On certification to the Superior Court, Appellate Division, whose opinion is reported at 353 N.J. Super. 114 (2002).
(This syllabus is not part of the opinion of the Court. It has been prepared by the Office of the Clerk for the convenience of the reader. It has been neither reviewed nor approved by the Supreme Court. Please note that, in the interests of brevity, portions of any opinion may not have been summarized).
The issue in this appeal is whether a jury may be instructed that, as a matter of law, a victim's determination to be removed from life support is a foreseeable event that does not remove or lessen criminal responsibility for death.
This case involves an automobile accident in which the victim suffered catastrophic injuries and was consequently placed on life support. On December 29, 1995, sixty-six-year-old William Patrick was driving northbound on Route 1 in South Brunswick when defendant, with a blood alcohol content (BAC) between.19 and.22, struck Patrick's vehicle from behind. Patrick had to be removed from his vehicle with the "jaws of life" and transported to the Robert Wood Johnson University Hospital. He suffered numerous injuries, including a fracture of the spinal column, resulting in paralysis from the chest down, a "flailed chest," contusion and puncture of his lung, a head injury, fractured sinuses, and a broken hip. Patrick was placed on a ventilator and underwent various surgical procedures. Among other complications, Patrick suffered from a number of infections, sepsis, and experienced several bouts with pneumonia. On March 13, 1996, Patrick was transferred to the Kessler Institute for Rehabilitation (Kessler). While there, Patrick was unable to breathe on his own and suffered from multi-organ system failure. In addition, doctors at Kessler determined that he was "significantly" brain injured. Although Patrick improved somewhat during the month of April, by early May he again experienced severe infections and pneumonia. On May 30, 1996, Patrick was removed from the ventilator and two hours later was pronounced dead. The Deputy Middlesex County Medical Examiner determined that the cause of death was sepsis and bronchopneumonia resulting from multiple injuries from the motor vehicle accident. It was undisputed at trial that Patrick had expressed to his family a preference not to be kept alive on life support.
Defendant was charged with first-degree aggravated manslaughter in contravention of N.J.S.A. 2C:11-4a. Defense counsel filed a mo tion to dismiss the indictment, contending that the removal of the ventilator constituted an independent intervening cause that insulated defendant from criminal liability. The trial court denied that motion, holding that the removal of life support was not an intervening cause and stating its intention to instruct the jury to that effect at trial. Consistent with that intention, the trial court included in its jury charge on causation an instruction concerning intervening cause and a victim's determination to remove life support. In pertinent part, the trial court instructed the jury: "the removal of life supports, in this case a ventilator, is not sufficient intervening cause to relieve the defendant of criminal liability." The trial court added that the causal link is not broken "as long as you find that the death was the natural result of the defendant's actions."
The jury acquitted defendant of aggravated manslaughter, but convicted him of the lesser-included offense of second-degree vehicular homicide. Defendant appealed, arguing that the trial court erred when it instructed the jury that removal of life support was not an intervening cause if death was the "natural result" of defendant's actions. The Appellate Division agreed and reversed the conviction.
The Supreme Court granted the State's petition for certification.
HELD: The trial court did not err in instructing the jury that a victim's decision to invoke his right to terminate life support may not, as a matter of law, be considered an independent intervening cause capable of breaking the chain of causation triggered by defendant's wrongful actions.
1. The public policy of this State, as developed by case law, beginning with In re Quinlan, 70 N.J. 10, cert denied sub nom. Garger v. New Jersey, 429 U.S. 922, 97 S. Ct. 319, 50 L. Ed. 2d 289 (1976), and through legislative enactments such as the "New Jersey Advance Directive for Health Care Act," clearly recognizes that an individual has the right to refuse devices or techniques for sustaining life, including the withholding of food and the removal of life support. (Pp. 11-16)
2. Causation is an essential element of the charges of aggravated manslaughter and second-degree vehicular homicide, and is defined by the New Jersey Code of Criminal Justice (Code). The causation requirement of the Code contains two parts, a "but-for" test and, when applicable, a culpability assessment: "Although the jury may find that the defendant's conduct was a 'but-for' cause of the victim's death... it may nevertheless conclude... that the death differed in kind from that designed or contemplated [or risked] or that the death was too remote, accidental in its occurrence, or dependent on another's volitional act to justify a murder conviction." State v.Martin, 119 N.J. 2, at 13. Although our Code, like the Model Penal Code (MPC), does not identify what may be an intervening cause, removal of life support, as it relates to causation, should be judged only by the criteria of the Code, assuming that the law recognizes the possibility that removal can be an intervening cause. Generally, to avoid breaking the chain of causation for criminal liability, a variation between the result intended or risked and the actual result of defendant's conduct must not be so out of the ordinary that it is unfair to hold defendant responsible for that result. A defendant may be relieved of criminal liability for a victim's death if an "independent" intervening cause has occurred, an act that breaks the chain and in effect becomes the cause of the victim's injury. (Pp. 16-20)
3. Removal of life-sustaining treatment is a victim's right. It is thus foreseeable that a victim may exercise his or her right not to be placed on, or to be removed from, life support systems. Because the exercise of the right does not break unexpectedly, or in any extraordinary way, the chain of causation that a defendant initiated and that led to the need for life support, it is not an intervening cause that may be advanced by defendant. We do not view the trial court's jury instruction as constituting an improper comment on the quality of the evidence nor do we agree with defendant that the trial court directed a verdict on causation. The trial court's statement was correct as a matter of law and its effect was not the equivalent of directing a verdict when the charge is read a whole. Decisions from other jurisdictions have reasoned similarly and have held that removal of life support is not an independent intervening cause in varied, but related, settings. Similarly, courts have denied requests by defendants for a jury instruction charging that a victim's removal from life support constitutes an independent intervening cause sufficient to relieve the defendant of criminal liability. (Pp. 20-29)
The judgment of the Appellate Division is REVERSED and the matter is REMANDED to the trial court for reinstatement of the judgment of conviction.
JUSTICE ALBIN filed a separate, dissenting opinion, in which JUSTICE LONG joins, stating that the trial court's jury instruction deprived defendant of the opportunity to have the jury decide the essential issue of causation and that a judge cannot direct a verdict against a defendant on an element of an offense, even where evidence of guilt appears overwhelming.
CHIEF JUSTICE PORITZ and JUSTICES COLEMAN, VERNIERO, and ZAZZALI join in JUSTICE LaVECCHIA's opinion. JUSTICE ALBIN filed a separate dissenting opinion, in which JUSTICE LONG joins.
The opinion of the court was delivered by: LaVECCHIA, J.
This criminal appeal focuses on a disputed jury instruction involving the subject of causation. Defendant was convicted of second-degree death by auto, in contravention of N.J.S.A. 2C:11-5. At trial, the court instructed the jury that a car-accident victim's voluntary removal from a respirator was legally insufficient as an independent intervening cause and thus incapable of breaking the chain of causality between defendant's acts and the victim's death. Specifically, the charge informed the jury that if it found "that the defendant's actions set in motion the victim's need for life support[,] the causal link between the defendant's actions and the victim's death is not broken by the removal or refusal of life support as long as you find that the death was the natural result of the defendant's actions." The Appellate Division reversed and remanded for a new trial because, in its view,"the charge to the jury on intervening cause deprived defendant of his constitutional right to have the jury in a criminal trial... decide all elements of the charged offense." State v. Pelham, 353 N.J. Super. 114, 126 (2002). We reverse.
It is beyond dispute that individuals have the right to self-determination in respect of medical care generally and, specifically, in respect of rejecting or removing life support devices or techniques. We conclude that the jury may be instructed, as a matter of law, that a victim's determination to be removed from life support is a foreseeable event that does not remove or lessen criminal responsibility for death.
The facts of the horrific car accident in which defendant, Sonney Pelham, was involved are summarized from the trial record. On the evening of December 29, 1995, William Patrick, a sixty-six-year-old lawyer, was driving his Chrysler LeBaron in the right lane of northbound Route 1 in South Brunswick. At approximately 11:42 p.m., a 1993 Toyota Camry driven by defendant struck the LeBaron from behind. The LeBaron sailed over the curb and slid along the guardrail, crashing into a utility pole before it ultimately came to rest 152 feet from the site of impact. The Camry traveled over a curb and came to rest in a grassy area on the side of the highway.
Two nearby police officers heard the collision and rushed to the scene. The officers found Patrick, still wearing his seatbelt, unconscious and slumped forward in the driver's seat. The rear of the LeBaron was crumpled through to the rear tire and the backseat, and the convertible top was crushed. Patrick was making "gurgling" and "wheezing" sounds, and appeared to have difficulty breathing. His passenger, Jocelyn Bobin, was semi-conscious. Emergency crews extricated the two using the "jaws of life" and transported them to Robert Wood Johnson University Hospital (Robert Wood Johnson). Bobin was treated and later released.
At the accident scene, Officer Heistand smelled an odor of alcohol on defendant's breath, and noted that he was swaying from side to side and front to back. He had no injuries, but was "belligerent." Heistand believed defendant was intoxicated. Three field sobriety tests were conducted. Defendant failed all three. He was placed under arrest for driving while intoxicated, transported to the police station, and later taken to Robert Wood Johnson for a blood alcohol test. He eventually consented to be tested approximately two hours after the accident. Two separately administered tests indicated that defendant's blood alcohol content (BAC) at that time was.18 to.19. Experts assessed his BAC between.19 and.22 at the time of the accident.
Patrick's condition was critical on his arrival at Robert Wood Johnson. He had suffered a constellation of injuries, including a spinal column fracture that left him paralyzed from the chest down and a "flailed chest," a condition in which the ribs are broken in multiple places causing uneven chest wall movement during each breath. Other injuries included a contusion and puncture of his lung, a head injury, fractured sinuses, and a broken hip. The catastrophic injuries Patrick experienced made it virtually impossible for him to breathe on his own. Paralysis rendered him unable to use his abdominal muscles and he had aspirated contents of his stomach that were now lodged in his airway despite an implanted nasal gastric tube. He was placed on a ventilator. Within five days of the accident, Patrick experienced "Adult Respiratory Distress Syndrome," a diagnosis indicating that his lungs had begun to fail. His heart beat was rapid and irregular, and his blood pressure was dropping because of the turmoil within his body. Low blood pressure triggered the start of kidney failure.
Patrick's paralysis rendered him at an increased risk for pulmonary thromboemboli, or blood clots. Accordingly, doctors implanted a vena cava filter through the major vein in the groin area and into the major blood vessel to the heart. The filters were intended to trap clots that form in the lower extremities. A ventilator tube inserted through Patrick's throat was converted to a surgical airway through his neck and into his windpipe. Because Patrick was unable to feed himself, he was fed initially by a tube inserted through his nose to the stomach, and later by a tube directly into the stomach. In addition, because paralysis left him unable to control his bladder or bowels, a Foley catheter was inserted.
During his hospitalization, Patrick continually had bladder and urinary tract infections as a result of the catheter, and sepsis occurred. He also experienced antibiotic-resistant infections common to hospital settings, as well as numerous bouts with pneumonia.
On March 13, 1996, Patrick was transferred to the Kessler Institute for Rehabilitation (Kessler), because it specialized in the care of patients with spinal cord injuries. When he arrived, Patrick was unable to breathe on his own, and was suffering from multi-organ system failure. Medication was required to stabilize his heart rhythm. He was extremely weak, with blood-protein levels that placed him at high risk of death. He was unable to clear secretions in his airways, and thus his oxygen levels would drop requiring medical personnel repeatedly to clear the secretions. Complications from the ventilator caused pneumonia to recur due to his inability to cough or to protect himself from bacteria. Bowel and urinary tract infections continued.
While at Kessler, Patrick also was monitored by psychiatric staff. He presented as depressed, confused, uncooperative, and not engaged psychologically. At times he was "hallucinating," even "psychotic." The staff determined that he was "significantly" brain injured. Nonetheless, Patrick was aware of his physical and cognitive disabilities. During lucid moments, he expressed his unhappiness with his situation, and, on occasion, tried to remove his ventilator.
Patrick improved somewhat during the month of April, but then his condition rapidly regressed. By early May, severe infections returned, as well as pneumonia. It was undisputed at trial that Patrick had expressed to his family a preference not to be kept alive on life support. Because of his brain damage, his lack of improvement, and his severe infections Patrick's family decided to act in accordance with his wishes and remove the ventilator. He was transferred to Saint Barnabas Medical Center and within two hours of the ventilator's removal on May 30, 1996, he was pronounced dead. The Deputy Middlesex County Medical Examiner determined that the cause of death was sepsis and bronchopneumonia resulting from multiple injuries from the motor vehicle accident.
Defendant was charged with first-degree aggravated manslaughter in contravention of N.J.S.A. 2C:11-4a. Defense counsel filed a motion to dismiss the indictment, contending that the removal of the ventilator constituted an independent intervening cause that insulated defendant from criminal liability.*fn1 The trial court held that the removal of life support was not an intervening cause and denied the motion. State v. Pelham, 328 N.J. Super. 631, 638-39 (Law Div. 1998). In its decision, the court stated its intention to instruct the jury to that effect at trial. Ibid.
At trial, defendant's arguments focused on the reliability of the blood evidence and challenged the integrity of the chain of custody. He contended that the destruction of blood evidence, along with the inconsistent results of both BAC tests, demonstrated the unreliability of the results. Although the State produced expert testimony that Patrick's death was causally connected to the injuries he suffered as a result of the accident, defendant did not counter with a medical expert to refute the causal connection between Patrick's death and his accident injuries.
Consistent with its earlier stated intention, the trial court included in its jury charge on causation an instruction concerning intervening cause and a victim's determination to remove life support. On those points, the trial court instructed the jury as follows:
To establish causation the State must prove two elements beyond a reasonable doubt. First, that but for defendant's conduct William Patrick wouldn't have died. Second, William Patrick's death must have been within the risk of which the defendant was aware. If not it must involve the same kind of injury or harm as the probable result of the defendant's conduct and must also not be too remote, too accidental in its occurrence or too dependant [sic] upon another's volitional act to have a just bearing on the defendant's liability or on the gravity of the offense. In other words, the State must prove beyond a reasonable doubt that William Patrick's death was not so unexpected or unusual that it would be unjust to find the defendant guilty of aggravated manslaughter.
Now, it is alleged that the victim William Patrick died approximately five months after the collision which occurred on December 29, 1995. With regard to the issue of remoteness there is no requirement that the State prove that the victim died immediately or within a certain period of time after the collision. Nevertheless, you may consider the time that elapsed between the collision and Mr. Patrick's death along with all of the other evidence in the case in determining whether the State has proven beyond a reasonable doubt that the defendant caused William Patrick's death as I've defined that term. The State alleges that William Patrick died as a result of medical complications from the injuries which he sustained in the collision. Subject to the definition of causation which I have already given you the State may satisfy its burden of proving causation by proving beyond a reasonable doubt that William Patrick died from medical complications that resulted from injuries which he sustained in the collision provided that these injuries and medical complications were the precipitating and contributing causes of his death.
With regard to the issue of accident, if you find that Mr. Patrick's death resulted from pre-existing medical conditions independent of the injuries and accompanying medical complications which he received as a result of the collision as the defendant contends then you must find him not guilty. If you find that Mr. Patrick died as a result of prior medical conditions being exacerbated or made worse by the collision ...