Opinion ID: 2230457
Heading Depth: 2
Heading Rank: 2

Heading: relevant factors in the substituted judgment determination.

Text: The immediate question confronting us is resolved by our conclusion that, when a timely determination needs to be made, it is to be made by a judge. However, because of the likelihood that a proper determination will be sought by these or other parties in the future, we set forth below guidelines to be followed in order to ensure accuracy and consistency in proceedings in the Probate Court. The factors we identify below are to be considered by the probate judge in order to identify the choice which would be made by the incompetent person, if that person were competent, but taking into account the present and future incompetency of the individual as one of the factors which would necessarily enter into the decision-making process of the competent person. Superintendent of Belchertown State School v. Saikewicz, 373 Mass. 728, 752-753 (1977). The determination must give the fullest possible expression to the character and circumstances of that individual. Id. at 747. We observe that this is a subjective rather than an objective determination. [16] Cf. id. at 746-747. All persons involved in such an inquiry will readily admit that the bounds of relevance therefor are exceedingly broad. In this search, procedural intricacies and technical niceties must yield to the need to know the actual values and preferences of the ward. In this spirit we briefly identify the following relevant factors, cautioning that they are not exclusive, recognizing that certain of them may not exist in all cases, and declining to establish their relative weights in any individual case. They are: (1) the ward's expressed preferences regarding treatment; (2) his religious beliefs; (3) the impact upon the ward's family; (4) the probability of adverse side effects; (5) the consequences if treatment is refused; and (6) the prognosis with treatment. (1) The ward's expressed preferences regarding treatment. If the ward has expressed a preference while not subjected to guardianship  and presumably competent, Lane v. Candura, supra at 382,  such an expression is entitled to great weight in determining his substituted judgment unless the judge finds that either: (a) simultaneously with his expression of preference the ward lacked the capacity to make such a medical treatment decision, or (b) the ward, upon reflection and reconsideration, would not act in accordance with his previously expressed preference in the changed circumstances in which he currently finds himself. Cf. In re Boyd, 403 A.2d 744, 751 (D.C. App. 1979). Even if the ward lacks capacity to make treatment decisions, his stated preference is entitled to serious consideration as a factor in the substituted judgment determination. Although [the ward] failed to understand his mental condition and his need for treatment, we think his stated preference must be treated as a critical factor in the determination of his `best interests.' Doe v. Doe, 377 Mass. 272, 279 (1979). This respect for the ward's preference and the reasons for this deference have long been recognized in our cases. A man may be insane so as to be a fit subject for guardianship, and yet have a sensible opinion and strong feeling upon the question who that guardian shall be. And that opinion and feeling it would be the duty as well as the pleasure of the court anxiously to consult, as the happiness of the ward and his restoration to health might depend upon it. Allis v. Morton, 4 Gray 63, 64 (1855). (2) The ward's religious beliefs. An individual might choose to refuse treatment if the acceptance of such treatment would be contrary to his religious beliefs. If such a reason is proffered by or on behalf of an incompetent, the judge must evaluate it in the same manner and for the same purposes as any other reason: the question to be addressed is whether certain tenets or practices of the incompetent's faith would cause him individually to reject the specific course of treatment proposed for him in his present circumstances. We adopt the approach taken by the court in In re Boyd, 403 A.2d 744 (D.C. App. 1979). In Boyd the court detailed the spectrum of tenacity with which an individual may adhere to religious beliefs and practices, and identified various factors to be considered in determining whether an individual would act consistently with previously held beliefs under unexpected circumstances. Id. at 751-752. Compare Developments in the Law  Civil Commitment of the Mentally Ill, 87 Harv. L. Rev. 1190, 1218 n. 95 (1974). While in some cases an individual's beliefs may be so absolute and unequivocal as to be conclusive in the substituted judgment determination, in other cases religious practices may be only a relatively small part of the aggregated considerations. (3) The impact upon the ward's family. An individual who is part of a closely knit family would doubtless take into account the impact his acceptance or refusal of treatment would likely have on his family. Such a factor is likewise to be considered in determining the probable wishes of one who is incapable of formulating or expressing them himself. In any choice between proposed treatments which entail grossly different expenditures of time or money by the incompetent's family, it would be appropriate to consider whether a factor in the incompetent's decision would have been the desire to minimize the burden on his family. If this factor would have been considered by the individual, the judge must enter it into the balance in making the substituted judgment determination. If an incompetent has enjoyed close family relationships and subsequently is forced to choose between two treatments, one of which will allow him to live at home with his family and the other of which will require the relative isolation of an institution, then the judge must weigh in his determination the affection and assistance offered by the incompetent's family. We note, however, that the judge must be careful to avoid examination of these factors in any manner other than one actually designed and intended to effectuate the incompetent's right to self-determination. As we discuss fully in Part C, infra, if there are no overriding State interests, [17] then the values and preferences of any institutions or persons other than the incompetent are irrelevant except in so far as they would affect his choice. (4) The probability of adverse side effects. We have described the adverse side effects of antipsychotic medication in Part II A (2), supra. Clearly any competent patient choosing whether to accept such treatment would consider the severity of these side effects, the probability that they would occur, and the circumstances in which they would be endured. The judge must also consider these factors in arriving at a determination of substituted judgment on behalf of an incompetent. Saikewicz, supra at 753-755. (5) The consequences if treatment is refused. If the prognosis without treatment is that an individual's health will steadily, inevitably and irreversibly deteriorate, then that person will, in most circumstances, more readily consent to treatment which he might refuse if the prognosis were more favorable or less certain. This general rule, however, will not always indicate whether an individual would, if competent, accept treatment. For example, in regard to the religious beliefs we discussed in Part II B (2), supra, even in a life-or-death situation one's religion can dictate a `best interest' antithetical to getting well. In re Boyd, supra at 750. This factor, as all the rest of the factors, must be utilized to reach an individual determination. While no judge need ignore the basic logic and common values which ordinarily underlie individual preference, he must reach beyond statistical factors and general rules to see the complexities of the singular situation viewed from the unique perspective of the person called on to make the decision. Saikewicz, supra at 747. (6) The prognosis with treatment. We think it can fairly be stated as a general proposition that the greater the likelihood that there will be cure or improvement, [18] the more likely an individual would be to submit to intrusive treatment accompanied by the possibility of adverse side effects. Additionally, professional opinion may not always be unanimous regarding the probability of specific benefits being received by a specific individual upon administration of a specific treatment. Both of these factors  the benefits sought and the degree of assurance that they actually will be received  are entitled to consideration. Finally, the judge making the substituted judgment determination should address, in the following manner, each of the six factors we have described above, as well as any others relevant in the case before him. He is to make written findings for each factor, indicating within each finding those reasons both for and against treatment. Cf. Saikewicz, supra at 733-735. Following this he must analyze the relative weight of the findings in that particular case. On this basis he is to conclude whether the substituted judgment of the incompetent would be to accept or reject treatment. If the determination is to accept treatment, the judge is to order its administration. [19] If the determination is to refuse treatment, the judge may order treatment only in accordance with the procedures we discuss in Part C, infra.