Norwood Hosp. v. Munoz

• Decision Date: 15 January 1991
• Citation: Norwood Hosp. v. Munoz, 409 Mass. 116, 564 N.E.2d 1017 (Mass. 1991)
• Parties: , 59 USLW 2487 NORWOOD HOSPITAL v. Yolanda MUNOZ et al. 1
• Court: Supreme Judicial Court of Massachusetts Supreme Court

Page 1017

564 N.E.2d 1017

409 Mass. 116, 59 USLW 2487

NORWOOD HOSPITAL v.Yolanda MUNOZ et al.¹

Supreme Judicial Court of Massachusetts Norfolk.

Argued Oct. 3, 1990.

Decided Jan. 15, 1991.

John G. Dugan, Medfield, for Yolanda Munoz.

Jonathan Brant, Boston, guardian ad litem.

Andrew C. Pickett, Boston, for plaintiff.

Before LIACOS, C.J., and WILKINS, ABRAMS, NOLAN, LYNCH, O'CONNOR and GREANEY, JJ.

LIACOS, Chief Justice.

In this case, a competent adult, who is a Jehovah's Witness and a mother of a minor child, appeals from a judgment of the Probate and Family Court authorizing Norwood Hospital to administer blood or blood products without her consent.

We state the facts.Yolanda Munoz, a thirty-eight year old woman, lives in Dedham with her husband, Ernesto Munoz, and their minor son, Ernesto, Jr. Ernesto's father, who is over seventy-five years old, also lives in the same household.

Ms. Munoz has a history of stomach ulcers.Approximately ten years ago, she underwent surgery for a bleeding ulcer.On April 11, 1989, Ms. Munoz vomited blood and collapsed in her home.During the week before she collapsed, Ms. Munoz had taken two aspirin every four hours to alleviate a pain in her arm.The aspirin apparently made her ulcer bleed.Ernesto took his wife to the Norwood Hospital emergency room.Physicians at Norwood Hospital gave Ms. Munoz medication which stopped the bleeding.Ms. Munoz was then admitted to the hospital as an inpatient.During the evening, her hematocrit (the percentage of red blood cells to whole blood) was 17%.A normal hematocrit level for an adult woman is approximately 42%.Ms. Munoz was placed under the care of Dr. Joseph L. Perrotto.It was his medical opinion that the patient had a 50% probability of hemorrhaging again.If Ms. Munoz started to bleed, Dr. Perrotto believed that she would in all probability die unless she received a blood transfusion.Ms. Munoz, however, refused to consent to a blood transfusion in the event of a new hemorrhage.

Ms. Munoz and her husband were baptized as Jehovah's Witnesses over sixteen years ago.They are both members of the Jamaica Plain Kingdom Hall of Jehovah's Witnesses.Ms. Munoz attends three religious meetings every week.A principal tenet of the Jehovah's Witnesses religion is a belief, based on interpretations of the Bible, that the act of receiving blood or blood products precludes an individual resurrection and everlasting life after death.

Norwood Hospital has a written policy regarding patients who refuse to consent to the administration of blood or blood products.According to this policy, if the patient arrives at the hospital in need of emergency medical treatment and there is no time to investigate the patient's circumstances or competence to make decisions regarding treatment, the blood transfusion will be performed if necessary to save the patient's life.If the patient, in a nonemergency situation, refuses to consent to a blood transfusion, and the patient is a competent adult, not pregnant, and does not have minor children, the hospital will accede to the patient's refusal.If the patient, in a non-emergency situation, refuses to consent to a blood transfusion, and the patient is a minor, an incompetent adult, pregnant, or a competent adult with minor children, the hospital's policy is to seek judicial determination of the rights and responsibilities of the parties.

The patient in this case, while no longer in an emergency situation once her ulcer stopped bleeding, has a minor child.The hospital sought a court order; on April 12, the hospital filed a complaint for a declaratory judgment in the Norfolk Division of the Probate and Family Court pursuant to G.L. c. 231A (1988 ed.).The hospital requested that Ms. Munoz be required to accept blood transfusions which her attending physician believed to be reasonably necessary to save her life.On that same day, the judge granted a temporary restraining order authorizing the hospital to "administer transfusions of blood or blood products in the event that [the patient] hemorrhages to the extent that her life is severely threatened by loss of blood in the opinion of her attending physicians."The court also appointed Mr. Jonathan Brant to serve as guardian ad litem for five year old Ernesto, Jr.

On April 13, the judge held a full evidentiary hearing.Dr. Perrotto stated in an unchallenged affidavit that, if Ms. Munoz were to begin bleeding again, she would have an excellent chance of recovering if she received a blood transfusion.If she started to bleed, however, and did not receive a blood transfusion, she would probably die.In addition, Dr. Perrotto stated that there was no alternative course of medical treatment capable of saving the patient's life.Ernesto Munoz and James Joslin, Ms. Munoz's brother-in-law, testified at the hearing in favor of allowing Ms. Munoz to refuse the blood transfusion.The guardian ad litem's report, which recommended that the hospital's request for a declaratory judgment be denied, was admitted in evidence.

On April 14, the judge granted the declaratory judgment authorizing blood transfusions which were "reasonably necessary to save [the patient's] life."The judgment also absolved the hospital and its agents from any civil or criminal liability, except for negligence or malpractice, which might arise from a blood transfusion.On May 11, 1989, the judge issued a detailed opinion explaining his reasons for granting the declaratory judgment.The judge found the patient competent; she understood the nature of her illness, and the potential serious consequences of her decision, including the risk of imminent death if her bleeding resumed and blood transfusions were not administered.While recognizing that a competent adult may usually refuse medical treatment, the judge stated that the hospital could administer the blood transfusions because, if they did not and Ms. Munoz subsequently died, Ernesto, Jr., would be "abandoned."The judge concluded that the State's interest in protecting the well-being of Ernesto, Jr., outweighed Ms. Munoz's right to refuse the medical treatment.

In order further to understand the judge's reasoning, we need to discuss his factual findings in more detail.Ernesto works sixteen hours a day Monday through Friday and seven hours on Saturday driving his own commercial truck.Ms. Munoz works at a beauty salon from 9 A.M. to 3 P.M. three days a week.Ernesto, Jr., is enrolled in a day-care center Monday through Friday from 9 A.M. until 4 P.M.The judge found that Ms. Munoz was the "principal homemaker and principal caretaker of Ernesto, Jr."The judge also found that, while Ernesto's father was available to assist in caring for Ernesto, Jr., his assistance would be inadequate because of his advanced age, his inability to speak English, his unemployment, his lack of a driver's license, and because he had not, in the past, played a significant role in caring for his grandson.In addition, the judge found, that while Sonia and James Joslin, Ernesto's sister and brother-in-law, expressed a willingness to help Ernesto take care of the child in the event that Ms. Munoz died, the family had not formulated a concrete plan for the care and support of Ernesto, Jr.The judge concluded that Ms. Munoz's death "would be likely to cause an emotional abandonment of Ernesto, Jr., which would more probably than not be detrimental to his best interests."The judge ruled that "[t]he State, as parens patriae, will not allow a parent to abandon a child, and so it should not allow this most ultimate of voluntary abandonments."

Ms. Munoz argues that the judge erred because she has a right, as a competent adult, to refuse life-saving medical treatment, and the State's interests do not override that right.We agree.

I

Mootness.Ms. Munoz's ulcer did not hemorrhage after the entry of the judgment.She was released from the hospital without receiving a blood transfusion.The hospital argues that the case is moot.

We agree that the case is moot.There is no evidence in the record that Ms. Munoz's ulcer problems will recur, and, even if they do, there is no evidence that she intends to return to Norwood Hospital.The general rule is that courts ordinarily will not decide moot questions.There are, however, exceptions to the general rule.We have answered moot questions "where the issue was one of public importance, where it was fully argued on both sides, where the question was certain, or at least very likely, to arise again in similar factual circumstances, and especially where appellate review could not be obtained before the recurring question would again be moot."Lockhart v. Attorney Gen., 390 Mass. 780, 783, 459 N.E.2d 813(1984).

The instant case meets all the exceptions to the general rule.Whether a competent individual may refuse medical treatment is unquestionably an issue of public importance.In this case, the issue has been fully argued by both sides and is capable of repetition while evading review.SeeMetros v. Secretary of the Commonwealth, 396 Mass. 156, 159-160, 484 N.E.2d 1015(1985).Cases such as this one often arise in emergency situations; patients, physicians, and trial judges must make difficult decisions in very limited periods of time.By the time the cases reach the appellate courts, the issue is usually moot because the patients have either died or left the hospital without the need for further medical treatment.Due to the importance of the issue, and because of its proclivity to repeat itself while evading review, we proceed to address the merits.

II

We are asked to decide when a competent individual may refuse medical treatment which is necessary to save that individual's life.In Brophy v. New England Sinai Hosp., Inc., 398 Mass. 417, 497 N.E.2d 626(1986), and in Superintendent of Belchertown State School v. Saikewicz, 373 Mass. 728, 370 N.E.2d 417(1977), we were asked to decide the rights of incompetent...