Motion and Procedural Rulings.
It is ordered, sua sponte, that this cause is no longer held for the decision in 2008-2502, State v. Bodyke, ___ Ohio St.3d ___, 2010-Ohio-2424, ___ N.E.2d ___.
It is further ordered by the court that this cause is now held for the decisions in 2008-1624, In re Smith, Allen App. No. 1-07-58, 2008-Ohio-3234, 2009-0088, State v. Williams, Warren App. No. CA2008-02-029, 2008-Ohio-6195, and 2009-0189, In re Adrian R., Licking App. No. 08CA17, 2008-Ohio-6581, and the briefing schedule remains stayed.
duals to make decisions relating to their own health care as a "qualified" one).
Appellees challenge Appellants' contention that the guardianship statute provides authority, in and of itself, for plenary guardians to decline life-preserving treatment on behalf of an incompetent. Appellees explain that the powers withheld from a guardian are not limited to those specifically enumerated in Sections 5521(d) and (f), as Appellants assert. Rather, Section 5521(f) expressly provides that "[t]he court may not grant to a guardian powers controlled by other statute, including, but not limited to," those specifically identified in the statute and portrayed by Appellants as the exclusive restrictions. Id. § 5521(f) (emphasis added). Appellees also observe that, because the Act was implemented fourteen years after the guardianship statute, the latter obviously could not have accounted for the former. Therefore, Appellees maintain, a court cannot convert a guardian into a health care agent. Moreover, Appellees refute any contention that the Legislature overlooked guardianship interests in drafting Section 5462(c)(1), in view of the Act's multiple references to guardians and explicit delineation of the relationship between health care agents and guardians, see id. § 5460(a) (providing for the accountability of a health care agent to a guardian).
As concerns the Superior Court's decision, Appellees specifically take issue with its holding that the Act simply does not apply to persons who have always lacked competence. In this regard, Appellees argue that the Superior Court incorrectly treated a stated purpose of Chapter 54 — to provide a means for competent adults to control their health care through advance health care directives or health care representatives, see id. § 5423(a) — as the chapter's only aim. Appellees explain that the Act also explicitly provides for default surrogates not chosen by the principal, namely, health care representatives, without differentiating between persons who have always lacked competence and those who have lost their previous capacity to make medical decisions. See id. § 5461; supra note 3. Moreover, Appellees highlight that no explanation has been offered "why the General Assembly would value the life of a once-competent person over that of a never-competent person." Brief for Appellees at 6 n. 4.
Appellees posit that, in light of the plain language of Section 5462(c)(1), it is unnecessary to speculate as to the General Assembly's underlying intent. Nevertheless, they offer that the Legislature may have been focused on the specific involvement of the principal in creating and shaping the relationship in the agency situation, as contrasted with a guardianship scenario, in which the principal has no such opportunity. Additionally, Appellees believe, as do a number of their amid, that the statute reflects the concern that guardians do not always act in the best interest of incapacitated persons, despite their charge to do so. See, e.g., Clark v. Cohen, 613 F.Supp. 684, 699 (E.D.Pa. 1985), aff'd. 794 F.2d 79 (3d Cir. 1986). See generally Brief for Appellees at 16 ("[T]he legislature concluded that case-by-case determinations based on `quality of life' considerations — whether made by guardians or by courts of common pleas — would too often be wrongly decided, decided against life."). According to Appellees, any doubt as to whether a major goal of Section 5462(c)(1) was to protect disabled persons from such discrimination is eliminated by Section 5462(c)(2), which references the Americans with Disabilities Act, 42 U.S.C. § 12101, et seq. See 20 Pa.C.S. § 5462(c)(2).
Appellees also argue that, even assuming the Act is inapplicable to those who have never been competent to make personal medical decisions, the same result is reached under the common law rule. See In re Estate of Dorone, 517 Pa. 3, 9, 534 A.2d 452, 455 (1987).
Finally, citing Cruzan v. Director, Missouri Department of Health, 497 U.S. 261, 110 S.Ct. 2841, 111 L.Ed.2d 224 (1990), Appellees develop that a state may properly assert an unqualified interest in the preservation of human life to be weighed against the constitutionally protected interests of the individual. See id. at 282, 110 S.Ct. at 2853. Although Appellees highlight that no constitutional issues have been raised here, they believe that aspects of the Cruzan decision are illuminating.
Also aiding our review, amicus briefs have been submitted by: Disability Rights Network of Pennsylvania, the ARC of Pennsylvania, Achieva, Vision for Equality, Liberty Resources, Inc., Pennsylvania Developmental Disabilities Council, and Not Dead Yet; the Pennsylvania Medical Society and the Hospital and Healthsystem Association of Pennsylvania; and Dr. George Isajiw, Dr. John A. Flamini, Dr. John M. Travaline, Dr. Karl Benzio, and the Pennsylvania Family Institute.
The issue before us is one of statutory interpretation; it is therefore a question of law subject to plenary review by this Court to be conducted de novo. As neither party challenges the Superior Court's determination that the appeal falls within exceptions to the mootness doctrine, we decline to exercise our discretion to review that finding and proceed on that premise. Cf. Rendell v. Pa. State Ethics Comm'n, 603 Pa. 292, 309, 983 A.2d 708, 718 (2009).
In statutory interpretation, our task is to discern the intent of the Legislature, and the foremost indication of legislative intent is the plain language of the statute. See 1 Pa.C.S. § 1921(a)-(b); see, e.g., In re Erie Golf Course, 605 Pa. 484, 501, 992 A.2d 75, 85 (2010). Here, as Appellees amply develop, and as the orphans' court determined, Section 5462(c)(1) explicitly limits the category of persons empowered to refuse life-preserving medical treatment on behalf of an incompetent person who is not faced with an end-stage condition or permanent unconsciousness to health care agents. See 20 Pa.C.S. § 5462(c)(1). Although the Act provides certain powers to guardians and health care representatives, see, e.g., id. §§ 5460(b), 5461(c), it does not explicitly authorize either surrogate to object to life-preserving care under Section 5462(c)(1) in the noted circumstances. Cf. 1 Pa.C.S. § 1924 ("Exceptions expressed in a statute shall be construed to exclude all others.").
Chapter 54 reflects a careful legislative effort to balance various rights and interests in the sensitive arena of personal medical care provided to one who is not competent to assert his or her own rights. On the one hand, the statute manifests respect for advance health care directives, as well as the decisions of close relatives and friends, where the incompetent person suffers from an end-stage condition or permanent unconsciousness, and enables health care providers to comply with such decisions. See, e.g., 20 Pa.C.S. §§ 5423(a)(1), 5423(c)(4), 5426, 5431, 5456, 5462(c). The enactment, on the other hand, more sharply regulates the situation in which the incompetent person suffers from a life-threatening but treatable condition, obviously reflecting the Legislature's assertion of a policy position of greater state involvement to preserve life in such circumstances. As Appellees develop, Section 5462(c)(1) does allow for life-preserving medical treatment to be refused in such instances, but only by a health care agent (or the principal should he or she regain the capacity to make health care decisions). Moreover, since' a health care agent can only be designated by a competent principal, see id. § 5452(a) ("An individual of sound mind may make a health care power of attorney . . ."), we also agree with Appellees and the orphans' court that such refusal is unavailable in the case of one who has never been competent to delegate the act of personal medical decision-making in the first instance.
Also in line with Appellees' arguments and the orphans' court's decision, and for the reasons they have advanced, we agree that the guardianship statute does not alter this regime. Section 5521(d) and (f) of the Probate, Estates and Fiduciaries Code, by their own terms, do not provide the exclusive list of unauthorized acts for guardians. Rather, the proscription expressly subsumes acts forbidden of guardians under other statutes, such as Section 5462(c)(1). See id. § 5521(f).
We also agree that the Superior Court adopted too limited a perspective concerning the Act's scope. While the Act clearly reflects the express policy of empowering competent adults to effectuate advance health care directives, the provision for health care representation even in the absence of such directives, see id., § 5461, clearly conveys that the statute advances other purposes as well. Accordingly, we are unable to disregard the limitations inherent in Section 5462(c)(1)'s clearly-worded exception to the general requirement for treatment for life-threatening but curable medical conditions.
To the extent that Appellants argue that applying Section 5462(c)(1) to a lifelong incompetent implicates that person's common law right to refuse medical care, this Court has held that, "[w]here the Legislature expressly provides a comprehensive legislative scheme, these provisions supersede the prior common law principles." Sternlicht v. Sternlicht, 583 Pa. 149, 163, 876 A.2d 904, 912 (2005). Thus, by virtue of that provision, which requires that life-preserving treatment must be provided to an incompetent who is not suffering from end-stage medical condition or permanent unconsciousness and has not appointed a health care agent, the Legislature has supplanted the common law right to refuse medical treatment in these instances.
With regard to Appellants' argument that the accountability provision of the Act demonstrates a legislative intent to afford guardians powers at least coextensive with the health care agent, since that section subordinates a health care agent's decision-making authority to that of a guardian, see id. § 5460(a), we disagree. Section 5460(a) can readily be construed as providing an additional layer of protection to incompetent persons, as a health care agent may be deprived of the power to make life-ending decisions by a guardian. Moreover, although the statute expressly affords a guardian the ability to "revoke" or "amend" the appointment of a health care agent, see id., it does not confer the power to appoint such an agent in the first instance. This dovetails with the plain-meaning interpretation of the overall enactment reflected in Appellees' arguments and the orphans' court's decision — the Act simply does not allow for the refusal of life-preserving care to one who has never had the ability to appoint a health care agent and does not suffer from an end-stage condition or permanent unconsciousness.
We recognize Appellants' concern with the possibility that David may face additional medical interventions which they may quite reasonably regard as painful and intrusive. Further, we make no policy-oriented criticism of the position Appellants have taken, which we have no doubt reflects deeply held beliefs arising out of their personal experience with David's profound disability and ongoing medical needs. We find only that the salient policy decision has been made by the Legislature, in Section 5462(c)(1) of the Act, as is its prerogative as the policy-setting branch. See Program Admin. Servs., Inc. v. Dauphin County Gen. Auth., 593 Pa. 184, 192, 928 A.2d 1013, 1017-18 (2007). In the absence of meritorious arguments grounded in the Constitution, the courts are bound to enforce the statutory qualifications on David's right to control his treatment as exercised by his guardians.
We hold that where, as here, life-preserving treatment is at issue for an incompetent person who is not suffering from an end-stage condition or permanent unconsciousness, and that person has no health care agent, the Act mandates that the care must be provided.
The Pennsylvania Medical Society and the Hospital and Healthcare Association of Pennsylvania, as amici, have submitted a brief centrally focused on their concern that the Superior Court's holding, broadly read, might unduly impinge on statutorily authorized surrogate decision-making in the end-of-life and permanent-unconsciousness scenarios. Nothing in this matter should be so read, as Appellants obviously favor broad decision-making powers on behalf of surrogates; Appellees have consistently expressly distinguished the "life-sustaining treatment" scenario as being "radically different" from that involving a life-threatening but curable condition; and thus, a "life-sustaining treatment" situation has never been before the courts in this case. See generally Commonwealth v. McCann, 503 Pa. 190, 195, 469 A.2d 126, 128 (1983) (reflecting the axiom that the holding of an opinion is to be read against the facts that are before the court).
The order of the Superior Court is affirmed, albeit we have disapproved a portion of its reasoning. Jurisdiction is relinquished.
Chief Justice CASTILLE, Justices EAKIN, BAER, TODD, McCAFFERY and ORIE MELVIN join the opinion.