Spring, Matter of

• Decision Date: 13 May 1980
• Citation: Spring, Matter of, 405 N.E.2d 115, 380 Mass. 629 (Mass. 1980)
• Parties: In the Matter of Earle N. SPRING.
• Court: Supreme Judicial Court of Massachusetts

Page 115

405 N.E.2d 115

380 Mass. 629

In the Matter of Earle N. SPRING.

Supreme Judicial Court of Massachusetts Franklin.

Argued Jan. 10, 1980.

Decided May 13, 1980.

Mark I. Berson, Greenfield, guardian ad litem, pro se.

Marguerite M. Dolan, Greenfield, for petitioners.

George J. Annas and Leonard H. Glantz, Boston, for the American Soc. of Law & Medicine, Inc., amicus curiae.

Lee J. Dunn, Jr., Nancy E. Ator, Patricia D. King, William H. Roach, Jr., Chicago, Ill., Kenneth C. Robbins, Oak Park, Ill., and Miles J. Zaremski, Chicago, Ill. for the Illinois Assn. of Hospital Attys., amicus curiae.

Ronald B. Schram, Michael J. Beautyman & Patrick R. Carroll, Boston, for the Massachusetts Hospital Ass'n, Inc., amicus curiae.

Warner & Stackpole, (Stanley V. Ragalevsky, Thomas M. Reardon and Karen J. Bloom), Boston, for the Massachusetts Medical Soc., amicus curiae.

Jonathan Brant, Boston, and Thomas F. O'Hare, Wellesley, for the Mental Health Legal Advisors Committee, amicus curiae.

Before HENNESSEY, C. J., and BRAUCHER, KAPLAN, LIACOS and ABRAMS, JJ.

BRAUCHER, Justice.

Earle N. Spring, an incompetent person, was receiving life-prolonging hemodialysis treatment. On the petition of his wife and his son, who was his temporary guardian, a judge of the Probate Court found that the ward "would, if competent, choose not to receive the life prolonging treatment," and ordered the entry of judgment that "the ward's attending physician together with the ward's wife and son are to make the decision with reference to the continuance or termination of the dialysis treatment." The Appeals Court affirmed the judgment. Matter of Spring, --- Mass.App. --- ^a, 399 N.E.2d 493 (1979).

We allowed an application by the guardian ad litem for further appellate review. We concluded that the finding quoted above was warranted by the evidence, but on the authority of Superintendent of Belchertown State School v. Saikewicz, 373 Mass. 728, 370 N.E.2d 417 (1977), we concluded that it was error to delegate the decision to the attending physician and the ward's wife and son. We issued an order reversing the judgment of the Probate Court and remanding the case for the entry of a new judgment ordering the temporary guardian to refrain from authorizing any further life-prolonging treatment except by further order of the Probate Court. We emphasized that the judge might issue a further order "upon receiving evidence of significant change in the condition of the ward or in the treatment available for him or other evidence leading to revision of his findings." We said that a rescript and opinion would follow, and we now issue that opinion.

1. The proceedings. In November, 1978, the son filed a petition that he be appointed conservator of the property of his father, and the appointment was made on January 16, 1979. On January 25, 1979, the son was appointed temporary guardian of his father, and the same day the son and the wife of the ward filed a petition for an order that no life-prolonging medical treatment be administered to the ward by his physicians. The probate judge appointed a guardian ad litem, who filed a report on February 12, 1979.

After an evidentiary hearing on April 5, the judge on May 15, 1979, ordered that the temporary guardian refrain from authorizing any further life-prolonging medical treatment. On motion of the guardian ad litem the order was stayed, and the guardian ad litem appealed to the Appeals Court. After further consideration, on July 2, 1979, the judge filed "Findings, Rulings and Order for Entry of Judgment," vacated the order of May 15, and ordered the entry of judgment that "the ward's attending physician together with the ward's wife and son are to make the decision with reference to the continuance or termination of the dialysis treatment."

The July 2 judgment was stayed, but no further appeal was taken, and no application was made for direct appellate review by this court. The case was argued in the Appeals Court in September, and an opinion affirming the July 2 judgment was released on December 21, 1979. The guardian ad litem filed an application for further appellate review on December 31, 1979. The case was argued before this court on January 10, 1980, and our order was issued January 14, 1980. ¹

2. The facts. The evidence is described in detail in the opinion of the Appeals Court. We here summarize the facts shown, which were substantially undisputed. The ward was born in 1901, had been married for fifty-five years at the time of the hearing, and had one son, the temporary guardian. The ward was suffering from "end-stage kidney disease," which required him to undergo hemodialysis treatment (filtering of the blood) three days a week, five hours a day. He also suffered from "chronic organic brain syndrome," or senility, and was completely confused and disoriented. Both the kidney disease and the senility were permanent and irreversible; there was no prospect of a medical breakthrough that would provide a cure for either disease. Apart from the kidney disease and senility the ward's health was good.

Without the dialysis treatment the ward would die; with it he might survive for months. Survival for five years would be not probable, but conceivable. The treatment did not cause a remission of the disease or restore him even temporarily to a normal, cognitive, integrated, functioning existence, but simply kept him alive. He experienced unpleasant side effects such as dizziness, leg cramps, and headaches; on occasion he kicked nurses, resisted transportation for dialysis, and pulled the dialysis needles out of his arm. His disruptive behavior was controlled through heavy sedation. He would not have suffered any discomfort if the dialysis had been terminated. There was no evidence that while competent he had expressed any wish or desire as to the continuation or withdrawal of treatment in such circumstances, but his wife and son were of the opinion that if competent he would request withdrawal of treatment.

3. The legal setting. This is another in a series of recent cases in which we have been called upon to apply legal principles to questions of life and death presented by modern medical procedures. Superintendent of Belchertown State School v. Saikewicz, 373 Mass. 728, 370 N.E.2d 417 (1977) (order withholding chemotherapy from incompetent and profoundly retarded leukemia patient at State school). Custody of a Minor, --- Mass. --- ^b, 379 N.E.2d 1053 (1978) (order permitting chemotherapy for minor leukemia patient over parental objection). Custody of a Minor, --- Mass. --- (1979) ^c, 383 N.E.2d 836 (1979) (same). Commissioner of Correction v. Myers, --- Mass. --- (1979) ^d, 399 N.E.2d 452 (1979) (order for involuntary hemodialysis for prisoner). See Commonwealth v. Golston, 373 Mass. 249, 252-256, 366 N.E.2d 744 (1977), cert. denied, 434 U.S. 1039, 98 S.Ct. 778, 54 L.Ed.2d 788 (1978) (upholding finding of "brain death" before removal of respirator from murder victim); Commonwealth v. Edelin, 371 Mass. 497, 516-517, 359 N.E.2d 4 (1976) (insufficient evidence of recklessness of physician with respect to aborted fetus); Matter of Dinnerstein, --- Mass.App. --- ^e, 380 N.E.2d 134 (1978) (declaration that validity of order not to resuscitate patient with Alzheimer's disease did not depend on prior court approval); Lane v. Candura, --- Mass.App. --- ^f, 376 N.E.2d 1232 (1978) (denial of authority to amputate leg of nonconsenting competent adult).

Similar questions have arisen in other jurisdictions as well. Rogers v. Okin, 478 F.Supp. 1342, 1360-1371 (D.Mass.1979) (injunction against involuntary treatment of mental patients with psychotropic drugs). In re Boyd, 403 A.2d 744 (D.C.App.1979) (remand to consider bearing of incompetent patient's religious beliefs on her putative rejection of psychotropic drugs). Satz v. Perlmutter, 362 So.2d 160 (Fla.Dist.Ct.App.1978) (authorizing removal of respirator as desired by competent, terminally ill patient). In re Quinlan, 70 N.J. 10, 355 A.2d 647, cert. denied sub nom. Gorger v. New Jersey, 429 U.S. 922, 97 S.Ct. 319, 50 L.Ed.2d 289 (1976) (authorizing removal of respirator from patient in irreversible vegetative coma). Matter of Eichner, App.Div., 426 N.Y.S.2d 517 (1980) (same). Those cases, particularly the Quinlan and Saikewicz cases, have been the subject of voluminous discussion in both medical and legal literature. See, e. g., Annas, Reconciling Quinlan and Saikewicz : Decision Making for the Terminally Ill Incompetent, 4 Am.J. of Law & Med. 367 (1979); Cantor, Quinlan, Privacy, and the Handling of Incompetent Dying Patients, 30 Rutgers L.Rev. 243 (1977).

These materials suggest that there is something approaching consensus in support of some of the principles elaborated in the Saikewicz opinion. A person has a strong interest in being free from nonconsensual invasion of his bodily integrity, and a constitutional right of privacy that may be asserted to prevent unwanted infringements of bodily integrity. Thus a competent person has a general right to refuse medical treatment in appropriate circumstances, to be determined by balancing the individual interest against countervailing State interests, particularly the State interest in the preservation of life. In striking that balance, account is to be taken of the prognosis and of the magnitude of the proposed invasion. The same right is also extended to an incompetent person, to be exercised through a "substituted judgment" on his behalf. The decision should be that which would be made by the incompetent person, if he were competent, taking into account his actual interests and preferences and also his present and future incompetency.

The procedure to be followed in such cases, however, has been more controversial. It is reported that our Saikewicz decision was interpreted by some as requiring judicial approval before life-prolonging treatment could be withheld from an incompetent patient, even in cases...