In the Matter of M.B.
| Decision Date | 23 March 2006 |
| Citation | 6 N.Y.3d 437,846 N.E.2d 794 |
| Parties | In the Matter of M.B. Mental Hygiene Legal Service, Appellant; Staten Island Developmental Disabilities Services Office et al., Respondents. |
| Court | New York Court of Appeals Court of Appeals |
Eliot Spitzer, Attorney General, New York City (Jean Lin, Caitlin Halligan and Daniel Smirlock of counsel), for respondent.
Under the Health Care Decisions Act for Persons with Mental Retardation, a guardian can make health care decisions for a mentally retarded person, including the decision to terminate life-sustaining medical treatment, under carefully prescribed circumstances. The issue in this case — solely one of statutory interpretation — is whether the Act applies only to guardians appointed after its March 2003 effective date or whether it also affects the authority of persons already serving as guardians before March 2003. Based on the language and history of the Act, we conclude that the Legislature also granted existing guardians full health care decision-making authority, subject to the detailed procedures set forth in the statute.
Under New York common law, a competent adult generally has the right to make health care decisions, including the right to refuse life-sustaining treatment (see Matter of Fosmire v. Nicoleau 75 N.Y.2d 218, 551 N.Y.S.2d 876, 551 N.E.2d 77 [1990]). If the individual suffers an illness or injury resulting in a loss of decision-making capacity, family and friends may obtain a court order authorizing the cessation of treatment if they can prove — by clear and convincing evidence of the patient's previously-expressed views — that the individual would have refused life-sustaining treatment if capable of making that decision (id. at 225, 551 N.Y.S.2d 876, 551 N.E.2d 77).1
Although a guardian of a mentally retarded person was imbued under the common law with the authority to make abroad spectrum of health care decisions, this authority did not encompass the power to end life-sustaining medical treatment. Viewing the guardian's role as comparable to that of a parent — who could not deprive a child of lifesaving treatment — this Court concluded in Matter of Storar, 52 N.Y.2d 363, 438 N.Y.S.2d 266, 420 N.E.2d 64 [1981], cert. denied 454 U.S. 858, 102 S.Ct. 309, 70 L.Ed.2d 153 [1981] that the guardian of a 52-year-old mentally retarded man lacked the authority to order the cessation of blood transfusions. Predicating our analysis on principles developed under the common law, we indicated that the Legislature could establish procedures governing the discontinuance of life-sustaining treatment for incompetent individuals if it determined this was desirable or appropriate, noting that any "change should come from the Legislature" (id. at 383, 438 N.Y.S.2d 266, 420 N.E.2d 64).
In the wake of Storar, a distinction arose between the common-law rights of competent adults, who could make their wishes concerning end-of-life care known to family and friends, and mentally retarded persons who had never been competent to make their own health care decisions and for whom life-sustaining treatment could not be refused. When these mentally retarded individuals became irreversibly, terminally ill they were, in effect, ineligible for hospice or other palliative care because their guardians were unable to refuse more intrusive, acute medical treatments aimed at extending life for as long as possible.
As a consequence of this disparity, family members, caregivers and advocacy groups for the mentally retarded sought relief from the Legislature. They shared the stories of mentally retarded patients forced to suffer painful, intrusive life-sustaining medical treatments after it was clear that they would never regain any quality of life because the requests of their guardians (usually parents or siblings) to end life-sustaining measures could not be honored. This was the situation the Legislature sought to remedy when it enacted the Health Care Decisions Act for Persons with Mental Retardation (HCDA) (see Bill Jacket, L. 2002, ch. 500).
The HCDA was passed by both houses and signed by the Governor in the fall of 2002 but it did not become effective until 180 days later — March 16, 2003 (L. 2002, ch. 500, § 4). The legislation added a new subdivision to Surrogate's Court Procedure Act § 1750, the provision that addresses the guardianship of mentally retarded persons. Before the enactment of the HCDA, section 1750 stated that, upon the certification of appropriate medical personnel that a mentally retarded person was "incapable to manage him or herself and/or his or her affairs by reason of mental retardation and that such condition is permanent in nature or likely to continue indefinitely," a guardian "of the person or of the property or of both" could be appointed (SCPA 1750[1]). A guardianship "of the person" was viewed as authorizing some degree of medical decision-making power, but the scope of this authority was unclear, particularly in the aftermath of Storar.
The new provision — SCPA 1750(2) — imposes an additional certification requirement, clearly applicable to all future guardianship proceedings. Along with filing a certification from medical professionals that the mentally retarded person is incapable of managing his or her affairs, prospective guardians now must also file a "specific determination by such [medical personnel] as to whether the mentally retarded person has the capacity to make health care decisions, as defined by [Public Health Law § 2980(3)], for himself or herself" (SCPA 1750[2]). In the event the mentally retarded individual has the ability to make health care decisions, the HCDA allows a guardian to be appointed to make other types of decisions. If not, the guardian is granted full medical decision-making power. In the latter event, the HCDA removed any uncertainty concerning the scope of that authority, clarifying that health care decisions include "any decision to consent or refuse to consent to health care" (see SCPA 1750-b[1], cross-referencing Public Health Law § 2980[6]). Thus, under the HCDA, a guardian can, under certain circumstances, order the cessation of life-sustaining medical treatment for a mentally retarded person who never had capacity to make such a decision.
The HCDA also amended article 17-A of the Surrogate's Court Procedure Act by adding a new section 1750-b governing health care decision-making for mentally retarded persons. Section 1750-b establishes a "[d]ecision-making standard" requiring that guardians base all health care decisions "solely and exclusively on the best interests of the mentally retarded person and, when reasonably known or ascertainable with reasonable diligence, on the mentally retarded person's wishes, including moral and religious beliefs" (SCPA 1750-b [2][a]). This provision lists the factors that must be considered in determining the mentally retarded person's best interests, which include "the dignity and uniqueness" of the individual; "the preservation, improvement or restoration of the. . . person's health"; "the relief of the mentally retarded person's suffering by means of palliative care and pain management"; the effect of treatment, including artificial nutrition and hydration, on the mentally retarded person; and the patient's overall medical condition (SCPA 1750-b [2][b]). A medical decision cannot be based on financial considerations or a failure to afford the mentally retarded individual the respect that would be afforded any other person in the same circumstances (SCPA 1750-b [2][c]). In addition, the statute imposes on the guardian "the affirmative obligation to advocate for the full and efficacious provision of health care, including life-sustaining treatment" (SCPA 1750-b[4]), defined as "medical treatment which is sustaining life functions and without which, according to reasonable medical judgment, [the] patient will die within a relatively short time period" (see SCPA 1750-b [4], cross-referencing Mental Hygiene Law § 81.29[e]).
In the event a guardian contemplates the withdrawal or withholding of life-sustaining treatment, SCPA 1750-b imposes a decision-making procedure that must be followed before the decision can be carried out. The threshold requirement is that the mentally retarded person's physician confirm to a reasonable degree of medical certainty, after consultation with another physician or a licensed psychologist, that the person currently lacks the capacity to make health care decisions (SCPA 1750-b [4][a]). The attending physician and another concurring physician must further attest that the mentally retarded person has one of three types of conditions: a terminal condition, permanent unconsciousness or "a medical condition other than such person's mental retardation which requires life-sustaining treatment, is irreversible and which will continue indefinitely," and life-sustaining treatment imposes or would impose an extraordinary burden on the patient in light of the patient's medical condition and the expected outcome of the life-sustaining treatment (SCPA 1750-b [4][b][i], [ii]). In the case of the withdrawal or withholding of artificially provided nutrition or hydration, the two physicians must also confirm that "there is no reasonable hope of maintaining life" or that the artificial nutrition or hydration itself "poses an extraordinary burden" on the patient (SCPA 1750-b [4][b][iii]). These conclusions by medical professionals are a condition precedent to any valid decision to end life-sustaining treatment — without them, life-sustaining treatment must be afforded to the patient.
If the requisite medical conclusions are made, the next step is for the guardian to express a decision to end life-sustaining treatment either in writing, signed by a witness, or orally in the...
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