Supreme Court of Pennsylvania.
COMMONWEALTH of Pennsylvania, Appellee,
Dennis E. NIXON, Appellant.
Commonwealth of Pennsylvania, Appellee,
Lorie A. Nixon, Appellant.
Argued March 7, 2000.
Decided Nov. 27, 2000.
Defendants were convicted in the Court of Common Pleas, Blair County,
Nos. 1260, 1261 CR 1996, Callan, J., of involuntary manslaughter and
endangering the welfare of a child, based on parents' refusal to
obtain medical treatment for their child. Defendants appealed. The
Superior Court, Nos. 1310PGH1997, 1311PGH1997, 718 A.2d 311,
affirmed. Defendants sought allocatur. The Supreme Court, Nos. 87, 88
W.D. Appeal Docket 1999, Zappala, J., held that: (1) "mature minor
doctrine" did not provide an affirmative defense, and (2) victim's
privacy rights were not violated by convictions.
Cappy, J., concurred in result and filed opinion.
Robert E. Stewart, Pittsburg, for appellants, Dennis and Lorie Nixon.
David Gorman, Hollidaysburg, for the Com.
Peter N. Georgiades, Pittsburgh, James G. Dwyer, Chicago, IL, for Amicus-Child.
Before FLAHERTY, C.J., and ZAPPALA, CAPPY, CASTILLE, NIGRO, NEWMAN and SAYLOR, JJ.
We granted allocatur for this Court to consider two issues. First,
we consider whether to adopt a "mature minor doctrine" which would be
an affirmative defense to the parental duty to provide care to a
minor. Secondly, we consider whether Shannon Nixon had a right to
refuse medical care pursuant to her privacy rights under the
constitutions of the United States and this Commonwealth. For the
reasons that follow, we choose not to adopt a "mature minor doctrine"
as a criminal defense and further, we find that Shannon Nixon's
constitutional right to privacy did not relieve her parents from
fulfilling their statutory obligations. Therefore, we affirm the order
of the Superior Court, which, in turn, affirmed the order and judgment
of sentence of the Court of Common Pleas of Blair County.
This case arose from the following facts. Dennis and Lorie Nixon,
Appellants, were the parents of the victim, Shannon Nixon. Shannon
Nixon was sixteen years old at the time of her death. In mid-June
1997, it became obvious to Appellants that Shannon was not feeling
well. Appellants began to pray for their daughter's health. They also
took her to their place of worship where Shannon was "anointed". [FN1]
Shannon initially reported feeling somewhat better, but then her
condition deteriorated. She became increasingly weak and fell into a
coma. After a few hours in a comatose state, Shannon Nixon died. An
autopsy determined that Shannon died from diabetes acidosis, which was
a treatable, though not curable, condition.
FN1. Appellants and their children were members of the
Faith Tabernacle Church, a religion in which illnesses are addressed
through spiritual treatment rather than by medicine.
Appellants were convicted of involuntary manslaughter, 18 Pa.C.S. § 2504, and also of endangering the welfare of a child under 18 Pa.C.S. § 4304. These statutes respectively state:
(a) General rule.--A
person is guilty of involuntary manslaughter when as a direct result of
the doing of an unlawful act in a reckless or grossly negligent manner,
or the doing of a lawful act in a reckless or grossly negligent manner,
he causes the death of another person.
Endangering welfare of children
(a) Offense defined.--A parent, guardian, or other person
supervising the welfare of a child under 18 years of age commits an
offense if he knowingly endangers the welfare of the child by
violating a duty of care, protection or support.
first argument is that we should adopt a "mature minor doctrine" and
allow Appellants to assert such doctrine as an affirmative defense to
the endangering welfare of children charge. If the affirmative duty
created by 18 Pa.C.S. § 4304 was removed from Appellants, then it
follows that the involuntary manslaughter conviction would also
fall. This is because the Commonwealth used § 4304 to show an
unlawful act, one of the alternative prerequisites to § 2504.
By placing an affirmative duty upon parents and guardians, the
legislature has acted to partially fulfill the Commonwealth's duty to
care for those individuals who for one reason or another are legally
incapacitated. This duty to care for those who are legally
incapacitated arose under the sovereign's duty of parens
patriae, and following independence was assumed by the individual
states. See Commonwealth v. Baldwin, 54 Watts 1 (Pa.1832). By
mandating primary responsibility for the child's wellbeing upon the
parents, the legislature has not only acted toward fulfilling its role
as parens patriae, but also has recognized that parents have a
duty to provide for their children which accompanies the right to
raise children with minimal state encroachment. As the United States
Supreme Court stated:
It is cardinal with us that the custody, care and nurture of the
child reside first in the parents, whose primary function and freedom
include preparation for obligations the state can neither supply nor
hinder. And it is in recognition of this that these decisions have
respected the private realm of family life which the state cannot
enter. But the family itself is not beyond regulation in the public
interest, as against a claim or religious liberty. And neither rights
of religion nor rights of parenthood are beyond limitation. Acting to
guard the general interest in youth's well being, the state as parens
patriae may restrict the parent's control by requiring school
attendance, regulating or prohibiting the child's labor, and in many
other ways. Its authority is not nullified merely because the parent
grounds his claim to control the child's course of conduct on religion
or conscience. Thus, he cannot claim freedom from compulsory
vaccination for the child more than for himself on religious
grounds. The right to practice religion freely does not include
liberty to expose the community or the child to communicable disease
or the latter ill health or death.
Prince v. Commonwealth of Massachusetts, 321 U.S. 158, 166-67,
64 S.Ct. 438, 88 L.Ed. 645 (1944) (citations and footnotes
The Appellants argue that their daughter was mature enough to make her
own decisions regarding health care and religion, and therefore ask us
to create an exception to their obligation on the basis of their
daughter's maturity. In defining the mature minor doctrine, Appellants
refer us to a decision from our sister state of Tennessee which
Whether a minor has the capacity to consent to medical treatment
depends upon age, ability, experience, education, training and degree
of maturity or judgment obtained by the minor or, 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 and probable consequences, and the minor's
ability to appreciate the risk and consequences are to be
Cardwell v. Bechtol, 724 S.W.2d 739, 748 (Tenn.1987). See
also Belcher v. Charleston Area Medical Center, 188 W.Va. 105, 422
S.E.2d 827 (1992), and In re E.G., 133 Ill.2d 98, 139
Ill.Dec. 810, 549 N.E.2d 322 (1989).
This doctrine is not the
legal equivalent of emancipation, for an emancipated minor assumes all
legal responsibility for his or herself. Thus, in the situation of an
emancipated minor, the legal duty to provide care is no longer
applicable. There is no indication in argument or record that Shannon
Nixon was emancipated. Rather, she lived in Appellants' home and did
not assert her independence from Appellants in a manner which would
lead to a finding of emancipation. See Nicholason
v. Follweiler, 735 A.2d 1275, 1278 (Pa.Super.1999); Ross
v. Commonwealth of Pennsylvania, Department of Public Welfare, 60
Pa.Cmwlth. 403, 431 A.2d 1135, 1138 (1981); and Detwiler
v. Detwiler, 162 Pa.Super. 383, 57 A.2d 426 (Pa.Super.1948).
We believe that, without passing comment upon the wisdom of the mature
minor doctrine itself, a terse review of the facts and circumstances
which confronted the courts of our sister states readily reveals why
the doctrine is not applicable to Appellants' case.
In Cardwell v. Bechtol, the Supreme Court of Tennessee
addressed the issue in the context of a civil medical malpractice
suit, under that state's common law of torts. The defendant, a
licensed osteopath, performed spinal manipulations on a 17-year-old
woman, without the consent of her parents. After complications arose,
her parents brought suit against the osteopath for a variety of
complaints related to the failure to obtain proper informed
consent. As a defense, the osteopath asserted that the young woman was
competent to, and actually did give informed consent for the procedure
that he performed. The Tennessee court agreed with the defendant, and
adopted the mature minor exception, as defined above.
In Belcher v. Charleston Area Medical Center, the Supreme
Court of Appeals of West Virginia also adopted a version of the mature
minor doctrine. That court addressed the doctrine in the context of a
wrongful death suit, where the plaintiffs asserted that their son, a
17-year-old man with muscular dystrophy, should have been consulted
prior to his doctor's withholding medical treatment from him due to a
"Do Not Resuscitate" order which had been requested by his
parents. When the young man had a respiratory arrest and cardiac
failure, the hospital staff attempted to revive him only with the
minimal procedures allowed by a "Do Not Resuscitate" order. That
court held that except in very extreme cases, a physician has no legal
right to perform a procedure upon, or withhold treatment from a
patient without the patient's consent, nor upon a child without the
consent of the child's parents or guardian, unless the child is a
mature minor, in which case the child's consent would be required.
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 determination would also involve whether the minor has the
capacity to appreciate the nature, risks, and consequences of the
medical procedure to be performed, or the treatment to be administered
Belcher, 422 S.E.2d at 838.
Finally, Appellants bring the case of In re E.G., a Minor, 133 Ill.2d 98, 139 Ill.Dec. 810, 549 N.E.2d 322 (1989), to our attention. The Supreme Court of Illinois held there that
[t]he common law right to control one's health care was also the basis
for the right of an incompetent patient to refuse life-sustaining
treatment through a surrogate.... We see no reason why this right of
dominion over one's own person should not extend to mature minors.
139 Ill.Dec. 810, 549 N.E.2d at 326. The rationale of the Illinois
court demonstrates the limitations of the doctrine. As the Illinois
[t]he trial judge must determine whether a minor is mature enough to
make health care choices on her own. An exception to this, of course,
is if the legislature has provided otherwise, as in the Consent by
Minor to Medical Operations Act. We feel the intervention of a judge is appropriate for two reasons.
First, Illinois public policy values the sanctity of life. When a
minor's health and life are at stake, this policy becomes a critical
consideration. A minor may have a long and fruitful life ahead that an
immature, foolish decision could jeopardize. Consequently, when the
trial judge weighs the evidence in making a determination of whether a
minor is mature enough to handle a health care decision, he must find
proof of this maturity by clear and convincing evidence.
Second, the State has a parens patriae power to protect those
incompetent to protect themselves. "[I]t is well-settled that the
State as parens patriae has a special duty to protect minors and, if
necessary, make vital decisions as to whether the condition is life
threatening, as wrenching and distasteful as such actions may be." The
State's parens patiae power pertaining to minors is strongest when the
minor is immature and thus incompetent (lacking capacity) to make
these decisions on her own. The parens patriae authority fades,
however, as the minor gets older and disappears upon her reaching
adulthood. The State interest in protecting a mature minor in these
situations will vary depending upon the nature of the medical
treatment involved. Where the health care issues are potentially life
threatening, the State's parens patriae interest is greater than if
the health care matter is less consequential.
139 Ill.Dec. 810, 549 N.E.2d at 327 (citations omitted).
We find the current case to have a crucial distinction from the cases
relied upon by Appellants. [FN2], [FN3] The legislature of this
Commonwealth has provided a statute which identifies those minors who
are deemed sufficiently mature to give consent to medical
FN2. Because we find that an affirmative duty was
statutorily placed upon Appellants, we need only note that this Court
has indicated that, "[t]he inherent dependency of a child upon
his parent to obtain medical aid, i.e., the incapacity of a child to
evaluate his condition and summon aid himself, supports imposition of
such a duty upon the parent." Commonwealth v. Konz, 498
Pa. 639, 450 A.2d 638, 641 (1982)(emphasis added).
FN3. Appellants fail to cite, and our own
research fails to reveal any cases from our sister states which hold
that the doctrine espoused by Appellants is viable as a defense in a
Any minor who is eighteen years of age or older, or has
graduated from high school, or has married, or has been pregnant, may
give effective consent to medical, dental and health services for
himself or herself, and the consent of no other person shall be
Act of Feb. 13, 1970, P.L. 19, No. 10, § 1, 35 P.S. § 10101.
Our legislature, as Appellants assert, has created several other
situations where a minor may give lawful consent for medical
treatment. See Act of April 14, 1972, P.L. 221, No. 63 §
12, 71 P.S. § 1690.112 (minors may consent to diagnosis or
treatment when suffering from the use of controlled or harmful
substances); Act of April 23, 1956 P.L. (1955) 1510 § 14, 35
P.S. § 521.14 (allows minors to consent to the treatment of
venereal disease); and Act of Dec. 9, 1969 P.L. 333, § 1 as
amended, 35 P.S. § 10001 (allows minors over 17 years old to
voluntarily donate blood without parental consent) but cf. 18
Pa.C.S. § 3206(c) (requires a minor to petition court for consent
to an abortion when the parents do not consent; before giving such
consent, the court must ascertain that the minor is mature and capable
of giving informed consent).
We agree that these statutes create specific exceptions to the general
rule of incapacity. The statutes do not, contrary to Appellants'
assertion, show a legislative intent that any minor, upon the
slightest showing, has capacity either to consent to or to refuse
medical treatment in a life and death situation. We therefore hold
that the maturity of an unemancipated minor is not an affirmative
defense applicable to the charges brought against Appellants. [FN4]
FN4. We note
that our Superior Court has held, that "even if [the minor victims]
were considered mature enough to freely exercise their religious
beliefs, it does not dispel [the parents'] duty while the children are
in their care, custody, and control to provide them with parental care,
direction and sustenance." Commonwealth v. Cottam, 420
Pa.Super. 311, 616 A.2d 988 (1992).
Appellants' second argument is that the parental duty to provide
medical care was negated by Shannon Nixon's privacy interests under
the constitutions of the United States and Pennsylvania. [FN5] This
Court has acknowledged that both constitutions do offer protections of
personal privacy, which results from the "penumbra" of articulated
rights. See In re "B", 482 Pa. 471, 394 A.2d 419 (1978). The
Pennsylvania Constitution encompasses "the right to be let alone."
Stenger v. Lehigh Valley Hospital Center, 530 Pa. 426, 609 A.2d
796 (1992). The difference between the two constitutions is in the
tests involved in determining if a violation of privacy has
occurred. In order to determine if a violation of the United States
Constitution has occurred, a flexible balancing approach is employed
with increasing levels of scrutiny corresponding to increasing levels
of confidentiality intrusions. See id. at 801. On the other
hand, under Pennsylvania's constitution, while the right to privacy is
not absolute, we do not apply a flexible approach. In this
Commonwealth, only a compelling state interest will override one's
privacy rights. Id. at 802, citing Fabio v. Civil Service
Commission of the City of Philadelphia, 489 Pa. 309, 414 A.2d 82
FN5. Neither the Commonwealth nor Appellants have
addressed whether parents of a deceased minor have standing to assert
the minor's constitutional rights as a bar to prosecution of their own
criminal behavior. In the present circumstances, we decline to address
this question sua sponte.
A compelling interest in the welfare of minors may impinge upon the
constitutional rights of both minors and adults simultaneously. In
Commonwealth v. Wormser, 260 Pa. 44, 103 A. 500 (1918), this
Court examined whether a criminal prosecution could stand for the
crime of employing a minor at night and without a certificate. As a
defense, the appellant argued that such a criminal prosecution
infringed upon his, and the minor's, constitutional right to contract.
[t]he statute in question was enacted under the general police power
of the Commonwealth. Its object is declared to be "to provide for the
health, safety, and welfare of minors," and it is too clear for
discussion that this is an appropriate subject for legislative action
not only in the exercise by the Commonwealth of its authority as
parens patriae but also of the inalienable power to enact such laws as
promote the health, morals and general welfare of the people.
260 Pa. at 46, 103 A. at 501.
As we find that the state's interest as parens patriae in the
very life of an unemancipated minor is a compelling interest, and the
imposition of a parental duty to provide care for a minor in their
custody is an appropriate subject for legislative action, we need not
to examine this constitutional question further. Additionally, as we
find that Pennsylvania's Constitution is more protective of privacy
than the United States Constitution, an analysis of that jurisprudence
In summary, we hold that the mature minor doctrine suggested by
Appellants is not an applicable defense in this case. We also hold
that Appellants' convictions are not an unconstitutional violation of
the victim's right to privacy. We therefore affirm the order of the
Superior Court. [FN6]
FN6. We note that Superior Court addressed
various constitutional arguments regarding convictions under 18
Pa.C.S. § 2504 and § 4304 in Commonwealth
v. Barnhart, 345 Pa.Super. 10, 497 A.2d 616 (1985) and
Commonwealth v. Cottam, 420 Pa.Super. 311, 616 A.2d 988 (1992).
We have not addressed many of the issues presented in those cases and
will not do so here, as the parties do not raise them.
Justice CAPPY files a concurring opinion.
CAPPY, Justice, concurring.
From my review of the record, it is evident that Shannon Nixon did not
have the maturity to make an informed decision regarding medical
treatment. Thus, I concur in the majority's result, which affirms the
order of the Superior Court, upholding the trial court's judgment of
sentence. I write separately, however, because I do not agree with the
majority's characterization of the question that appellants raised for
our consideration or with the majority's view of the role that
legislative intent should play in this case or with the majority's
ultimate decision to reject the mature minor doctrine. [FN1]
FN1. I found the majority opinion ambiguous. When I read
the majority's statement on page 5 of its opinion that "[w]e believe
that, without passing comment on the wisdom of the mature minor
doctrine itself, a terse review of the facts and circumstances which
confronted the courts of our sister states readily reveals why the
doctrine is not applicable to Appellants' case", I was given to
believe that the majority had decided not to determine, one way or the
other, whether the doctrine would be adopted in Pennsylvania. If this
had been the case, then the better course of action would have been
the dismissal of this appeal as improvidently granted, rather than the
issuance of an opinion containing dicta. It was after some
deliberation of the majority's discussion of the statutory exceptions
to the general rule of minor incapacity on pages 7 and 8 of its
opinion, that I concluded that the majority has evaluated the doctrine
and determined that it will not be part of our common law under any
The question raised in this appeal--did Shannon Nixon, even though a
minor, have the right to refuse medical attention--is of weighty
import, and involves a matter which has "deep roots in our common
law." In re Fiori, 543 Pa. 592, 673 A.2d 905, 909 (1996). In
Pennsylvania, the control of one's own person and the right of
self-determination are closely guarded through the principle of
informed consent, which declares that absent an emergency, medical
treatment may not be imposed without a person's permission.
Id. The right to refuse treatment or to withdraw treatment once
it has begun is a logical corollary to that principle. Id.
Under the common law, a minor is deemed incompetent to provide
informed consent. Parents United for Better Schs., Inc. v. School
Dist. of Phila. Bd. of Educ., 166 Pa.Cmwlth. 462, 646 A.2d 689,
691 (1994). Until the age of majority, a minor's parents make medical
treatment decisions on his or her behalf. Id.
The Pennsylvania legislature, however, has rendered the authority of
parents to speak for their minor child with respect to health care
less than absolute in certain circumstances, by enacting several
statutes that allow minors to speak for themselves. Under 35
P.S. § 10101, a minor who is eighteen or older or graduated from
high school or who has married or has been pregnant, may consent to
health care treatment; under 35 P.S. § 10001, a minor who is
seventeen years of age or older may donate blood in any voluntary,
non-compensatory program without parental permission; under 35
P.S. § 10103 and 35 P.S. § 521.14(a), a minor who may be
pregnant or infected with a venereal disease may seek and receive
treatment; under 71 P.S. § 1690.112, a minor who suffers from use
of a controlled or harmful substance may consent to the furnishing of
medical care or counseling; and finally, under 18 Pa.C.S. §
3206(c), a minor who proves in the court of common pleas that she is
mature and capable of giving informed consent may consent to and
obtain an abortion.
These statutes are at the heart of the majority's holding. The
[These] statutes create specific exceptions to the general rule of
incapacity. The statutes do not, contrary to Appellants' assertion,
show a legislative intent that any minor, upon the slightest showing,
has capacity either to consent to or to refuse medical treatment in a
life and death situation. We therefore hold that the maturity of an
unemancipated minor is not an affirmative defense applicable to the
charges brought against Appellants.
While the majority and I agree that these statutes provide "specific
exceptions" to the general precept that minors are legally incapable
of informed consent, the majority and I part company in several
First, I believe that the majority's characterization of
appellants' position is inaccurate. In my view, appellants did not
assert that a minor upon the "slightest showing" of capacity should be
permitted to consent to or to refuse health care treatment or premise
application of the mature minor doctrine on a "life and death
situation." Instead, appellants argued that "a minor of demonstrated
maturity" or "[a] minor who is able to demonstrate the requisite
maturity" "should have the ability to make determinations as to
medical care." (Brief for Appellants, pp. 11-12.).
Second, I do not believe that legislative intent should have the
decisive role in the case sub judice that the majority
apparently gives it. The majority's holding against recognition of the
mature minor doctrine is expressly and exclusively premised on the
intent with which the legislature enacted its statutory exceptions to
the general rule of parental consent. While it is certainly proper and
advisable for this court to take note of relevant statutory authority
in assessing the wisdom of the doctrine, and to strive for a judicial
pronouncement that is consistent with that authority, see Pugh
v. Holmes, 486 Pa. 272, 405 A.2d 897, 904, 905 (1979), it is not
appropriate to give it a dispositive role. Except where the
legislature has established a comprehensive statutory scheme, aimed at
occupying an entire area, this court is guided, not directed, by
legislative action. Id.
Lastly, I, unlike the majority, would recognize the mature minor
doctrine. Indeed, the same statutes that inform the majority's
rejection of the doctrine lead me to the opposite result. I agree with
the legislature's willingness to make appropriate exceptions to the
rule of minor incapacity in the first place and with the policies
reflected in the exceptions the legislature has seen fit to enact. By
their terms, the exceptions fall into two broad categories: those that
are premised on a specific medical condition that ought to be treated
and those that focus on a minor's status. With regard to the latter,
the legislature has decided, for example, that turning eighteen,
marrying, becoming a parent or graduating from high school are
indicative of one's readiness to make health care decisions on one's
own. 35 P.S. § 10101.
In the same way, I believe that when it is demonstrated that a minor
has the capacity to understand the nature of his or her condition,
appreciate the consequences of the choices he or she makes, and reach
a decision regarding medical intervention in a responsible fashion, he
or she should have the right to consent to or refuse treatment. I
would, therefore, adopt the mature minor doctrine.
The record falls far short of establishing that Shannon Nixon met this
standard. Accordingly, I concur in the majority's result. [FN2]
FN2. Because I conclude that the mature minor doctrine
does not apply in this case as a matter of fact, I decline to address
appellants' contention that the doctrine provides them with an
"affirmative defense" to the charges the Commonwealth brought against
them. Because I would find that under the common law, a mature minor
may consent to or refuse medical treatment, I would not reach, and I
express no opinion on, the privacy issue appellants raise under the
United States and Pennsylvania
Constitutions. P.J.S. v. Pennsylvania State Ethics Comm'n, 555
Pa. 149, 723 A.2d 174, 176 (1999).
Com. v. Nixon
761 A.2d 1151, 563 Pa. 425