provision for the termination of medical treatment; to the contrary, it places an express, affirmative duty on guardians to assure that the ward receives medical care and provides the guardian with the power to give consent for that purpose. We thus find no statutory basis for the argument that the guardian possesses authority, as a guardian, to order the termination of medical treatment. Assuming, arguendo, the guardian possesses such power, it must be derivative of the rights which the incompetent maintains as a person. Having found that such rights do exist, Quinlan held, broadly and without precedential support, that the right of privacy and the right to refuse medical treatment may be exercised by surrogates in the event of incompetency. In this manner a rationale was born to reach the end sought. [20] Recall the language of Quinlan : The only practical way to prevent destruction of the right is to permit the guardian and family of Karen to render their best judgment, subject to the qualifications [21] hereinafter stated, as to whether she would exercise it in these circumstances. 355 A.2d at 664. As we said, these rights have been explained as rooted in personal autonomy and self-determination. Autonomy means self lawthe ability to decide an issue without reference to or responsibility to any other. It is logically inconsistent to claim that rights which are found lurking in the shadow of the Bill of Rights and which spring from concerns for personal autonomy can be exercised by another absent the most rigid of formalities. Given the fact that these patients are irreversibly comatose or in a chronic vegetative state, attributing rights to these patients at all is somewhat problematic.... To be sure, these patients are not dead in most of the increasingly multiple senses of the term, but the task of giving content to the notion that they have rights, in the face of the recognition that they could make no decisions about how to exercise any such rights, remains a difficult one. Tribe, American Constitutional Law, at 1368, n. 25. In discussing the constitutional right of privacy, the United States Supreme Court wrote that the right of privacy, when exercised in an abortion context, is one that cannot be vetoed by any third party. [T]he State does not have the constitutional authority to give a third party an absolute, and possibly arbitrary, veto over the decision of the physician and his patient.... Any independent interest the parent may have in the termination of the minor daughter's pregnancy is no more weighty than the right of privacy of the competent minor mature enough to have become pregnant. Planned Parenthood of Central Missouri v. Danforth, 428 U.S. 52, 74, 75, 96 S.Ct. 2831, 2843, 2844, 49 L.Ed.2d 788 (1975). Assuming, arguendo, that the right of privacy may be exercised by a third party in the absence of strict formalities assigning that right, the risk of arbitrary decisionmaking and grave consequences attaches all the more when the third party seeks to cause the death of an incompetent. Just as the State may not delegate to any person the right to veto another's right to privacy choices, no person can assume that choice for an incompetent in the absence of the formalities required under Missouri's Living Will statutes or the clear and convincing, inherently reliable evidence absent here. Nor do we believe that the common law right to refuse treatmentfounded in personal autonomyis exercisable by a third party absent formalities. A guardian's power to exercise third party choice arises from the state's authority, not the constitutional rights of the ward. The guardian is the delegatee of the state's parens patriae power. In re Link, 713 S.W.2d 487, 493 (Mo. banc 1986). Cases which relied on the doctrine of substituted judgment to permit guardians to choose termination of life support simply failed to consider the source of the guardian's authority to decide. Instead those decisions assumed, without benefit of legal precedent, that the guardian's power to decide is derivative of the incompetent's right to decide, if competent. See Quinlan, 355 A.2d at 664. That the doctrine has an historical antecedent, Saikewicz, 370 N.E.2d at 431, does not change its raison d'etre or the scope of its reach. To fail to appreciate the legal foundation is to risk permitting the application of the doctrine in an unprincipled manner. As applied in right-to-terminate-treatment decisions, the doctrine of substituted judgment is applied in abrogation of the state's parens patriae power, not in furtherance of it. In cases like this one, the doctrine authorizes a guardian to cause the death of a ward unilaterally, without interference by the state, and contrary to the state's vital interests in preserving life and in assuring the safekeeping of those who cannot care for themselves. As one commentary warns: [T]hird party consent allows the truly involuntary to be declared voluntary, thus bypassing constitutional, ethical and moral questions, and avoiding the violation of taboos. Third party consent is a miraculous creation of the lawadroit, flexible, and useful in covering the unseemly reality of conflict with the patina of cooperation. Price and Burt, Sterilization, State Action, and the Concept of Consent, Law and Psychology Review, p. 58 (Spring 1975).