BY THE COURT.
This case concerns a 77-year old widow, Mrs. Rosaria Candura, of Arlington, who is presently a
We hold that Mrs. Candura has the right under the law to refuse to submit either to medical treatment or a surgical operation, that on the evidence and findings in this case the decision is one that she may determine for herself, and that therefore her leg may not be amputated unless she consents to that course of action.
The right of a person in most circumstances to decline treatment is clearly recognized in the important recent case of Superintendent of Belchertown State Sch. v. Saikewicz, 373 Mass. 728 (1977). "The constitutional right to privacy, as we conceive it, is an expression of the sanctity of individual free choice and self-determination as fundamental constituents of life. The value of life as so perceived is lessened not by a decision to refuse treatment, but by the failure to allow a competent human being the right of choice." Id. at 742. Although the Saikewicz case also recognizes certain countervailing interests of the State which may in some cases outweigh the right of a competent individual to refuse life saving or life prolonging treatment,
The principal question arising on the record before us, therefore, is whether Mrs. Candura has the legally requisite competence of mind and will to make the choice for herself. We look first to the findings of fact made by the judge who heard the testimony, including that of Mrs. Candura herself. His decision does not include a clear-cut finding that Mrs. Candura lacks the requisite legal competence. The nearest approach to such a finding is contained in the following passage from his decision:
"It is fair to conclude — without necessarily finding that the ward is mentally ill for all purposes — that she is incapable of making a rational and competent choice to undergo or reject the proposed surgery to her right leg. To this extent, at least, her behavior is irrational. She has closed her mind to the entire issue to the extent that the Court cannot conclude that her decision to reject further treatment is rational and informed.... In the absence of substantial evidence that the ward has come to her current position as a result of a rational process after careful consideration of the medical alternatives, the Court finds that her confused mental condition resulting from her underlying senility and depression warrants the exercise of the jurisdiction of this Court and the application of a substitute choice for the ward as enunciated in the [Saikewicz] case...."
In context, the quoted passage means only that, given some indications of a degree of senility and confusion on
The facts found by the judge or established by uncontradicted evidence are as follows. Mrs. Candura was born in Italy, emigrated to the United States in 1918, was married, and had a daughter and three sons. She lost her husband in 1976 and has been depressed and unhappy since that time. Her relationship with her children is marked by a considerable degree of conflict. She lived in her own home until her hospitalization in November, 1977. In 1974 she had an infection in a toe on her right foot which became gangrenous. It was discovered at that time that she was diabetic. The toe was amputated. In 1977 she bruised her right leg while getting into a bus. The bruise developed into gangrene which resulted in an operation in November, 1977, in which a portion of her right foot was amputated. At that time an arterial bypass was done to decrease the likelihood that gangrene would recur. She went from the hospital to a rehabilitation center, where she remained until April. She then returned to the hospital and was found to have gangrene in the remainder of the foot. She originally agreed to amputation of the leg, but she withdrew her consent on the morning scheduled for the operation. She was discharged on April 21 and went to her daughter's home but returned to the Symmes Hospital after a few days. Around May 9, responding to the persuasion of a doctor who has known Mrs. Candura for many years, she consented to the operation,
We start with the proposition that, in a proceeding for the appointment of a guardian under G.L.c. 201, § 6A or § 14 (permanent and temporary guardianships, respectively), the burden is on the petitioner to prove that the proposed ward is incompetent. Willett v. Willett, 333 Mass. 323, 324 (1955). A person is presumed to be competent unless shown by the evidence not to be competent. Howe v. Howe, 99 Mass. 88, 98-99 (1868). See Wright v. Wright, 139 Mass. 177, 182 (1885). Such evidence is lacking in this case. We recognize that Dr. Kelley, one of two psychiatrists who testified, did state that in his opinion Mrs. Candura was incompetent to make a rational choice whether to consent to the operation. His opinion appears to have been based upon (1) his inference from her unwillingness to discuss the problem with him that she was unable to face up to the problem or to understand that her refusal constituted a choice; (2) his characterization of "an unwilling[ness], for whatever reason, to consent to life saving treatment ... as suicidal"; and (3) a possibility, not established by evidence as a reasonable probability, that her mind might be impaired by toxicity caused by the gangrenous condition.
A careful analysis of the evidence in this case, including the superficially conflicting psychiatric testimony, indicates that there is no real conflict as to the underlying facts. Certainly, the evidence presents no issue of credibility. The principal question is whether the facts established by the evidence justify a conclusion of legal incompetence. The panel are unanimous in the opinion that they do not.
The decision of the judge, as well as the opinion of Dr. Kelley, predicates the necessity for the appointment of a guardian chiefly on the irrationality (in medical terms) of Mrs. Candura's decision to reject the amputation. Until she changed her original decision and withdrew her consent to the amputation, her competence was not questioned.
Mrs. Candura's decision may be regarded by most as unfortunate, but on the record in this case it is not the uninformed decision of a person incapable of appreciating the nature and consequences of her act. We cannot anticipate whether she will reconsider and will consent to the operation, but we are all of the opinion that the operation may not be forced on her against her will.
The order appointing a temporary guardian and the judgment authorizing the temporary guardian to consent to the operation are reversed, and a new judgment is to enter dismissing the petition.
Q. "Have you ever had any concern over her ability to rationalize clearly on questions?"
A. "To some extent but I would say the emotional factor in her just tuning out has as much to do with it if not more than perhaps any organic process."
Q. "So, you find her rational to a point and then tuning out as to other matters?"
A. "Yes. I've also seen her tuning out in direct relationship to the input that she is getting that is not acceptable to her."
Q. "[D]o you feel that you could say, in your experience having interviewed and talked with Mrs. Candura as often as you have, that she does understand the nature and consequences of her decision when she refuses to have surgery?"
A. "I certainly felt when I started to see her in the beginning that she did but at this point I think there are a lot of other issues that are tied up in this. The issue of control over her own life and the response she has to people trying to influence her, the negative response she has to that."