Court Opinion

ID: 9732746
Source: CourtListenerOpinion
Date Created: 2023-08-26 16:33:36.030557+00
Date Added: 2024-06-11T18:26:32.539954
License: Public Domain

Lynch, J.
(dissenting in part). This case turns on a fine balancing of competing interests. I disagree with the majority and believe that that balance tips in favor of continuing to provide nutrition and hydration to Paul Brophy.
Although I indorse the reasoning and careful scholarship of much of the majority opinion, and would reaffirm Superintendent of Belchertown State School v. Saikewicz, 373 Mass. 728 (1977), today’s decision goes beyond that pronouncement. My principal objection is that the State’s interest in the preservation of life has not been given appropriate weight. In addition, unlike Saikewicz,the majority nullify, if only in part, the law against suicide.
The interest in the preservation of life consists of at least two related concerns. First, the State has an interest in preserving the life of the particular patient. Second, the State has a closely related interest in preserving the sanctity of all human life.1 Matter of Conroy, 98 N.J. 321, 349 (1985). But see *444Cantor, Quinlan, Privacy, and the Handling of Incompetent Dying Patients, 30 Rutgers L. Rev. 243, 249 (1977). Those two concerns manifest themselves in a variety of ways, and represent traditional values in the law.
The majority recognize that the first concern is implicated in this case but fail to acknowledge significant concern for preserving the sanctity of all human life. The withdrawal of the provision of food and water results in particularly difficult, painful and gruesome death;2 the cause of death would not be some underlying physical disability like kidney failure or the withdrawal of some highly invasive medical treatment, but the unnatural cessation of feeding and hydration which, like breathing, are part of the responsibilities we assume toward our bodies routinely. Such a process would not be very far from euthanasia, and the natural question is: Why not use more humane methods of euthanasia if that is what we indorse? The State has an interest in maintaining the public integrity of the symbols of life — apparent euthanasia, and an apparently painful and difficult method of euthanasia, is contrary to that interest.
*445Moreover, until this case, it was clear that the State’s interest in life was to be balanced against the individual’s right to privacy and bodily integrity. No case in this Commonwealth has ever construed the right to privacy and bodily integrity as more than the right to avoid invasive treatments and certain other bodily invasions under appropriate conditions. Today, however, the majority essentially equate the right to privacy and bodily integrity with a right to choose or refuse all bodily invasions. Thus, if an individual’s choice would be to refuse treatment or care, it is not important that that treatment or care is minimally invasive (except to the extent that it factors into the individual’s choice). The majority now go well beyond Saikewicz in following the Supreme Court of New Jersey’s pronouncement that the primary focus should be on the patient’s choices and not on the type of treatment involved. After today’s decision, the finding of a substituted judgment essentially will be conclusive in the “balancing” process. Such a rule essentially has been adopted by both the California and New Jersey courts. See Bolivia v. Superior Court, 179 Cal. App. 3d 1127, 1137-1138 (1986); Barber v. Superior Court, 147 Cal. App. 3d 1006, 1019 (1983); Matter of Conroy, supra at 355.
In upholding a substituted judgment decision to refuse nutrition and hydration, this court and the California and New Jersey courts have not been willing to take the final step and rule directly that the right to privacy and bodily integrity entails a (limited) right to die. Cf. Bouvia v. Superior Court, supra at 1146-1148 (Compton, J., concurring). Massachusetts law has not heretofore acknowledged a right to die emanating from the right to privacy, but now, in essence, it does. Under Saikewicz and its progeny, the invasiveness of the procedure sought to be terminated was an important factor to be considered in assessing the strength of the State’s interest in preserving life against the individual’s rights. For all intents and purposes, this element has been eliminated and the Saikewicz “balancing test” is all but chimerical once it has been discerned what the individual’s choice would be. It is not enough to retreat behind the argument that discerning degrees of invasiveness would be difficult.
*446In Saikewicz, supra at 738, 743-744, we did speak with approval of the medical ethics distinction made between extraordinary and ordinary care — a distinction we perceived as having been recognized as extant in the medical community by the New Jersey Supreme Court in Matter of Quinlan, supra at 47. The majority now join those who are critical of this distinction. The validity of the criticisms aside, they are not telling against an evaluation of procedures according to their invasiveness. Here it is clear that the continued use of a G-tube presents few risks, no surgery, no pain or discomfort, and is minimally invasive; it is hardly more invasive than letting air into the room so that a patient can breathe. While the degree of invasiveness involved in a particular medical regimen may present issues of difficult line-drawing, this is not such a case.
Second, it appears that the majority have refused to overrule Saikewicz directly and to rule in favor of a constitutional right to die, so as to avoid the obvious conflict with the law against suicide. The State has an interest in the prevention of suicide. The underlying State interest in this area is the prevention of irrational self-destruction. Saikewicz, supra at 743 n.11. We have stated that an adult’s refusing medical treatment is not necessarily suicide because “(1) in refusing treatment the patient may not have the specific intent to die, and (2) even if he did, to the extent that the cause of death was from natural causes the patient did not set the death producing agent in motion with the intent of causing his own death.” Id. Here, Brophy is not terminally ill, and death is not imminent, and the judge specifically found that Paul Brophy’s decision would be to terminate his life by declining food and water. The judge also found that “Brophy’s decision, if he were competent to make it, would be primarily based upon the present quality of life possible for him, and would not be based upon the burdens imposed upon him by receiving food and water through a G-tube, which burdens are relatively minimal . . . .” Where treatment is burdensome and invasive, no such specific intent is normally at issue because, whether or not the patient seeks to die, the patient primarily seeks to end invasive or burdensome *447treatment.3 There is no question that the intent here is to end a life that is “over.” Moreover, death here would not be from natural causes, i.e., causes he or his agents did not set in motion, but instead, the death producing agent would be set in motion by a volitional act with the intent to cause death.4
Suicide is primarily a crime of commission, but can, and indeed must, also be conceived as an act of omission at times. See In re Caulk, 125 N.H. 226, 228, 231-232 (1984) (suicide can be committed by starvation [or dehydration]). If nutrition and hydration are terminated, it is not the illness which causes the death but the decision (and act in accordance therewith) that the illness makes life not worth living. There is no rational distinction between suicide by deprivation of hydration or nutrition in or out of a medical setting5 — both are suicide.
The State therefore has an interest in preventing suicide in this case that is greater than that in any previous case which has been before this court. The majority are apparently willing to recognize a limited right to commit suicide when an individual chooses to forgo life sustaining nutrition and hydration in a medical setting. The law against suicide predates our Constitution, and we should not nullify it without express legislation to this effect. Commonwealth v. Mink, 123 Mass. 422, 425-429 (1877).
A delicate case such as this calls for doctrinal exaction and for judicial restraint and caution. In an admirable effort to affirm individual autonomy and to authorize individuals to *448protect their humanity from the cruelty of fate, the majority have overlooked the limits of our power to accomplish such goals. A substituted judgment standard is our best legal tool to divine individual intent and to protect autonomous choice. But it would be an error of great magnitude to conflate a substituted judgment with an actual judgment. Such a mistake is a far greater blow against individual autonomy than it might at first seem. It is paternalism masquerading as the mere ratification of autonomous choice. Here, where Paul Brophy did not specifically advert to the choice which the majority now make for him, we should not be so quick to overlook the State’s interests in protecting human life and the law against suicide. After all, those interests are handed to us from a tradition which seeks to protect human autonomy. In such a close case we should be cautious, and the course of caution here lies in the direction of preserving life.

 Maintaining the sanctity of life may well be the reason society invests the State with sovereign authority. As Hobbes relates in Leviathan, the life of man in the state of nature is “solitary, poor, nasty, brutish, and short” and is characterized by a “war of every man against every man.” The social contract invests the sovereign with authority to end that war. Hobbes, Leviathan, in 23 Great Books of the Western World 85, 100-101 (R. Hutchins ed. 1952). Even in John Locke’s less hostile view of the state of nature, the formation of the State is largely justified on the ground that it affords *444protection for property. Locke, Concerning Civil Government, Second Essay, in 35 Great Books of the Western World 53 (R. Hutchins ed. 1952). Locke believed that a person’s property right in his or her body is foremost among property rights. Id. at 30.

 Removal of the G-tube would likely create various effects from the lack of hydration and nutrition, leading ultimately to death. Brophy’s mouth would dry out and become caked or coated with thick material. His lips would become parched and cracked. His tongue would swell, and might crack. His eyes would recede back into their orbits and his cheeks would become hollow. The lining of his nose might crack and cause his nose to bleed. His skin would hang loose on his body and become dry and scaly. His urine would become highly concentrated, leading to burning of the bladder. The lining of his stomach would dry out and he would experience dry heaves and vomiting. His body temperature would become very high. His brain cells would dry out, causing convulsions. His respiratory tract would dry out, and the thick secretions that would result could plug his lungs and cause death. At some point within five days to three weeks his major organs, including his lungs, heart, and brain, would give out and he would die. The judge found that death by dehydration is extremely painful and uncomfortable for a human being. The judge could not mie out the possibility that Paul Brophy could experience pain in such a scenario. Paul Brophy’s attending physician described death by dehydration as cmel and violent.

 This is not a case where a patient subject to burdensome or invasive treatment seeks to end that treatment and seeks to die. Ordinarily, mere knowledge that death will invariably result from the withdrawal of treatment is not sufficient to show a specific intent to die.

 Contrast the situation of a person on a respirator or dialysis machine, whose failed respiratory system or kidneys is the problem that will cause death.

 Query: Do the majority recognize a right to die via starvation-dehydration if done at home, or elsewhere outside of a medical facility?