Brophy v. New England Sinai Hospital, Inc.
1986 Mass. LEXIS 1499, 398 Mass. 417, 497 N.E.2d 626 (1986)
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Rule of Law:
The substituted judgment of an incompetent patient in a persistent vegetative state to decline the artificial maintenance of nutrition and hydration must be honored, even if it leads to death, provided it aligns with the patient's previously expressed wishes and does not violate the ethical integrity of the medical profession or other compelling state interests.
Facts:
- On March 22, 1983, Paul E. Brophy, Sr., a healthy fireman and EMT, suffered a ruptured basilar artery aneurysm and became unconscious.
- Following unsuccessful surgery on April 6, 1983, Brophy never regained consciousness and was diagnosed with a persistent vegetative state, unable to chew or swallow.
- On December 22, 1983, a gastrostomy tube (G-tube) was surgically inserted to provide him with nutrition and hydration.
- Brophy's wife, Patricia, who was his guardian, and his family, wished to have the G-tube removed or clamped.
- Brophy's attending physicians and the New England Sinai Hospital refused to remove or clamp the G-tube, believing it would wilfully cause his death.
- Prior to his illness, Brophy had made statements indicating he would not want to be kept alive on a life-support system or in a state where he could not interact meaningfully.
- The probate judge found that if Brophy were competent, he would choose to decline artificial nutrition and hydration via the G-tube and terminate his life.
- Brophy was not terminally ill and not in danger of imminent death from any other medical cause, and could live in a persistent vegetative state for several years with the G-tube.
Procedural Posture:
- Patricia E. Brophy, as legal guardian for her husband, Paul E. Brophy, Sr., filed a complaint for declaratory judgment in the Probate and Family Court Department for Norfolk County, requesting authority to discontinue all life-sustaining treatment, including artificial nutrition and hydration.
- The Probate Court judge ordered the treating physicians to continue all life-sustaining measures until further court order and appointed a guardian ad litem-investigator.
- Plaintiff (Patricia Brophy) filed an amended complaint naming New England Sinai Hospital as a defendant.
- The hospital filed a motion to dismiss and a motion to substitute the guardian ad litem, both of which were denied.
- Evidentiary hearings were held over several days, and additional testimony was taken after a motion to reopen evidence was allowed.
- The probate judge issued extensive findings of fact and conclusions of law, entering a judgment ordering the continuation of nutrition and hydration via the G-tube and enjoining both the hospital and the guardian from removing or clamping the tube.
- Plaintiff (Patricia Brophy) filed a notice of appeal, and defendant (New England Sinai Hospital) appealed the denial of its motion to dismiss.
- The Supreme Judicial Court of Massachusetts transferred the case to itself on its own motion.
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Issue:
Does the substituted judgment of an incompetent patient in a persistent vegetative state, expressing a wish to discontinue artificial nutrition and hydration, override the State's interests in preserving life, preventing suicide, and maintaining the ethical integrity of the medical profession?
Opinions:
Majority - Liacos, J.
Yes, the substituted judgment of an incompetent patient in a persistent vegetative state to discontinue artificial nutrition and hydration can override state interests, particularly if the treatment is intrusive and the patient's previously expressed wishes support the decision. The right of a patient to refuse medical treatment stems from both common law and the constitutional right to privacy, which extends to incompetent patients through the doctrine of substituted judgment. This doctrine aims to determine what the individual would have chosen if competent, honoring their dignity and autonomy. The court acknowledges four countervailing State interests: preservation of life, protection of innocent third parties, prevention of suicide, and maintenance of the ethical integrity of the medical profession. The State's interest in preserving life is high when an affliction is curable but wanes when the underlying condition is incurable and would only prolong suffering. While Brophy was not terminally ill, being maintained by a G-tube for an extended period was deemed intrusive, and his prior statements indicated he would consider such a state degrading. The court rejected the distinction between ordinary/extraordinary care and withholding/withdrawing treatment as the sole or major factor, emphasizing that the patient's desires and experience of pain/enjoyment are primary. Furthermore, discontinuing the G-tube is not considered suicide because Brophy's death would be from his underlying affliction, not a self-inflicted injury. The court also held that compelling the hospital to act against its ethical principles when there is significant disagreement in the medical community would violate the integrity of the medical profession. Therefore, while the hospital cannot be forced to remove the tube, the guardian is authorized to transfer Brophy to a facility or home where his wishes can be carried out.
Dissenting - Nolan, J.
No, the substituted judgment of an incompetent patient to discontinue artificial nutrition and hydration should not be honored because it rests on the erroneous premise that food and liquids are medical treatment. Food and water are basic human needs, not medicines or invasive medical treatment. Approving the cessation of feeding is tantamount to endorsing euthanasia and suicide. Brophy would die directly from dehydration and starvation, not from his aneurysm or brain damage, which is intrinsically evil. Furthermore, the evidentiary basis for Brophy's supposed wish to decline food and water is weak, as there is no evidence he understood the horrors of death by dehydration. The court's decision degrades the human person and represents a triumph of 'anti-life principles.'
Dissenting - Lynch, J.
No, the balance of competing interests tips in favor of continuing nutrition and hydration for Paul Brophy. The majority opinion fails to give appropriate weight to the State's interest in the preservation of life, which includes both the life of the particular patient and the sanctity of all human life. Death by dehydration and starvation is particularly difficult, painful, and gruesome, and is not a natural cessation of life but rather an unnatural one, nearing euthanasia. Historically, the right to privacy and bodily integrity in Massachusetts only extended to avoiding invasive treatments. The majority's decision effectively equates this right with a general right to choose or refuse any bodily invasion, making the 'substituted judgment' conclusive and nullifying the Saikewicz balancing test. Furthermore, this case involves an intent to end life, not merely to avoid burdensome treatment, and thus constitutes suicide, which the law has traditionally forbidden. Brophy is not terminally ill, and his death would be from a volitional act (or omission), not natural causes. The court should not recognize a limited right to commit suicide in a medical setting without express legislative action, especially when the law against suicide predates the Constitution. Judicial caution is warranted, and in a close case, preserving life is the safer course.
Concurring in part and dissenting in part - O’Connor, J.
I agree that the hospital should not be compelled to act against its ethical views, but I disagree that the court should honor Brophy's attributed choice to remove or clamp his G-tube. The trial judge's findings, crucially, indicated that Brophy's primary purpose in declining food and water was to 'thereby terminate his life,' not due to the treatment being intrusive or burdensome. This case, therefore, involves whether an individual has a legal right to choose to die and enlist assistance to effectuate that choice because life itself is intolerable, irrespective of the treatment. Such rights, encompassing suicide and euthanasia, should never be recognized. Previous cases, like Saikewicz and Conroy, focused on refusing burdensome treatment, not on a specific intent to die. The court's ruling, in effect, establishes an absolute right to commit suicide or a right dependent on a judicial assessment of the quality of life, both of which radically depart from this Commonwealth's policy and tradition. Every human life, regardless of condition, possesses inherent value, and denying this principle undermines the dignity of all human life and the foundation of American law. The court's decision, by implicitly or explicitly denying that every human life is worthy of state protection, is a blow against human autonomy and deviates from societal reverence for life.
Analysis:
This case significantly advanced the jurisprudence on a patient's right to refuse life-sustaining treatment, particularly for incompetent patients in a persistent vegetative state. It reaffirmed the use of the 'substituted judgment' standard and expanded its application to artificial nutrition and hydration, emphasizing patient autonomy over medical paternalism. By rejecting the 'ordinary/extraordinary' care distinction and the 'withholding/withdrawing' treatment distinction, the court clarified that the focus should be on the patient's wishes and the nature of the treatment's burden, rather than the type of intervention. The ruling created a framework that balances individual rights against state interests, but notably allowed medical institutions to decline participation in ethically conflicting procedures, requiring patient transfer instead. This balance influences future cases by supporting patient self-determination in end-of-life decisions while respecting the conscience of healthcare providers.
