Court Opinion

ID: 9748502
Source: CourtListenerOpinion
Date Created: 2023-08-27 16:03:48.647894+00
Date Added: 2024-06-11T07:25:36.320491
License: Public Domain

Justice WINTERSHEIMER,
dissenting.
I must respectfully and completely dissent from the majority opinion. It is deeply disappointing that this Court would decide to allow an agency of this State to end the life of a totally innocent ward of that very same State. It is even more shameful to realize that the State would seek to terminate the innocent human life of a person entrusted to its care and protection. Equally disturbing is the role of the hospital and the ethics committee charged with the care and comfort of the patient in actively participating in this deplorable situation.
The lengthy majority opinion is fatally flawed in that it recites incomplete facts, misinterprets previous cases, and seeks moral justification from outdated sources. It requires a detailed and comprehensive response.
The major concern here is whether the Kentucky Living Will Directive Act, KRS 311.621 to KRS 311.643, is applicable and allows the Commonwealth of Kentucky, as a guardian, to authorize the withdrawal of life-sustaining medical treatment from a lifelong incompetent ward of the State.
This case involves the decision to end the life of a person, a ward of this state with mild to moderate mental retardation, although he committed no crime and did not seek this judgment from the court. It is estimated that there are more than 2500 people in Kentucky who have state guardians. Some have mental retardation and others have mental illness. Such individuals are particularly helpless and vulnerable and thus deprived of the opportunity to make choices for themselves. Cei1;ainly, it *52is generally understood that there is a necessity to protect individuals with substantial mental disabilities from the adverse consequences of potentially unwise, ill-informed or incompetently made decisions. See James W. Ellis, Decisions by and for People with Mental Retardation: Balancing Considerations of Automomy and Protection, 37 Villanova L.Rev. 1779 (1992). This includes a person’s inalienable right to life as articulated in the United States Declaration of Independence and guaranteed by the Kentucky Constitution § 1, as set out in DeGrella v. Elston, Ky., 858 S.W.2d 698 (1993). Kentucky law requires that guardians assure that the personal, civil and human rights of the ward are protected. KRS Chapter 387 and De-Grella, supra, should govern the decision of a guardian to withdraw or withhold treatment under KRS 311.629 and KRS 311.631.
Woods was a 54 year old, mildly retarded man, who had been a ward of the state since he was 18 years old. The evidence indicates that he had an I.Q. of 71 and the intellectual capacity of an 8 to 10 year old child.
Woods apparently lived a full life in a family care home. It is entirely likely that he had Mends in the home and knew professionals who worked with him fairly well. He had a girlMend. He went to an adult day treatment program three days a week. He attended church and was comfortable traveling across town by bus to visit his Mends. His guardian provided him with limited medical and financial decision-making assistance and Woods was capable of taking care of his personal needs. He had always been very friendly and frequently greeted total strangers with enthusiasm and exuberance. He was outgoing, polite, liked to dress up and occasionally smoked a cigarette. In 1995, while en route to the University of Kentucky Medical Center for a routine asthma treatment, he suffered a serious heart attack.
In 1991, a district court jury found Woods partially disabled in managing his personal affairs and financial resources pursuant to KRS 387.500 et seq. Consequently, the district court appointed the Commonwealth as a limited guardian for Woods. The district court order deprived Woods of his right to dispose of property; to execute instruments; to enter into contracts; to determine living arrangements; to consent to medical procedures; to obtain an automobile driver’s license; and to manage his financial affairs. The Commonwealth, as limited guardian, had the responsibility and the authority to exercise such rights for Woods.
It should be clear that Woods was considered pursuant to appropriate civil action not to be of sound mind before he fell into an unconscious state and was placed on a mechanical ventilator. As noted by the Court of Appeals and the circuit court, Woods probably never had the capacity to decide whether he would have wanted life-supporting measures discontinued if he ever required such measures. He had not prepared any advance directive or living will, nor was he ever capable of doing so.
The circuit court should not have applied the Living Will Directive Act. As a Court of final review, we are not required to adopt the decisions of the trial court as to a matter of law, but must interpret the statutes according to the plain meaning of the act and in accordance with the legislative intent. Floyd County Bd. of Ed. v. Ratliff, Ky., 955 S.W.2d 921 (1997). It is clear from a plain reading of the Living Will Directive Act that the General Assembly did not intend that it would apply to someone like Matthew Woods because the Act only applies to adults who are at least 18 years old and of sound mind.
*53The Act focuses on two time periods: 1) Before the adult patient loses decisional capacity and 2) After the adult patient loses such capacity. The Act does not address the situation of a person who has been a life-long incompetent. Such a person could never have made an advance directive because he was never of sound mind prior to the time in which he lost his decisional capacity to make and communicate health care decisions.
The proper approach was set out in the statutes relating to guardianship and con-servatorship for disabled persons in Chapter 387 and as interpreted consistent with DeGrella. If such criteria had been used, the Commonwealth would have had no basis on which to request the removal of life-supporting treatment from the patient.
The principal issue in DeGrella was whether the trial court could lawfully approve the right of a legal guardian to authorize the termination of artificial nutrition and hydration of an incompetent person when that person, while competent, had expressed her wishes that life-supporting measures be discontinued. Although a majority of this Court upheld the decision to withdraw nutrition and hydration from DeGrella, the majority made it clear that it would not permit the withdrawal of life-support from an incompetent person where the wishes of that person were unknown. In fact, DeGrella established that the withdrawal of life-supporting measures violated the inalienable right to life of a patient if such withdrawal were not based on the clearly expressed wishes of the patient.
The clear and unambiguous language of the Act required an adult patient to be at least 18 years of age and of sound mind in regard to a civil matter. KRS 311.621(1).
Woods had previously been deprived of his right, among other things, to consent to medical procedures by the district court in 1991. The Living Will Directive Act provides that, “If an adult patient, who does not have decisional capacity, has not executed an advance directive or to the extent the advance directive does not address a decision that must be made, ... [certain specified individuals] shall be authorized to make health care decisions on behalf of the patient.” KRS 311.631(1).
II. Guardianship Statutes
There is always the possibility that this situation will arise again, and some guidance should be available to individuals and organizations that are confronted with this or a similar situation. It is respectfully suggested that the statutes relating to guardianship and conservatorship for disabled persons, Chapter 386 et. seq., should be invoked.
Pursuant to KRS 387.640, a limited guardian or guardian, has the general duty to carry out diligently and in good faith the specific duties and powers assigned by the Court and, in part, to assure that the personal, civil and human rights of the ward are protected. Although specific duties can be modified by court order, a limited guardian must follow KRS 387.660(2), (3) and (4) as follows:
(2) To make provision for the ward’s care, comfort, and maintenance and arrange for such educational, social, vocational, and rehabilitation services as are appropriate and as will assist the ward in the development of maximum self-reliance and independence.
(3) To give any necessary consent or approval to enable the ward to receive medical or other professional care, counsel, treatment or service, except that a guardian may not consent on behalf of a ward to an abortion, sterilization, psy-chosurgery, removal of a bodily organ, or amputation of a limb unless the pro-*54eedure is first approved by order of the court or is necessary, in an emergency situation, to preserve the life or prevent serious impairment of the physical health of the ward.
(4) To act with respect to the ward in a manner which limits the deprivation of civil rights and restricts his personal freedom only to the extent necessary to provide needed care and services to him.
These statutes do not mention the withdrawal of life-support systems. In DeGrella, this Court considered the guardianship statutes as remedial and not exclusive, stating that those statutes intend to provide services for incompetent persons, not only as specifically articulated, but also as reasonably inferable from the nature of the powers of the guardian.
The rationale of the court relied in large measure on Rasmussen by Mitchell v. Fleming, 154 Ariz. 207, 741 P.2d 674 (1987). This Court approved the statement in Rasmussen, supra, that the court will presume the patient wishes to continue to receive medical treatment and the party wishing to discontinue that treatment bears the burden to prove to the contrary. See DeGrella, 858 S.W.2d at 705. This Court considered the term “best interest” of the ward solely from the standpoint of the health and well being of the ward and synonymous with the decision the ward would have chosen if conscious and competent to do so. However, this Court made it clear when it stated, “We do not go to the. next step, as the Arizona court did in the Rasmussen case to decide that ‘best interest’ can extend to terminating life-sustaining medical treatment where the wishes of the ward are unknown.” Id.
Consequently, although the majority of the DeGrella court determined that the statutes related to guardianship and con-servatorship for disabled persons were remedial and intended to provide services for incompetent persons as reasonably infera-ble from the nature of the guardian’s power, the majority refused to allow a guardian to withdraw life support measures from an incompetent ward where the wishes of the ward were unknown. The DeGrella opinion recognized that the rights of self-determination and informed consent in obtaining and withholding medical treatment can be exercised by an incompetent through the process of surrogate decision-making so long as the wishes of the patient were known.
' Thus, under DeGrella and the guardianship statutes of this Commonwealth, the decision to withhold life support systems from Woods was improper. Such a decision could only have been made if his wishes were known, which they were not. As stated in DeGrella, “we do not approve permitting anyone to decide when another should die,on any basis other than clear and convincing evidence that the patient would chose to do so.” 858 S.W.2d at 702.
The DeGrella opinion states that- “as long as the case is confined to substitute decision-making by a surrogate in conformity with the patient’s previously expressed wishes, the case involves only the right to self-determination and not the quality of life. ” DeGrella, 858 S.W.2d at 702 (emphasis added). Our court noted that when the withdrawal of life support becomes solely another person’s decision about that patient’s quality of life, which reasonably would occur when the patient’s wishes are unknown, the patient’s inalienable right to life outweighs any consideration of the quality or value of the life involved.
Pursuant to KRS 387.640(1) and KRS 387.660(4), any decision favoring the removal of life support systems based solely on the quality of life is inherently invalid, particularly where as in this case, the *55views of the ward on the subject of life support are unknown. It is fundamental that guardians are charged with the protection of the civil and human rights of their wards.
There is significance in the fact that KRS 387.660(3) requires that in nonlife-threatening circumstances, court approval is necessary before a guardian may consent on the behalf of a ward to an abortion, sterilization, psychosurgery, removal of a bodily organ or amputation of a limb. It would appear by analogy that from such a requirement, the legislature intended to protect all wards from those guardians who did not have their “best interest” at heart. At a minimum, it would appear that a life-long incompetent ward should receive the same level of protection from harm. Therefore, it is logically inconceivable that a guardian would seek to end the life of his ward.
III. Court of Appeals Error
The Court of Appeals erred in determining that the 1994 amendments to KRS 311.621-311.643, the Kentucky Living Will Directive Act, superseded the guidelines of this Court in DeGrella. The statutes in question were not a legislative response to DeGrella, but rather a departure from any reasonable application of that case. Although there are significant factual differences, it is clear that the DeGrella majority contemplated the situation involving Woods and other individuals similarly situated. DeGrella gave clear direction to those who would be involved in future decisions involving the right to nutrition and hydration to the effect that the right to live should be respected and upheld in the absence of clear and convincing evidence as to what the individual would choose to do.
The opinion states in part:
At the point where the withdrawal of life-prolonging medical treatment becomes solely another person’s decision about the patient’s quality of life, the individual’s “inalienable right to life,” as so declared in the United States Declaration of Independence and protected by Section One (1) of our Kentucky Constitution, outweighs any consideration of the quality of the life, or the value of the life, at stake. Nothing in this Opinion should be construed as sanctioning or supporting euthanasia, or mercy killing. We do not approve permitting anyone to decide when another person should die on any basis other than clear and convincing evidence that the patient would choose to do so.
DeGrella, 858 S.W.2d at 702.
Here, there was no evidence presented as to the intent of Woods to his preference for the withdrawal of life-sustaining treatment. Every witness testified that they did not know his intentions and there was no record of his intentions. In DeGrella, the patient had made her medical desires known prior to becoming incompetent. Woods was never competent enough to make such a choice. He was entitled to the protection of the State or of his duly appointed guardian to protect his right to live. He was extremely vulnerable, unprotected against any termination of his medical treatment. Any deprivation of life is subject to strict scrutiny. Bowers v. Hardwick, 478 U.S. 186, 106 S.Ct. 2841, 92 L.Ed.2d 140 (1986) overruled on other grounds by Lawrence v. Texas, 539 U.S. 558, 123 S.Ct. 2472, 156 L.Ed.2d 508 (2003). Any state action in interfering with a fundamental right is subject to strict scrutiny. See City of Cleburne, Texas v. Cleburne Living Center, Inc., 473 U.S. 432, 105 S.Ct. 3249, 87 L.Ed.2d 313 (1985).
*56When the decision is between life and death, and the state is involved, the decision maker is limited to those options conforming to the constitutional preference for life over death. In civil matters, life must be chosen. Incompetent individuals retain a right to life pursuant to the Fourteenth Amendment to the United States Constitution and Sections One and Two of the Kentucky Constitution. Cf. DeGrella.
IV. Best Interest Test
The Court of Appeals erred when it adopted the “best interest” test announced in Rasmussen. The Court of Appeals was mistaken when it held that KRS 311.631 authorized a guardian to exercise, “substitute decision-making” for an incompetent person based on the best interest standard. Such a conclusion was considered and clearly explained in DeGrella to the effect that the best interests was to be viewed exclusively from the standpoint of the health and well-being of the ward and synonymous with the decision the ward would choose to make if conscious and competent to do so. As noted in DeGrella:
We do not go to the next step, as the Arizona court did in the Rasmussen case, to decide that “best interest” can extend to terminating life-sustaining medical treatment where the wishes of the ward are unknown.
858 S.W.2d at 705.
The Court of Appeals does not define what it means by “best interest” and thus opens the door to any subjective interpretation of such a standard. The majority of this Court recognized in DeGrella that using substituted judgment that incorporates a quality of life assessment creates a very dangerous situation which can involve the application of subjective values in determining a minimum that can be accepted as a quality life. The right to live is a natural and fundamental right. It arises automatically and not as a result of any personal surrogate or governmental choice.
In applying the strict scrutiny test, we find that the state can make no showing that its interests outweigh the private interests of the individual as guaranteed by the federal and state constitutions. The state, through its agents, must prove that a governmental interest in the nontreatment of a patient overrides the interest in life of the patient. Such a burden was not satisfied in this case and could not be satisfied in any case involving a ward of the state.
The State attempted to present evidence that providing life-sustaining measures to Woods denied him a “meaningful life,” was “inhumane,” “futile,” “not in his best interest,” and “abusive.” Such beliefs amount to a personal subjective judgment by state bureaucrats about the quality of life of the ward. The State should not be allowed to determine the quality of life question.
The public policy of Kentucky as expressed in Chapter 387 is to consider the wishes of the ward in the manner expressed by him and to involve the ward in decision-making to the greatest extent possible.
Decisions under KRS 311.629 and KRS 311.631 may be irreversible, but all such decisions should err on the side of caution, if at all. Here, although the trial judge found Woods to be “permanently unconscious” as defined by law, the guardian ad litem indicated that Woods began to improve dramatically the evening of the trial. There is some medical evidence that Woods was actually no longer in a persistent vegetative state but was recovering from anoxic encephalopathy.
The function of legal process, as that concept is embodied in the Constitution, and in the realm of factfinding, is to minimize the risk of erroneous decisions. *57Because of the broad spectrum of concerns to which the term must apply, flexibility is necessary to gear the process to the particular need; the quantum and quality of the process due in a particular situation depend on the need to serve the purpose of minimizing the risk of error.
Greenholtz v. Inmates of Nebraska Penal and Correctional Complex, 442 U.S. 1 at 13, 99 S.Ct. 2100, 60 L.Ed.2d 668 (1979).
Y. Errors in the Majority Standard
The lengthy analysis of the majority opinion seemingly ignores the relatively recent, dispositive and contrary holding of this Court in DeGrella. The majority opinion attempts to hoist itself into intellectual integrity and judicial consistency with DeGrella by asserting that “DeGrella did not require us to reach the ‘best interests’ analysis as the case could be decided on the basis of substituted judgment.”
Actually, intellectual honesty compels the recognition that DeGrella specifically rejected the “substituted judgment test” now embraced by this majority and improperly attributed to DeGrella. In fact, DeGrella made clear:
We do not approve permitting anyone to decide when another should die on any basis other than clear and convincing evidence that the patient would chose to do so ...
858 S.W.2d at 702. DeGrella also stated:
There is one prefatory issue which we must address before embarking on this discussion lest our words be misunderstood as the first step onto a slippery slope, or misapplied by trial courts in future cases: that is the quality of life issue. As long as the case is confined to substituted decision making by a surrogate in conformity with the patient’s previously expressed wishes, the case involves only the right of self-determination and not the quality of life.

Id.

The majority opinion ignores the fact that the district court order deprived Woods of the following rights: to dispose of property, to execute instruments, to enter into contractual relationships, to determine living arrangements, to consent to medical procedures, to obtain a motor vehicle operator’s license, and to manage his own financial affairs.
The majority attempts to persuade that Woods would nonetheless be within the purview of the Kentucky Living Will Act, citing a variety of inapplicable cases that hold that a person can make a testamentary will even if he does not have the requisite mental capacity to transact business, generally. The opinion ignores the crucial distinction between the jealous protection by the law of every testator’s right to dispose of his property as he sees fit on the one hand, and the necessity for the law to protect the sanctity of innocent human life on the other hand. “Life” issues are certainly not disposed of appropriately by cases dealing with “property” issues.
The legislative intent that the act should apply only to adults who are at least 18 years of age and who are of sound mind patently excludes such persons as Woods who had been a ward of the state since his 18th birthday, had a mental age of 8 or 9 years and had never been shown to be of sound mind or testamentary capacity. Even testamentary wills disposing of property cannot be made unless a person is 18 years of age and of sound mind, much less decisions regarding the furnishing of food and water and essential medical care.
A. “Permanently Unconscious” is a Fallacy
One of the most disturbing aspects of the majority opinion is the subtle reliance *58on the statutory term “Permanently Unconscious” as defined in KRS 311.621(12), supra, maj. op., at note 1. That term has medical meaning but the common import is senseless because it infers irreversibility to the unconscious state. The illogic of the import is that it implies a certainty that the person labeled such will never recover. In this sense, the only person permanently unconscious is one that is already dead. Using the label however, makes the person attempting to govern the life or death of another moderately more likely to assume that recovery is impossible and thereby order the death of another when the likelihood of consciousness is not adequately ascertainable or if the likelihood becomes difficult to predict.
Perhaps the most chilling aspect of this case is that the treating physicians had arrived at the conclusion that Woods had reached a state of permanent unconsciousness in order to recommend withdrawal of life support. Such a recommendation had been made on the belief that he was permanently unconscious, however, Woods had later shown a recovery strong enough to cause one doctor to retract his previous recommendation.
1. Medicinally-Induced Permanent Unconsciousness?
It is even more serious to realize that the lack of improvement in Woods’ condition may have been the result of his being medicated by a paralyzing drug. Ostensibly for the purpose of diminishing an occasional jerking motion, Woods had been placed on a medication designed to paralyze his movements. Such medication is at least likely to be the cause of “permanent unconsciousness”. In a motion to the court filed June 23, 1995, Dr. Suhl was noted to report that the administration of the paralyzing drug had been stopped on the date of the hearing. In addition to saying, “his myoclonus (twitching/spasms) improved,” he noted that, in the next couple days: it became apparent that Woods was able to open his eyes and look at him when he was awakened; Woods appeared to show pain when he was struck with an intravenous needle; and, through neurological analysis by Dr. Robertson, Woods was no longer in a Persistent Vegetative State. In other words, when the paralyzing drug had been stopped Woods’s condition improved.
Restarting the medication placed Woods back in a state of perceived unconsciousness. In a letter dated June 2, 1995, Dr. Robertson had re-evaluated Woods and drawn the conclusion that Woods’s recovery was temporary because the response to external stimuli had dropped. However, he also noted that the myoclonic jerks had diminished as “perhaps the result of medication”. Medication made for the purpose of paralyzing seems likely to produce a coma-like state. There was no indication in Dr. Robertson’s letter that the downward turn in Woods’s condition was not the exclusive result of medication.
Woods became awakened and showed signs of pain when. the paralyzing drug was removed. According to Webster’s New Collegiate Dictionary, Awake means “1: to cease sleeping 2: to become aroused or active again 3: to become conscious or aware or aware of something.” The only fair inference from evidence that he could be awakened is that Woods was no longer permanently unconscious. The majority opinion has a different interpretation of this evidence, but that’s a difference of opinion, not a matter of accuracy as it suggests. Therefore, it is unclear as to the extent to which the paralyzing drug administered to Woods had on contributing to his appearance of “permanent unconsciousness,” nor is it clear that the paralyzing drug did not hinder his recovery. Dr. Hurst, who treated Woods at St. *59Joseph Hospital, had ordered withdrawal of food, water, and ventilation because of certain seizures Woods experienced. It should be noted that the majority opinion cites part of the impassioned plea made by Dr. Hurst, “Frankly, I do not see much difference between what we are doing here and some of the atrocities that we read about in Bosnia”. The remarks by Dr. Hurst could be subject to various interpretations as he offered no further explanation. However, it can be reasonably inferred that the true atrocity is the termination of Woods’s life.
Because of the improvements and the potential for recovery, Dr. Suhl had retracted his earlier recommendation of withdrawing mechanical ventilation and specifically recommended “continuation of artificially provided nutrition and hydration and all care needed for his comfort and hygiene.” Such life-sustaining “treatments”, i.e. food, water, and air, are necessary for every person to live, including those who are conscious. Dr. Suhl still recommended a lesser standard for resuscitation, meaning no longer providing life-prolonging treatments such as resuscitation or surgeries. However, the key is that Dr. Suhl separated food, water, and air from other types of medical treatments.
Despite Dr. Suhl’s retraction and Woods’s potential recovery, the majority opinion conveniently ignores this evidence and asserts that the eleven members (including four physicians) of the hospital ethics committee unanimously agreed with the recommendation.
B. “Medical Treatments” is Too Broad and Without Distinction Would Give Prisoners More Rights Than a Sick Person.
Among the several types of care available, three categories are apparent: 1) basic hydration, nutrition, and ventilation; 2) medicine; and, 3) procedures. When we speak of withholding medical treatment from a ward, or any person, we must specify what we mean. Food, water, and ah’ are basic to life. Without any of these three things, any person, conscious or not, will die. Therefore, it can be said that every person is in a state of mors inter-ruptus (death interrupted) save for food, water, and air. Death is interrupted by the supply of these things. The interposition of latín, however, makes the term seem more frightening and therefore makes the decision to remove the medical treatments seem acceptable. The terms we are using to describe the trae actions are masking reality: removing food, water and air from a living person is an atrocity. Change the words to “removing life-prolonging treatment from a person who is permanently unconscious” and it all sounds nice and easy to swallow. Care must be taken then to prohibit the language of our standard from masking atrocity.
Many of the considerations on whether to withdraw food, water, and ventilation are made on poor judgments concerning the probability of the patient’s recovery from an unconscious state. Although at one time it looked unlikely that Woods could become conscious again and three doctors thought Woods should be taken from the ventilator and thereby die, he made a recovery once he was taken off of the paralyzing drag. Notwithstanding that Woods had been labeled “permanently unconscious,” Dr. Suhl reported that Woods did recover during a period of time concurrent with the removal of the paralyzing drug. Once the paralyzing drug was administered to him again, Woods went back into the coma-like conditions. Such recovery, had it been permitted to continue without intervention of the paralyzing drag, may have later included breathing without the machine ventilator.
*60An overbroad standard that by its loose language includes food, water, and air under the label of “medical treatment” will permit the withdrawal of these basic necessities by the guise of “removing life-prolonging medical treatment”. Nowhere else is the restriction of food, water, or air permitted by the State from a person under its care, including prisoners, which are to be furnished with food at least “sufficient to sustain normal health”. See Cunningham v. Jones, 667 F.2d 565 (6th Cir. (Ky.) 1982). Other necessities are required to be furnished as well. Starving, dehydrating, or suffocating a prisoner is therefore impermissible, as well as it ought to be for any other person under State care, including wards requiring medical treatment through prolonged care.
Allowing- substituted judgment or best interest standards to animate decisions regarding withdrawal of basic life necessities places the ward in a position worse than a prisoner. Regarding food, water, and air, the only standard is for the ward to demand their supply at all times because it is necessary to all life. Prisoners are not even able to make a choice to refuse to eat because the State will force-feed them to preserve their health. See, e.g., Martinez v. Turner, 977 F.2d 421 (8th Cir.1992) (rejecting constitutional challenge to decision by prison officials to force-feed an inmate on hunger strike). However, the majority opinion will allow a ward to be denied food.
Types of medical treatment beyond basic necessity, such as surgeries, medicine, and invasive procedures, should be treated differently than ordinary or basic care. The prison cases place these types of treatment under different balancing than provision of necessity. See, e.g., McCormick v. Stalder, 105 F.3d 1059 (5th Cir.1997) (due process did not prevent forced medical treatment of prisoner with tuberculosis because of danger to other prisoners); see also Washington v. Harper, 494 U.S. 210, 110 S.Ct. 1028, 108 L.Ed.2d 178 (1990) (due process did not prevent forced medication of mentally-ill prisoner to prevent harm to himself or others). Those cases use a balancing standard, but the hunger strike case did not because food, water, and air are a basic necessity. A prisoner has the ability to refuse some medical treatments, however. See Whitley v. Albers, 475 U.S. 312, 106 S.Ct. 1078, 89 L.Ed.2d 251 (1986) (prisoners may refuse some unwanted medical treatments as unnecessary and wanton infliction of pain in violation of the Eighth Amendment); see also Noble v. Schmitt, 87 F.3d 157 (6th Cir.1996).
The bottom line is that while a prisoner may refuse certain treatments, he or she cannot refuse, necessities of life and the State must provide those necessities, even forcibly if necessary.
In the case of a ward being medically treated and under the care of a guardian ad litem, the standard ought to be that food, water, and air or mechanical ventilation may never be removed — the State must provide them until death because these are life-sustaining necessities and not merely medical treatment. Using the standard proposed by the majority will reduce the rights of a sick innocent person to something less than we give prisoners.
C. Characterizations of Medical Care
The majority opinion seeks moral justification by citing outdated comments by Pope Pius XII (1939-1958) from an earlier time when the philosophy of death was not so prevalent. The recent pronouncements of Pope John Paul II built upon those of Pope Pius XII and are more in concert with traditional moral philosophy.
Specifically, the majority opinion fails to make a common distinction in care. The best interest standard, as presented by the *61majority opinion, can easily be abused in the future because it does not differentiate between ordinary care and extraordinary care. By failing to safeguard basic care as mandatory, the standard would allow the withdrawal of these items under a quality of life determination. Although it cites some moral sources, it fails to properly conform the best interest standard to the limited type of care for which it is meant to be applied. Moral commentators tend to divide medical care into two categories: ordinary and extraordinary care. See, e.g., Rev. Michael P. Orsi, Catholic Thinking on End of Life Decisions (Pauline Books & Media 2000). Ordinary care is the proportionate means of preserving life. Ordinary care includes basic care, which is the provision of food and water, whether by artificial means or naturally, hygiene, and comfort. Extraordinary care includes surgical procedures and other types of care not generally associated with basic life support. Ordinary care may never be withdrawn from a living person. See, e.g. Orsi, supra.
Extraordinary care is best suited to the standard adopted by the majority because it balances the many aspects of the decision, such as the proportionality of the care to the situation. A person needing extraordinary care may, when death is clearly imminent and inevitable, “refuse forms of treatment that would only secure a precarious and burdensome prolongation of life, so long as the normal care due to the sick person in similar cases is not interrupted”. Pope John Paul II, The Gospel of Life: Evangelium Vitae (1995), at para. 65, citing Congregation for the Doctrine of the Faith, Declaration on Euthanasia Iura et Bona (5 May 1980), at IV: AAS 72 (1980), at 551. However, and the crucial limitation in the cite is: so long as normal care due to the sick person is not interrupted. The distinction is clear, because of the limitation. Continuing, Evangelium Vitae states, “To forego extraordinary or disproportionate means is not the equivalent of suicide or euthanasia; it rather expresses acceptance of the human condition in the face of death.” Id. In other words, extraordinary care may be refused, but to refuse ordinary care is the equivalent of suicide or euthanasia. Therefore, the best interest standard contained in the majority should be limited to methods of extraordinary care. Safeguarding ordinary care as a basic right is the only standard consistent with the Kentucky law, as in DeGrella the powers of guardianship outlined above, or with the reading of the moral authorities cited by the majority.
Ordinary care is basic health care. Clearly delineating the provision of ordinary care from extraordinary care, earlier this year, Pope John Paul II stated in a Vatican Address, “I should like particularly to underline how the administration of water and food, even when provided by artificial means, always represents a natural means of preserving life, not a medical act.” Address of Pope John Paul II, To the Participants in the International Congress on “Life Sustaining Treatments and Vegetative State: Scientific Advances and Ethical Dillemas” at para. 5 (March 20, 2004) (emphasis in original). Like all other persons, the “sick person in a vegetative state, awaiting recovery or a natural end, still has the right to basic health care (nutrition, hydration, cleanliness, warmth, etc.), and to the prevention of complications related to the confinement in bed”. Id. Concurrently, and with Pope John Paul II, an International Congress of health care providers and ethicists convened whose purpose was to discuss life-sustaining treatments and the vegetative state. See www.vegetativestate.org (last visited August 5, 2004). That congress resulted in a joint statement that accords with all *62points of the Pope John Paul II address. However, the strongest point is the accord with the distinction made above between extraordinary and ordinary care. The papal address states:
The obligation to provide the “normal care due to the sick in such cases” (Congregation for the Doctrine of the Faith, lura et Bona, p. IV) includes, in fact, the use of nutrition and hydration (cf. Pontifical Council “Cor Unum”, Dans le Cadre, 2, 4, 4; Pontifical council for Pastoral Assistance to Health Care Workers, Charter of Health Care Workers, n. 120). The evaluation of probabilities, founded on waning hopes for recovery when the vegetative state is prolonged beyond a year, cannot ethically justify the cessation or interruption of minimal care for the patient, including nutrition and hydration. Death by starvation or dehydration is, in fact, the only possible outcome as a result of their withdrawal. In this sense it ends up becoming, if done knowingly and willingly, true and proper euthanasia by omission.
Pope John Paul II Address, supra, at para 4 (emphasis in original).
Finally, lest there be any confusion over the stance espoused on euthanasia, Evangelium Vitae, supra, at para 66, says,
The choice of euthanasia becomes more serious when it takes the form of a murder committed by others on a person who has in no way requested it and who has never consented to it. The height of arbitrariness and injustice is reached when certain people, such as physicians or legislators, arrogate to themselves the power to decide who ought to five and who ought to die. Once again we find ourselves before the temptation of Eden: to become like God who ‘knows good and evil’ (cf. Gen 3:5).
By adopting a standard that allows one person to determine to Mil another by omitting food and water from them, we are sanctioning murder. It is made worse through adopting the standard by citing references that clearly state that basic care may never be willingly and knowingly removed. Therefore, we ought not allow our standard to permit the State, through a guardian ad litem or otherwise, deprive a KentucMan of life.
The papal address also states that “it is not enough to reaffirm the general principle according to which the value of a man’s life cannot be made subordinate to any judgment of quality expressed by other men; it is necessary to promote the taking of positive actions as a stand against pressures to withdraw hydration and nutrition as a way to put an end to the lives of these patients.” Id. (emphasis added.)
The standard expressed in the majority opinion has failed to make an adequate distinction of ordinary care from extraordinary care.
The reference by the majority opinion that the afterlife is somehow better than impaired life is founded only on sincere religious faith. These religions generally assert that euthanasia and suicide are wrong because the end of life is in God’s hands, not man’s.
Not only does the majority ignore the above authorities, but also, it ignores the clear teaching of DeGrella against quality of life tests. Again, the “quality of life” ethic was rejected most recently in Grubbs v. Barbourville Family Health Center, P.S.C.:
The argument that there is a Mnd of “quality of life” ethic is without any merit. This Court has rejected the quality of life philosophy in DeGrella By and Through Parrent v. Elston, Ky., 858 S.W.2d 698 (1993), which recognized that an individual has an inalienable right to *63life as declared by the United States Declaration of Independence and protected by Section One of the Kentucky Constitution. Any quality of life ethic favors the life of the healthy over the infirm, the able-bodied over the disabled and the intelligent over the mentally challenged. If logically extended, it could produce a culture that condones the extermination of the weak by the strong or the more powerful.
The Nazi regime under Adolph Hitler is a not too distant reminder of this kind of eugenic approach. Unfortunately, such thoughts are not limited to foreign nations but can also be found in the writings of Justice Oliver Wendell Holmes in Buck v. Bell, 274 U.S. 200, 47 S.Ct. 584, 71 L.Ed. 1000 (1927), which approved of sterilization of the mentally incompetent. Taylor [v. Kurapati 236 Mich.App. 315, 600 N.W.2d 670 (1999)], calls to our attention the influence that Hitler’s experiments with sterilization had on the American eugenics movement. Eugenics espouses the reproduction of the fit over the unfit and discourages the birth of the unfit. Bowman, The Road to Eugenics, 3 U. Chic. L. Sch. Roundtable 491 (1996).
120 S.W.3d at 692 (Wintersheimer concurring).
In conclusion, the majority standard has been built by ignoring the distinctions well seated within the authorities it used. Ordinary care, even for persons reliant on the State for such care, may not be subjected to a substituted judgment standard because it is the person’s basic and fundamental right to receive such care. For these purposes, it fails to protect the basic rights of Kentuckians who rely on the State during these times when they are sick. Instead, the majority has opened the potential for atrocities similar to Bosnia where people relying on the State to speak on their behalf will be slowly killed by the removal of food and water. We have done so with the veneer of moral authority, but the core decision is full of error.
D. The Proposed Standard is Not Objective
The analysis of best interests by the majority opinion is logically contradictory by permitting “the surrogate to base the decision on an object of inquiry into the incompetent patient’s best interest.” There is no mention of standards or objective measurements of this so-called best interest test.
The philosophic and logical inconsistencies, and indeed the contradictory nature of the analysis, are immediately apparent by a simple reference to Webster’s Collegiate Dictionary. “Objective” is defined as “viewing events, phenomena, ideas, etc. as external and apart from self-consciousness.” “Objectivism” is defined as “stressing the objective reality, especially as distinguished from the purely subjective existence, of the phenomenal world, or the moral good or the like.”
“Subjective” is defined as “not determined by universal reason or the universal condition of human experience and knowledge.” “Subjectivism” is defined as “a theory which attaches great or supreme importance to the subjective elements in experience... the doctrine that individual feeling or apprehension is the ultimate criterion of what is the good and the right.”
The focus of the majority opinion upon “the incompetent patient’s best interests” is actually a subjective test. Simply calling it objective does not make it so.
The refusal of the majority opinion to recognize the dichotomy of the objective/subjective problem is further illustrated by the following: “We elaborate that in determining the best interests of the patient, ‘the quality of life’ is not considered *64from the subjective point of view of the surrogate, but is an objective inquiry into ‘the value that the continuation of life has for the patient.” ’
Once again, focusing on the subject and dealing with the ‘quality of life’ is obviously subjective. Calling it objective is of no avail.
YI. Conclusion
It has been said that no person or court can substitute its judgment as to what is an acceptable quality of life for another person. In re Westchester County Medical Center on Behalf of O’Connor, 72 N.Y.2d 517, 534 N.Y.S.2d 886, 531 N.E.2d 607 (1988).
There is no question that significant safeguards for incompetent wards should be required of any process by which this State might seek to terminate life sustaining medical treatment of incompetént wards of the state. Most of the cases in the field of the so-called “right to die” jurisprudence deal with situations where a competent person or a formerly competent person who has become incapacitated has expressed some thought or wish about how he or she wanted to be treated in such a situation.
Even DeGrella requires that at least a clear and convincing standard of proof is the necessary standard for determining whether a healthcare surrogate may authorize the withdrawal or withholding of nutrition and hydration and that the substantive standard of proof is substantial and specific.
The right to life is a natural right which inheres automatically and can be asserted by all human beings. It does not rise through the exercise of any personal surrogate or governmental choice. It is bestowed on man by his Creator (cf. Declaration of Independence). The strict scrutiny which is constitutionally required when a State seeks to terminate medical treatment for one of its wards is glaringly absent in KRS 311.631; the State and its agents must prove that a governmental interest in a patient’s nontreatment overrides the individual’s right to life. This burden was clearly not satisfied in the case of Matthew Woods and it could not be satisfied for any other similarly situated case involving a ward of the state.
KRS 311.631 establishes a potential abuse of patient’s rights because how can it be in the patient’s best interests to die? There is a great potential for serious conflict of interest for the State when it is paying the médical bill for the treatment of its ward. It is distressing to note that it was only 24 days after the heart attack of Woods that the Commonwealth filed in district court seeking approval to terminate medical treatment. The ward improved immediately after the trial to the point where his doctor rescinded his recommendation about discontinuing the ventilator. According to his physicians, Woods was never clinically brain dead, nor was he in any other legal sense, dead.
It was erroneous for the Court of Appeals to determine that KRS 311.631 authorized a guardian to exercise “substituted decision-making” for an incompetent person based on a subjective best interests test. It was error for the Court of Appeals to decide that the 1994 amendments to the Kentucky Living Will Directive Act, KRS 311.621 and 311.644, superseded the clear constitutional directives established by this Court in DeGrella.
The assertion by the majority that it is not approving euthanasia or assisted suicide is hollow. It would certainly appear that the majority has now taken the next step down the slippery slope away from the sanctity of all innocent human life and toward the secular value of meaningful life *65introduced in Roe v. Wade, 410 U.S. 113, 93 S.Ct. 705, 35 L.Ed.2d 147 (1973). It is a complete abandonment of DeGrella, which only eleven years ago specifically rejected the subjective “substituted judgment test.” It must be recognized for what it is — a severe departure from De-Grella. Permitting anyone to decide when another should die on any basis other than clear and convincing evidence that the patient would chose to do so, is specifically condemned in DeGrella and now tragically approved in the majority opinion. The concern about the slippery slopes articulated in both the majority and dissenting opinions in DeGrella is obviously upon us. In any society which claims to have even the veneer of civilization such behavior is totally unacceptable. We cannot close our eyes to the destruction of innocent life at any stage of development or any impaired condition of existence. To do so degrades our own culture and all of us. The English poet John Donne (1570-1631) expressed it well when he wrote:
Any man’s death diminishes me, because I am involved in mankind; and therefore, never send to know for whom the bell tolls, it tolls for thee.
Today, this case involves a mentally deficient ward of the State. Who knows whom it will involve in the future? Only by making the mistaken assumption that it could never happen, the power of the State has been unleashed to kill its own citizens.
STUMBO, J., joins this dissent as to Parts I through IV.