In Re Guardianship of Browning
1990 WL 133476, 568 So. 2d 4 (1990)
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Rule of Law:
An incompetent patient's previously expressed wish to refuse life-sustaining medical treatment, including artificial nutrition and hydration, based on their constitutional right to privacy, can be honored by a surrogate without prior judicial approval, even if the patient is not in a persistent vegetative state or facing imminent death from a terminal condition, provided there is clear and convincing evidence of the patient's intent.
Facts:
- On November 19, 1985, a competent Estelle Browning executed a declaration (living will) stating that if she had a terminal condition with no recovery and imminent death, life-prolonging procedures, including artificial nutrition and hydration via gastric tube or intravenously, should be withheld or withdrawn.
- At 86 years of age, Mrs. Browning suffered a massive brain hemorrhage (stroke) on November 9, 1986, which permanently damaged the cognitive part of her brain and rendered her unable to swallow.
- On November 20, 1986, a gastrostomy was performed to insert a feeding tube directly into her stomach.
- Doris Herbert, Mrs. Browning's second cousin and only living relative, was subsequently appointed guardian of her person and property.
- On May 19, 1988, the gastrostomy tube was replaced by a nasogastric tube due to complications with the initial tube.
- Mrs. Browning was noncommunicative but appeared alert, following visitors with her eyes, though she could not follow commands or speak clearly, and medical consensus indicated no reasonable probability of recovering competency.
- Neighbors and Doris Herbert testified that Mrs. Browning had orally expressed her wishes several times about not wanting to be maintained through artificial life-support mechanisms.
- Medical evidence indicated Mrs. Browning suffered major and permanent brain damage with virtually no chance of recovery; doctors testified she would die within seven to ten days if the nasogastric tube was removed, but her life could be prolonged up to one year with continued artificial feeding.
Procedural Posture:
- Doris Herbert, as guardian for Estelle Browning, filed a petition in circuit court to terminate nasogastric feeding based on Mrs. Browning's living will.
- The circuit court denied the petition, concluding that Mrs. Browning's death was not imminent under Florida's "Life-Prolonging Procedure Act."
- The guardian appealed the circuit court's decision to the Florida Second District Court of Appeal.
- The District Court of Appeal affirmed that the statute did not permit the termination of treatment in Mrs. Browning's situation, but held that she was entitled to relief under Florida's constitutional right of privacy, authorizing the guardian to make the decision according to procedures outlined in its opinion.
- The District Court of Appeal then certified a question of great public importance to the Supreme Court of Florida.
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Issue:
Does the guardian of a patient who is incompetent but not in a permanent vegetative state, and who suffers from an incurable but not terminal condition, have the authority to exercise the patient's right of self-determination to forego sustenance provided artificially by a nasogastric tube, without prior judicial approval?
Opinions:
Majority - Barkett, Justice
Yes, a guardian may exercise an incompetent patient's right of self-determination to forego artificial sustenance, even if the patient is not in a permanent vegetative state or facing imminent death from a terminal condition, provided there is clear and convincing evidence of the patient's wishes. The Florida Supreme Court affirmed the district court's decision, holding that chapter 765 of the Florida Statutes (1987) was not applicable, but Mrs. Browning's fundamental right of self-determination, rooted in Florida's constitutional right of privacy (Article I, Section 23), controlled the case. This right extends to all medical choices, including refusing life-sustaining treatment, and applies equally to competent and incompetent individuals. When a person is unable to personally exercise this right, a surrogate (like a guardian or close family member/friend) may do so on their behalf, guided by the patient's previously expressed wishes (substituted judgment), not what the surrogate believes is in the patient's best interest. The Court found no significant legal distinction between different forms of artificial life support. The state's compelling interests (preservation of life, protection of third parties, prevention of suicide, ethical integrity of the medical profession) do not override an individual's right to refuse medical treatment when the affliction is incurable, and the issue is not whether death will occur, but when. The Court established procedures for surrogates to follow, requiring them to be satisfied that the patient's instructions were made knowingly and willingly, that recovery of competency is unlikely, and that any conditions in the declaration are met, all supported by clear and convincing evidence, often through physician certificates. Prior judicial approval is not required if the patient has clearly expressed their wishes, but courts remain open for challenges by interested parties, with written declarations carrying a rebuttable presumption of clear and convincing evidence. In Mrs. Browning's case, her conditions for refusal were met as her death was imminent within days without artificial support, and her brain damage was permanent.
Concurring - McDonald, Justice
Justice McDonald concurred with the majority opinion, adding that to the extent they were not explicitly expressed in the majority opinion, he would incorporate, include, and adopt sections VIII, IX, and X of the district court's opinion under review.
Concurring in part and dissenting in part - Overton, Justice
Justice Overton concurred with the majority opinion except for the part that allows a guardian or surrogate to assert an incompetent's right to forego treatment based solely on a prior oral statement by the incompetent. He argued that judicial involvement is appropriate in such circumstances to ensure the validity of the oral statement and the medical certificates, especially where the decision-makers might have a financial interest in the early termination of the ward's life. He emphasized that the value of life is significant and judicial protection is necessary to protect the ward's interests when intent is unknown or based only on oral statements, and to assure the public of a proper decision.
Analysis:
This case significantly expanded the scope of individual autonomy and the right to refuse medical treatment in Florida by extending the constitutional right of privacy to encompass decisions about life-sustaining treatment for incompetent patients, reinforcing the "substituted judgment" standard. The ruling also explicitly clarified that there is no legal distinction between various forms of life support, including artificial nutrition and hydration, and that prior judicial approval is not always necessary, streamlining end-of-life decisions. However, the requirement for "clear and convincing evidence" and the explicit procedures for surrogates introduce safeguards, preventing unchecked power and potential abuse, though the dissenting opinion highlighted ongoing concerns about the reliability of solely oral declarations. The case encourages individuals to articulate their end-of-life wishes clearly and completely in writing.
