In re Cassandra C. ( 2015 )

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IN RE CASSANDRA C.*
(SC 19426)
Rogers, C. J., and Palmer, Zarella, Eveleigh, McDonald, Espinosa and
Robinson, Js.
Argued January 8—officially released January 8, 2015**
Michael S. Taylor, assigned counsel, with whom was
James P. Sexton, assigned counsel, for the appellant
(respondent mother).
Joshua Michtom, assigned counsel, for the appellant
(minor child).
John E. Tucker, assistant attorney general, with
whom were Rosemarie T. Webber, assistant attorney
general, and, on the brief, George Jepsen, attorney gen-
eral, and Benjamin Zivyon and Michael Besso, assis-
tant attorneys general, for the appelllee (petitioner).
Daniel J. Krisch, Sandra Staub and David McGuire
filed a brief for the American Civil Liberties Union Foun-
dation of Connecticut as amicus curiae.
Opinion
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 prop-
erly 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,1 were
refusing to obtain appropriate medical treatment for
Cassandra, who had been diagnosed with Hodgkin’s
lymphoma, the petitioner, the Commissioner of Chil-
dren and Families (commissioner), filed a neglect peti-
tion seeking an order of temporary custody of
Cassandra pursuant to General Statutes § 46b-129 (a)
and (b). The trial court, Westbrook, J., granted the order
placing Cassandra in the temporary custody of the
department and ordered that Cassandra be removed
from the residence where she lived with her mother
and be placed in her cousin’s home. After conducting
an evidentiary hearing, the trial court, Taylor, J., sus-
tained the order of temporary custody and ordered that
Cassandra be placed back in her own home on the
condition the respondents allow the department to have
unfettered access to Cassandra and that the respon-
dents cooperate with her medical care providers. Cas-
sandra subsequently started chemotherapy, but ran
away from home before the treatment could be com-
pleted. The commissioner then filed a motion to rear-
gue, for reconsideration, for clarification and to reopen
the evidence ‘‘in order to consider evidence regarding
[Cassandra’s] subsequent behaviors and whether she is
competent to make life/death decisions regarding her
medical care.’’ That motion was granted and an eviden-
tiary hearing was held before the trial court, Quinn, J.
At the conclusion of the hearing, Judge Quinn ordered
that Cassandra remain in the custody and care of the
department and that she be removed from her home,
and authorized the department to make all medical
decisions for her. Thereafter, the respondents filed this
appeal2 claiming that Judge Quinn improperly had found
that Cassandra was not competent to make her own
medical decisions and had violated the respondents’
constitutional due process right to bodily and family
integrity. After hearing oral argument on an expedited
basis, this court affirmed Judge Quinn’s judgment from
the bench and indicated that a written decision would
be issued in due course. This is that written decision.
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 suf-
fered from stomachaches, lower back pain, chest pain
and an enlarged and tender cervical gland. When antibi-
otic treatment failed to resolve her condition, her pri-
mary care physician, Hemant K. Panchal, referred
Cassandra to another physician, Henry M. Feder, an
infectious disease specialist. After an initial appoint-
ment 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 Cassan-
dra in early August, at which time he ordered a chest
X ray that revealed enlarged lymph nodes. At that point,
Feder suspected that Cassandra might have cancer and
he scheduled an appointment for a needle biopsy of
her enlarged cervical gland. Cassandra did not attend
the appointment, which concerned Feder. Feder sched-
uled a second appointment at which a needle biopsy
was taken that was suspicious for lymphoma.
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 Chil-
dren’s Specialty Group, who recommended that Cassan-
dra 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 con-
clusively 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.3
On September 19, 2014, Gillan spoke by telephone
with Cassandra’s mother and informed her of the diag-
nosis. 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 Cassan-
dra’s diagnosis to the respondents. Gillan recom-
mended that Cassandra undergo further evaluations to
determine the stage of the cancer and to discuss treat-
ment, but the mother refused.
At some point, Gillan asked her partner, Michael Isa-
koff, 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 treat-
ment that he recommended. When the mother
expressed great concern about giving Cassandra ‘‘poi-
sons,’’ Isakoff acknowledged that the treatment had
some toxic side effects, but explained that chemother-
apy 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 angry and hostile toward Isakoff. She further
indicated that she did not believe the diagnosis and
asked about getting a second opinion. Specifically, she
questioned why the biopsy report showed no signs of
the Epstein-Barr virus when, based on her research,
that virus is always present with Hodgkin’s lymphoma.
Isakoff repeatedly assured the mother that that was not
the case, but Isakoff was not convinced that she was
comfortable with his response. Toward the end of the
conversation, Isakoff told the mother bluntly that he
was very concerned about the amount of time that had
elapsed since the biopsy and that it was important for
Cassandra to start treatment within two weeks. He
asked the mother to contact him within two days to let
him know how she wanted to proceed. At that point,
the mother got up and walked out. On October 17, 2014,
Isakoff wrote a letter to Cassandra’s mother to express
his concerns about the ongoing delays in the evaluation
and treatment of Cassandra’s disease and asked her to
contact his office as soon as possible.
The respondents sought a second opinion about Cas-
sandra’s diagnosis from Matthew Richardson, a pediat-
ric 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 regard-
ing 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 Cassan-
dra’s treating physician. Two days later, the mother
called Richardson and indicated that she wanted Rich-
ardson to treat Cassandra.
On October 23, 2014, a PET scan was performed that
revealed extensive stage three lymphoma in Cassan-
dra’s neck, chest and abdomen. That same day, Richard-
son 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 tele-
phoned 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 hos-
tility and unwillingness to obtain treatment for Cassan-
dra in a timely manner. In addition, Richardson told
Isakoff that the respondents were seeking to have a
second biopsy performed. Isakoff believed that a sec-
ond 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 unwill-
ingness to obtain treatment for Cassandra’s disease to
the department. At that point, Margaret Nardelli, an
investigator for the department, contacted the mother
to discuss the referral. The mother indicated that she
was not willing to meet with the department and that
she was meeting Cassandra’s needs. She also stated that
she was obtaining a second opinion about Cassandra’s
condition. When Nardelli tried to follow up, the mother
did not return her telephone calls. Finally, on October
21, 2014, Nardelli left a note at the respondents’ resi-
dence. At that point, the mother called Nardelli. She
was very upset and was yelling and swearing. The
mother told Nardelli that she was not allowed to go to
her home ever again, that Cassandra’s needs were being
met, and that she did not have to tell Nardelli anything or
do anything that the department requested. The mother
also told Nardelli that Cassandra felt fine and that she,
the mother, did not think that Cassandra had cancer.
Nardelli responded that if the mother did not want to
meet with the department, Nardelli would speak with
an attorney for the department about ways to ensure
that Cassandra’s needs were being met. The mother
said that she did not care what the department did and
hung up the telephone.
During Nardelli’s investigation of the case, Richard-
son 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 appoint-
ments. 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 informa-
tion that previously had been provided to her. Although
the mother eventually attended scheduled meetings
with the department, she continued to question Cassan-
dra’s diagnosis and to demand further assessments that
Cassandra’s medical providers had found to be inappro-
priate. On the basis of these concerns, the commis-
sioner 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 Cassan-
dra 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 Novem-
ber 6, 2014, at which time Judge Westbrook ordered
a guardian ad litem for Cassandra and scheduled an
evidentiary hearing for November 12. At that eviden-
tiary hearing, which took place before Judge Taylor,
Nardelli, Feder, Campbell and Isakoff testified as to
the foregoing facts. Cassandra’s guardian ad litem, Jon
David Anthony Reducha, testified that Cassandra had
told him the previous day that she was willing to be
treated for her disease, but that she would refuse treat-
ment if she were not allowed to go home. Reducha
acknowledged that Cassandra’s decision to refuse treat-
ment for her life threatening disease if she were not
allowed to go home was not a rational decision. It was
Reducha’s understanding that Cassandra initially had
resisted treatment because she was doing her own
research and she needed time to absorb the informa-
tion. Reducha believed that it would be in Cassandra’s
best interest to be allowed to go home so that she would
agree to treatment.
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 Cassan-
dra’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 with-
out treatment. She further testified that she ‘‘[a]bso-
lutely’’ 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 cus-
tody. The court ordered that Cassandra be placed back
in her home with her mother subject to certain condi-
tions, 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 for more than twelve hours without the prior
authorization of the department or the court.
On November 17 and 18, 2014, Cassandra underwent
her first two chemotherapy treatments. Her mother did
not attend the second treatment. After the second treat-
ment, 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’’4 surgically placed. Isakoff arranged
for a surgeon to perform the procedure the next morn-
ing so that Cassandra could receive her scheduled treat-
ment later that day. When a department employee
arrived at the respondents’ home on the morning of
November 19, 2014, to transport Cassandra to her third
chemotherapy treatment, Cassandra was not there. Her
mother indicated that she did not know Cassandra’s
whereabouts. She made no efforts to find Cassandra
and did not notify the police. The mother told the
department that Cassandra would not be coming home.
During the next several days, the department went to
the respondents’ home on a daily basis to search for
Cassandra, and also went to the home of one of Cassan-
dra’s friends and to her workplace. The department
also issued a ‘‘silver alert’’5 and searched online social
media in an attempt to locate Cassandra. Several days
after she disappeared, Cassandra’s attorney called the
department and stated that she wanted to return home.
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 chemo-
therapy 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 reargument and reconsideration,
for clarification and to reopen evidence. The commis-
sioner requested that the trial court conduct a hearing
‘‘to consider evidence regarding [Cassandra’s] subse-
quent behaviors and whether she is competent to make
life/death decisions regarding her medical care.’’ An
evidentiary hearing for that purpose was held before
Judge Quinn on December 9, 2014.6 Isakoff testified at
the hearing that he did not believe that Cassandra was
competent to make the decision to refuse chemother-
apy treatment for her disease. Indeed, he testified that,
if an adult were to make that decision, it would lead him
to question that person’s competence. Isakoff believed
that it was unreasonable for Cassandra to subject her-
self to chemotherapy in order to be allowed to return
home, especially if she intended to worsen her own
prognosis by interrupting the treatment, but to refuse
further chemotherapy to cure her fatal disease. He fur-
ther testified that if Cassandra did not start chemother-
apy within two weeks of the hearing, there would be
a much higher probability that Cassandra would have
to undergo radiation therapy. Isakoff also did not
believe that Cassandra’s mother was competent to
make decisions regarding Cassandra’s medical care.
Although he understood the mother’s concerns about
putting ‘‘poisons’’ in Cassandra’s body, the chemother-
apy treatment provided Cassandra with her only chance
of survival. Isakoff further testified that the mother’s
doubts about the diagnosis also were unreasonable, as
the diagnosis had been repeatedly confirmed.
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 chemo-
therapy 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 deci-
sions 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 Decem-
ber 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 treat-
ment would begin with the surgical placement of the
port-a-cath and that chemotherapy would immediately
follow. The respondents indicated that they had peti-
tioned the trial court for an injunction against the treat-
ment until they could file in this court an application to
file an expedited appeal from Judge Quinn’s December 9
ruling pursuant to General Statutes § 52-265a, and that
Judge Taylor had denied the petition. They contended
that Cassandra had a right to refuse treatment under
the mature minor doctrine and requested that this court
enjoin the treatment until further order of this court.
This court treated the respondents’ motion as a motion
for review of a denial of an emergency motion for a
stay and, after the commissioner filed an expedited
response to the motion pursuant to this court’s order,
denied the motion. The respondents then filed an appli-
cation for certification to appeal to this court from
both Judge Taylor’s November 14, 2014 ruling and from
Judge Quinn’s December 9, 2014 ruling, pursuant to
§ 52-265a. They also filed an appeal in the Appellate
Court. The Chief Justice denied the respondents’ appli-
cation pursuant to § 52-265a, but we ordered that the
respondents’ appeal to the Appellate Court be trans-
ferred to this court and that it be heard on an expe-
dited basis.7
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 sup-
port of the chemotherapy and that Cassandra is con-
cerned 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 treat-
ment.’’ Judge Quinn concluded that the ‘‘mother has
engaged in a passive refusal to follow reasonable medi-
cal advice for her mortally ill child.’’ She further con-
cluded 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 ‘‘over-
shadowed by the strong negative opinions her mother
holds about her cancer diagnosis and treatment, includ-
ing 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 wit-
nesses, the observations of the [department’s] investiga-
tions worker, and Cassandra’s own actions all support
the conclusion that she is an immature seventeen year
old.’’ Accordingly, she concluded that ‘‘Cassandra is
not a mature minor. She is as yet incapable of acting
independently concerning her own life threatening med-
ical condition. And time is running out for the recom-
mended course of treatment to have a positive outcome
for her future.’’8
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 provi-
sions of the fifth amendment to the United States consti-
tution 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.9 We conclude that the ques-
tion of Cassandra’s competence to make medical deci-
sions 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 respon-
dents have not established the factual predicate for
their due process claim—that they were deprived of a
hearing at which to determine Cassandra’s competence
to refuse medical treatment—we reject that claim.
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. Ameri-
can 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 over which
our review is plenary. Commissioner of Environmental
Protection v. Farricielli, 307 Conn. 787, 819, 59 A.3d
789 (2013) (‘‘[w]hether [a party] was deprived of his
due process rights is a question of law, to which we
grant plenary review’’ [internal quotation marks
omitted]).
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 pro-
vided 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., 315 (‘‘[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 minor10
[who] is emancipated . . . (1) . . . may consent to
medical, dental or psychiatric care, without parental
consent, knowledge or liability . . . .’’ (Emphasis
added; footnote added.) Thus, under the ‘‘tenet of statu-
tory construction referred to as expressio unius est
exclusio alterius, which may be translated as the
expression of one thing is the exclusion of another’’;
(internal quotation marks omitted) Felician Sisters of
St. Francis of Connecticut, Inc. v. Historic District
Commission, 284 Conn. 838, 851, 937 A.2d 39 (2008);
it is implicit that unemancipated minors do not have this
ability. Similarly, other statutes providing that under
specific, narrowly limited circumstances, minors may
make medical decisions clearly imply legislative recog-
nition of the common-law principle that they generally
are not competent to do so.11 We conclude, therefore,
that the general rule in this state is that minors are
presumed to be incompetent to make medical deci-
sions.12 A number of courts have concluded, however,
that there is an exception to this general common-law
principle for mature minors. See In re E.G., 133 Ill. 2d
98, 111, 549 N.E.2d 322 (1989) (‘‘[i]f the evidence is
clear and convincing that the minor is mature enough
to appreciate the consequences of her actions, and that
the minor is mature enough to exercise the judgment
of an adult, then the mature minor doctrine affords her
the common law right to consent to or refuse medical
treatment’’); In re Swan, 569 A.2d 1202, 1205 (Me. 1990)
(minor has capacity to consent to withholding of medi-
cal treatment when ‘‘the minor has the ability of the
average person to understand and weigh the risks and
benefits’’ and ‘‘if he is capable of appreciating the
nature, extent, and probable consequences of the con-
duct consented to’’ [internal quotation marks omitted]);
Cardwell v. Bechtol, 724 S.W.2d 739, 748 (Tenn. 1987)
(‘‘Whether a minor has the capacity to consent to medi-
cal treatment depends upon the age, ability, experience,
education, training, and degree of maturity or judgment
obtained by the minor, as well as upon the conduct
and demeanor of the minor at the time of the incident
involved. Moreover, the totality of the circumstances,
the nature of the treatment and its risks or probable
consequences, and the minor’s ability to appreciate the
risks and consequences are to be considered.’’); Belcher
v. Charleston Area Medical Center, supra, 188 W. Va.
116 (‘‘[W]e hold that, except in very extreme cases, a
physician has no legal right to perform a procedure
upon, or administer or withhold treatment from a . . .
child without the consent of the child’s parents or guard-
ian, unless the child is a mature minor, in which case
the child’s consent would be required. Whether a child
is a mature minor is a question of fact. Whether the
child has the capacity to consent depends upon the age,
ability, experience, education, training, and degree of
maturity or judgment obtained by the child, as well as
upon the conduct and demeanor of the child at the time
of the procedure or treatment. The factual determina-
tion would also involve whether the minor has the
capacity to appreciate the nature, risks, and conse-
quences of the medical procedure to be performed, or
the treatment to be administered or withheld.’’); see
also In the Matter of Rena, 46 Mass. App. 335, 337, 705
N.E.2d 1155 (1999) (court may ‘‘consider the maturity
of the child to make an informed choice’’ when
determining whether refusal of medical treatment is in
child’s best interest).
With these principles in mind, we turn to the respon-
dents’ 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 the evidence. We
disagree. For purposes of the mature minor doctrine,
a mature minor is a minor who is competent to make
medical decisions. As we have explained, the very rea-
son that the commissioner asked for the December 9,
2014 hearing was to determine Cassandra’s competence
to refuse chemotherapy treatment for her cancer.
Accordingly, the issue of whether Cassandra was suffi-
ciently mature to make this decision despite the fact
that she was a minor was squarely before the court.
Under the authority previously set forth, there is a legal
presumption that Cassandra was not competent to
make the life or death decision whether to undergo
chemotherapy treatment for her cancer because she
was a minor, and the burden was therefore on the
respondents to establish that she was sufficiently
mature to do so. Because the respondents failed to
produce any evidence on that factual issue, despite
being on notice that that was the purpose of the hearing,
there was no basis for Judge Quinn to find that Cassan-
dra was a mature minor under any standard.13 Accord-
ingly, we conclude that her finding that Cassandra was
not competent to make her own medical decisions was
not clearly erroneous.
Moreover, although the burden was not on the depart-
ment 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 reluc-
tant 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 medi-
cal evaluation at the medical center emergency room
that followed the hearing; that the reasons that Cassan-
dra 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 depen-
dent 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 influ-
enced by their independent research into Hodgkin’s
lymphoma and its medical treatments, even after
numerous physicians contradicted that research;14 that
Cassandra had intentionally misrepresented her inten-
tions to Judge Taylor and the department when she
stated that she was willing to undergo treatment; and
that Cassandra intentionally violated Judge Taylor’s
order and placed her own health at serious risk when
she interrupted chemotherapy and ran away from
home. In turn, Judge Quinn’s factual findings amply
support her ultimate determination that Cassandra was
not a mature seventeen year old and, therefore, was
not competent to make her own medical decisions.
The respondents claim, however, that Judge Quinn
improperly relied on Isakoff’s testimony that Cassandra
was not competent to make the decision rejecting treat-
ment because that testimony was based on the ‘‘impos-
sible 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 treat-
ment 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 pur-
ported ‘‘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.15 Accordingly, we conclude that the record
amply supports Judge Quinn’s ultimate finding that Cas-
sandra was not a mature seventeen year old, and, there-
fore, was not competent to refuse a course of medical
treatment that would provide her with her only chance
of survival.16 Thus, there is no need for us to reach the
question of whether we should adopt the mature minor
doctrine because, even if we were inclined to do so,
the doctrine would not apply to Cassandra.
We further conclude that the respondent’s constitu-
tional 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 pre-
sent evidence on that question, they have failed to estab-
lish 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.17 Although the respondents
contend that the December 9, 2014 hearing did not
comply with constitutional due process requirements
because there was no expert testimony regarding Cas-
sandra’s decision-making capacity, the burden was on
them to prove that Cassandra was competent. They
make no claim that they were prohibited from pre-
senting such evidence.18 Accordingly, even if we were
to assume that the respondents had a constitutional
right to present expert testimony, they were not
deprived of that right.
The judgment is affirmed.
In this opinion the other justices concurred.
* In accordance with the spirit and intent of General Statutes § 46b-142
(b) and Practice Book § 79a-12, the names of the parties involved in this
appeal are not disclosed. The records and papers of this case shall be open
for inspection only to persons having a proper interest therein and upon
order of the Appellate Court.
** January 8, 2015, the date that the order was issued in this case, is the
operative date for all substantive and procedural purposes.
1
For purposes of convenience, references herein to both the mother and
Cassandra jointly are to the respondents.
2
The respondents appealed from the judgment of the trial court to the
Appellate Court, and we transferred the appeal to this court pursuant to
General Statutes § 51-199 (c) and Practice Book § 65-1.
3
Matthew Richardson, a pediatric oncologist from whom the respondents
subsequently sought a second opinion, explained in a report that if treatment
is delayed, the cancer can spread to other lymph nodes and other parts of
the body. As the affected lymph nodes continue to grow, they can compress
vital structures such as veins and airways, which can be fatal. In addition,
the larger the affected lymph nodes are when chemotherapy starts, the
greater is the risk of a condition known as tumor lysis syndrome, which
can result in heart arrhythmias and kidney failure.
4
A ‘‘port-a-cath’’ is ‘‘[a] central venous catheter . . . that goes into a vein
in [the patient’s] chest . . . .’’ United States National Library of Medicine,
‘‘MedlinePlus, Central Venous Catheters—Ports,’’ available at http://
www.nlm.nih.gov/medlineplus/ency/patientinstructions/000491.htm (last
visited April 10, 2015).
5
‘‘The Silver Alert system . . . [is] an emergency notification system for
law enforcement agencies to broadcast local, regional, or statewide public
alerts via radio, television and electronic highway signs. The Silver Alert
system mandates that law enforcement immediately begin searching for
missing individuals who are ages [sixty-five] or older, or ages [eighteen]
and over if mentally impaired. Once the police receive a missing person’s
report and a description of the missing person, the information is broadcast
via radio, television, and electronic highway signs through the Emergency
Alert System . . . . The plan alerts the public as quickly as possible to the
disappearance so everyone may assist in the search for the safe return of
the individual.’’ State of Connecticut, Department on Aging, ‘‘Connecticut
Silver Alert System—An Elderly And Or Mental Impairment Locator System,’’
(last modified on December 5, 2011), available at http://www.ct.gov/agingser-
vices/cwp/view.asp?Q=442724&A=2513 (last visited April 10, 2015).
6
A transcript of the November 12, 2014 hearing was introduced as an
exhibit at the December 9, 2014 hearing before Judge Quinn. Although the
exhibits that had been introduced at the November 12 hearing were not
introduced as exhibits at the December 9 hearing, they were part of the
court file that was before Judge Quinn.
7
We also granted permission to the American Civil Liberties Union Foun-
dation of Connecticut to file an amicus curiae brief in support of the respon-
dents’ position.
8
The respondents filed a motion for review of Judge Quinn’s articulation,
claiming that the issue of whether Cassandra is a mature minor had not been
raised at the hearing before Judge Quinn. They claimed that the articulation
should be disregarded. This court granted the motion but denied the
requested relief.
9
The respondents point out that they did not expressly rely on the mature
minor doctrine at the December 9, 2014 hearing before Judge Quinn and
that their constitutional claims are also unpreserved. Accordingly, they seek
review of their claims pursuant to State v. Golding, 213 Conn. 233, 239–40,
567 A.2d 823 (1989). Because the respondents were on notice that the issue
of Cassandra’s competence to make medical decisions would be addressed
at the evidentiary hearing before Judge Quinn, we conclude that the issue
of whether Cassandra was sufficiently mature to make medical decisions
was not unpreserved. Rather, the respondents failed to present evidence
on the issue. Because the respondents had a hearing on the issue, there is,
as we discuss more fully later in this opinion, no basis for their constitu-
tional claims.
10
‘‘Except as otherwise provided by statute, on and after October 1, 1972,
the terms ‘minor’, ‘infant’ and ‘infancy’ shall be deemed to refer to a person
under the age of eighteen years and any person eighteen years of age or
over shall be an adult for all purposes whatsoever and have the same legal
capacity, rights, powers, privileges, duties, liabilities and responsibilities as
persons heretofore had at twenty-one years of age, and ‘age of majority’
shall be deemed to be eighteen years.’’ General Statutes § 1-1d.
11
See General Statutes § 17a-688 (d) (minor may consent to treatment for
drug and alcohol addiction); General Statutes § 19a-216 (a) (minor may
obtain treatment for venereal disease without parental consent); General
Statutes § 19a-285 (a) (minor may consent to medical treatment of minor’s
child); General Statutes § 19a-592 (a) (minor may be treated for human
immunodeficiency virus infection without parental consent if notification of
parent will result in treatment being denied or if minor will refuse treatment if
parents are notified); General Statutes § 19a-601 (minor may have abortion
without parental consent).
12
We emphasize that we merely conclude that, by enacting statutes provid-
ing that minors may consent to medical treatment only in certain limited
circumstances, the legislature has implicitly recognized the common-law
rule that minors are presumed to be incompetent to make medical decisions.
We leave for another day the question of whether the legislature intended
that this would be a conclusive presumption in the absence of a statutory
exception and, therefore, the courts are precluded from allowing minors to
rebut the presumption under the mature minor doctrine. Accordingly, we
need not address the amicus’ argument that, because many statutes treat
sixteen and seventeen years olds in the same manner as adults, minors of
that age are entitled to a hearing on the question of whether they are
sufficiently mature to make medical decisions.
13
Cassandra testified at the November 12, 2014 hearing that she has
worked since she was fourteen years old and pays some of her own bills.
This evidence has little bearing on her competence to make life and death
medical decisions on her own. In addition, Cassandra’s mother testified at
the December 9, 2014 hearing that Cassandra was a ‘‘very bright, intelligent
girl’’ who ‘‘can make her own decisions.’’ This conclusory statement also
provides little support for the respondents’ position. Although Cassandra
may be intelligent, intelligence, in and of itself, is not evidence of maturity,
and she provided no reasoned argument for refusing chemotherapy
treatment.
14
The mother’s testimony that Cassandra did not want to put ‘‘poisons’’
in her body that could affect her for the rest of her life did not justify
Cassandra’s decision in any rational way. There was ample evidence that
Cassandra would die within a relatively short period of time if she did not
receive chemotherapy and that there was a high probability of cure if she
received treatment. Even if the chemotherapy will have some long-term side
effects, there was no evidence presented that there is a significant risk that
those side effects will be worse than certain death in the near future.
15
We emphasize that we do not suggest that the refusal of lifesaving
medical treatment is unreasonable, per se. Such a decision may well be
justified by, for example, deeply held religious convictions, advanced age,
a small chance of long-term survival or the significant likelihood of a poor
quality of life. The respondents in the present case, however, have presented
no plausible justification for Cassandra’s refusal to be treated. They have
merely made the bare assertion that it is her ‘‘right’’ to refuse treatment,
for any reason or for no reason.
The respondents suggest that Isakoff was not competent to evaluate
whether Cassandra was sufficiently mature to make her own medical deci-
sions 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. 115 (treating physician
must exercise best medical judgment as to whether minor patient is suffi-
ciently mature to be able to consent to treatment).
16
We cast no aspersions on Cassandra. It is perfectly understandable that
a seventeen year old who is confronted with a devastating medical diagnosis
would be confused and anxious, would depend heavily on a parent for
guidance and emotional support, would have some fear and distrust of
medical providers, and would go through a period of denial. These natural
emotions, however, do not evince maturity. Indeed, the fact that children
and adolescents are more prone to such emotions than adults and more
easily swayed by them when making important decisions is the very reason
for the common-law rule that minors generally are not competent to make
medical decisions.
17
The respondents characterized Cassandra’s right not to be subjected to
unwanted medical treatment and their right to family integrity as substantive
due process rights in their brief to this court. At oral argument, however,
the mother conceded that the respondents are raising a procedural due
process claim that they were entitled to a hearing on the question of whether
Cassandra was a mature minor.
18
The respondents contend that Cassandra did not know that she was
entitled to present expert testimony on the issue of her competence to make
medical decisions at the December 9, 2014 hearing because this court has
not yet adopted the mature minor doctrine. The mere fact that this court
has not yet adopted the doctrine, however, would not have prevented Judge
Quinn from applying it for the first time if she had been asked to do so,
had determined that the doctrine is consistent with the public policy of this
state and had found Cassandra to be a mature minor.