Opinion ID: 1889433
Heading Depth: 1
Heading Rank: 4

Heading: The Substituted Judgment Versus the Best Interests of the Child Standard

Text: B.I. insists that, after the trial court decided to exercise jurisdiction over the DNR matter, the court should have applied the substituted judgment rather than the best interests of the child standard in determining whether to issue the DNR. She states that [t]he District of Columbia is a `substituted judgment' jurisdiction and cites cases from this and other jurisdictions applying the substituted judgment standard. We conclude that the trial court did not err in rejecting the substituted judgment in favor of the best interests of the child standard. Historically, the substituted judgment standard arose in estate cases involving incompetent persons, and generally has been invoked in cases of adults who at one time were competent but later became incompetent. See In re A.C., 573 A.2d 1235, 1249 (D.C.1990) (en banc); Superintendent of Belchertown State School v. Saikewicz, 373 Mass. 728, 370 N.E.2d 417, 431 (1977). In applying the doctrine, [t]he court, as surrogate for the incompetent, is to determine as best it can what choice [the] individual, if competent, would make with respect to medical procedures. In re Boyd, 403 A.2d 744, 750 (D.C.1979) (footnote omitted). [T]he substituted judgment inquiry is primarily a subjective one, A.C., supra, 573 A.2d at 1249, and in both In re A.C. and In re Boyd, supra , we set forth factors to be followed in ascertaining the decision that the incompetent person would make. These factors include giving the greatest weight . . . to the previously expressed wishes of the patient. In re A.C., supra, 573 A.2d at 1249-50. As we said in In re A.C., to determine the subjective desires of the patient, the court must consider the totality of the evidence, focusing particularly on written or oral directions concerning treatment to family, friends, and health-care professionals. The court should also take into account the patient's past decisions regarding medical treatment, and attempt to ascertain from what is known about the patient's value system, goals, and desires what the patient would decide if competent. Id. at 1251 (citations omitted). In In re Barry, 445 So.2d 365, 371 (Fla. App. 2 Dist.1984), the court noted that: The [substituted judgment] doctrine has been helpful in the case of adults, but it is difficult to apply to children or young adults. Indeed, most of the substituted judgment cases cited by B.I., including those from this jurisdiction, In re A.C., supra , and In re Boyd, supra , concerned adults. See Mack v. Mack, 329 Md. 188, 618 A.2d 744 (1993); In re Estate of Longeway, 133 Ill.2d 33, 139 Ill.Dec. 780, 549 N.E.2d 292 (1990); Superintendent of Belchertown, supra . Moreover, unlike K.I.'s situation, in one of the cases cited by B.I. which involved a minor, there was no neglect adjudication, and both parents agreed to petition the court for approval to remove life support systems. See In re Barry, supra . In the other case regarding a child, Custody of a Minor, 385 Mass. 697, 434 N.E.2d 601 (1982), the court took into consideration the best interests of the child in reaching its conclusion. Id. at 609 ([T]he Juvenile Court judge applied the substituted judgment test and examined the best interests of the child.). To attempt to apply the substituted judgment test in this case where B.I. and D.M. disagree; where K.I., a child born in June 1997, has never been healthy; has issued no oral or written directives as to medical matters or formed any opinions about anything, let alone a value system; not only would be impossible, but also would violate the spirit of the substituted judgment standard, the purpose of which is to implement the wishes of the incompetent individual. Consequently, we hold, consistent with the trial court's memorandum opinion, that in cases involving minor respondents who have lacked, and will forever lack, the ability to express a preference regarding their course of medical treatment, and where the parents do not speak with the same voice but disagree as to the proper course of action, the best interests of the child standard shall be applied to determine whether to issue a DNR.