Court Opinion

ID: 9579507
Source: CourtListenerOpinion
Date Created: 2023-08-21 21:55:48.77502+00
Date Added: 2024-06-11T13:35:33.937675
License: Public Domain

Levin, J.
(dissenting). Two issues are presented. The first is whether the trial court clearly erred in finding by clear and convincing evidence that before his injuries, Michael Martin expressed a medical "preference to decline life-sustaining medical treatment under the circumstances presented.”1
*235The second asks what showing, if any, justifies the withdrawal of life-sustaining medical treatment in the absence of clear and convincing evidence of such preinjury wishes.
1 dissent from the majority’s holdings on both issues. On the second issue, I do not agree with the majority that, on the facts of this case, life-sustaining medical treatment can only be removed with clear and convincing evidence of the patient’s expressed preinjury wishes. I would not reach the question what showing, other than clear and convincing evidence, would justify withdrawal of life-sustaining medical treatment, because the trial court did not clearly err in finding that clear and convincing evidence was presented that Michael Martin, before his injury, did not want to be kept alive in his current condition.
i
The Court of Appeals began by noting that a competent adult has a right to refuse life-sustaining medical treatment, and that an incompetent patient, while not losing this right, must have it exercised by a surrogate decisionmaker.2 The Court explained that if a patient has the capacity to decide whether to accept life-sustaining medical treatment, it is his decision to make. Before the choice can be made by anyone other than the patient, there must be clear and convincing evidence that the patient lacks this capacity and will not regain it in the future. If such evidence is shown, a decisionmaker should then ask whether there is clear and convincing evidence of the patient’s previously expressed desires regarding life support under the conditions in which the court *236finds the patient to be. If so, those desires must be effectuated.3 This is a purely subjective inquiry into the patient’s prior wishes.4
Up to this point, the majority and the Court of Appeals would apply a similar analysis.5 The majority does not dispute the trial and appellate courts’ conclusion that Michael Martin permanently lacks the capacity to exercise his right to have life-sustaining medical treatment removed.6 The majority disagrees with the finding that clear and convincing evidence has been presented of Michael Martin’s preinjury wishes.7
n
In ruling that clear and convincing evidence has not been presented, the majority becomes the first disinterested body to examine Michael Martin’s case without being convinced by the ample evidence of his prior wishes.
The bioethics committee of the hospital caring for Michael concluded that the request to remove life-sustaining medical treatment "was in accord with Mr. Martin’s wishes as expressed . . . prior to his injury.” The court-appointed guardian ad litem—whose role is to represent Michael’s best interests—also recommended the withdrawal of life support. The trial court and Court of Appeals *237agreed that Michael "clearly and convincingly reveal[ed] his expressed preference to decline life-sustaining medical treatment under the circumstances presented.”8
Evidence is "clear and convincing” when it
"produce[s] in the mind of the trier of fact a firm belief or conviction as to the truth of the allegations sought to be established, evidence so clear, direct and weighty and convincing as to enable [the factfinder] to come to a clear conviction, without hesitancy, of the truth of the precise facts in issue.”[9]
The probative value of a once-competent patient’s past statements about life-sustaining medical treatment varies, "depending on the[ir] remoteness, consistency, and thoughtfulness,” as well as their specificity and the maturity of the person making the statement.10
An appellate court may only reverse a trial court’s findings of fact if they are clearly erroneous.11 Instead of respecting the trial court’s role as factfinder, the majority has engaged in a de novo review of the facts. It ignores the admonition that in cases like this an appellate court "must also be cognizant of the profound responsibility which has been vested in the trial court and should not substitute its judgment for that of a trial court.”12
The evidence adduced at trial demonstrated Michael’s deeply felt, consistent, and long-term desire not to be maintained artificially in a helpless condition. Michael’s sister Patricia Major—one of *238the appellants seeking to keep him alive—testified that even as a teenager Michael told her seriously that he did not want to be maintained on a respirator while unconscious. He later told friends and co-workers that "if he ever was in a [sic] accident & was in a vegetable [sic] state, he hoped someone pulled the plug.”
The majority dismisses these statements because they referred to a persistent vegetative state, rather than Michael’s current condition.13 But the bioethics committee concluded that
the persistence of [Mr. Martin’s] condition and the level of functioning were equivalent to a persistent vegetative state for purposes-of considering the removal of nutrition support ....
While not vegetative, Michael has minimal cognition and essentially no ability to communicate. Additionally, as one physician testified, when laypersons express a desire not to be a "vegetable,” they usually are not referring strictly to a persistent vegetative state. Rather, the popular understanding involves a "spectrum of things, but the commonality of that is, independence of life . . . things in terms of basic needs of [the] human body,—bathing, eating and able to void.”
Moreover, Michael did not refer only to life as a "vegetable.” These statements must be viewed in combination with the testimony of Mary Martin. Mary testified about a series of conversations with Michael over a period of years, in which he expressed his desire not to be kept alive artificially if "he had to be dependent on people and machines . . . .” She testified that his concern was not with being unconscious, but with being dependent on others for the most basic bodily functions.
*239As the Court of Appeals stated:
Prevalent throughout Michael’s statements is the preference not to be maintained in a condition where he was incapable of performing basic functions such as walking, talking, dressing, bathing, or eating, and, instead, was dependent upon others or machines for his basic needs. This is exactly the condition in which Michael now finds himself.[14]
The conversations between Michael and Mary were not merely idle talk or emotional reactions to watching other persons suffer.15 Mary testified that the last conversation occurred as she was awaiting surgery for internal hemorrhaging. Michael and Mary each promised not to leave the other dependent on artificial life support, should such a tragedy occur. Mary’s affidavit reported that Michael told her on one occasion that if she left him dependent on machines, "I’ll always haunt you, Mary.”
Not even the two appellants seeking to keep Michael alive offer any basis for questioning the veracity of this testimony. Michael’s sister, Patricia Major, conceded she had no reason to doubt that these conversations had occurred.16 His mother, Leeta Martin, also testified that before the accident, Michael "would not have wanted to be helpless and dependent on others.”17
Other courts have found clear and convincing evidence of prior expressed wishes from similar or less compelling testimony than that in this case. *240See, e.g., In re Swan, 569 A2d 1202, 1205 (Me, 1990), affirming a finding of clear and convincing evidence of a prior expressed decision where a seventeen-year-old patient, after seeing or hearing of others receiving life-sustaining medical treatment, had twice expressed orally a desire not to be maintained artificially, Elbaum v Grace Plaza of Great Neck, 148 AD2d 244, 249-254; 544 NYS2d 840 (1989), ruling that oral statements to family members made over a period of years, most of which were in response to observing others receiving life-sustaining medical treatment, constituted clear and convincing evidence of the patient’s prior wishes.18
The majority insists that a person’s wishes are not clearly known unless the applicable medical conditions are accurately specified.19 In effect, this requirement will force most persons to seek legal assistance to assure that their wishes will be effectuated. By referring to being "dependent” or a "vegetable,” Michael was
"express[ing] [his] wishes in the only terms familiar to [him], and ... as clearly as a lay person should be asked to express them. To require more is unrealistic, and for all practical purposes, it precludes the right of patients to forego life-sustaining treatment.[20]
*241The majority also states that "[statements made in response to seeing or hearing about another’s prolonged death do not fulfill the clear and convincing standard.”21 This bright-line rule ignores that many persons only consider their own mortality seriously upon hearing about the end of other people’s lives. Admittedly, the emotional content of such statements must be carefully considered in weighing their probative value. But the majority’s "categorical exclusion of [this] relevant evidence dispenses with any semblance of accurate factfinding.”22
The majority’s treatment of the evidence in this case suggests that it would require a highly formal oral or written statement concerning the patient’s specific medical condition. To impose such rules would be unrealistic.23
*242Ill
Petitioner presented clear and convincing evidence of her husband’s prior wishes. As a result, I would not decide in this case whether the search for clear and convincing evidence of a patient’s previously expressed wishes needs to be followed by another subjective inquiry, an objective inquiry, or some amalgam of the two.
Although the trial court found that clear and convincing evidence had been presented, the Court of Appeals outlined additional steps for a decision-maker to take when such evidence is lacking. It stated that in such a case, the decisionmaker, should next apply a "substituted judgment” standard. This would require some trustworthy evidence of the patient’s preinjury wishes, even if less than clear and convincing evidence. In addition, if this evidence suggests the patient would want treatment withdrawn under the conditions that exist, the court must also decide that the burdens of prolonged life outweigh its benefits before allowing withdrawal.24
Finally, if there is no evidence at all of the patient’s prior wishes, the Court of Appeals stated that a pure best interests standard should be applied. This is also referred to as an "objective” test, because it seeks to determine a patient’s *243objective best interests rather than his subjective wishes.25 The Court of Appeals explained:
The logic of this sequential analysis is rooted in the fact that, as we progress from one step to the next, we are moving away from deferring to the wishes of the patient to the point where we allow others (fiduciaries, family members, ethics committees, and courts) to decide whether the patient will live or die without reference to the patient’s wishes. Our premise is that this should not be permitted except as a last resort, given society’s reverence for life and its acknowledgment that patients have an inherent right of self-determination. Nevertheless, we may not eliminate [the pure best interests approach] because to do so would be to hold that where the patient is incompetent, never expressed a preference, and the court cannot determine what the patient would do under existing circumstances, life support may never be withdrawn. That is not the current state of the law.[26]
This approach originated with the New Jersey Supreme Court decision in In re Conroy,27 and has been praised by commentators.28
iv
The majority would make Michigan one of a small minority of states to forbid termination of life support unless clear and convincing evidence is presented that the patient has expressly stated his wishes that it be removed under the specific *244conditions applicable.29 Courts have attached differing meanings to terms such as "clear and convincing”30 or "substituted judgment.”31 But most courts to address this issue have permitted termination of life-sustaining medical treatment on the basis of an objective test, or at least a more lenient subjective standard than the one required by the majority.32 These cases typically seek to respect the patient’s wishes whenever they can be determined without "foreclos[ing] the possibility of humane actions, which may involve termination of life-sustaining treatment, for persons who never *245clearly expressed their desires about life-sustaining treatment. . . ,”33
A
The majority first chooses to apply only a purely subjective inquiry in this case. It notes that "the evidentiary and decision-making standards appropriate in a given case do not depend on the source of the right;”34 yet its analysis rests on its choice of informed consent as the sole basis for the right to refuse life-sustaining medical treatment in this case. The majority rightly points out that the substituted judgment standard, and especially the best interests standard, "entail[] some level of objective analysis.”35 But this has not constrained other courts to look solely at the patient’s prior expressed wishes. Instead, courts have employed their parens patriae authority to allow surrogate decision making with both objective and subjective inquiries.36
But with little discussion, the majority declines to make use of its parens patriae power.37 The majority claims that cases adopting an approach with objective elements have generally involved patients in circumstances different than Michael Martin.38 The majority offers no convincing expla*246nation why Michael Martin’s condition must be treated differently.39
Implicit in the majority’s refusal to inquire into those benefits and burdens seems to be a judgment that the costs of not making that inquiry are less than for patients in other circumstances. The majority seems to assume that life in Michael Martin’s situation is somehow more tolerable for him. This suspicion is heightened by the majority’s suggestion that an objective inquiry into Michael Martin’s best interests would support maintaining him on life-sustaining medical treatment.40 This conclusion, however, is flatly contradicted by the court-appointed guardian ad litem, who concluded that removing life-sustaining medical treatment would be in Michael’s best interests.
B
After limiting the inquiry to the patient’s prior expressed wishes, the majority compounds its error by imposing a heightened standard of proof. The majority recognizes the principle that "a decision to refuse medical treatment in future situations, made while competent, is not lost because of incompetency or the inability to communicate.”41 Yet its "clear and convincing” burden of proof will have that effect in many cases, including this one.42
*247As one court has recently noted, the patient’s "right to self determination would not be protected, but rather, might well be negated” if life-sustaining medical treatment withdrawal were forbidden absent clear and convincing evidence of a patient’s prior expressed wishes addressed to the current condition.43 Under the majority’s approach, courts inevitably will reject trustworthy evidence concerning a patient’s prior wishes on the ground that it fails to meet the clear and convincing evidence standard. As one commentátor stated, "those few states that require a 'clear and convincing’ standard of evidence will likely fail to honor an incompetent patient’s desires.”44
V'
The majority characterizes its ruling as a cautious approach to a life-or-death decision.45 It suggests that " '[a]n erroneous decision not to terminate [life-sustaining medical treatment] results in a maintenance of the status quo’ ” and that such an error can be corrected in the future.46 But keeping Michael Martin alive is not the neutral, safe solution. As Justice Brennan stated in Cruzan,
from the point of view of the patient, an erroneous decision in either direction is irrevocable. An erroneous decision to terminate artificial nutrition and hydration, to be sure, will lead to . . . complete brain death. An erroneous decision not to terminate life support, however, robs a patient of the very qualities protected by the right to avoid unwanted medical treatment. His own degraded existence is perpetuated; his family’s suffering is pro*248tracted; the memory he leaves behind becomes more and more distorted.[47]
The majority’s tightly constricted inquiry greatly increases this risk. In this case, it has sentenced Michael Martin to life in a helpless, degraded condition against his prior wishes. To quote the majority’s own opinion, "to condemn persons to lives from which they cry out for release is nothing short of barbaric.”48

 In re Martin (After Remand), 205 Mich App 96, 99; 517 NW2d 749 (1994) (Martin II).

 In re Martin, 200 Mich App 703, 713; 504 NW2d 917 (1993) (Martin I).

 Id., p 713.

 Meisel, The Right to Die, § 9.10, p 270.

 As the majority notes, the requirement of clear and convincing evidence is not an entirely different standard. It is simply the burden of proof for the exercise of the substantive inquiries. Meisel, n 4 supra, 1994 cum supp, § 8.38, p 230. Some authorities, however, have used it as shorthand for a court’s refusal to allow removal of life-sustaining medical treatment absent clear and convincing evidence of a patient’s prior wishes. See, e.g., Beebe, The right to die: Who really makes the decision?, 96 Dick L R 649 (1992).

 Ante, p 217, n 10.

 Id., p 207.

 Martin II, n 1 supra, p 105.

 In re Jobes, 108 NJ 394, 407; 529 A2d 434 (1987); (quoting State v Hodge, 95 NJ 369, 376; 471 A2d 389 [1984]).

 In re Conroy, 98 NJ 321, 362; 486 A2d 1209 (1985).

 In re Cornet, 422 Mich 274, 277-278; 373 NW2d 536 (1985).

 In re Fiori, 438 Pa Super 610, 637; 652 A2d 1350 (1995).

 Ante, p 229.

 Martin II, n 1 supra, pp 103-104.

 Ante, pp 230-232.

 Id., pp 229-230.

 Leeta Martin argued that, if the court found Michael lacked the capacity to decide his own fate, his prior wishes should not control because "when the good Lord wants him, the good Lord will take him.”

 See also In re Guardianship of Browning, 568 So 2d 4, 17 (Fla, 1990). Browning had executed a written declaration providing that life-sustaining medical treatment should be withheld if she were terminally, irreversibly ill and her death were imminent. A stroke left her in a condition similar to Michael Martin’s in which she was dependent on artificial nutrition. Despite her ability to live indefinitely on the feeding tube, the court permitted withdrawal of life-sustaining medical treatment under the dictates of her directive.

 Ante, p 229, requiring that the prior statements describe "these exact circumstances, or circumstances highly similar” to the patient’s current condition.

 Cruzan v Director, Missouri Dep’t of Health, 497 US 261, 324; 110 S Ct 2841; 111 L Ed 2d 224 (1990) (Brennan, J., dissenting), quoting In *241re Westchester Co Medical Center, 72 NY2d 517, 551; 531 NE2d 607 (1988) (Simons, J., dissenting).

 Ante, p 228.

 Cruzan, n 20 supra, p 321 (Brennan, J., dissenting), criticizing the Missouri court’s refusal to consider such evidence. See also Conroy, n 10 supra, p 361, noting that prior statements of intent "might take the form of reactions that the patient voiced regarding medical treatment administered to others.”

 For various reasons, most persons neglect to formalize their wishes this way, even though they may feel strongly about them. Cruzan, n 20 supra, pp 323-324.
Appellants also argue that even if clear and convincing evidence exists of Michael’s preaccident wishes not to continue life-sustaining medical treatment in this situation, he has since changed his mind. They claim that he has shown “a present desire to accept treatment . . . .” The majority does not reject this contention. Ante, p 217, n 10. The evidence, however, demonstrates that Michael lacks the ability to understand or express a decision about ending his life.
The majority does not question the trial court’s ruling that "Michael does not have, nor will he regain, sufficient decision-making capacity with respect to a decision to withdraw life-sustaining medical treatment.” Martin II, n 1 supra, p 100. Several physicians testified at trial that Michael has only a very limited comprehension of his condition. Doctors testified that he lacks the capacity to "understand! ] the treatment choices, [ ]or the consequences of those.” One physician opined that Michael could comprehend a question phrased *242in terms of "does he want to live or die?” Another doctor disagreed, however.
Michael lacks the ability to communicate. The guardian ad litem testified that Michael "is unable to communicate on any meaningful level.” Appellants point to Michael’s head nods and constant smile as evidence of his desire to live. But the head nods given "in response” to questions are far too inconsistent to allow him to communicate with any effectiveness.
In light of Michael’s inability to express or even understand such a choice, appellants’ claim that he has changed his mind about life-sustaining medical treatment seems overly optimistic at best. Their well-intentioned hopes should not be allowed to override the wishes he clearly expressed while competent.

 Martin I, n 2 supra, p 712.

 Meisel, n 4 supra, § 9.16, p 278.

 Martin I, n 2 supra, p 713.

 Conroy, n 10 supra, pp 361-366.

 Meisel, n 4 supra, § 9.10, p 269.

 Only New York and Missouri courts have imposed such a rigid standard. In re Westchester, n 20 supra, pp 530-531; Cruzan v Harmon, 760 SW2d 408, 425 (Mo, 1988), aff’d Cruzan v Director, n 20 supra. See also DeGrella v Elston, stating:
In all but two states, Missouri and New York, even when the court has been unable to precisely determine the express wishes of the patient, it has allowed the patient’s family, or the patient’s guardian, to exercise substituted judgment as to what the patient would wish. [858 SW2d 698, 706 (Ky, 1993).]

 See n 5.

 The majority describes the "substituted judgment” standard as "entail[ing] some level of objective analysis” because it allows the decisionmaker to consider a broad range of factors, including the patient’s personal values and other behavior, to determine what the patient "would choose.” Ante, pp 219-221.
Some courts appear to have allowed the decisionmaker actually to substitute his own judgment for the wishes of the incompetent patient. See, e.g., In re Torres, 357 NW2d 332, 341 (Minn, 1984). But properly applied, the substituted judgment standard closely resembles a subjective inquiry with a burden of proof lower than "clear and convincing evidence.” It "attempt[s] to replicate what the patient would have decided if competent to do so.” Meisel, n 4 supra, § 9.10, p 270.

 Most courts have ruled that even where a patient has not expressly stated wishes regarding life-sustaining medical treatment, a substituted judgment standard is used to determine "what decision the patient would make if he were competent to do so.” In re Longeway Estate, 133 Ill 2d 33, 49; 549 NE2d 292 (1989). See also Guardianship of Doe, 411 Mass 512, 517-518; 583 NE2d 1263 (1992); Browning, n 18 supra, p 13. A smaller number of courts have employed a pure objective "best interests” standard. See, e.g., Conroy, n 10 supra; Rasmussen v Fleming, 154 Ariz 207, 221-222; 741 P2d 674 (1987).

 Conroy, n 10 supra, p 364.

 Ante, p 216. See also Meisel, n 4 supra, § 3.4, p 50.

 Ante, p 220.

 See, e.g., Longeway, n 32 supra, pp 52-53; Conroy, n 10 supra, p 364.

 It states simply that "we find nothing that prevents the state from grounding any objective analysis on a threshold requirement of pain, terminal illness, foreseeable death, a persistent vegetative state, or affliction of a similar genre.” Ante, pp 222-223.

 Id. The majority, however, fails to cite any factually similar cases in which courts have refused to go beyond the subjective inquiry. In Browning, n 18 supra, p 13, the Florida Supreme Court espoused a substituted judgment standard where the patient was in a condition *246similar to Michael Martin’s and had executed a prior directive that only arguably addressed her current condition.

 For example, the majority notes that courts have used objective inquiries where a patient was never competent. Ante, p 223. But as one commentator notes, "decisionmaking for never-competent patients is merely a variant of the larger problem of decisionmaking for patients whose preferences are unknown and unknowable.” Meisel, n 4 supra, § 9.14, p 275.

 Ante, p 223, n 16.

 Ante, p 217.

 The majority tries to limit its ruling to the facts of this emotionally difficult case. See, e.g., id., p 223, n 15. But trial courts and the *247Court of Appeals will follow this Court’s lead in other cases involving very different facts.

 Fiori, n 12 supra, p 623.

 See Beebe, n 5 supra, p 665.

 Ante, pp 224-225.

 Id., p 226.

 Cruzan v Director, n 20 supra, p 320 (Brennan, J., dissenting).

 Ante, p 208.