Court Opinion

ID: 9766900
Source: CourtListenerOpinion
Date Created: 2023-08-29 05:02:10.773327+00
Date Added: 2024-06-11T07:30:27.040270
License: Public Domain

HIGGINS, Judge,
dissenting.
In my opinion, the decision in this important case of first impression in Missouri rests on an unsound opinion by a tenuous majority of judges sitting in the case. Accordingly, and with due respect, I dissent.
The trial court ruled that Ms. Cruzan had the right to be free from unwanted intrusion of her body by medical agents of the State and ordered the defendant doctors to honor the expressed wishes of Ms. Cruzan and the consent and authority given by her guardians for removal of a surgically implanted life support device. The majority cites more than 50 appellate decisions from 16 jurisdictions that support and validate the trial court’s findings of fact, conclusions of law and the judgment in this case; yet, ironically, it reverses the judgment in favor of Ms. Cruzan by finding “that the trial court erroneously declared the law.” Because the majority acts in my view, contrary to the facts and the law, and because of the importance of the case and its effect on the rights of the citizens of Missouri, I register my formal dissent. It begins with the judgment entered by the trial court:
“On Tuesday, January 11, 1983 at approximately 12:50 a.m., Nancy Beth Davis nee Cruzan, our ward, was driving a 1963 Rambler Classic Sedan, alone, East on Elm Road (a/k/a Krummel Nursery Road), 2.1 miles East of Alternate U.S. Highway 71, Southeast of Carthage, Missouri, Jasper County. Elm Road is a two lane east-west asphaltic pavement, 18 feet wide on an easterly uphill grade in an open area. The weather was clear and the pavement dry on a cool January night. The driver’s condition is unknown prior to the accident. An accident was reported and Trooper Dale Penn, Missouri State Highway Patrol was summoned to the scene at 12:54 a.m., arriving at 1:00 a.m. where he found Nancy lying face down in a ditch some 35 feet across a private driveway south and east from her .... overturned-vehicle which was resting in a ditch on the west side of the private driveway with all four wheels skyward. Nancy was lifeless and not breathing when Trooper Penn examined her without moving her. She had apparently expired. She was apparently eastbound at a speed too fast for the conditions when her car ran off the left (north) side of the pavement and struck some small trees, a mailbox and then swerved back across and off the pavement on the right (south) side and ran through a fence and overturned several times coming to rest on its top some 210 feet from the mailbox on the north side of Elm Road in the ditch of the private driveway.
“The Carthage Fire Department was notified. Squad 107 was dispatched at 1:05 a.m.; Lieutenant Ed Nuse in command, Firefighter Bob Smith driving, and Firefighter Mike Lee on the back step. They arrived at 1:12 a.m. Lee commenced a search of the area for a baby reportedly thrown from the vehicle while Lt. Nuse and Smith went to the assistance of the paramedics with Firefighter Smith administering CPR when Nancy resumed breathing.
“At approximately 1:02 a.m. the Carthage Ambulance service at McCune-Brooks Hospital was notified and Paramedics Robert Williams and Rick Maynard were dispatched in an ambulance. On arrival at 1:09 a.m., they found Nancy lying face down in the ditch ‘code blue,’ i.e. in total respiratory and cardiac arrest. She had some facial lacerations, lacerations within her mouth, cuts and massive swelling of the face. The only evidence of the cause of death was her position, lying face down in the ditch in a position in which she could not breathe. No evidence of severe head injury or other explanation of ‘code blue’ was observed. Cardiopulmonary resuscitation (CPR) was commenced. She was unconscious. Advance life support procedures were instituted at 1:11 a.m. per orders of the emergency room doctor at the *431hospital. A tube was placed down her windpipe to gain complete control of her respiratory system and at 1:12 a.m. an I.V. was introduced, administering medication and sodium bicarbonate because she had been ‘down a while.’ Results were achieved at about 1:12 a.m. with a BP 60/0. It couldn’t be heard by stethoscope but could be felt by fingertips. At 1:13 a.m., the heart monitor disclosed a pulse rate around 92 per minute and BP 80/0. She started spontaneous respiration 12 per minute, a rate normal for some adults. Suction was returning ‘a lot of blood and mucous.’ At 1:56 a.m., after being prepared, she was transported to McCune Brooks Hospital Emergency Room with vital signs of BP 110/80, pulse 92, and respiration 14 and spontaneous. Arrival was at 2:03 a.m.
“She was examined and it was determined that she should be taken to Freeman Hospital, Joplin, a distance of about 21 miles. After further efforts to maintain a stable condition, she was transported.
“Upon arrival at Freeman Hospital Emergency Room she was still unconscious, now requiring manual respiratory assistance, unresponsive to painful stimuli and wearing mass trousers. Her vital signs were stabilized and she was taken to surgery.
“An exploratory laparotomy disclosed a laceration to her liver which was repaired. Multiple facial fractures were repaired by an oral surgeon. It was noted she did not require much sedation or anesthetic.
“Dr. H.S. Majzoub, a neurosurgeon, examined Nancy in the ICU following surgery, reviewing a CAT scan of her head showing no significant abnormalities. He found the upper hemispheric ventricles of the brain essentially normal in size with no evidence of intracranial mass lesion or any edema. All her basal systems appeared normal. The diagnosis was probable cerebral contusions compounded by significant anoxia with the prognosis hinging on the duration of her anoxia which was unknown to him.
“Estimates of the duration of Nancy’s anoxia range from 6 to 20 minutes with the most probable duration 12 to 14 minutes. Less than 6 minutes is perhaps the maximum period for the brain to be without oxygen without causing some permanent brain damage. The longer the duration, the more the permanent damage.
“Nancy’s recovery from surgery was apparently uneventful. She remained in a coma for about three more weeks when she appeared to have progressed to an unconscious state. She has never recovered or improved from this state. On February 1, 1983, with the consent of her then husband, a # 20 gastrostomy feeding T-tube was surgically inserted. This tube has been her only source of nutrition and hydration since her admission to the Mt. Vernon State Hospital. She was discharged from Freeman Hospital as improved on February 21, 1983 to St. John’s Regional Medical Center, Brady Rehabilitation Facility, Joplin, where rehabilitative measures were attempted for six weeks when she was discharged essentially unimproved and unresponsive to rehabilitation. She could not be fed orally, being unable to swallow a significant amount of food or water.
“Her husband took her to his grandmother’s home where she was served by round the clock professional nursing care. After two or three weeks, she developed pneumonia, probably from food aspiration as a result of oral feeding efforts and was re-hospitalized for a short time and then returned to the grandmother’s home.
“A short time later, she was admitted to a local nursing home where after about six days, she was admitted to Jane Chinn Hospital, Webb City, with a fever of 107 from some kind of an infection. She was discharged to be admitted to the Mt. Vernon State Hospital on October 19, 1983 where she remains a patient.
“Her parents, the Petitioners, were appointed guardians and conservators after hearing on January 25, 1984 and Letters duly issued. Her husband did not attend or inquire of any of the proceedings. A dissolution of marriage was subsequently decreed.
“Continuous observations by primary care givers, her family and attending physicians and a recent neurological examination *432by Dr. George Wong report that Nancy remains unconscious, is unresponsive to her environment with atrophy and contrac-tures of her four extremities. Her fingernails now sometimes cut into her wrists. She is a spastic quadriplegic. Her vital signs, BP 130/80, pulse 78 and regular, and respiration spontaneous at 16 to 18 per minute, all essentially normal for a 30 year old female. At no time has her electroencephalogram registered isoelectric or flat. Her condition is considered permanent. A recent CAT scan of her head reveals abnormalities suggesting severe irreversible upper hemispheric brain damage with massive enlargement of ventricles from filling with cerebrospinal fluid because the brain is degenerating. The degeneration is called cerebral cortical atrophy which is progressive from her initial condition reflected on CAT scan. The fluid is replacing the area where there is no more brain tissue. This permanent and irreversible condition is the apparent result of time duration of anoxia which was initially feared by the examining and consulting neurosurgeon. Her normal weight of 115 pounds has now risen to about 140 pounds.
“Prior to the accident, Nancy resided with her husband of about a year, Paul, further east on Elm Road from the accident scene. She was employed on either the 3 to 11 or the graveyard shift at Schreiber Foods. She is described as a vivacious, active, outgoing, independent person who preferred to do for herself.
“About a year prior to her accident in discussions with her then housemate, friend and co-worder, she expressed the feeling that she would not wish to continue living if she couldn’t be at least halfway normal. Her lifestyle and other statements to family and friends suggest that she would not wish to continue her present existence without hope as it is.
“After examination and treatment by a number of physicians, including three neurologists, a neurosurgeon, and a specialist in rehabilitative medicine and considering the observations of the primary nursing care providers, her family and co-guardians, the Court by clear and convincing evidence finds the current medical condition of our ward to be as follows:
1. That her respiration and circulation are not artificially maintained and within essentially normal limits for a 30 year old female with vital signs recently reported as BP 130/80; pulse 78 and regular; respiration spontaneous at 16 to 18 per minute.
2. That she is oblivious to her environment except for reflexive responses to sound and perhaps to painful stimuli.
3. That she has suffered anoxia of the brain resulting in massive enlargement of the ventricles filling with cerebrospi-nal fluid in the area where the brain has degenerated. This cerebral cortical atrophy is irreversible, permanent, progressive and ongoing.
4. That her highest cognitive brain function is exhibited by her grimacing perhaps in recognition of ordinarily painful stimuli, indicating the experience of pain and her apparent response to sound.
5. That she is spastic quadriplegic.
6. That she has contractures of her four extremities which are slowly progressive with irreversible muscular and tendon damage to all extremities.
7. That she has no cognitive or reflexive ability to swallow food or water to maintain her daily essential needs. That she will never recover her ability to swallow sufficient to satisfy her needs.
“The Petitioners, her mother and father, and duly appointed co-guardians, seek this Court’s approval of their request to the Respondent Lampkins, Superintendent of the Mt. Vernon State Hospital, to discontinue further nutrition and hydration by gas-trostomy tube and if refused by Respondents after this Court’s approval then to direct Respondents to carry out their request.
“The only economic considerations in this case rest with Respondent’s employer, the State of Missouri, which is bearing the entire cost of care. Our ward is an adult without financial resources other than Social Security whose not inconsiderable medical insurance has been exhausted since January 1986.
*433“The Court has been well and ably advised in the premises by counsel for the Petitioners, William Colby, Esq., Kansas City and Walter Williams, Esq., Joplin; for the Respondents, The Honorable William L. Webster, Attorney General of Missouri, Robert Presson, Esq., Assistant Attorney General, and Robert R. Northcutt, Esq., General Counsel Missouri Department of Health, all of Jefferson City; and the Court appointed Guardians Ad Litem and attorneys for our Ward, Thad C. McCanse, Esq., and David Mouton, Esq., both of the law firm of Flanigan, McCanse and Lasley, Carthage, and Amici Curiae Briefs from Society For The Right to Die, the Ethics and Advocacy Task Force of the Nursing Home Action Group filed by the National Legal Center for the Medically Dependent and Disabled and the Missouri Citizens For Life.
“Now being fully advised in the premises, the Court enters its conclusions and judgment, accordingly.
“The due process clause of the Constitution of the United States and the statutes of the State of Missouri1 require clear and convincing evidence of a physical or mental condition before a person may be declared incapacitated and a guardian appointed. It follows that no less a standard must be met before the Court may authorize the Guardians to request Respondents to withdraw nutrition and hydration from their Ward with the inevitable attendant consequences of carrying out such an act.
“We believe the Petitioners, Co-guardians, her parents, have met this heavy burden as the Court has found her present medical condition to be by clear and convincing evidence.
“The maintenance of nutrition and hydration to our Ward, unresponsive to her environment and without hope of further recovery becomes medical treatment when it can only be provided by gastrostomy tube. While the feeding itself may be more nutritional than medical, a surgical procedure personally invasive to the body is required to implant the tube in the stomach and if repair or replacement of the tube should become necessary further surgical procedure would be required. Nutrition or hydration under these circumstances is medical treatment because it can only be and has for the past five years been maintained by the surgically implanted gastrostomy tube.
“Nancy’s present unresponsive and hopeless existence is not the will of the Supreme Ruler but of man’s will to forcefully feed her when she herself cannot swallow thus fueling respiratory and circulatory pumps to no cognitive purpose for her except sound and perhaps pain.
“Her expressed thoughts at age twenty-five in somewhat serious conversation with a housemate friend that if sick or injured she would not wish to continue her life unless she could live at least halfway normally suggests that given her present condition she would not wish to continue on with her nutrition and hydration.
“The Law of this State2 and legislatively enunciated public policy prohibits withholding or withdrawal of nutrition or hydration as a death-prolonging procedure and euthanasia or mercy killing by act or omission. Death-prolonging procedures may only be withheld if no innocent third parties require the protection of the state, no homicide or suicide occurs and good ethical standards in the medical profession are maintained. Our law does recognize an individual’s primary right to refuse medical treatment and to direct physicians attending to withhold or withdraw further treatment.
“In this case there are no innocent third parties requiring state protection, neither homicide nor suicide will be committed and the consensus of the medical witnesses indicated concerns personal to themselves or the legal consequences of such actions rather than any objections that good ethical standards of the professions would be breached if the nutrition and hydration were withdrawn the same as any other *434artificial death prolonging procedures the statute specifically authorizes. Euthanasia is not statutorily defined and there are differing definitions in both lay and professional terms.
“There is a fundamental natural right expressed in our Constitution as the ‘right to liberty’3, which permits an individual to refuse or direct the withholding or withdrawal of artificial death prolonging procedures when the person has no more cognitive brain function than our Ward and all the physicians agree there is no hope of further recovery while the deterioration of the brain continues with further overall worsening physical contractures. To the extent that the statute or public policy prohibits withholding or withdrawal of nutrition and hydration or euthanasia or mercy killing, if such be the definition, under all circumstances, arbitrarily and with no exceptions, it is in violation of our ward’s constitutional rights by depriving her of liberty without due process of law. To decide otherwise that medical treatment once undertaken must be continued irrespective of its lack of success or benefit to the patient in effect gives one’s body to medical science without their consent. We could then sing, less fervently of the land of the free, but as medical science advances to new horizons, much more fervently of the land of the brave. If we are the victim we might not be cognizant of our bravery.
“To deny the Co-guardians the authority to act in this instance is to deprive the Ward of the equal protection of the law which is constitutionally guaranteed.4
“In this case the Court acts only to authorize the Co-guardians to exercise our Ward’s constitutionally guaranteed liberty to request the Respondents to withhold nutrition and hydration.
“The Co-guardians are required only to exercise their legal authority to act in the best interests of their Ward as they discharge their duty and are free to act or not with this authority as they may determine.
“The Respondents, employees of the State of Missouri, are directed to cause the request of the Co-guardians to withdraw nutrition or hydration to be carried out. Such a request having Court approval, shall be taken the same as a request for discontinuance of any other form of artificial life support systems. Under those circumstances, further feeding could raise the spectre of civil liability and recovery of damages from the provider. The care and compassion the Respondents and their associates have already shown our Ward and her guardians, incomparable by any standards, are in keeping with the overwhelming tragedy that has been visited upon us all.
“IT IS SO ORDERED, ADJUDGED AND DECREED this 27th day of July, 1988.”
The mandate of this Court for its review of this case is that the judgment of the trial court “will be sustained ... unless there is no substantial evidence to support it, unless it is against the weight of the evidence, unless it erroneously declares the law, or unless it erroneously applies the law.” Murphy v. Carron, 536 S.W.2d 30, 32 (Mo. banc 1976). “Due regard shall be given to the opportunity of the trial court to have judged the credibility of witnesses.” Rule 73.01(c)(2). I submit under this mandate, and for the reasons that follow, the judgment should be affirmed.
Appellants Harmon and Lamkins contend the court erred in concluding that the living will statute does not prohibit withdrawal of the artificial life support in this case; in holding that refusal of the withdrawal would deny Nancy Cruzan’s “Right To Liberty” and to deny the guardians to act on her behalf would deprive her of equal protection of the law; in failing to decide whether withdrawal of the support was appropriate, in failure to have clear and convincing evidence to support its findings, and in identifying the factors that authorize the withdrawal.
*435Appellant guardian ad litem advises this court:
we informed the [trial] court that we felt it was in Nancy Cruzan’s best interests to have the tube feeding discontinued. We now find ourselves in the position of appealing from a judgment we basically agree with. We felt then that an appeal should be made because our responsibility to her as attorneys and guardians ad litem was to pursue this matter to the highest court in the state in view of the fact that this is a case of first impression in Missouri.
Appellant guardian ad litem contends similarly to the contentions of appellants Harmon and Lamkins. He contends additionally that the court erred in authorizing the guardian ad litem to exercise Nancy Cru-zan’s right to refuse life sustaining medical treatment because to do so conflicts with a guardian’s statutory duty and the right to refuse life support here is personal to Nancy Cruzan.
Respondents co-guardians Lester L. Cru-zan, Jr., and Joyce Cruzan contend for the judgment of the trial court asserting that the trial court was correct in ruling that their daughter, Nancy Cruzan, has a right to be free from invasive, unwanted and non-beneficial treatments because such rights are granted to all persons by the right to liberty found in the natural law, the common law right to self-autonomy and the constitutional rights to liberty and privacy; that she did not forfeit the right to be free of intrusive treatment because of her incompetency when her guardians consented according to her rights; that no state interest is present that outweighs her right to be free from the state’s intrusive medical care; that all the credible evidence, medical and otherwise, supports the withdrawal of the artificial life system implanted in Nancy Cruzan; that the living will statute does not stand to exclude withdrawal of the surgically implanted support system; and that the appellant doctors’ hospital cannot disregard the request of the guardians to withdraw the unwanted life support.
Amicus curiae briefs in support of appellants were filed by The Missouri Citizens For Life and The Association For Retarded Citizens of the United States and The Ethics and Advocacy Task Force of the Nursing Home Action Group. Amicus curiae briefs in support of respondents-guardians and the judgment in their favor were filed by The American Medical Association; Society For The Right To Die; Concern For Dying; SSM Health Care System and The Center For Health Care Ethics, St. Louis University Medical Center; and The American Academy of Neurology.
Contrary to the diversionary question posed by the majority, the parties as aforesaid present the question answered by the trial court in favor of Nancy Cruzan: Whether, under the evidence and applicable law, Nancy Cruzan, an adult incompetent, has the right to be free from an unwanted artificial life support device surgically implanted in her body, requested and authorized to be removed by her guardians. Yet no matter how the question is posed, the judgment for review under Murphy is supported by the law and the facts and should be upheld.

The Facts

Although appellants emphasize selected testimony for purposes of their arguments, none of appellants’ contentions dispute the facts as found by the trial court. Accordingly, the facts stand as found and recited in the judgment. Murphy; Rule 73.01.
Nevertheless, the majority refinds facts to support its result, an inexcusable exercise for this Court. For example, the majority states, “the continuation of feeding through the tube is not heroically invasive.” Yet the trial court found:
a surgical procedure personally invasive to the body is required to implant the tube in the stomach and if repair or replacement of the tube should become necessary further surgical procedure would be required. Nutrition or hydration under these circumstances is medical treatment because it can only be and has for the past five years been maintained *436by the surgically implanted gastrostomy tube.
The majority’s statement that subject medical treatment is not invasive is contrary to both the facts of this case and the cases that describe the use of a gastrostomy tube as “intrusive as a matter of law.” McConnell et al. v. Beverly Enterprises, et al., No. 0293888, slip op. at 25 (Conn.Super.Ct. July 8, 1988); Brophy v. New England Sinai Hosp., 398 Mass. 417, 435, 497 N.E.2d 626, 636 (1986).
For further example, the majority says, “the statements [in regard to whether Nancy would want to receive this medical treatment] attributable to Nancy in this case are similarly unreliable for the purpose of determining her intent.” The trial court, however, found, by clear and convincing evidence, “given [Nancy’s] present condition she would not want to continue on with her nutrition and hydration.” The record is replete with evidence to support this finding and the majority should not say otherwise. Murphy; Rule 73.01.
Finally, the majority says, “We further hold that the evidence offered at trial as to Nancy’s wishes is inherently unreliable.” This substitution of judgment for that of the trial court constitutes an incredible denial of the deference due the trial court’s exclusive power to judge the credibility of witnesses. Rule 73.01(c)(2).

The Law

All parties agree this is a case of first impression. Accordingly, it is proper to look to the law of other jurisdictions that have ruled on the question in this case. Although the majority cites more than 50 cases from 16 states that support the judgment in this case, it rejects all and fails to point to a single case in support of its analysis and ultimate conclusion to reverse the judgment. Again, the irony in the majority view is its reversal on the ground of “erroneous declaration of law.” Without exception, the cases cited in the majority’s footnote 4 uphold a right to refuse life sustaining medical treatment, either personally or through a guardian.
Specifically in point and persuasive for resolution of this case are: Bouvia v. Superior Court, 179 Cal.App.3d 1127, 225 Cal.Rptr. 297 (1986) (discussed by the majority): The court allowed a competent patient to have a nasogastric tube removed from her body based on a constitutional right to privacy and a common law right to refuse treatment. In Re Drabick, 200 Cal.App.3d 185, 245 Cal.Rptr. 840 (1988): The court allowed a conservator to exercise the right on behalf of an incompetent patient in a persistent vegetative state even without prior court approval if the decision is made in good faith. Rassmussen v. Fleming, 154 Ariz. 207, 741 P.2d 674 (1987): A public fiduciary was allowed to remove a nasogas-tric feeding tube from a nursing home patient in a chronic vegetative state. The court balanced the constitutional right to privacy and the common law right to refuse medical treatment against the state’s interests. In light of the minimal benefit of continued medical treatment, the court found that the patient’s rights, exercised through his guardian, outweighed the state’s interest in preserving life. Brophy v. New England Sinai Hospital, Inc., 398 Mass. 417, 497 N.E.2d 626 (1986): The court engaged in the balancing test espoused by the majority. It held that the common law right to refuse treatment, and the constitutional right of privacy are not absolute, but held a gastronomy tube to be “intrusive” as a matter of law and found that the patient’s rights outweighed the state’s interests, notwithstanding that Bro-phy’s condition was not terminal. Foody v. Manchester Memorial Hospital, 40 Conn.Super. 127, 482 A.2d 713 (1984): The patient was in a semicomatose state, kept alive by life support systems. The patient was incompetent, and had never expressed her view on whether she would want to be kept alive under her circumstances. The court recognized that there were both constitutional and common law rights to be freed from unwanted medical treatment. The court applied a balancing test and concluded “that no state interest [including the preservation of life] exists to the degree necessary to outweigh the right of Sandra Foody to exercise her right to refuse fur*437ther life-sustaining treatment.” Foody, 482 A.2d at 720. The court “recognized the right of a guardian of the person to vicariously assert the right of an incompetent or unconscious ward to accept or deny medical care. To deny the exercise because the patient is unconscious is to deny the right. It is incumbent upon the state to afford an incompetent the same panoply of choices it recognizes in competent persons.” Foody, 482 A.2d at 718. Corbett v. D’Alessandro, 487 So.2d 368 (Fla.App.1986): The court upheld the constitutional right of a person in a persistent vegetative state to forgo the use of artificial life support (a nasogastric feeding tube), and allowed the patient’s husband to exercise the right on her behalf. Florida has a living will statute similar to Missouri’s, see Fla.Stat. § 765.03(3)(b) (Supp.1984). Estate of Prange, 166 Ill.App.3d 1091, 117 Ill.Dec. 595, 520 N.E.2d 946 (1988): The patient had made her wishes known while she was competent. The court upheld the guardian’s decision that the patient would have wished to terminate nutrition and hydration and allowed the guardian to carry out that wish based on a common law right to be free from non-consensual bodily invasions and a constitutional right of privacy. In Re Gardner, 534 A.2d 947 (Me.1987): The court permitted the patient’s feeding tube to be removed based on a common law right to refuse medical treatment. The court affirmed the trial court’s finding that it was the patient’s clear and convincing intent not to be maintained on artificial life support in a vegetative state. It based this finding on statements he had made to his friends and family before the automobile accident which resulted in his incapacitation. The Supreme Court held “that when an individual has clearly and convincingly in advance of treatment expressed his decision not to be maintained by life-sustaining procedures in a persistent vegetative state, health care professionals must respect that decision.” 534 A.2d at 953. In addressing the emotional distinction between nutrition and hydration and other medical procedures, the court stated:
The symbolism is lost in the artificial introduction of food and water into the body of someone in Gardner’s unfortunate condition. There is no symbolic virtue in imposing that procedure upon the body of a person who previously declared that he would not want to receive such treatment but who now is no longer able personally to prevent what is being done to his body.
Id. at 955. McConnell et al. v. Beverly Enterprises et al., No. 0293888 (Conn.Super.Ct. July 8, 1988): The patient was diagnosed as being in a persistent vegetative state as a result of traumatic brain injuries sustained in an automobile accident. Her family requested the court to order the removal of the gastrostomy tube which was providing her nutrition and hydration and to allow her to die. This was a case of first impression in Connecticut where a statute allowed the withdrawal of a respirator, but excluded the withdrawal of nutrition and hydration. Despite the statute, the court held there was a constitutional right to refuse medical treatment, and a common law right of self determination to accept or reject medical treatment. The patient, while competent, had indicated she would not want to be kept alive by life-prolonging equipment. The court further held:
other cases that have been decided ... found no distinction between the discontinuation of a respirator and any of the variety of artificial nutrition and hydration methods.... While there is more difficulty in coming to terms with the discontinuation of nutrition and hydration, no appellate court that has addressed this precise issue has found such a distinction.
McConnell, slip op. at 22. The court held that a guardian could exercise a patient’s rights and stated, “[w]hen a family is unanimous ... the court must place great weight on their decision to enforce the desires of their loved one.” McConnell, slip op. at 26. See also, Delio v. Westchester County Medical Center, 129 A.D.2d 1, 516 N.Y.S.2d 677 (1987); Leach v. Akron General Medical Center, 68 Ohio Misc. 1, 426 N.E.2d 809 (Comm.Pl.1980); Matter of Welfare of Colyer, 99 Wash.2d 114, 660 P.2d 738 (1983).
*438Because New Jersey broke the first ground in this area, its cases deserve particular attention. The majority cites Matter of Jobes, 108 N.J. 394, 529 A.2d 434 (1987), contending it is factually similar to Nancy’s case. In Jobes, however, the court found the evidence was not clear and convincing that Mrs. Jobes would want to die if faced with life in a persistent vegetative state. Nonetheless, the court allowed her family’s wishes to be carried out under the “substituted judgment” test.
New Jersey has perhaps the longest line of cases on this subject. In the Jobes opinion, the court briefly restated its rationale by tracing the relevant case law:
In summary, we state again that the fateful decision to withdraw life-supporting treatment is extremely personal. Accordingly a competent patient’s right to make that decision will outweigh any countervailing state interests. [In re Farrell, 108 N.J. 335, 354, 529 A.2d 404, 414.] An incompetent patient does not lose her right to refuse life-sustaining treatment. Where such a patient has clearly expressed her intentions about medical treatment, they will be respected. [In re] Peter, 108 N.J. at 378, 529 A.2d at 425.
529 A.2d 434, 451.
The court only then turned to the problem of a patient whose wishes are not clear, and restated the “substituted judgment” doctrine as developed in In re Quinlan, 70 N.J. 10, 355 A.2d 647 (1976). Significantly, the problem in Quinlan and Jobes is not before this Court because the trial court found by clear and convincing evidence that Nancy Cruzan would have chosen to have the feeding tube withdrawn had she been competent to choose. Judgment, supra.
Notwithstanding this distinction, the majority engages in criticism of the New Jersey Supreme Court: “In Quinlan, the New Jersey Supreme Court attempted to establish guidelines for decisions concerning the termination' of life support apparatus. More than ten years later, that same court wrote, ‘We recognize, ... that given the fundamental societal questions that must be resolved, the legislature is the proper branch of government to set guidelines in this area_’ In re Farrell, 529 A.2d at 407. Quinlan had failed to provide sufficient guidelines to meet the broad diversity of cases presenting termination of life-support issues.” The majority projects the impression that in In re Farrell the New Jersey Supreme Court found some inherent fault in their Quinlan decision. The New Jersey Supreme Court, however, recognized the legislature was the proper branch to set guidelines in this area, yet went on to hold “[nevertheless, patients and their families and physicians are increasingly being faced with these difficult and complex decisions without legislative guidelines and ... [u]ntil the Legislature acts, it is to the courts that the public must look for the guidelines and procedures under which life-sustaining medical treatment may be withdrawn or withheld.” In re Farrell at 408. The true lesson of the New Jersey cases is that more than ten years had elapsed since the Quinlan decision, yet an unresponsive legislature had failed to establish procedures and guidelines for the withholding or withdrawing of life sustaining medical treatment.
The only case cited by the majority in which a court did not allow the removal of life-sustaining medical treatment is Matter of Conroy, 98 N.J. 321, 486 A.2d 1209 (1985). It is distinguishable because the guardian ad litem opposed withdrawal of the feeding tube, and there was no evidence from which the court could draw an inference as to the patient’s intent, or general beliefs on the subject of life prolonging procedures.
Not mentioned by the majority is Gray v. Romeo, 697 F.Supp. 580 (D.R.I.1988). It is the most recent case on removal of a feeding tube and deals with all the issues presented in Nancy’s case. In Gray, as in Nancy’s case, the family was appointed guardian and a guardian ad litem was appointed. In Gray, as in Nancy’s case, the effect of removal of the feeding tube would bring about death. Marcia Gray, like Nancy, was in a persistent vegetative state. Marcia Gray, like Nancy had, while *439competent, voiced her wish not to have her life sustained by life support systems when there is no hope of recovery. Marcia Gray’s guardians, like Nancy’s guardians, felt it was in her best interest and that she would not want to have life sustained in a persistent vegetative state with no hope of recovery. Also, the health care personnel caring for Marcia Gray were adamant in their opposition to the proposal to remove nutrition and hydration.
The distinction between Marcia Gray’s case and the majority’s treatment of Nancy’s appeal is that the court in Gray, based on the above facts, followed the law and granted the request of the guardians to remove the feeding tube and thus allowed Marcia Gray to exercise her rights. The court stated the issue, “whether or not the state can insist that a person in a vegetative state incapable of intelligent sensation, whose condition is irreversible, may be required to submit to medical care under circumstances in which the patient prefers not to do so.” Gray at 584.
The logic and legal analysis of the Gray court follow:
First, the court resolved the issue whether there is a right to refuse life-sustaining medical' treatment. The court discussed the United States Supreme Court decisions relating to the issue and held,
“although the Supreme Court has never directly addressed the issue of a person’s federal constitutional right to refuse life-sustaining medical treatment, the Court’s decisions have repeatedly affirmed the principle of individual self-determination. A person has the right, subject to important state interests, to control fundamental medical decisions that affect his or her own body. This right, whether described as the principle of personal autonomy, the right of self-determination, or the right of privacy, is properly grounded in the liberties protected by the Fourteenth Amendment’s due process clause. This right is also grounded in the notion of an individual’s dignity and interest in bodily integrity.” Gray at 585.
The majority in dealing with the Supreme Court decisions on this subject cites Bowers v. Hardwick, 478 U.S. 186, 194, 106 S.Ct. 2841, 2846, 92 L.Ed.2d 140, reh’g. denied 478 U.S. 1039, 107 S.Ct. 29, 92 L.Ed.2d 779 (1986) for the proposition that the right to privacy does not go beyond the bounds of the right to procreate within the bonds of marriage. The Gray court held, “[decisions concerning medical treatment bear little connection to the claimed constitutional right to engage in homosexual acts, rejected in Bowers. Instead, the right to control fundamental medical decisions is an aspect of the right of self-determination and personal autonomy that is ‘deeply rooted in this Nation’s history and tradition.’ ” Gray at 586.
Second, the court resolved the issue “whether nutrition and hydration supplied through a gastrostomy tube are a form of medical treatment that Marcia Gray may properly refuse.” Gray at 586. Unlike the majority’s avoidance of this issue1 the Gray court looked to other case law “addressing this issue and concluded that analytically no difference exists between artificial feeding and other life support measures.” Gray at 586.
Although an emotional symbolism attaches itself to artificial feeding, there is no legal difference between a mechanical device that allows a person to breathe artificially and a mechanical device that artificially allows a person nourishment. If a person has the right to decline life on a respirator, then a person has the equal right to decline a gastrostomy tube. Accordingly, Marcia Gray’s right to refuse medical treatment includes the right to have the [gastrostomy tube] removed. Gray at 587 (citation omitted).
Third, the court resolved the issue whether Marcia Gray, an incompetent like Nancy, “still retains her right to decide whether the [gastrostomy tube] remains implanted or removed.” Gray at 587. Un*440like the majority, the court in Gray followed the prior case law and held “the right to refuse medical treatment ‘must extend to the case of an incompetent patient because the value of human dignity extends to both. Any other view would permit obliteration of an incompetent’s panoply of rights merely because the patient could no longer sense the violation of those rights.’ ” Gray at 587 (citations omitted).
The majority states, “A guardian’s power to exercise third party choice arises from the state’s authority, not the constitutional rights of the ward.” The majority further states “we ... find no statutory basis for the argument that the guardian possesses authority, as a guardian, to order the termination of medical treatment.” To the contrary, § 475.123.1, provides, “No medical or surgical procedure shall be performed on any ward unless consent is obtained from the guardian of his person.RSMo 475.123.1 (1986). As the court in Gray held:
The [gastrostomy tube] was initially inserted with the consent of Marcia Gray’s husband. No analytical difference exists between withholding and withdrawing medical treatment, however. A patient’s right to refuse medical treatment obviously includes both the right to refrain from beginning the treatment and the right to order it’s cessation. ‘Moreover, from a policy standpoint, it might well be unwise to forbid persons from discontinuing a treatment under circumstances in which the treatment could permissibly be withheld. Such a rule could discourage families and doctors from even attempting certain types of care and could thereby force them into hasty and premature decisions to allow a patient to die.’
Gray at 588 n. 4.
Last, the Gray court, following cited authority, balanced an incompetent’s right to self determination against the state’s interest in preserving life for all and held the incompetent’s rights prevailed. In contrast, the majority balanced these same interests in Nancy’s case yet declared, without authority, that the state’s interest prevailed. The majority has failed to recognize
[a] state’s interest in preservation of life is highest when the state seeks to protect an individual who may potentially be the subject of abuse because he or she cannot protect his or her own interests. That clearly is not the situation here; rather, a number of persons are attempting to ensure that [an incompetent’s] wishes are respected. In this situation [the incompetent’s] right to self-determination must prevail over the state’s interest in preserving life for all.
Gray at 589.
At the outset the majority asserts: “Because we find that the trial court erroneously declared the law, we reverse.” A reader of the ensuing opinion searches and waits in vain for citation of a single authority to support the majority’s bold assertion and its drastic action. Yet the majority itself recognizes that courts in at least 16 states have found a way to allow persons in the plight of Nancy Cruzan wishing to die to meet that end. As demonstrated in this dissenting opinion, the cases recognized in the majority’s footnote 4 uphold a right to refuse life sustaining medical treatment, either personally or through a guardian. Comparison of the majority’s opinion and this dissenting opinion reveals no disagreement on the “White Horse" case law available and applicable to resolution of the issues in this case. These authorities provide all the support necessary for the trial court’s declarations and applications of law under the facts of this case. Should not a reader ask the majority why it projects the irony of recognizing yet rejecting this abundance of dispositive case law in favor of its non-supported assertion of “erroneous declaration of law?” Is it because of its “public policy” bootstrapped from a statute that all parties in this case, the trial judge and the majority agree has no application in this case; or is it because the majority would have this Court abdicate its responsibilities to Nancy Cruzan under the Constitution and the common law and deny her rights in deference to some yet unspecified and unconsidered legisla*441tion2; or is it because of the majority’s unarticulated “concerns of medicine, ethics, morality, philosophy, theology and law”; or is it simply because the majority elects to ignore the facts and law of this case and “choose(s) to err” on the side of life of incompetent persons who may wish to live, a case not before the Court at this time? 3
In summation, respondents’ counsel observed: “The family came to the trial court after long and careful deliberation. Either way this Court decides, the Cruzan family does not win. The trial court found it was Nancy’s wish, clear wish, to be free from this unwanted medical treatment and we would request that this Court affirm that.”
In my opinion, the trial judge made a courageous voyage in an area not previously charted by Missouri courts, and the resulting judgment is supported unquestionably by both the evidence and the law. Nancy Cruzan and those Missourians who may be in her situation deserve the common law and constitutional rights that the trial court has accorded them. This Court should do no less and affirm that judgment.

. Addington v. Texas (1979) 441 U.S. 418, 99 S.Ct. 1804, 60 L.Ed.2d 323; Section 475.075.7, RSMo 1986.

. Section 459.015.1; Section 459.010(3); Section 459.055(l)-(5).

. Article I, Section 2; Article I, Section 10; Constitution of Missouri; Article XIV Amendments to the United States Constitution.

. Section 2, Article I Constitution of Missouri; Article XIV, Section 1. Amendments to the United States Constitution.

. "The issue is not whether the continued feeding and hydration of Nancy is medical treatment."

. "[Preference for legislative treatment cannot shackle the courts when legally protected interests are at stake. As people seek to vindicate their constitutional rights, the courts have no alternative but to respond. Legislative inaction cannot serve to close the doors of the courtrooms of this state to its citizens who assert cognizable constitutional rights." Satz v. Perlmutter, 379 So.2d 359, 360 (Fla.1980).

. "I suggest the trial court and this Court fulfill their constitutional and lawful duties when the law is followed and upheld — rather than conjuring up reversible error where none exists.” State v. Goree, — S.W.2d — No. 70112 (Mo. banc Nov. 15, 1988) (Billings, C.J., concurring).