Opinion ID: 2234743
Heading Depth: 2
Heading Rank: 2

Heading: Best Interests and Substituted Judgment

Text: Apart from the question of standing, AUL contends that the relief sought by the public guardian conflicts with his statutory duties to provide for Mr. Greenspan's support, care, comfort, health, education and maintenance and appropriate professional services. (Ill. Rev. Stat. 1987, ch. 110 1/2, par. 11a-17(a); see In re Estate of Burgeson (1988), 125 Ill.2d 477, 486.) AUL says that the public guardian must act in Mr. Greenspan's best interests (see In re Estate of Robertson (1986), 144 Ill. App.3d 701, 712; In re Estate of D.W. (1985), 134 Ill. App.3d 788, 791) and that discontinuance of Mr. Greenspan's artificial nutrition and hydration would result in his death, would not be in his best interest, and would not be consistent with his support, care, comfort, health, or maintenance. Analogizing to the holding in Cruzan v. Harmon (Mo. 1988), 760 S.W.2d 408, 424, 426, aff'd (1990), 497 U.S. ___, 111 L.Ed.2d 224, 110 S.Ct. 2841, that coguardians lacked statutory authority to order termination of medical treatment, AUL asks us to hold that a guardian lacks statutory authority to order withdrawal of life-sustaining food and water from an incompetent ward. That, of course, is not precisely the issue here. Instead of ordering withdrawal of artificial nutrition and hydration on the basis of any asserted statutory authority of his own, the public guardian has sought leave of court to order such withdrawal as Mr. Greenspan's surrogate and in order to give effect to what are represented as Mr. Greenspan's own wishes; and the question as initially framed by AUL is whether taking such a measure would conflict with the public guardian's statutory duties as Mr. Greenspan's guardian. After the parties' briefs were filed, we had occasion in another cause to address several of the legal issues involved here. (See In re Estate of Longeway (1989), 133 Ill.2d 33.) Artificial nutrition and hydration through a feeding tube are considered death-delaying procedures by the Illinois Living Will Act (Ill. Rev. Stat. 1987, ch. 110 1/2, par. 702(d); Longeway, 133 Ill.2d at 41), even though the Act forbids withdrawal of nutrition and hydration pursuant to a living will if death would result solely from such withdrawal rather than from an existing terminal condition. Artificial nutrition and hydration are also considered health and medical care by the Powers of Attorney for Health Care Law (Ill. Rev. Stat. 1987, ch. 110 1/2, pars. 804-10(a), (b)(1); Longeway, 133 Ill.2d at 41) and may be withdrawn pursuant to that Law ( Longeway, 133 Ill.2d at 46). Neither the Act nor the Law applies directly to a person such as Mr. Greenspan who has executed neither a living will nor a health care power of attorney. However, those statutes' classification of artificial nutrition and hydration as death-delaying medical procedures, rather than merely alternative methods of nourishment, is instructive. (See Longeway, 133 Ill.2d at 41-42.) When, as the result of incurable illness, a patient cannot chew or swallow and a death-delaying feeding tube is withdrawn in scrupulous accordance with law, the ultimate agent of death is the illness and not the withdrawal. Longeway, 133 Ill.2d at 42. We decided in Longeway that a patient's right to refuse medical treatment, including artificial nutrition and hydration, is supported by the common law (133 Ill.2d at 44-45) and that under section 11a-17 of the Probate Act of 1975 (Ill. Rev. Stat. 1987, ch. 110 1/2, par. 11a-17), in the case of an incompetent patient, the right may be exercised by a guardian as surrogate (133 Ill.2d at 45-46). However, we also decided in Longeway (133 Ill.2d at 47-53) that, pending any constitutionally permissible modification of the common law by the legislature, a surrogate can exercise the right for an incompetent patient only if: (1) the incompetent is terminally ill as defined in section 2(h) of the Illinois Living Will Act (Ill. Rev. Stat. 1987, ch. 110 1/2, par. 702(h)), i.e., the patient's condition is incurable and irreversible so that death is imminent and the application of death-delaying procedures serves only to prolong the dying process; (2) the incompetent has been diagnosed as irreversibly comatose or in a persistently vegetative state; (3) the incompetent's attending physician and at least two other consulting physicians have concurred in the diagnosis; (4) the incompetent's right outweighs any interests of the State, as it normally does; (5) it is ascertained, by an appropriate means  e.g., by the procedure of substituted judgment on the basis of clear and convincing evidence as outlined in Longeway  what the incompetent presumably would have decided, if competent, in the circumstances; and (6) a court enters an order allowing the surrogate to exercise the incompetent's right to refuse the treatment. In view of the foregoing, AUL's argument that the authorized withdrawal of artificial nutrition and hydration would itself cause Mr. Greenspan's death is erroneous. ( Cf. Hodgman & Frazer, Withholding Life Support Treatment in Illinois, 73 Ill. B.J. 106, 108 (1984) (mere withdrawal is not suicide).) AUL's associated argument that withdrawal would not be in Mr. Greenspan's best interest is more problematic but fails as well. Though a guardian's duty is to act in a ward's best interest, such a standard is necessarily general and must be adapted to particular circumstances. One such circumstance is a ward's wish to exercise common law, statutory, or constitutional rights, which may sometimes influence or even override a guardian's own perception of best interests. (See, e.g., In re Estate of Brooks (1965), 32 Ill.2d 361 (conservator could not compel arguably incompetent ward to accept blood transfusion she had steadfastly refused on first amendment grounds while competent); In re Gardner (1984), 121 Ill. App.3d 7 (given statutory due process rights of involuntary commitment respondents, court had no power to order guardian to apply, and guardian had no power to apply, for admission of nonconsenting ward to mental health facility as voluntary patient).) This tension between a ward's legal rights of volition and a guardian's own judgment of the ward's best interests resembles the tension this court discerned in Longeway (133 Ill.2d at 48-49) between the best-interests and substituted-judgment theories for deciding whether to discontinue an incompetent and terminally ill patient's artificial life support. In Longeway, this court approved application of the substituted-judgment theory, which requires a surrogate decisionmaker to establish, as accurately as possible, what the patient would decide if competent. ( Longeway, 133 Ill.2d at 49.) Ascertainment of what the patient would decide must be based on clear and convincing evidence of the patient's intent, derived either from a patient's explicit expressions of intent or from knowledge of the patient's personal value system. Longeway, 133 Ill.2d at 49-51, citing In re Jobes (1987), 108 N.J. 394, 415, 529 A.2d 434, 445. If it is clearly and convincingly shown that Mr. Greenspan's wishes would be to withdraw artificial nutrition and hydration, and if the other established criteria for permitting such withdrawal are met, Mr. Greenspan's imputed choice cannot be governed by a determination of best interests by the public guardian, AUL, or anyone else. Otherwise, the substituted-judgment procedure would be vitiated by a best-interests guardianship standard, elevating other parties' assessments of the meaning and value of life  or, at least, their assessments of what a reasonable individual would choose  over the affected individual's own common law right to refuse medical treatment. Accordingly, the public guardian is not prevented by a best-interests standard from seeking relief in accordance with Mr. Greenspan's wishes as determined by substituted-judgment procedure. See Longeway, 133 Ill.2d at 45-46 (a guardian has power, in accordance with prescribed guidelines, to exercise disabled ward's right to refuse artificial sustenance); cf. Newman v. Newman (1963), 42 Ill. App.2d 203, 213 (certain rights are so personal that conservator can neither exercise them for incompetent nor change an act performed under such right by incompetent prior to disability, though courts can permit conservator to exercise particular rights of incompetent where shown to be beneficial to ward's maintenance and welfare); Lewis v. Hill (1943), 317 Ill. App. 531, 534-35, appeal after remand (1944), 322 Ill. App. 68, aff'd (1944), 387 Ill. 542 (except as required to support testator, conservator of an insane person could not revoke provisions of will made when person had testamentary capacity).