In Re Phillip B.
92 Cal. App. 3d 796, 156 Cal. Rptr. 48 (1979)
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Rule of Law:
Parents have a constitutionally protected right to autonomy in raising their children, but the state, acting parens patriae, may intervene to ensure a child's welfare when parents fail to provide adequate medical care; however, the state bears a serious burden of justification and must prove by "clear and convincing evidence" that such intervention is necessary, weighing the seriousness of harm, medical evaluation, treatment risks, and the child's preferences.
Facts:
- Phillip B. is a 12-year-old boy suffering from Down's Syndrome.
- At birth, Phillip's parents decided he should live in a residential care facility.
- Phillip suffers from a congenital heart defect (ventricular septal defect) that causes his heart to work three times harder than normal and results in elevated pulmonary blood pressure.
- If the heart defect is not corrected, Phillip will suffer increasing lung damage, leading to a progressive loss of energy, a bed-to-chair existence, and eventual death within approximately 20 years.
- In 1973, Dr. Gathman, a pediatric cardiologist, examined Phillip and recommended cardiac catheterization, which Phillip's parents refused.
- In 1977, Phillip's parents consented to catheterization, which revealed the extensive nature of his defect, leading Dr. Gathman to recommend surgery.
- Dr. William French, a second pediatric cardiologist, estimated the surgical mortality rate at 5-10% and noted that Down's Syndrome children face a higher than average risk of postoperative complications.
- Dr. French found that Phillip's pulmonary vessels had already undergone some change from high pulmonary artery pressure, making his specific case riskier for surgery than the average.
Procedural Posture:
- The juvenile probation department filed a petition in the juvenile court, alleging that Phillip B., a minor, came within the provisions of Welfare and Institutions Code section 300, subdivision (b), because his parents refused to consent to cardiac surgery for a congenital heart defect.
- The juvenile court dismissed the petition.
- The juvenile probation department appealed the order of dismissal to the California Court of Appeal, First District, Division Four, with Richard W. Bothman, as Chief Probation Officer, etc., et al. as appellants, and Warren B. et al. as respondents.
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Issue:
Does a juvenile court abuse its discretion by refusing to declare a child a dependent of the court, thereby allowing parents to refuse life-saving cardiac surgery, when there is conflicting medical evidence regarding the risks and benefits of the surgery for a child with Down's Syndrome, applying a "clear and convincing evidence" standard?
Opinions:
Majority - Caldecott, P.J.
No, the juvenile court did not abuse its discretion by refusing to declare Phillip B. a dependent child, as there was substantial evidence to support its decision not to intervene in the parents' refusal of surgery, based on the clear and convincing evidence standard. The court recognized that parental autonomy in child-rearing is constitutionally protected, though not absolute. The state, acting under the doctrine of parens patriae, has a duty to protect children and may intervene when parents fail to provide adequate medical care. However, the state carries a serious burden of justification to abridge parental autonomy. The court outlined factors to consider: the seriousness of the harm the child is suffering, the medical profession's evaluation of the treatment, the risks involved in medically treating the child, and the child's expressed preferences, all with the child's best interests as the underlying consideration. In Phillip's case, expert testimony indicated his surgery was riskier than average due to his Down's Syndrome and existing pulmonary vascular changes, with a 5-10% mortality rate. The trial court's decision involved balancing these risks and benefits. The appellate court's role is not to reweigh the evidence but to determine if any substantial evidence supports the trial court's conclusion. Given the conflicting evidence regarding the surgical risks for Phillip, the appellate court could not find, as a matter of law, that there was no substantial evidence to support the trial court's decision. The court also affirmed that the "clear and convincing evidence" standard of proof was correctly applied by the trial court in this dependency hearing.
Analysis:
This case reinforces the substantial deference courts give to parental autonomy in medical decision-making for their children, even in life-or-death situations. It establishes a high burden of proof ("clear and convincing evidence") and a multi-factor test that the state must satisfy before overriding parental medical choices. The decision highlights the appellate court's limited role in reviewing factual findings, particularly when the trial court carefully balanced complex medical risks and benefits. This precedent may make it more challenging for state child protective services to mandate risky, albeit potentially life-extending, treatments for children with severe disabilities against parental wishes, emphasizing a highly individualized assessment of the child's unique circumstances and the specific medical intervention proposed.
