Child welfare: Court may determine whether life-sustaining treatment should be withdrawn

In In re Christopher I., the California Court of Appeal upheld a juvenile court's decision to withdraw life-sustaining medical treatment for a then-1-year-old dependent of the court.1 Christopher I. had come under juvenile court custody after his biological father, Moises I., physically abused him and rendered him comatose. Christopher's biological mother, Tamara S., was either unwilling or unable to protect him.2 After the disposition hearing, Tamara petitioned for a "Do Not Resuscitate" (DNR) order for Christopher and/or removal of his life-sustaining medical treatment. Moises opposed, asserting that the juvenile court did not have authority to make medical decisions for a dependent child, for whom counsel had been assigned, without appointing a guardian.3 The juvenile court rejected Moises's argument and proceeded with an evidentiary hearing. All six physicians who testified supported the withdrawal of treatment or at least a DNR order.4 Christopher was in a persistent vegetative state, had no cognitive function, and, according to five of the six testifying physicians, would not improve with continued treatment (one physician offered no opinions on whether continued treatment would benefit Christopher).5 The juvenile court thus found clear and convincing evidence that withdrawal of life-sustaining treatment was in Christopher's best interest.

On appeal, Moises for the first time complained that the Orange County Social Services Agency did not provide adequate notice pursuant to the federal Indian Child Welfare Act when it initially took Christopher into protective custody.6 Moises also claimed that the juvenile court erred by failing to (1) examine Tamara's competency or (2) appoint a 0guardian ad litem for her.7 He did not challenge the sufficiency of the evidence, the clear and convincing standard of proof, or the "best interest of the child" standard.8

With respect to the statutory claim, Moises argued that Christopher was a member of the Pima Indian Tribe. Under the Indian Child Welfare Act, a tribe must receive notice of state actions that may separate a Native American child from his or her family.9 The appellate court dismissed the allegation of inadequate notice as irrelevant:

Any error on the part of [the Social Services Agency] in this case would be harmless. There is no reason to believe that Christopher is an Indian child, nor is there any reason to believe more notices over more time will result in any more information. Indeed ... two specific Pima tribes declined to assert any right to become involved in these proceedings, and determined that Christopher is not an enrolled member of the tribe or eligible for membership. Even if Christopher were an Indian child, his condition would prevent him from ever being a part of an Indian family or tribe, participating in the cultural heritage of an Indian tribe, or appreciating the values of Indian culture.10

Similarly, the court held that Tamara's competency posed no genuine concern.

[T]he determination for the juvenile court was whether Tamara could understand the nature of the proceedings against her and cooperate with counsel in protecting her interests. The evidentiary hearing regarding withdrawal of Christopher's life-sustaining medical treatment was not a proceeding against Tamara, and her best interests were not at issue.11

In short, the court's principal conclusions were that the juvenile court (1) had authority to make the medical decision in question after conducting a hearing, and (2) applied the correct evidentiary and substantive standards. Christopher's parents had forfeited their right to make decisions about his welfare. The juvenile court hence had parens patriae power to make such determinations.12 In that vein, the "best interests of the child" rather than a substituted judgment standard applied. A substituted judgment standard "permits a surrogate to make decisions regarding medical care based on what the patient would have chosen had he or she been competent."13 The court noted that Christopher, because of his age at the time he became comatose, "ha[d] never been competent to make his own decisions or express his emotions and feelings on the subject."14 As for clear and convincing evidence of a child's best interests, courts must consider such factors as (1) the child's physical, sensory, emotional, and cognitive capacities; (2) quality of life, life expectancy, and prognosis for recovery with and without treatment; (3) treatment options and their accompanying risks, side-effects, and benefits; (4) the nature and degree of physical pain or suffering resulting from the medical condition; (5) whether treatment causes or may cause pain, suffering, or serious complications; (6) the pain or suffering to the child if treatment is withdrawn; (7) whether the benefits from treatment outweigh the burdens to the child; (8) the likelihood that pain or suffering from withholding or withdrawal of treatment could be avoided or minimized; (9) the degree of humiliation, dependence, and loss of dignity resulting from the condition and treatment; (10) the opinions of the family, the reasons behind those opinions, and the reasons the family either has no opinion or cannot agree on a course of treatment; (11) the motivations of the family in advocating a particular course of treatment; and (12) the child's preference, if it can be ascertained.

Generally, the holding in Christopher I. suggests that juvenile courts will have clear authority to make pressing decisions about dependent minors when parents are unable to make those decisions, or have forfeited such rights. While juvenile courts might rarely exercise power over life and death, the logical conclusion is that if a court can make major determinations, it also has the power to make more minor decisions as well.