ROGERS, C.J.
This appeal raised the question of whether Connecticut should recognize as a matter of our common law the "mature minor" doctrine, which allows a sufficiently mature minor to consent to or to refuse medical treatment. The threshold issue that we must resolve, however, is whether the trial court properly determined that Cassandra C., the minor daughter of the respondent mother (mother), was not competent to make her own medical decisions at the time of the underlying events. After certain medical providers reported to the Department of Children and Families (department) that Cassandra and her mother,
In sum, we conclude that the question of Cassandra's competence to make medical decisions was squarely before Judge Quinn and that her finding that Cassandra was not a mature minor was not clearly erroneous. We further conclude that, because the evidence does not support a finding that Cassandra was a mature minor under any standard, this is not a proper case in which to decide whether to adopt the mature minor doctrine. Finally, because the respondents have not established the factual predicate for their due process claims—that they were deprived of a hearing at which to determine Cassandra's competence to refuse medical treatment—we reject that claim.
The record reveals the following facts on which Judge Quinn reasonably could have relied in determining that Cassandra was not competent to make her own medical decisions and procedural history. Cassandra was born on September 30, 1997. From May, 2014 through July, 2014, when Cassandra was sixteen years old, she suffered from stomachaches, lower back pain, chest pain and an enlarged and tender cervical gland. When antibiotic treatment failed to resolve her condition, her primary care physician, Hemant K. Panchal, referred Cassandra to another physician, Henry M. Feder, an infectious disease specialist. After an initial appointment on July 1, 2014, Feder attempted to follow up with the respondents to determine whether the treatment he had prescribed was effective, but Cassandra missed two scheduled appointments. Feder finally saw Cassandra in early August, at which time he ordered a chest X ray that revealed
At that point, Cassandra was referred to the cancer and blood disorders services division of hematology and oncology at the Connecticut Children's Medical Center (medical center) in Hartford. An appointment was scheduled for September 4, 2014, but Cassandra did not show up. Another appointment was scheduled for September 9, at which Cassandra was examined by Eileen Gillan, a physician with the Connecticut Children's Specialty Group, who recommended that Cassandra undergo a biopsy procedure of an enlarged lymph node. On September 12, 2014, Brendan Campbell, a surgeon, performed an incisional biopsy on Cassandra's enlarged cervical gland. Pathological tests showed conclusively that Cassandra was suffering from Hodgkin's lymphoma, a type of cancer that is invariably fatal if not treated, but that has a high probability of cure if treated in a timely manner. Interrupting chemotherapy treatment of the disease can lead to resistance of the cancer to treatment. Delaying chemotherapy treatment may increase the risk of a poor outcome and may require radiation treatment, which has increased risks of harmful side effects, especially for young women.
On September 19, 2014, Gillan spoke by telephone with Cassandra's mother and informed her of the diagnosis. The mother was upset that Gillan had not called her earlier and by what she perceived as Gillan's attitude when she "nonchalantly" stated that she had been unsure how to break the bad news regarding Cassandra's diagnosis to the respondents. Gillan recommended that Cassandra undergo further evaluations to determine the stage of the cancer and to discuss treatment, but the mother refused.
At some point, Gillan asked her partner, Michael Isakoff, a pediatric oncologist, to take over Cassandra's treatment. Gillan told Isakoff that, on the basis of her interactions with the mother, she believed that Isakoff would be able to deal more effectively with her. Gillan also told Isakoff that the mother had been angry and hostile toward her and that the respondents were not interested in getting treatment or tests to determine the stage of the disease. Isakoff was able to schedule an appointment with the respondents to discuss these issues for October 7, 2014, but only Cassandra's mother and uncle attended that appointment. The mother was upset because she had been expecting to meet with Gillan. Isakoff explained the further testing and treatment that he recommended. When the mother expressed great concern about giving Cassandra "poisons," Isakoff acknowledged that the treatment had some toxic side effects, but explained that chemotherapy was the only way to treat the disease and that there were ways to reduce the toxicity. The mother also complained about the manner in which information had been relayed to her and other "process" issues, and was
The respondents sought a second opinion about Cassandra's diagnosis from Matthew Richardson, a pediatric oncologist at Baystate Medical Center in Springfield, Massachusetts. Richardson examined Cassandra on October 14, 2014, and, after reviewing the scans and pathology reports from the medical center, agreed with the diagnosis that Cassandra had Hodgkin's lymphoma. Richardson attempted to contact the respondents seven times over two days and left telephone messages regarding his diagnosis and the urgency of the situation. The mother finally returned his calls on October 20, 2014, and Richardson told her that it was urgent that the staging of Cassandra's cancer be completed and that treatment be started. The mother indicated that she had not yet decided whether Richardson would be Cassandra's treating physician. Two days later, the mother called Richardson and indicated that she wanted Richardson to treat Cassandra.
On October 23, 2014, a PET scan was performed that revealed extensive stage three lymphoma in Cassandra's neck, chest and abdomen. That same day, Richardson telephoned the mother and left a message on her telephone indicating that it was necessary to complete the staging evaluation and to start treatment, and that he was concerned that the period that had elapsed since the biopsy was beginning to be outside the standard of care. Richardson ultimately attempted to telephone the mother six times between October 25 and October 27, 2014, but received no answer. The mother finally telephoned Richardson on October 30, 2014, and stated that she had decided Cassandra would be receiving care from another physician. When Richardson asked where he should send Cassandra's medical records, the mother stated that she would pick them up. She also indicated that she did not have time to discuss the results of the PET scan and that Cassandra would not be following through with the pretreatment tests that had been scheduled.
Richardson spoke with Isakoff at some point and indicated that he had concerns about the mother's hostility and unwillingness to obtain treatment for Cassandra in a timely manner. In addition, Richardson told Isakoff that the respondents were seeking to have a second biopsy performed. Isakoff believed that a second biopsy was medically inappropriate because, even if it was negative, it would not invalidate the results of the first biopsy, and the biopsy procedure involves risk.
Meanwhile, on October 2, 2014, Feder had reported his concerns about the respondents' apparent unwillingness to obtain
During Nardelli's investigation of the case, Richardson called her and indicated that he was concerned that the respondents were not moving quickly enough to obtain treatment for Cassandra's disease and that they were consistently not keeping medical appointments. Panchal also called Nardelli and stated that the respondents were not keeping scheduled appointments. In addition, Panchal reported that the mother had told him that he would no longer be Cassandra's physician and had demanded her medical records.
On the basis of this information, the department became concerned that the mother was not following through in a timely manner to obtain treatment for Cassandra's life threatening illness. The department also became concerned about the mother's "anxiety" and that the mother did not always remember information that previously had been provided to her. Although the mother eventually attended scheduled meetings with the department, she continued to question Cassandra's diagnosis and to demand further assessments that Cassandra's medical providers had found to be inappropriate. On the basis of these concerns, the commissioner filed a neglect petition alleging that the mother had "failed to meet the medical needs" of Cassandra and sought an ex parte order of temporary custody pursuant to § 46b-129 (b). The trial court, Westbrook, J., found that there was reason to believe that Cassandra was in immediate physical danger and granted an ex parte order of temporary custody on October 31, 2014. Immediately thereafter, the department brought Cassandra to the emergency room at the medical center for an evaluation. At that time, Cassandra was "very fearful" of staying in the hospital and of waking up with
"tubes sticking out of her." She also expressed concerns about not wanting to anger her mother, who, she said, was very distrustful of physicians. Pursuant to Judge Westbrook's order, Cassandra was removed from her home and placed in the home of a cousin pending a hearing.
A preliminary hearing on the commissioner's request for an order of temporary custody was held on November 6, 2014, at which time Judge Westbrook ordered a guardian ad litem for Cassandra and scheduled an evidentiary hearing for November 12. At that evidentiary hearing, which took place before Judge Taylor, Nardelli, Feder, Campbell and Isakoff testified
Cassandra also testified at the November 12, 2014 hearing. Before she testified, her attorney requested the court's permission for her to testify from where she was sitting in the courtroom instead of from the witness stand, because she was nervous. When the trial court denied the request, the attorney requested permission to stand close to Cassandra "to give her a little comfort and moral support." The court also denied that request. Cassandra testified that her mother had told her many times that she did not want to lose a child and that
she wanted her to undergo chemotherapy. Cassandra initially did not want to undergo chemotherapy because of "everything that happens when you go through chemo." After her best friend told Cassandra that she did not want to lose her and would "drag [her] to the hospital and make [her] do it," however, Cassandra changed her mind. Because the treatment was going to be very difficult, Cassandra wanted to be at home while she was undergoing chemotherapy. If she were not allowed to go home, she would refuse treatment. When told that the department was concerned that, if she were allowed to go home, she would still refuse treatment, Cassandra stated that "[i]f you let me go home today, I would start chemo tomorrow."
Cassandra's mother testified at the hearing that she had wanted to obtain a second opinion about Cassandra's condition because she had "a right to a second opinion" and the first diagnosis was serious. When the respondents went to Richardson, the mother asked him not to contact Isakoff because she wanted a "second opinion, not a second agreement. . . ." She was upset when she found out that Richardson had spoken to Isakoff. After she discontinued Cassandra's treatment with Isakoff, the mother decided not to comply with the department's request to "keep in touch" because she "was doing what [she] was supposed to be doing." The mother testified that, although she continued to believe that she had a right to a second and even a third opinion about Cassandra's diagnosis, she believed that Cassandra had cancer and that she would die without treatment. She further testified that she "[a]bsolutely" agreed that Cassandra should be treated as soon as possible.
On November 14, 2014, Judge Taylor issued an order sustaining Judge Westbrook's order of temporary custody. The court ordered that Cassandra be placed back in her home with her mother subject to certain conditions, including that the mother allow the department unfettered access to Cassandra and her home, that she cooperate with Cassandra's medical providers and that she keep all medical appointments and appointments with the department. The court also ordered that Isakoff would serve as Cassandra's treating physician and that treatment was required to begin within seventy-two hours after Cassandra returned home. In addition, the court ordered that Cassandra remain within the state for the duration of this case and that she not leave her home
On November 17 and 18, 2014, Cassandra underwent her first two chemotherapy treatments. Her mother did not attend the second treatment. After the second treatment, Isakoff observed bruising around the site of the intravenous infusion. At that point, he told Cassandra that, because her veins were fragile, she would have to have a "port-a-cath"
Cassandra returned to her home on November 24, 2014, and, the next day, the department brought her to the medical center for an evaluation by Isakoff. Nardelli and two other department employees attended the meeting. Cassandra told Isakoff that she was adamant that she would not return for further chemotherapy. She stated that she did not feel sick and that when she started to feel sick she might reconsider her decision, but that she would not be treated at the medical center because she did not trust the physicians there. Isakoff told Cassandra that there was a danger that the cancer would become resistant if she interrupted the chemotherapy treatment. Cassandra then told Isakoff that she had never intended to start chemotherapy and that she had stated that she would do so in order to get the department and the court to agree to allow her to go home. She also stated that she was going to be eighteen years old soon, at which point she would not be in the position of being forced into treatment.
On December 1, 2014, the commissioner filed in the trial court a motion for
Cassandra's mother testified that she believed that Cassandra had cancer, that she believed that Cassandra needed chemotherapy, that she wanted Cassandra to have chemotherapy and that she had told Cassandra to undergo chemotherapy. She also testified, however, that she believed that it was Cassandra's "right as a human being" to refuse treatment and "to choose if she wants poisons that are going to affect her the rest of her life. . . ." When asked whether she knew that Cassandra would die without treatment, the mother stated, "[t]hat's what they say, but there's no guarantee with treatment of cancer. . . ."
At the conclusion of the hearing, Judge Quinn found that Cassandra's mother did not believe that Cassandra had Hodgkin's lymphoma or that she needed chemotherapy in order to have a chance to survive. Judge Quinn ordered that Cassandra remain in the custody of the department, that she be removed from her home and that the department make medical treatment decisions for her.
On December 17, 2014, the respondents filed in this court a joint motion for the emergency exercise of the court's supervisory power over the trial court. The respondents represented in their motion that Cassandra had been transferred to the medical center on December 9, 2014, and had not been permitted to leave since that time. They further represented that they had been informed that, on December 18, 2014, Cassandra's treatment would begin with the surgical placement of the port-a-cath and that chemotherapy would immediately follow. The respondents indicated that they had petitioned the trial court for an injunction against the treatment until they could file in this court an application to file an expedited appeal from Judge Quinn's December 9 ruling pursuant to
Thereafter, the commissioner filed a motion for an expedited articulation in which it requested that Judge Quinn articulate the basis for her December 9, 2014 ruling. Specifically, the commissioner requested that Judge Quinn specify: "(a) [t]he extent to which the trial court credited the testimony of . . . Isakoff in which [he] indicated that Cassandra did not have the capacity to make sound medical decisions concerning her cancer treatment, and (b) [t]o the extent that [Cassandra] and [her] mother have raised the `mature minor doctrine' on appeal, whether the trial court made a finding that the minor child was a mature minor." Judge Quinn issued an articulation in which she stated in response to part (a) of the request that she had credited Isakoff's testimony that Cassandra did not have the capacity to make sound medical decisions concerning her cancer treatment based on "[Cassandra's] apparent willingness to undergo treatment [during the November 12, 2014 hearing before Judge Taylor] while secretly knowing she would not, the consequences of such behavior on the efficacy of the future treatment, and the totality of all the facts she knew. . . ." Judge Quinn also stated that she had observed Cassandra's behavior at trial and "saw how closely she followed her mother's testimony and hung on her every word." Judge Quinn then observed that the mother "did not appear to be in support of the chemotherapy and that Cassandra is concerned about going against what her mother would like to see happen." She further observed that "[t]he record is replete with [the] mother's arguments with physicians about the diagnosis, her seeking three separate opinions about the diagnosis, attempting to change pediatricians and delaying follow-up appointments and needed treatment." Judge Quinn concluded that the "mother has engaged in a passive refusal to follow reasonable medical advice for her mortally ill child." She further concluded that Cassandra "does not possess the necessary level of maturity or independence to make life and death decisions about her own medical care, as demonstrated both by her conduct and her behavior subsequent to the initial court order," and that Cassandra was "overshadowed by the strong negative opinions her mother holds about her cancer diagnosis and treatment, including chemotherapy." In response to part (b) of the requested articulation, Judge Quinn stated that Isakoff's "thoughtful assessment of [Cassandra's] capacity, the court's own observations of the parties and the witnesses, the observations of the [department's] investigations worker, and Cassandra's own actions
The respondents contend on appeal that this court should adopt the mature minor doctrine, under which a sufficiently mature minor may be deemed competent to make important medical decisions on his or her own. They further contend that Judge Quinn's finding that Cassandra was not a mature minor and competent to make her own medical decisions was not supported by any evidence because that issue was not before the court at the December 9, 2014 hearing. Finally, they contend that removing Cassandra from her home and subjecting her to treatment against her will without a hearing to determine whether she was mature enough to make medical decisions for herself violated her liberty interest in bodily integrity under the due process provisions of the fifth amendment to the United States constitution and article first, §§ 8, 9 and 10, of the Connecticut constitution, violated the respondents' fundamental right to family integrity, and deprived the mother of her constitutionally protected interest in the care, custody and control of Cassandra.
We begin our analysis by setting forth the standard of review. Whether Cassandra is a mature minor and, as such, competent to make her own medical decisions is a question of fact. Belcher v. Charleston Area Medical Center, 188 W.Va. 105, 116, 422 S.E.2d 827 (1992) ("[w]hether a child is a mature minor is a question of fact"). Accordingly, Judge Quinn's finding that she was not mature is subject to review for clear error. American Car Rental, Inc. v. Commissioner of Consumer Protection, 273 Conn. 296, 309, 869 A.2d 1198 (2005). Whether the respondents' constitutional due process rights were violated is a question of law
We next review the governing legal principles. This court previously has not had the opportunity to address directly the question of whether and, if so, under what circumstances minors may be competent to make their own medical decisions. The United States Supreme Court has recognized, however, that "[m]ost children, even in adolescence, simply are not able to make sound judgments concerning many decisions, including their need for medical care or treatment. Parents can and must make those judgments." Parham v. J.R., 442 U.S. 584, 603, 99 S.Ct. 2493, 61 L.Ed.2d 101 (1979). Accordingly, "[a]t common law, minors generally were considered to lack the legal capacity to give valid con sent to medical treatment or services, and consequently a parent, guardian, or other legally authorized person generally was required to provide the requisite consent. In the absence of an emergency, a physician who provided medical care to a minor without such parental or other legally authorized consent could be sued for battery." American Academy of Pediatrics v. Lungren, 16 Cal.4th 307, 314-15, 940 P.2d 797, 66 Cal.Rptr. 210 (1997); see also id., at 315, 66 Cal.Rptr.2d 210, 940 P.2d 797 ("[t]he requirement that medical care be provided to a minor only with the consent of the minor's parent or guardian remains the general rule, both in California and throughout the United States").
Although this general common-law principle has not been expressly recognized by this court, it has been implicitly recognized by our legislature. For example, pursuant to General Statutes § 46b-150d, "a minor
With these principles in mind, we turn to the respondents' claims in the present case that Judge Quinn could not have determined that Cassandra was not a mature minor because that issue was not before her at the December 9, 2014 hearing and, even if the issue was before Judge Quinn, her finding that Cassandra was not a mature minor was not supported by
Moreover, although the burden was not on the department to show that Cassandra was not a mature minor, there was ample evidence to support Judge Quinn's express factual findings that Cassandra was not yet fully separated from or independent of her mother, that she was prone to engage in compulsive and risky actions, that she was unable or unwilling to speak her true mind to those in authority, and that she was reluctant to hold opinions that her mother did not share. Specifically, there was evidence: that Cassandra was extremely nervous and timid during the hearing before Judge Taylor, and that she was fearful during the medical evaluation at the medical center emergency room that followed the hearing; that the reasons that Cassandra did not want to undergo chemotherapy were that she was afraid of seeing "tubes sticking out of her" and that she did not yet feel sick, even though she had been told repeatedly that she would die without the treatment and that delaying treatment until she felt sick could have very serious consequences, potentially including her death; that Cassandra was very emotionally dependent on her mother, and was heavily influenced by her mother's distrust of physicians and other persons in positions of authority; that the respondents were influenced by their independent research into Hodgkin's lymphoma and its medical treatments, even after numerous physicians contradicted that research;
The respondents claim, however, that Judge Quinn improperly relied on Isakoff's testimony that Cassandra was not competent to make the decision rejecting treatment because that testimony was based on the "impossible position that an individual is proved incompetent to refuse medical care simply by the fact that she refuses medical care." The respondents concede that "[t]here is no dispute that Cassandra's refusal of treatment, if permitted, would be deleterious to her health," and they have pointed to no possible benefit that would have been gained if she had been permitted to refuse or delay treatment. Thus, they are effectively claiming that Cassandra had a right to reject lifesaving medical treatment for any reason or for no reason, and her assertion of this right had no bearing on the question of whether she was a mature minor. We disagree. Even if we were to assume that adults have the unfettered right to refuse lifesaving medical treatment, an issue that we need not address here, the law is clear that a seventeen year old does not have that right but, to the contrary, is presumed to be incompetent to do so, at least in the absence of proof of maturity. We conclude that it was well within Judge Quinn's discretion to credit Isakoff's eminently sensible opinion that Cassandra's assertion of her purported "right" to refuse the only treatment that could save her life for no reason except that it was her right to do so, did not constitute evidence of maturity, but its opposite.
We further conclude that the respondent's constitutional rights were not violated. Even if we were to assume that the mature minor doctrine applies, because the respondents were on notice that the purpose of the December 9, 2014 hearing before Judge Quinn was to determine Cassandra's competence to refuse lifesaving medical treatment and they had an opportunity to present evidence on that question, they have failed to estab the factual predicate of their claim that they were deprived of their constitutional due process rights to a hearing at which they could establish that Cassandra was a mature minor before she could be removed from the care and custody of her mother and subjected to forced medical treatment.
The judgment is affirmed.
In this opinion the other justices concurred.
The respondents suggest that Isakoff was not competent to evaluate whether Cassandra was sufficiently mature to make her own medical decisions because he was not a psychiatrist or psychologist. We disagree. Isakoff is a board certified pediatrician and has worked for more than nine years at the medical center, which specializes in treating children. In addition, he has taken courses in psychology and has had psychological training in helping families and patients to cope with a serious diagnosis. Even if we were to assume that the question of whether a minor is sufficiently mature to make medical decisions is a question that requires some specialized knowledge, and is not within the knowledge and experience of an ordinary person—a question that we do not decide here—we conclude that the issue is within the knowledge of an experienced pediatrician with psychological training who has treated the particular minor in question. See Belcher v. Charleston Area Medical Center, supra, 188 W.Va. at 115, 422 S.E.2d 827 (treating physician must exercise best medical judgment as to whether minor patient is sufficiently mature to be able to consent to treatment).
