Guardianship of Linda, In re

• Decision Date: 07 March 1988
• Citation: 519 N.E.2d 1296,401 Mass. 783
• Parties: In re GUARDIANSHIP OF LINDA.
• Court: United States State Supreme Judicial Court of Massachusetts Supreme Court

Page 1296

519 N.E.2d 1296

401 Mass. 783

In re GUARDIANSHIP OF LINDA.

Supreme Judicial Court of Massachusetts,

Berkshire.

Argued Jan. 5, 1988.

Decided March 7, 1988.

Marilyn J. Schmidt, Sp. Asst. Atty. Gen., for Dept. of mental health.

Alan J. Righi, Pittsfield, for the ward.

Before HENNESSEY, C.J., and WILKINS, ABRAMS, LYNCH and O'CONNOR, JJ.

HENNESSEY, Chief Justice.

The Department of Mental Health (department) filed a petition in the Probate Court under G.L. c. 201, § 6 (1986 ed.), seeking a guardianship of "Linda" (the ward), with authority in the guardian to permit the administration of antipsychotic drugs. ¹ At the time this action was commenced, the ward voluntarily was accepting such drugs. ² The Probate Court judge ruled that, by reason of mental illness, the ward was unable to make an informed judgment as to treatment. He appointed a guardian, with authority to permit the administration of antipsychotic drugs only for so long as the ward voluntarily accepted them. He expressly ruled that the department could not at that time obtain an order to compel treatment of the ward with antipsychotic drugs if she later refused to take them. The judge contemplated that, if at some future time the ward refused to accept antipsychotic drugs, an order compelling their forcible administration would issue only after a hearing based on current facts as to the ward's competence, capacity to make an informed treatment decision, and substituted judgment. The department appeals from that part of the order which conditions the guardian's authority to administer antipsychotic drugs on the ward's voluntary acceptance thereof, contending that the judge abused his discretion in imposing this condition. We reject this contention and affirm the order of the Probate Court.

At the outset, we note that the order has expired. We understand, however, that the department has obtained an interim extension of the order and is seeking a permanent extension. In any event, the issue presented is one that is capable of repetition, yet evading review, so we address its merits. See, e.g., Commonwealth v. Yameen, 401 Mass. 331, 333, 516 N.E.2d 1149 (1987), and cases cited.

The parties do not challenge the probate judge's findings of fact. The ward suffers from schizophrenia. In the past, she has experienced delusions, hallucinations, and mild paranoia, and she has been hospitalized repeatedly. Presently, she voluntarily is accepting treatment with antipsychotic drugs, which allows her to live outside an institutional setting. She does not understand the nature of these drugs; she accepts them because she believes they help her to sleep and calm her nerves. Anticipating that at some future time the ward might change her mind and refuse to accept treatment, the department requested that, "[w]hile the ward is now accepting anti-psychotic medication, an order issue now, but not to be effective until sometime in the future, compelling forcible medication in case of her later refusal." In effect, the department sought a "pocket" order, directed not to the present circumstances but to a future contingency, with which it could override the ward's expressed desire should she at some point refuse to accept antipsychotic drugs.

Much of the department's argument is directed to demonstrating that the condition imposed by the judge disserves the ward's "best interests," and implies that the medical profession is institutionally superior to the courts in making such determinations. We will not join this debate, as it is irrelevant to the issue of the ward's substituted judgment. "A substituted-judgment decision is distinct from a decision by doctors as to what is medically in the 'best interests' of the patient.... '[T]he goal is to determine with as much accuracy as possible the wants and needs of the individual involved.' " (Citations omitted.) Rogers v. Commissioner of the Dep't of Mental Health, 390 Mass. 489, 500, 458 N.E.2d 308 (1983). The inquiry, then, is directed to discovering "what the incompetent individual would do if competent ...", and is a "subjective rather than an objective determination." Guardianship of Roe, 383 Mass. 415, 435, 444, 421 N.E.2d 40 (1981). Of course, the ward's best interests are not irrelevant to this determination, but they are relevant only to the extent that the individual, if competent, would weigh them in deciding whether to accept treatment. We reemphasize that the substituted judgment inquiry is not a medical, but a judicial, function. Rogers, supra 390 Mass. at 497-500, 458 N.E.2d 308. Roe, supra 383 Mass. at 433-435, 421 N.E.2d 40.

This court has identified a number of considerations which are relevant to the substituted judgment inquiry, while "cautioning that they are not exclusive, recognizing that certain of them may not exist in all cases and declining to establish their relative weights in any individual case. They are: (1) the ward's expressed preferences regarding treatment; (2) his religious beliefs; (3) the impact upon the ward's family; (4) the probability of adverse side effects; (5) the consequences if treatment is refused; and (6) the prognosis with treatment" (emphasis added). Roe, supra at 444, 421 N.E.2d 40. "Even if the ward lacks capacity to make treatment decisions, his stated preference is entitled to serious consideration as a factor in the substituted judgment determination." Id. at 445, 421 N.E.2d 40.

The judge made his substituted judgment decision on the basis of the facts and circumstances existing at that time, among them that the ward had, in effect, "expressed a preference" for treatment by voluntarily accepting antipsychotic drugs. The department would have the judge consider not only the existing circumstances, but...