On January 17, 1987, Michael Martin, in his mid-twenties, was in a car-train accident in which he suffered multiple serious injuries, including a closed head injury affecting both hemispheres of his brain. Michael became almost totally paralyzed requiring a colostomy and artificially delivered nutrition and hydration. Because of his significant neurological impairments, he was unable to participate in decisions about his medical treatment. There was some evidence that Michael understood simple concepts and was able to interact with others and his environment to a very limited extent. Michael was not in a persistent vegetative state or terminally ill.
Prior to his accident, Michael had made numerous statements to his wife and co-workers that he would not want to live "like a vegetable" or be totally dependent on machines to live. Accordingly, Mrs. Martin, who had been appointed his guardian, sought to have his artificial nutrition and hydration stopped. The hospital where Michael was receiving treatment at the time for an intestinal obstruction told his wife that it would require a court order to withdraw the artificial nutrition and hydration. Michael’s sisters and mother opposed his wife’s petition to discontinue treatment, and sought to have her removed as his guardian.
The probate court which initially heard the case refused to grant Mrs. Martin’s request for an order to withdraw nutrition and hydration from Michael because he was not in a persistent vegetative state and because his prior statements about his medical treatment preferences were oral and not written. This court refused to remove Mrs. Martin as his guardian. All parties appealed, and in July, 1993, the appeals court instructed the probate court to rehear the matter to determine if Michael was incompetent to make medical treatment decisions. On rehearing, the probate court determined that Michael lacked decision-making capacity and therefore was incompetent. It also determined that his wife was the appropriate guardian and granted her an order to withdraw nutrition and hydration, based on a substituted judgment decision.
Dissatisfied with this result, Michael’s mother and sister appealed the case to the Michigan Supreme Court. On August 22, 1995, the Supreme Court reversed the Appeals Court’s order to remove treatment, holding that life sustaining medical treatment could not be removed from a formerly competent patient who had not made a living will or durable power of attorney for health care unless it could be shown by clear and convincing evidence, under what the Court referred to as a "purely subjective standard," that the patient would not want to receive treatment in the circumstances in which the patient now finds him or her self.
The Court stated that the "predominant factor" in defining clear and convincing evidence is a prior written directive in which the patient describes the situations in which he or she does not want medical intervention. While the Court strongly urged all persons to create written directives, it did not eliminate consideration of oral statements in determining whether evidence of prior wishes is clear and convincing: "[t]he amount of weight accorded to prior oral statements depends on the remoteness, consistency, specificity and solemnity of the prior statement." The court did, however, make the blanket pronouncement that casual statements made in response to seeing or hearing about another’s prolonged death do not fulfill the clear and convincing standard. Their definition of the clear and convincing standard follows:
The decision maker should examine the statement to determined whether it was a well thought out, deliberate pronouncement or a casual remark made in reaction to the plight of another. Statements made in response to seeing or hearing about another’s prolonged death do not fulfill the clear and convincing standard. Only when the patient’s prior statements clearly illustrate a serious, well thought out, consistent decision to refuse treatment under these exact circumstances, or circumstances highly similar to the current situation, should treatment be refused or withdrawn.
Michael Martin had never executed an advance directive (Michigan law does not recognize living wills per se and its Durable Power of Attorney for Healthcare legislation had not yet been enacted). Using the pure subjective test, that is, examining the oral statements that Michael had made to his family and co-workers prior to his accident regarding termination of life-sustaining treatment, the Supreme Court determined that there was not clear and convincing evidence that Michael would have wanted artificial nutrition and hydration stopped in the circumstances in which he now found himself. In the absence of clear and convincing evidence of a patient’s prior intention, the ruling implies that life-sustaining medical treatment should only be discontinued from a formerly competent patient if the patient is suffering from "pain, terminal illness, foreseeable death, a persistent vegetative state, or affliction of similar genre." Because it believed that Michael did not fall within any of these categories, the Court reversed the Appeal Court’s decision to grant Mrs. Martin’s petition to have the treatment discontinued. [Sources: In re Michael Martin, 200 Mich. App. 703, 1993; In re Michael Martin, a Legally Incapacitated Person, Michigan Supreme Court, Nos. 99699, 99700, August 22, 1995; ruling opinion by Conrad L. Mallett (6 votes); dissenting opinion by Charles L. Levin (1 vote).]
Principles & Concepts: autonomy, respect for autonomy, human dignity, informed consent, best interests, sanctity of life, proportionate/ disproportionate means, surrogate decision-making.
