In Matter of Guardianship of LW
482 N.W.2d 60, 167 Wis. 2d 53, 1992 WL 64539 (1992)
Premium Feature
Subscribe to Lexplug to listen to the Case Podcast.
Rule of Law:
An incompetent individual in a persistent vegetative state has a constitutionally protected right to refuse life-sustaining medical treatment, including artificial nutrition and hydration, and a court-appointed guardian may exercise this right on the ward's behalf if it is in the ward's "best interests" based on objective factors, without mandatory prior court approval.
Facts:
- L.W., a 79-year-old man, had a long history of chronic undifferentiated schizophrenia and had been institutionalized since 1951, with evidence suggesting he may never have been competent.
- L.W. had no close relatives or friends and had never expressed his wishes regarding life-sustaining medical treatment.
- On May 25, 1989, L.E. Phillips Career Development Center, a not-for-profit corporation, was appointed guardian of L.W.'s person and estate.
- On May 31, 1989, L.W. suffered a cardiac arrest and was moved from the Fairchild Nursing Home to St. Francis Medical Hospital.
- L.W.'s attending physicians informed the guardian that L.W. was in a chronic, persistent vegetative state.
- The physicians indicated that if L.W.'s condition did not improve within the following four weeks, they would request the guardian to consent to withdrawal of all life-sustaining medical treatment, including artificial nutrition and hydration, which would lead to L.W.'s death.
Procedural Posture:
- In 1951, L.W. was institutionalized due to chronic undifferentiated schizophrenia, implying an earlier finding of incompetency.
- On May 25, 1989, the circuit court for Eau Claire County appointed L.E. Phillips Career Development Center as guardian of L.W.'s person and estate.
- On June 8, 1989, the guardian petitioned the circuit court for a declaratory judgment to determine whether the guardian or the court had the authority to consent to the withdrawal of life-sustaining medical treatment.
- The circuit court appointed Paul J. Lenz to act as guardian ad litem for L.W.
- The circuit court issued an order granting L.E. Phillips Career Development Center, as guardian, the authority to consent to the withdrawal of all life-sustaining medical treatment, including artificial nutrition and hydration, if the guardian determined it to be in the ward's best interests.
- The guardian ad litem appealed this order, and the guardian and St. Francis Hospital cross-appealed to the Supreme Court of Wisconsin, bypassing the court of appeals.
Premium Content
Subscribe to Lexplug to view the complete brief
You're viewing a preview with Rule of Law, Facts, and Procedural Posture
Issue:
Does an incompetent individual in a persistent vegetative state have a right to refuse life-sustaining medical treatment, including artificial nutrition and hydration, and can a court-appointed guardian exercise that right on the ward's behalf using a "best interests" standard without prior court authorization?
Opinions:
Majority - Heffernan, Chief Justice
Yes, an incompetent individual in a persistent vegetative state has a constitutionally protected right to refuse life-sustaining medical treatment, including artificial nutrition and hydration, and a court-appointed guardian may exercise that right on the ward's behalf using a "best interests" standard without prior court authorization. The court affirmed that an individual's right to refuse unwanted medical treatment emanates from the common law right of self-determination and informed consent, the personal liberties protected by the Fourteenth Amendment, and Article I, section 1 of the Wisconsin Constitution. The court found no compelling distinction between artificial feeding and other forms of medical treatment, concluding that artificial feeding is medical treatment that may be refused. This right extends to incompetent as well as competent individuals. For individuals like L.W., who were never competent or whose wishes are unascertainable, the "best interests" standard is appropriate for a surrogate decision-maker, rather than a "substituted judgment" test which requires evidence of past wishes. The guardian, as a state actor fulfilling the state's parens patriae duty to protect the ward's best interests, has the authority and duty to consent to withholding or withdrawing treatment when it is in the ward's best interests. The court balanced this right against relevant state interests (preserving life, safeguarding medical integrity, preventing suicide, protecting innocent third parties), concluding that these interests do not outweigh the patient's liberty interest in the context of a persistent vegetative state where treatment only unnaturally prolongs the dying process. Finally, the court held that prior court approval of the guardian's decision is not required, recognizing the judicial process as cumbersome, but that court review remains available if any interested party objects.
Concurring - Ceci, J.
Justice Ceci concurred with the majority's decision and result, but emphasized the critical importance of physicians strictly complying with current medical practice for diagnosing a persistent vegetative state. He noted that an accurate diagnosis is usually considered possible only after three months and stressed that such a diagnosis must be established by clear and convincing evidence, as the decision involves the death of a human being. He cautioned that the court's decision allows the withdrawal of life-sustaining medical treatment only under "very limited circumstances."
Dissenting - Steinmetz, J.
No, the court should not be ruling on whether to withhold life-sustaining health care, especially since the case was moot due to L.W.'s death, and such matters should instead be decided by the legislature following significant public input and comprehensive studies. Justice Steinmetz argued that the Wisconsin legislature's existing Natural Death Act and Power of Attorney for Health Care Act already recognize the right to refuse treatment for competent individuals and include safeguards like comfort and freedom from pain, which the majority's decision for incompetents lacks. He questioned the majority's conclusion that artificial nutrition and hydration is simply medical treatment that may be refused, pointing out that the U.S. Supreme Court in Cruzan did not definitively rule on this. Furthermore, he criticized the majority for failing to define "parties in interest" who could seek judicial review and highlighted that L.W.'s condition was diagnosed prematurely (within four weeks of cardiac arrest when three months is typically required for certainty), with the trial court hearing no testimony on his actual condition. He concluded that presumptions favoring life should control life and death decisions until the legislature formulates clear guidelines, burdens of proof, and notice requirements.
Analysis:
This case is a landmark decision in Wisconsin, establishing a clear framework for end-of-life decisions for individuals in a persistent vegetative state who have never expressed their wishes. By adopting the "best interests" standard over "substituted judgment" for such patients, the court acknowledges the reality that many individuals do not leave advance directives and ensures that their fundamental right to refuse treatment is not lost due to incapacity. The ruling distinguishes between preserving life and unnaturally prolonging a vegetative state, setting an important precedent for balancing individual autonomy with state interests in the context of medical technology. It streamlines the decision-making process by removing the requirement for mandatory prior court approval, while still allowing for judicial oversight when disputes arise.
