Court Opinion

ID: 9715773
Source: CourtListenerOpinion
Date Created: 2023-08-26 06:13:57.686915+00
Date Added: 2024-06-11T18:23:38.056512
License: Public Domain

Smith, J.,

concurring in part and dissenting in part.

I fully agree with much of what Chief Judge Murphy has said in his excellent opinion for the majority. I disagree with the final result, however. I believe this record is sufficient for a court of equity, a court of conscience if you will, to grant the relief prayed.
There are a number of things which should be borne in mind in this case. First of all, the trial judge here was sitting as a chancellor in equity. As E. Miller, Equity Procedure § 1, *706at 1 (1897), puts it, "The chancery court of England has always been considered as the prototype of that of Maryland ....” Equity originated in England to avoid the harsh rules of the common law. A distinguished Maryland jurist and teacher of the last century, C. Phelps, comments in Juridical Equity 213 (1894), "Equity . . . recognizes new adjustments for new situations, not upon a dogmatic basis, but upon principles which address themselves to the conscience and intelligence, and therefore admit of a rational and progressive development.” Similarly, 27 Am. Jur. 2d Equity § 2, at 518 (1966), states, "It has been said that one of the most salutary principles of chancery jurisprudence is that, strictly speaking, it has no immutable rules. It lights its own pathway, blazes its own trail, paves its own highway; it is, in short, an appeal to the conscience of the court.” Then we find in 30 C.J.S. Equity § 1, at 780 (1965), that "a court of equity is a court of conscience .. . .”
Secondly, we need to remember as the majority opinion states, that we know that this young woman cannot exercise what some call "the fundamental right to bear and beget children” with any degree of understanding. This is so because her brain injury is irreversible; the psychiatrist in his testimony estimated that her IQ is "[t]wenty-five to thirty,” and said that given this IQ she would be comparable to an individual "of around the age of one or two, one and a half to two.” We know full well that a two year old would not understand the act of copulation. Thus, logic indicates that if she becomes pregnant it will not be the result of any. conscious decision on her part, but will be the consequence of some illegitimate act.
Thirdly, it was the difficulties connected with menstruation, not the problems arising from pregnancy, which apparently have motivated the aunt in her request for the operation. This is what she dwelt upon in her testimony on direct examination. (The aunt and the grandmother were the petitioners for guardianship. On the day of the hearing the grandmother was hospitalized.) The record states:
"Q Now, in living in the home in the last three *707years I would assume you had the observation — opportunity to observe Sonya before the menstrual cycle began and when it began, during and after; can you characterize her attitude for us prior to, during and after the menstrual cycle?
"A Well, as I stated before, Sonya is ill a lot but during that time it caused confusion for her. She appeared disoriented and uncomfortable.
"Sonya cannot communicate where her discomforts are and the family has to more or less determine what’s wrong with her when she seems to be ill or uncomfortable.
"We have to determine what is hurting her. It could be her head, and yet we would think it might have been her stomach that is hurting. She can’t — I suppose she doesn’t know where pain comes from. She feels uncomfortable, but she cannot communicate where the pain is coming from.”
One would not expect more from a person of Sonya’s mental age. The only time on direct examination of the aunt that pregnancy was even mentioned was this single question and answer:
"Q Do you think Sonya could care for a child if she were to conceive and have a child?
"A Not at all.”
Fourthly, the psychiatrist made it abundantly clear that the principal reason for this proposed "subtotal hysterectomy” was not the fear of pregnancy.1 Aside from *708that which we have quoted in n.l, no other reference to pregnancy was made on direct examination of the psychiatrist. Rather, the matter of pregnancy was a theory that Sonya’s court-appointed counsel developed on cross-examination. The record reflects on direct examination:
"Q Within a reasonable degree of medical certainty, do you have an opinion of whether or not this hysterectomy would be in the child’s best interest?
"A I believe it would be.
"Q Can you support it for any reason, sir?
"A Well, when Sonya has her period, which you must know I have not observed, it is strictly the history, and in psychiatry we have to rely on the history of those who are around, the description that I have is that she — .... When she has her period, she doesn’t come downstairs. She wants to stay in bed much of the day, and she can’t go to school.
"She whimpers, and she gets cross. She hollers to quote Mrs. Wentzel. She doesn’t wear her napkin. She may get up to go to the bathroom, and she takes her napkin off, and doesn’t quite understand what it’s all about.
"She has pain that she cannot really tell us about or tell her parents about anytime. It’s always been a problem when she’s febrific or ill that she has not *709been able to indicate where she’s having difficulty except through careful questioning and a woman’s intuition to understand.
"In view of the fact that she’s unable to communicate these matters it makes it difficult for those who are caring for her to understand always what is happening because she does not have the capacity to speak her mind when something is wrong, and in view of the fact that she is not able to give an indication when she is ill as to what the matter might be, and in view of the fact that she has such a great deal of discomfort with her periods it would seem to me reasonable to recommend this from a medical point of view.
"The emotional stirs inside of her and she doesn’t understand it, to me that is sufficient reason to recommend this.”
The record on cross-examination states:
"Q Isn’t it the truth that the principal reason why the family desires the hysterectomy is because they feel that Sonya Star Flanary is incapable of caring for a child; isn’t that correct?
"A No, sir. That’s not correct.
"Q You didn’t tell me that?
"A No.
"Q Doctor —
"A There is a problem there.
"Q Well, let’s hear the problem. The Court would like to know.
"A Well, you seem to have the problem, not I, about that.
"Q Isn’t it a fact, Doctor, that the reality of the situation and the tragedy of the situation is that Sonya is in a situation daily going to school and so forth that she could have an unwanted pregnancy; isn’t that correct?
*710"A That’s true. She could become pregnant, no doubt about that. There is no doubt that the parents are concerned about that possibility. I did not say that was the principal reason, okay. I said it’s multidetermined. Naturally. Of course. All right.
"Q And if Sonya had a child and you told me that she was perfectly capable from what you can understand of having a child and a normal child?
"A That’s correct.
"Q Because her disability is traumatically induced; if she had a child obviously she cannot take care of that child at all?
"A That’s correct.
"Q Then the burden and the decision would be, one, to abort or if to have the child this would be an added burden on the Wentzel/Flanary family, would it not?
"A That’s correct.
"Q And the Wentzel/Flanary family, Wentzel being the grandmother and Flanary being the mother, is very concerned about this fact, are they not, about the unwanted child?
"A They voiced concerns to me about the possibility, right. I think the reasons are obvious when you see her that she is rather an attractive girl even though she has limitations with the left side of her hemiparesis, the concern of the family is not so much at the present time but later on when Mrs. Wentzel is no longer able to care for her because of her age and so forth. I think that’s another subject concerning guardianship — I don’t care to be concerned, but when she is being treated by other people or taken care of by other people that’s a reasonable question. It is not the principal one.
"Q You think that the —
"A I don’t know that there is a principal one. I *711think that is a concern of theirs, but they also wish to see her free of a lot of discomfort and pain.
"Q But the freedom from discomfort and pain does not make this surgical procedure medically necessary, does it?
"A Not in itself.
"Q Well, is there anything life threatening about her having a child?
"A No, there is not a life threatening issue there.
"Q It just becomes medically more convenient to have the subtotal hysterectomy; is that correct, Doctor?
"A It is convenient in the sense that she would not have the discomfort and the emotional turmoil thereby surrounding it and other aspects of this are quite obvious in terms of her hygienic care and so on.
"Q Am I correct in characterizing this subtotal hysterectomy as an operation of convenience? Rather than an operation of necessity?
"A Well, it’s a matter of what one means by that.
"Q Well, then let’s break down necessity. Necessity means something you cannot do without, isn’t that true?
"A That’s true. If we take it in the strictest sense of the word, that’s true.
"Q Is this an operation that is necessitous in that respect?
"A No.
"Q Then it is then more an operation of convenience, am I correct, Doctor?
"A In that "medical sense” yes. Can we take into consideration emotions. Is that all right? We couldn’t say this is necessary. She’s not going to go *712crazy emotionally if she doesn’t have a hysterectomy, but from an emotional point of view we can’t compare her to other women with average intelligence and who can understand things and who can speak and walk and talk.”
One could hardly expect to achieve toilet training of a child by the time he or she reaches the mental age of this young woman. It thus becomes obvious that she cannot be expected to understand the difficulties and the bodily functions associated with menstruation.
Much of what the Supreme Court of New Jersey said in In re Grady, 85 N.J. 235, 426 A.2d 467 (1981), merits repeating here. The young woman there involved was 19 years old and "seriously afflicted with Down’s Syndrome.” She was then about to leave her special class in the public school system. Her parents feared they would predecease their daughter and that she would be unable to live independently. For that reason they sought to obtain for her a life less dependent on her family. They wished to place her in a sheltered work group and eventually in a group home for retarded adults. The court said that the parents saw "dependable and continuous contraception as a prerequisite to any such change in their daughter’s environment.” 85 N.J. at 242. The court further stated that it "believe[d] that an individual’s constitutional right of privacy included[d] the right to undergo sterilization voluntarily.” Id. at 247. It pointed out that "[a] right to sterilization has yet to receive express constitutional protection from the United States Supreme Court,” but said that this right "also derives from the rationale of [the New Jersey court’s] decision in In re Quinlan, [70 N.J. 10, 355 A.2d 647, cert. denied, 429 U.S. 922 (1976)].” 85 N.J. at 248-49. The court summarized its holding in Quinlan:
"There we held that a person has a constitutional right to discontinue use of artificial life-sustaining apparatus when the prognosis for returning to cognitive or sapient life is dim. Our holding grew out of a belief that, under some circumstances, an *713individual’s personal right to control her own body and life overrides the state’s general interest in preserving life. A decision to be sterilized is also a part of an individual’s personal right to control her own body and life. The state’s interest in procreation cannot be greater than its interest in preserving life. If one can decide to forgo artificial life-preservation and thereby sacrifice life, then one can certainly decide to forgo reproductive capacity and thereby relinquish the ability to procreate. Therefore, the right to be sterilized is included in the privacy rights protected by the federal Constitution.” 85 N.J. at 249.
The New Jersey court discussed what it called "the right of meaningful choice,” stating:
"Having recognized that both a right to be sterilized and a right to procreate exist, we face the problem, as in Quinlan, that Lee Ann Grady is not competent to exercise either of her constitutional rights. What is at stake is not simply a right to obtain contraception or to attempt procreation. Implicit in both these complementary liberties is the right to make a meaningful choice between them. Yet because of her severe mental impairment, Lee Ann does not have the ability to make a choice between sterilization and procreation, or between sterilization and other methods of contraception — a choice which she would presumably make in her 'best interests’ had she such ability. But her inability should not result in the forfeit of this constitutional interest or of the effective protection of her 'best interests.’ If the decision whether or not to procreate is 'a valuable incident of her right of privacy, as we believe it to be, then it should not be discarded solely on the basis that her condition prevents her conscious exercise of the choice.’ Quinlan, supra, at 41. To preserve that right and the benefits that a meaningful decision *714would bring to her life, it may be necessary to assert it on her behalf.
"... [W]e believe that an appropriate court must make the final determination whether consent to sterilization should be given on behalf of an incompetent individual. It must be the court’s judgment, and not just the parents’ good faith decision, that substitutes for the incompetent’s consent.” 85 N.J. at 250-51.
The court further said:
"Our decision thus far leads to the following conclusions. The right to choose among procreation, sterilization and other methods of contraception is an important privacy right of all individuals. Our courts must preserve that right. Where an incompetent person lacks the mental capacity to make that choice, a court should ensure the exercise of that right on behalf of the incompetent in a manner that reflects his or her best interests.” Id. at 252.
It found that "[t]he inherent parens patriae jurisdiction of [the New Jersey] Chancery Division is broad enough to encompass the decision whether consent for sterilization should be given by a court on behalf of a person who lacks the capacity to give or withhold consent for himself.” Id. at 259. The rules laid down by the New Jersey Supreme Court to determine whether a sterilization should be permitted are quite similar to those in the majority opinion.
On the issue of authority of a court to sanction the surgical procedure here contemplated, see also in the Matter of Mary Moe, 385 Mass. 555, 432 N.E.2d 712 (1982). After finding that the lower court possessed this authority, the Massachusetts court observed:
"We are aware of the difficulties of utilizing the substituted judgment doctrine in a case where the incompetent has been mentally retarded since birth. The inability, however, of an incompetent to choose, should not result in a loss of the person’s *715constitutional interests. In the Matter of A. W., [637 P.2d 366,] 375 [(Colo. 1981)]. To speak solely in terms of the 'best interests’ of the ward, or of the State’s interest, is to obscure the fundamental issue: Is the State to impose a solution on an incompetent based on external criteria, or is it to seek to protect and implement the individual’s personal rights and integrity? We reject the former possibility. Each approach has its own difficulties, but the use of the doctrine of substituted judgment promotes best the interests of the individual, no matter how difficult the task involved may be. We admit that in this case we are unable to draw upon prior stated preferences the individual may have expressed. An expression of intent by an incompetent person while competent, however, is not essential. In the Matter of Spring, [380 Mass. 629, 405 N.E.2d 115, 122 (1980)]. 'While it may thus be necessary to rely to a greater degree on objective criteria . . . the effort to bring the substituted judgment into step with the values and desires of the affected individual must not, and need not, be abandoned.’ [Superintendent of Belchertown State School v.] Saikewicz, [373 Mass. 728,] 751 [, 370 N.E.2d 417 (1977)]. Cf. In the Matter of Storar, 52 N.Y.2d 363, 380 (1981) (unrealistic to attempt substituted judgment where person incompetent since birth). The courts thus must endeavor, as accurately as possible, to determine the wants and needs of this ward as they relate to the sterilization procedure. See Saikewicz, supra at 750 n.15.”. 432 N.E.2d at 720.
I also find relevant the court’s comment in In re Weberlist, 79 Misc. 2d 753, 360 N.Y.S.2d 783 (1974). There an individual with an IQ of approximately twenty apparently had been abandoned by his parents. He was then about 22 years of age and a resident of Manhattan Developmental Services. Certain treatments were proposed for him which included "dental work and hand surgery, surgery for the cleft palate *716and jaw, and intracranial surgery for facial restoration.” 360 N.Y.S.2d at 785. The court grounded its decision on the parens patriae doctrine and, recognizing its responsibilities, stated:
"The Court is faced with the possibility that the ward may simply serve as an object for experimentation. Organized concern with the threat of human experimentation can be dated back to the so-called Nuremberg Code of 1946. (See, e.g. Symposium on Ethical Aspects of Experimentation with Human Subjects, 98 Daedalus 219, et seq. [1969]; Freund, Ethical Problems in Human Experimentation, 273 New Engl.J.Med. 687 [1967]; Curran & Beecher, Experimentation in Children, 10 J.A.M.A. 77 [1969]; Lasagna, Special Subjects in Human Experimentation, 98 Daedalus, 449 [1969]; Note, Experimentation on Human Beings, 20 Stan.L.Rev. 99 [1967]; Rules and Regulations of the U.S. Dept, of Health, Education and Welfare in the Protection of Human Subjects, effective July 1, 1974). It may well be that: 'Human experimentation has been a part of medical science since it gained the title of "science” some centuries ago. There are still physicians who insist that all medical treatment is still experimental.’ (Curran and Shapiro, Law, Medicine and Forensic Science [Second Edition, 1970] p. 887) but the critical factor in this case is its beneficial potential for Eugene Weberlist.” 360 N.Y.S.2d at 787 (brackets in original).
The court concluded:
"In this case, the Court must decide what its ward would choose, if he were in a position to make a sound judgment. Certainly, he would pick the chance for a fuller participation in life rather than a rejection of his potential as a more fully endowed human being. The Court does not know what the future holds in store for its unfortunate ward — *717whether the treatment will be successful. But the most humble of us is entitled to the promise of the Declaration of Independence for 'Life, Liberty and the pursuit of Happiness’. We owe the respondent that opportunity and accordingly, the Court authorizes the proposed medical intervention.” 360 N.Y.S.2d at 787.
Do my colleagues doubt for one instant what Sonya’s choice would be under the circumstances here if she "were in a position to make a sound judgment”? I am certain she would give her assent. From the testimony of the aunt and the psychiatrist which we have set forth, one can see how Sonya is completely unable to cope with menstruation. Furthermore, it would be a terrible thing for this young lady to become pregnant. Imagine what it would be like for a person with a mental age comparable to that of a one and half to a two year old child to be pregnant. She would not have the mentality to understand that which was taking place, just as she does not understand relative to menstruation and her hygienic care. The process of childbirth undoubtedly would be a terrifying one for her.
This case cries out to the conscience of an equity court for relief. This young woman, her mother, her aunt, and her grandmother are all suffering as a result of the accidental injuries inflicted upon the girl a number of years ago. They are all entitled, as the New York court put it in In re Weberlist, "to the promise of the Declaration of Independence for 'Life, Liberty and the pursuit of Happiness.’ ” Most of the members of this Court are parents. Each of us certainly has some conception of what may be expected from a child of the mental age of this young lady. No one questions the brain injury, the irreversible nature of the injury, and the mental age of the court’s ward. All agree as to the accuracy of this statement. Indeed, the majority says, "We think the trial judge properly concluded that Sonya lacked the mental capacity to herself consent to the operation.” Therefore, I am of the view that the testimony here of the aunt and the psychiatrist relative to the problems con*718cerning menstruation make out a case by clear and convincing evidence that it is in this young lady’s best interests that the surgical procedures which the psychiatrist advocates be performed. Although the problems which would be associated with her becoming pregnant are strong and compelling reasons for authorizing the procedure, these problems are merely additional reasons for granting the requested relief.
I would reverse and direct that a decree be entered authorizing the subtotal hysterectomy.

. He explained the nature of a subtotal hysterectomy:
"Q Could you characterize from a medical standpoint how this hysterectomy would benefit the child?
"A Well, a subtotal hysterectomy would be a hysterectomy in which her uterus would be removed, her ovaries would not be, she will not thereby be castrated.
"She would have ovarian function. She would ovulate regularly. She would not have menses, and she would not have the problems that youngsters her age or women would have, menstrual cramps, premenstrual tension, difficulties of that kind because she does not *708understand what is going on and has this kind of difficulty and does not comprehend all of this. It would seem that she would be happier without having all of that.
"Q Could you repeat, once again, the label that you gave to this operation?
"A It would be a subtotal hysterectomy.
"Q Subtotal hysterectomy?
"A Yes. '
"Q Would you give us your opinion of what effect a subtotal hysterectomy would have on her capability to bear children?
"A She would not be able to bear children period.”