Court Opinion

ID: 9730430
Source: CourtListenerOpinion
Date Created: 2023-08-26 15:12:04.857926+00
Date Added: 2024-06-11T18:26:06.422212
License: Public Domain

Nolan, J.,
(dissenting). The court again decides to play God. Death by starvation and dehydration will not assist Jane Doe in her unquestionable desire to “go in peace.” See Brophy v. New England Sinai Hosp., Inc., 398 Mass. 417, 444 n.2 (1986) (Lynch, J., dissenting) (detailing physical *526traumas resulting from withdrawal of hydration and nutrition). The majority’s insinuation that the decision to terminate her food and water will give effect to her wish is both morally offensive and intellectually curious, to say the least.
There is absolutely no basis on which to conclude that Doe would choose to die by starvation and dehydration if she were competent. The possibility that she wishes to terminate the provision of food and water is no more likely than the possibility that she fears this action and hopes, in her help-' less state, that society will continue to meet her basic needs.1 Given this reality, where lies the logical, moral, and ethical justification for depriving her of food and water? Without addressing this threshold dilemma, the majority determines that Ms. Doe would prefer death over life and concludes that we should assist her in meeting that end, under the guise of a heroic vindication of her liberty interests. There is no glory in this last hurrah.
As an initial matter, the substituted judgment doctrine, which even the majority opinion recognizes as a “legal fiction,” is a completely inappropriate device in cases involving the medical treatment of incompetents.2 Even if the substi*527tuted judgment doctrine were a proper approach for cases involving the medical treatment of incompetents, the majority opinion completely ignores the evidentiary constraints that are part and parcel of the doctrine. When this court initially adopted the substituted judgment doctrine, it relied upon an early Nineteenth Century British case, Ex parte Whitbread in re Hinde, a Lunatic, 35 Eng. Rep. 878 (1816), which involved the administration of the estate of an incompetent person. Superintendent of Belchertown State Sch. v. Saikewicz, 373 Mass. 728, 751 (1977). As the Saikewicz court recognized, the substituted judgment doctrine was used in Whitbread to authorize a gift from the estate of an incompetent to a person to whom the incompetent owed no duty of support. Id. at 751-752. As Professor Louise Harmon pointed out in her critique of the substituted judgment doctrine, Harmon, Falling Off the Vine: Legal Fictions and the Doctrine of Substituted Judgment, 100 Yale L.J. 1 (1990), there are serious ramifications that result from applying what is, in essence, property law to determine the rights of incompetent patients to medical treatment. See id. at 65-67 (discussing irresponsibility of applying property law to rights of incompetent patients).
Even if one were to overlook the basic inappropriateness of using a property law concept in this situation, the substituted judgment doctrine itself, as it developed in property law, bears little resemblance to its use in the area of medical treatment for incompetents. In the first place, the English common law differentiated two types of incompetents: the lunatic, who once possessed a sound mind and was expected to recover, and the idiot, who never possessed a sound mind. Id. at 16. The substituted judgment doctrine in property law applied only to lunatics, for whom there was evidence of their former intentional states, and it was not applied to an incompetent such as the patient in this case for whom there was no evidence of her former intentional state. See id. at 63-64 *528(substituted judgment doctrine appropriate only for lunatics, not idiots).
Even the Whitbread decision, which only concerned a lunatic, generated judicial distrust, and later decisions imposed strict evidentiary constraints upon its use. Id. at 24-25. Chief among these constraints was evidence of the lunatic’s former intentional state. Id. at 25. “Subsequent Chancellors looked for a degree of consanguinity, a history of prior warmth and affection, perhaps statements made by the lunatic of his intent to make gifts to the petitioner, or even evidence of past gift-giving on which to hang a moral obligation. He was no longer a generic, reasonable lunatic prone to giving his money away. [3] Instead, he was a specific individual with a past that had to be consulted.” (Footnote omitted.) Id. at 26.
When the substituted judgment doctrine in property law was transported to America, the evidentiary constraints were even stricter than those in England. Harmon, supra at 27. Indeed, a presidential commission stated: “The substituted judgment standard can be used only if a patient was once capable of developing views relevant to the matter at hand; further, there must be reliable evidence of these views.” President’s Commission for the Study of Ethical Problems in Medicine and Biomedical and Behavioral Research, Deciding to Forego Life Sustaining Treatment at 133 (1983). How ironic that a property law concept not only has been transformed to our jurisprudence on the rights of incompetents to medical treatment but also has been applied more liberally in this area.
The majority opinion observes, ante at 521, that “[t]he Commonwealth’s interest in preserving life is strongest when *529it is attempting to protect its citizens from abuse or infringement of their rights,” but then dismisses this potentially overriding interest by refocusing the issue in this case as the championing of Ms. Doe’s fundamental rights to bodily integrity. This clever approach omits to explain why the State’s strong interest in protecting its citizen’s right to receive nutrition from being abused or infringed upon is not so worthy of defense as the citizen’s right to self-determination, especially where there is no genuine expression of the citizen’s preference. Moreover, there is no recognition of the State’s duty to provide adequate food and medical care to its citizen, who has a protected liberty interest in the same. Youngberg v. Romeo, 457 U.S. 307, 324 (1982).
The court ostensibly involves itself in this matter to protect the interests of the vulnerable and then takes advantage of Ms. Doe’s vulnerability to fashion an argument that she is a social, medical and familial burden and that her simple, fundamental needs should no longer be met. Ms. Doe cannot speak, so the court utters fatal words on her behalf. The court should not guess as to what she would say, if she had the ability to do so. On balance, the only choice which truly respects the value of Ms. Doe’s life — indeed, human life — is the recognition and acceptance of our duty to feed and hydrate this dependent member of our society, until her inevitable demise.
“The feeding of the hungry, whether because they are poor or because they are physically unable to feed themselves, is the most fundamental of all human relationships. ... It is a most dangerous business to tamper with, or adulterate, so enduring and central a moral emotion.” Callahan, On Feeding the Dying, 13 Hastings Center Rep. at 22 (Oct. 1983). Widespread acceptance of this social sentiment is reflected in the fact that, out of thirty-nine living will statutes, twenty explicitly provide that “medically administered nutrition and hydration are not life-sustaining treatments which can be withdrawn pursuant to a directive.” Zinberg, Decisions For The Dying: An Empirical Study of Physicians’ Responses To *530Advance Directives, 13 Vt. L. Rev. 400, 458-459 & n.45 (1989).
The characterization of the provision of food and water as a medical treatment or a basic entitlement requires a determination of what life means — a task of no small magnitude. Yet, the conclusion easily reached today regrettably answers that profound question, stating, in effect, that those persons who depend on the care of others and technological advances for their comfort and survival do not have “life,” or at least do not have a protected interest in it.
Therefore, I dissent.

 would seem that a person who never has been physically or mentally competent, one who never has known or enjoyed the full panoply of life’s offerings, would be less expecting in terms of the quality of his or her life. The person may find whatever satisfaction he or she derives from his or her existence to be valuable and sacred. It is wrong, therefore, to discuss this matter in terms of what Ms. Doe would decide if she were competent, since that standard attributes knowledge of the loss of quality of life to the incompetent and presumes that the person’s decision would involve a comparison of his or her objectively poor situation in relation to healthy, competent persons.

 An ever-increasing number of commentators is reaching the same conclusion. See, e.g., Buchanan, The Limits of Proxy Decisionmaking for Incompetents, 29 UCLA L. Rev. 386, 393-397 (1981); Weber, Substituted Judgment Doctrine: A Critical Analysis, 1 Issues in Law and Med., 131, 131-159 (1985); Note, “Someone Make Up My Mind”: The Troubling Right to Die Issues Presented by Incompetent Patients with No Prior Expression of a Treatment Preference, 64 Notre Dame L. Rev. 394, 403-407 (1989). Two authors, in considering the substituted judgment doctrine, have referred to the doctrine by a more appropriate appellation, the “invented consent” doctrine. Bopp & Avila, The Sirens’ Lure of Invented *527Consent: A Critique of Autonomy-Based Surrogate Decisionmaking for Legally-Incapacitated Older Persons, 42 Hastings L.J. 779, 780 (1991).

 Compare the language used in Doe, ante at 518, quoting Saikewicz, supra at 752-753 (the choice is to 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”). Thus, while we have done away with the “generic, reasonable lunatic” in property law, we have created the generic reasonably competent incompetent in cases of medical treatment of incompetents.