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                                                                Electronically Filed
                                                                Supreme Court
                                                                SCWC-XX-XXXXXXX
                                                                17-DEC-2019
                                                                08:22 AM




           IN THE SUPREME COURT OF THE STATE OF HAWAI I

                                 ---o0o---


                           STATE OF HAWAI I,
                    Respondent/Plaintiff-Appellee,

                                     vs.

                       MICHAEL LIMJUCO ABELLA,
                   Petitioner/Defendant-Appellant.


                             SCWC-XX-XXXXXXX

         CERTIORARI TO THE INTERMEDIATE COURT OF APPEALS
               (CAAP-XX-XXXXXXX; CR. NO. 14-1-1253)

                            DECEMBER 17, 2019

 RECKTENWALD, C.J., NAKAYAMA, McKENNA, POLLACK, AND WILSON, JJ.

             OPINION OF THE COURT BY RECKTENWALD, C.J.

          This case requires us to determine whether a defendant

may be convicted of homicide if the victim’s death was the

immediate result of a choice by the victim’s family to withdraw

medical care.    Michael Limjuco Abella was charged with Murder in

the Second Degree after severely beating Shelton Higa on July 17,
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2014.   Higa was comatose for more than a week thereafter; medical

professionals estimated that his chances of survival were slim,

and if he did survive, his quality of life would likely be poor.

He was removed from life support and declared dead on July 29,

2014, twelve days after the altercation.          In the Circuit Court

for the First Circuit, a jury found Abella guilty of the lesser-

included offense of Manslaughter.         The Intermediate Court of

Appeals (ICA) affirmed the conviction.

           Abella argues that a defendant in these circumstances

cannot be charged and convicted of a homicide due to a provision

in the Uniform Health-Care Decisions Act that prohibits

designating as a homicide any “[d]eath resulting from the

withholding or withdrawal of health care” under the Act.              Hawai i

Revised Statutes (HRS) § 327E-13(b) (2010).           Abella asserts that

the plain language of the statute shields him from conviction

under these circumstances.       We disagree.     Viewing the Act as a

whole and given the historical context that led to its passage,

it is clear that the legislature intended to protect medical

professionals and family members making difficult choices, not

actors like Abella.

           However, we nonetheless vacate the judgment on appeal

and remand this case for a new trial.          Abella argues, and we

agree, that the jury should have been given instructions on

causation pursuant to HRS §§ 702-215 (2014) and 702-216 (2014).

Those instructions would have enabled the jury to consider

whether the intervening volitional conduct of the family and

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medical team interrupted the chain of causation between Abella’s

actions and Higa’s death such that it would be unfair or unjust

to hold him criminally culpable for homicide.              While we recognize

without qualification that the decision to remove a loved one

from life support is difficult and serious, and the law protects

that choice, nevertheless, the issues of causation raised in this

case must be decided by a jury.         Consequently, we hold that it

was plain error for the circuit court to fail to instruct the

jury on causation and culpability pursuant to HRS §§ 702-215 and

702-216.

                               I.   BACKGROUND

A.   Circuit Court Procecedings

            Abella was charged by indictment in the Circuit Court

of the First Circuit with Murder in the Second Degree in

violation of HRS § 707-701.5 (2014). 1         His jury trial began on

September 21, 2015.2

      1.    Witness’ Testimony

            The following testimony was adduced at trial.

            a.    Events of July 17, 2014

            Witnesses Ronald Landrio and Donald King each testified

that on July 17, 2014, at approximately 8:45 p.m., they were at

the intersection of Smith and Pauahi Streets in Honolulu when

      1
            The Honorable Colette Y. Garibaldi presided.
      2
            As relevant to Abella’s prosecutorial misconduct claim, which we
decline to reach, see infra note 9, Abella filed a pre-trial motion in limine
requesting a number of things. At the hearing for the motion, State agreed
not to “comment upon [Abella’s] assertion of his right to remain silent prior
to, or during, trial[.]”

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they heard the sound of a glass bottle breaking.            Each looked in

the direction of the sound and saw Shelton Higa fall to the

ground.

             Landrio further testified that after Higa fell to the

ground, a man stood over Higa and began punching him.              King

testified that after Higa fell to the ground, a man, whom he

identified as Abella, began “very violently” kicking Higa several

times, “trying to strike his head as much as he can.”              As Higa

was on the ground, King noticed that Higa was “holding his head”

and “trying to protect himself.”          King testified that he saw Higa

getting struck “[i]n the head, in the shoulders, and arms,

because . . . [Higa was] trying to cover his face and his head.”

             Landrio testified that while the man was punching Higa,

a group of people went over and stopped the man.            The man then

left the area.

             An ambulance and police officers arrived at the scene

at 9:04 pm.     Honolulu Police Department (HPD) Officer Celestino

Herana testified that he was dispatched to Smith and Pauahi

Streets on an assault call at approximately 8:54 p.m. and met

Higa.     Higa was holding the right side of his head, which was red

and swelling.     Officer Herana detected a slight odor of alcohol

emanating from Higa’s breath, but Higa was coherent.             Officer

Herana took photographs of the scene, had Higa fill out

paperwork, and left.

             Kell Tanabe, Jr., then a paramedic-in-training for the

City and County of Honolulu, testified to examining Higa and

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witnessing superficial lacerations to the right side of his face

and a hematoma3 to his right temple.          Tanabe testified that

Higa’s vital signs were stable and that Higa refused a ride to

the hospital.

            Antoinette Tuituu testified that she saw the ambulance

leave, and she went over to talk to Higa.            She said that Higa was

sitting at first, and then he got on his hands and knees, trying

to stand up and return to the ambulance.           She recounted that Higa

said he felt dizzy, and he asked Tuituu to call the ambulance

again.

            Tuituu continued that as Higa was on his hands and

knees, “[t]hat guy came ([pointing to Abella in the courtroom])

and starting hitting him just out of the blue[.]”              Tuituu

testified that Abella “was wild” and hitting Higa on the head

with both hands.     After seeing Higa get hit about “five, six

times,” Tuituu ran to the police station about a block away to

get help.

            King testified that he saw Abella kicking Higa “more

than several . . . maybe up to 14 or 20” times.             He said that

Higa was attempting to get away, but since there was a wall in

front of him, it was “like he’s trying to crawl into the wall to

get away from this guy.”

            Landrio testified that he intervened after seeing “the



      3
            A hematoma is “a mass of usually clotted blood that forms in a
tissue, organ, or body space as a result of a broken blood vessel.” Merriam-
Webster’s Collegiate Dictionary 579 (11th ed. 2009).

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same figure[,]” whom he identified as Abella, “beating on [Higa]

again.”   Landrio noted that Higa was not fighting back during the

incident because of his poor health.

           Landrio “came up behind [Abella] and grabbed him to

stop him from hitting [Higa] again.”          Landrio and Abella then

started punching each other, causing Landrio’s glasses to go

“flying” off of his face, and for Landrio to have a bloody nose

and hurt shoulder.     Landrio testified: “I managed to get a couple

of shots in.    He was hitting pretty good, so I jumped off into

the street on Smith Street again, just to regroup myself.”

According to Landrio, Abella then walked back toward Higa, hit

him a few more times, and “just walked off down Pauahi Street.”

           Tuituu testified that after she returned from the

police station to call for help, she saw Abella walking away.

Tuituu and King both testified that they began following Abella

until they caught up with him.         At approximately 9:42 p.m.,

Officer Herana responded to the same area on an assault call and

arrested Abella.

           b.    Abella’s Testimony

           During the defense’s case-in-chief, Abella took the

stand, advancing a theory of self-defense.           Abella testified that

on July 17, 2014, at around 8:45 p.m., he was present in

Chinatown near Smith and Pauahi.          He testified that he was “just

hanging around” with other people, and around that time, he saw

an ambulance and police lights.        He said that he did not go to

check it out, but instead walked over to the River of Life

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Mission to see what food would be served.              He testified that Higa

came up to him and instigated the fight; per Abella, “he just hit

me.”       After that, Abella claimed that another person jumped in

the fray, and he just blocked hits until he left.                He further

claimed that he did not know Higa nor know why Higa would hit

him.

               Abella identified Higa in a photograph and acknowledged

that Higa was older than him, but said, “he was quicker.                 He hit

me quick.       He hit me twice in my jaw.”        In response to the

State’s questions, Abella acknowledged that he did not have time

to react to the second punch, but thereafter, Abella reacted by

hitting Higa, and did not stop hitting Higa until Landrio broke

it up (“He jump in, too, yes.”)           Abella said that he and Landrio

exchanged punches a “little bit . . . .             But I - I fled after

that.”       Abella said that after he finished fighting with Landrio,

he walked over by the Fort Street Mall and was stopped by police.

On cross-examination, Abella said he thought he (Abella) has “a

pretty good punch[.]”4

               c.   Higa’s Medical Care

               Ashley Hashimoto, then a paramedic-in-training,

testified that at approximately 9:52 p.m., she responded to an

assault call at Smith Street in Chinatown, and when she arrived,


       4
            As relevant to the prosecutorial misconduct claim, on cross-
examination, the State asked Abella whether he reported to the police “that
this 57-year-old man had thrown two punches so fast that you couldn’t respond
in time[.]” Thereafter, the defense moved for a mistrial, arguing that this
line of questioning commented impermissibly on Abella’s right to remain
silent. The State immediately withdrew the questions, and the court ordered
the jury to disregard. The court denied the motion for a mistrial.

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she saw Higa lying on his back, rolling around, and screaming.

Higa was able to provide his name and date to the responding

medical team, but could not answer any other questions and was

“yelling and screaming and rolling.”         The responding medical team

placed Higa in “full spinal mobilization,” started an IV, took

his vital signs, and transported him to Queen’s Medical Center.

            Higa was taken to Queen’s, a trauma center, for a

possible brain injury and multiple contusions.            Hashimoto

testified that there are a range of symptoms that could indicate

a brain injury, some of which Higa exhibited: Higa was “altered”;

“very combative and agitated”; and had “significantly high” blood

pressure.

            At Queen’s, Higa was seen by the emergency room doctor

and was sent for a CT scan of his brain.          Higa was given a

sedative before undergoing the CT scan.          He fell unconscious and

did not regain consciousness thereafter.

            Dr. Susan Steinemann, a surgeon who was qualified as an

expert in trauma and general surgery, testified that she saw Higa

after his CT scan.     By the time Dr. Steinemann saw Higa, he was

“comatose” and “would not open his eyes.          He was not able to

vocalize.   And he had only some minimal movements of his arm and

leg.”   In grading the degree of his coma, Dr. Steinemann

explained that a score of three “would be someone that’s

basically dead” and a score of fifteen “is normal.”             Dr.

Steinemann scored Higa as a five.

            On cross-examination, defense counsel asked Dr.

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Steinemann about Higa’s sedation prior to his CT scan, suggesting

that Higa was verbal when he was first admitted to the emergency

room and that he was sedated prior to his CT scan because he was

agitated.    Dr. Steinemann testified that she did not review the

record regarding Higa’s state when he was first admitted, but

agreed that, in general, an agitated patient may be administered

a sedative prior to a CT scan, as “[t]he quality of the scan

would be poor if the patient were moving.” 5

            Dr. Steinemann testified that the type of sedation

given to Higa “go[es] away in a fairly predictable period of

time.”   She said, “We don’t generally sedate people to the point

of unconsciousness” prior to a CT scan.           She acknowledged that

for surgeries, “[o]nce they’re under anesthesia, they’re

unconscious.”     Regarding Higa’s state after his CT scan and prior

to surgery, defense counsel asked “And he was not conscious at

that time; isn’t that correct?”         Dr. Steinemann replied, “No, he

was comatose.”

            On direct examination, Dr. Steinemann testified that

Higa was comatose “[b]ecause of his severe brain injury” (a

“large subdural hematoma” or, in other words, “bleeding inside

the skull[.]”).     A subdural hematoma is dangerous because, as

“the blood clot enlarges, it puts pressure on the brain and

squashes the brain down[.]”        So, “[a] brainstem herniation is



      5
            Dr. Eric Oshiro similarly testified that in most circumstances,
prior to a CT scan, “a short-acting sedative” is used, and is expected to
“wear[ ] off” after the CT scan.

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often the response to significant subdural hematoma.”

             When asked to describe how a subdural hematoma and

brainstem herniation relate to being comatose, Dr. Steinemann

explained that “the subdural hematoma, where it is located, will

tend to affect more of the higher brain functions, the thinking,

the ability to control movements[,]” while “[t]he brainstem

controls those very basic life responses, breathing and heart

rate.”   She explained that “the brainstem herniation is usually

the last thing to happen before somebody’s considered brain

dead.”

             When asked to describe the size of the bleeding based

on Higa’s CT scan, Dr. Steinemann testified that it was

“[d]eadly.    If he didn’t have emergency surgery, deadly.            And

even with emergency surgery, high – high mortality would be

expected.”    She testified that “[t]he prognosis even with surgery

for a bleed of this type is – is not good.”

             Higa’s neurosurgeon, Dr. Oshiro, testified about the

craniotomy procedure he performed on Higa and the blood clot he

saw inside Higa’s skull.      Dr. Oshiro testified that Higa was in a

coma when Dr. Oshiro met him, and he was on a ventilator prior to

the surgery and after the surgery.

             Dr. Oshiro said that Higa’s CT scan “confirmed that

there was a large blood clot on the surface of the brain . . .

that was compressing the brain.”          He testified that from

reviewing Higa’s presenting exam and his CT scan, Higa’s blood

clot was “a life-threatening situation.”          He noted that while

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“not all” blood clots on the brain are life-threatening, Higa’s

was.     He drew this conclusion based on “[t]he size” of the clot

as well as “the fact that on clinical exam, he had a dilated

pupil, which is indication of brainstem compression.”

             Dr. Oshiro testified that external injuries, such as a

skull fracture, are not necessarily indicative of a serious brain

injury.     He testified that this kind of bleeding “is a direct

result of the acceleration/deceleration injury to the brain,”

which he explained “can occur without actually cracking the

skull” and “without having a noticeable outward sign of injury.”

Dr. Oshiro stated that this kind of injury can occur from trauma,

such as “[s]ome sort of impact, blow to the head.”                He testified

that Higa’s hematoma could be created by “somebody str[iking] him

on the right side of the skull with a 40-ounce beer bottle, which

cracked the glass” due to an occurrence called a “contracoup

injury.”     Because there is space inside the skull for the brain

to move, if the skull is hit on one side, the impact can cause

the brain to “bounce[ ]” and “hit[ ] the other side” of the

skull.     He explained that in this regard, the location of the

hematoma in relation to the location of the impact is “not that

predictable.”       Dr. Steinemann also testified that Higa’s injury

would be consistent with being punched or kicked in the head.

             Dr. Oshiro testified that the craniotomy procedure had

“satisfactory results as far as removing the blood clot and

reducing the pressure on the brain.”            He observed Higa’s brain

surface turn from “very tense” to having “a normal pulsation that

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curves with the heartbeat,” and he saw that Higa’s dilated pupil

on the left side “came back down” after the surgery.

             “[U]nfortunately,” however, a successful procedure

“does not guarantee a full recovery” because “sometimes you can’t

tell before doing the surgery how much damage is done already,

how much damage is permanent, [or] how much can be . . . improved

by reducing the pressure.”          According to Dr. Oshiro, “[i]n other

words, there may be some permanent injury to the brain already

done that cannot be reversed.”

             After the craniotomy, Dr. Oshiro examined Higa every

day.    He noticed that “[t]here was very slight improvement.                   His

pupils were reactive to light; that is, they reacted normally

when you shine a light.         Normal reaction is they constrict.              But

he never fully regained consciousness.”

             From July 20 to July 28, 2014, notes in Higa’s medical

record provided as follows.          On July 20, a note indicated

“minimal change” in Higa’s neurological exam.               On July 21, Higa

had a “slight eye opening,” which, in comparison to where he was

before, indicated “a slight bit of consciousness.”                Higa also

reacted to a sternum rub, which is “an irritating kind of

maneuver” used “to get a reaction” from a patient.                A July 22

note stated that “his eyes open briefly, and he blinks to threat

and tracks a little,” thus “show[ing] a slight improvement in

consciousness.”

             On July 25, Higa likewise showed a “slight improvement

in the neurologic exam” compared to the previous day.                 He was

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“clearly localizing with left arm,” meaning that when he was

given a sternum rub, he was able “to localize where the stimulus

is coming from and actually reach toward it[,]” as opposed to an

“abnormal response,” which would be “no movement at all” after a

sternum rub.   This, again, showed “little gradations of

consciousness” and was “somewhat of an improvement[.]”              On July

26, Higa showed “a slight improvement in eye opening.”

          On July 27, Higa was “more alert” and “improving levels

of alertness with sustained eye opening[.]”           On July 28, Higa’s

“eyes open to voice,” thus indicating “a slight improvement in

consciousness.”    He had a “stable neurologic exam,” meaning “that

it’s not worsening.”

          When asked whether Higa “was ever going to regain

independent breathing[,]” Dr. Oshiro testified that there was a

“less than 50/50” chance.       He opined that while it was “probably

possible” for Higa to regain independent breathing, it was “not

more likely than not.”      Dr. Steinemann testified that based on

the significance of Higa’s brain injury, if care were not

withdrawn, she “would expect that his prognosis would be poor for

return to independent living.”

          With respect to taking a patient off life support,

Dr. Steinemann explained that the decision “is usually made in

consultation with the family based upon the patient’s previously

expressed wishes about quality of life.”          Dr. Oshiro testified

that he does not recall whether he was “physically present” when

Higa’s breathing tube was removed.         He did not state whether he

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was aware that Higa’s improvements were or were not communicated

to Higa’s next of kin, and noted that “these decisions are

primarily made by the intensive care physician” or “the

neurointensive care physician.”

          On July 27, Higa’s daughter and next-of-kin (Daughter)

was notified about her father’s presence at the hospital, where

she worked as a registered nurse.         Daughter had an “estranged

relationship” with her father, but she was aware of his kidney

problems and that he was “going blind.”

          Daughter testified that after a social worker called

and found her, she spoke with an “ICU doctor” named Dr. Chang who

told her about Higa’s present condition and presented her with

the decision to take Higa off life support.

          Daughter said she decided to take her father off life

support because:

          [DAUGHTER:] I knew what he -- we had talked about that
          before when my grandmother was on life support and we had to
          make that decision. And I’ve seen what happens when you
          leave people on life support who -- and the doctors'
          prognosis.

          [STATE]: Which was what?

          A. That he wasn't going to have any kind of a meaningful
          recovery, and he’d probably be hooked up to the ventilator
          and wouldn’t be able to regain an independent lifestyle.

          Daughter testified that she was informed about Higa’s

condition over the previous ten days in which he was under the

care of Dr. Steinemann and Dr. Oshiro.          She said that she was

provided “a summary of what happened in the surgery and his

current condition[,]” but she was not notified “as to the

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improvement in his condition regarding his neural exams

throughout the ten days[.]”        She testified that, as a nurse, she

has seen people in a condition like her father’s.              She said that

she has never seen other people in such a condition regain or

even “somewhat regain” their faculties.

            d.    Higa’s Death

            Higa was pronounced dead on July 29, 2014, after his

breathing tube was removed.

            Dr. Oshiro opined that the sedation administered prior

to the CT scan did not kill Higa.          Dr. Oshiro also testified that

while Higa had end-stage renal disease, which complicated his

recovery, the renal disease did not cause Higa’s death. 6               Dr.

Oshiro testified that the subdural hematoma caused Higa’s death.

            The following exchange took place between defense

counsel and Dr. Oshiro on recross-examination:

            [DEFENSE COUNSEL:] . . . . in this case, there was slight


      6
            Higa’s end-stage renal disease meant that he could not survive
unless he was on dialysis. Dr. Oshiro did not know the last time Higa had
dialysis, but testified that he could “take a guess” that “it hadn’t been very
recent” based on Higa’s blood test. Dr. Oshiro explained that Higa’s
“creatinine and his BUN [blood urea nitrogen] were markedly elevated as well
as his potassium in his blood.” When asked to explain the blood interaction
with the body’s organs, Dr. Oshiro stated that the answer was “very complex”
and “beyond the scope of what I can answer.” However, he provided an example
that “potassium being high could make him go into a bad heart rhythm, which
would be fatal.” He also suggested that “electrolyte abnormalities” could
cause fluid accumulation in the lungs that “may create a problem with
oxygenation from the lungs.”
            When asked how the quality of the blood might affect the brain,
Dr. Oshiro noted that “the blood clotting is probably not completely normal,”
meaning “that it probably takes a little bit longer for the blood to clot than
it normally would.” Dr. Oshiro also noted that “the brain doesn’t function as
well as it normally should” when blood is not processed through dialysis when
necessary.
            Dr. Christopher Happy, the medical examiner, was asked whether the
end-stage renal disease contributed to Higa’s condition, to which Dr. Happy
responded: “to his overall health, sure, but not his death.”

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           improvement happening on a day-to-day basis; right?

           [DR. OSHIRO:] Yes.

           Q. And there’s no telling where that improvement was going
           to stop at that point when -- I mean, in two weeks’ time
           that you had him under your care, Mr. Higa; is that right?

           A. Correct.

           Q. And you said just before we took a recess that the cause
           of death was the subdural hematoma, but you really -- that’s
           not really accurate, because isn’t it true that Mr. Higa
           could well have survived a little longer than the two weeks
           without them pulling the tubes and pulling the plug? Isn't
           that right?

           A. Yes.

           Q. I mean, he wasn’t at a stage where he was going to die
           right then and there?

           A. That is correct.

           On July 30, 2014, Dr. Christopher Happy, the chief

medical examiner for the City and County, performed an autopsy on

Higa.   Dr. Happy concluded that Higa’s death was caused by

“[c]omplications from blunt force head injury with subdural

hemorrhage.”   He read Higa’s medical records and could see during

the autopsy that Higa had a prior surgery to remove the blood

from around his brain.      He explained that when there is bleeding

around the brain, it creates pressure in a finite space and

begins to push the brain downward “through the large hole at the

bottom of the skull.”      He explained that “the first thing that

goes through that hole is the brainstem[,]” which is “where the

blood pressure, heart rate, and respiratory rate are controlled.”

He testified that when it is pushed down, the brainstem is

impinged, “[a]nd so the heart will stop, breathing will stop.”

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            Dr. Happy testified that the brain injury Higa received

“in you or me or anybody healthy would cause death.”              He further

explained that a toxicology report was conducted.              He said that

the report indicated “some morphine, which was given in the

hospital for pain control,” as well as “acetone, which is a

ketone, which is sometimes formed after a prolonged period of a

person being essentially brain dead.”

            On cross-examination, Dr. Happy testified that he was

not aware that, after Higa’s craniotomy, he was “improving in his

alertness[.]”     However, he testified that this fact would not

have made a difference in his final report regarding Higa’s cause

of death.

      2.    Motion for Judgment of Acquittal

            After the close of the State’s evidence, the defense

made an oral motion for judgment of acquittal.             Defense counsel

asked the court to grant the motion based on HRS § 327E-13(b), 7

arguing that the statute provides a basis for dismissing the

murder charge, as well as “other lesser charges” that cover the

death of a person.      He contended that “we could continue the

trial on the basis of an assault in the second degree or less.”


      7
            HRS § 327E-13(b) provides:

            Death resulting from the withholding or withdrawal of health
            care in accordance with this chapter shall not for any
            purpose constitute a suicide or homicide or legally impair
            or invalidate a policy of insurance or an annuity providing
            a death benefit, notwithstanding any term of the policy or
            annuity to the contrary.

            Although the legislature amended HRS § 327E-13 in 2018, subsequent
to Abella’s trial, subsection (b) remains unchanged.

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             In response, the State argued that HRS Chapter 327E

should not absolve criminal defendants from penal liability under

these circumstances.       The State argued: “[HRS §] 327E-13(b)

applies, and it applies to [Daughter] in this case.             It does not

apply to the defendant.       To do so would lead to an absurd

result.”

             In rebuttal, defense counsel focused on “the plain

language of the statute,” and argued that “the standard that the

legislature has put on this type of case” means “that nobody’s

going to be held responsible for homicide if someone else pulls

the plug.”     The court asked him whether anything in the

legislative history supported his argument, to which he replied:

             Well, I did not go into the legislative intent of this
             statute. However, when the -- when they say, shall not for
             any purpose constitute a homicide, they know what a homicide
             is. It’s not a surprise to them, that murder is a homicide,
             involves homicide. Manslaughter involves homicide. Assault
             in the first degree involves potentially a homicide. So it’s
             not a surprise to the legislature that those types of cases
             are happening under -- under the framework of homicide. So,
             you know, it’s in the plain language of this statute, you
             know, so I would assume that the legislature knew what it
             was doing when it did this.

             The court denied the motion.       The court determined that

the statute’s “reference that death from withholding medical care

would not constitute a homicide or suicide appears to protect

healthcare providers and the decision-makers,” as well as “the

beneficiaries of the decedent[.]”          It reasoned that defense

counsel’s reading of the statute “would produce absurd results in

situations similar to” this case.



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     3.      Jury Instructions

             The parties agreed to the court’s general jury

instructions and reviewed the court’s supplemental instructions.

             Supplemental instruction “T” provided: “Conduct is the

cause of a result when it is an antecedent but for which the

result in question would not have occurred.”           The defense

objected to this instruction and argued, “I think it confuses -

this instruction is more confusing than anything.             It’s not

necessary.     It’s duplicative of what’s going on in the [c]ourt’s

general instructions.”       The State, on the other hand, argued that

the instruction was necessary

             in light of the fact that it was the defendant’s conduct
             that caused the subdural bleed which put him in respiratory
             distress which caused him to be put on the ventilator and
             lose consciousness, which ultimately resulted in the
             decision by his daughter to take him off life support. So
             all of these events stem from the defendant’s conduct.
                   In other words, but for the defendant’s conduct, none
             of the - the operation or the treatment at Queen’s or
             lifesaving decision would have occurred. So in light of the
             facts of this case, this is an applicable and relevant
             statement of the law to help the jury explain - help the
             jury.

             The court included the instruction over defense’s

objection, noting that the instruction came verbatim from HRS

§ 702-214 (2014).      Defense counsel did not request an instruction

on causation pursuant to HRS §§ 702-215 and -216, and the court

did not provide one.

             Ultimately, the jury was instructed with regard to the

offenses of Murder in the Second Degree, Manslaughter based upon

reckless conduct, Assault in the First Degree, Assault in the


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Second Degree (Substantial Bodily Injury), Assault in the Second

Degree (Serious Bodily Injury), Assault in the Third Degree, and

Reckless Endangering in the Second Degree.           The jury was also

instructed as to self-defense, deadly force, causation, and the

relevant states of mind.       The Manslaughter instruction read:

                 If and only if you find the Defendant not guilty of
          Murder in the Second Degree or you are unable to reach a
          unanimous verdict as to this offense, then you must consider
          whether the Defendant is guilty or not guilty of the
          included offense of Manslaughter based upon reckless
          conduct.
                 A person commits the offense of Manslaughter based
          upon reckless conduct if he recklessly causes the death of
          another person.
                 There are two material elements of this offense, each
          of which the Prosecution must prove beyond a reasonable
          doubt.
                 These two elements are:

                 1. That on or about July 17, 2014, to and including
                 July 29, 2014, in the City and County of Honolulu,
                 State of Hawaii, the Defendant caused the death of
                 Shelton Higa; and

                 2.   That the Defendant did so recklessly.

(Emphasis added.)

          Consistent with its ruling as to instruction “T,” the

court instructed the jury on causation as follows: “Conduct is

the cause of a result when it is an antecedent but for which the

result in question would not have occurred.”

     4.   Verdict and Sentence

          The jury returned a verdict finding Abella guilty of

Manslaughter pursuant to HRS § 707-702 (2014).            The circuit court

subsequently sentenced Abella to a term of imprisonment for

twenty years.    Abella timely filed a notice of appeal.


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B.   ICA Proceedings

            On appeal, Abella argued that the circuit court plainly

erred by failing to instruct the jury regarding the causal

connection, or lack thereof, between Abella’s conduct and Higa’s

death.   He also claimed that the circuit court erred by failing

to apply HRS § 327E-13 to his case.          Accordingly, Abella asked

that the ICA reverse the circuit court’s judgment and dismiss his

case.8

            Abella argued that the circuit court plainly erred when

it failed to instruct the jury, sua sponte, on the issue of

causation between Abella’s conduct and Higa’s death, and that

this failure was prejudicial.         Abella contended that his conduct

could not have caused Higa’s death, in light of the twelve days

that passed between the confrontation at issue and his death, and

the intervening acts by numerous persons within that time frame,

“i.e., medical treatment, and a decision made that terminated

Higa’s life.”

            In light of these circumstances, Abella argued that

Higa’s death was “too remote” or “too dependent on another’s

      8
            Abella also argued that the circuit court should have ordered a
mistrial in light of the prosecutor’s attempts to elicit testimony from Abella
about why he did not report his interactions with Higa to the police. See
supra note 4. Abella argued that the prosecutor’s line of questioning
encroached upon Abella’s constitutional right to remain silent.
            The ICA did not credit this argument, determining that the
prosecutor’s actions did not amount to misconduct, and even if the questioning
was improper, the circuit court’s subsequent instructions to the jury
constituted a “prompt curative instruction.” State v. Abella, 144 Hawai i
141, 152, 438 P.3d 273, 284 (App. 2019).
            Abella raises this issue again in his application for writ of
certiorari. Because, as discussed infra, we decide this case on the basis of
the jury instructions and remand for a new trial as a result, we need not and
do not reach this issue.

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volitional conduct” to assign responsibility to Abella for Higa’s

actual death.     As such, Abella argued that the instructions as a

whole, which did not include a causation instruction based on HRS

§§ 702-2159 and -21610, were “prejudicially insufficient,

erroneous, inconsistent, and misleading.”

             Abella also argued that the circuit court erred by

failing to apply HRS § 327E-13 to his case when its plain

language prohibited his conviction.          Abella explained that,

pursuant to HRS § 327E-13, a “[d]eath resulting from the . . .

withdrawal of health care in accordance with [Chapter 327E] shall

not for any purpose constitute a . . . homicide,” and that

further, under Chapter 327E, “death” occurs “when a person has

experienced [the] irreversible cessation of spontaneous

respiratory and circulatory functions” and “at the time when the

irreversible cessation of the functions first coincide.”

             Applying Chapter 327E, Abella contended that Higa’s

death necessarily occurred when his ventilator was removed, and

could not have occurred before that time.           Abella pointed to Dr.

Oshiro’s testimony that “Higa had a 50% possibility of regaining

independent breathing,” that “there was no telling where that

improvement was going to stop,” and that “Higa could have

survived longer than he did” had his ventilator not been

withdrawn.



     9
             For the text of HRS § 702-215, see infra note 12.
     10
             For the text of HRS § 702-216, see infra note 13.

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             The ICA disagreed.    State v. Abella, 144 Hawai i 141,

438 P.3d 273 (App. 2019).       With regard to Abella’s argument that

the medical treatment was an intervening cause of Higa’s death,

citing to several cases from other jurisdictions, the ICA

determined that the “removal of life support is not an

independent intervening cause [of death] in settings similar to

the instant case.”     Id. at 148, 438 P.3d at 280.         The ICA

therefore concluded that the circuit court did not plainly err in

failing to instruct the jury “regarding intervening acts by

persons terminating Higa’s medical treatment.”            Id. at 149, 438

P.3d at 281.

             In addition, based on the plain language of HRS § 327E-

13, the ICA determined that, “[c]ontrary to Abella’s argument,

HRS § 327E-13(b) applies to advance health-care directives and

other health-care decision-making procedures and the persons

involved.     It does not apply to criminal conduct which leads to

the need for health-care.”        Id. at 150, 438 P.3d at 282 (emphasis

added).     The ICA further noted that the relevant legislative

history lacked any indication that HRS § 327E-13(b) was meant to

“absolve defendants of alleged criminal conduct which

necessitated that a victim receive medical treatment in the first

place.”     Id.   Accordingly, the ICA rejected Abella’s argument

that HRS § 327E-13(b) should apply.

             On the circuit court’s failure to give jury

instructions pursuant to HRS §§ 702-215 and 702-216, the ICA

concluded that the “removal of life support is not an independent

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intervening cause [of death] in settings similar to the instant

case,” citing to cases from other jurisdictions.             Id. at 148-49,

438 P.3d at 280-81.      Accordingly, the ICA held that the circuit

court did not plainly err by failing to give those instructions.

Id. at 149, 438 P.3d at 281.

C.   Supreme Court Proceedings

           Abella timely filed an application for a writ of

certiorari, which we accepted.         His application argues that the

ICA gravely erred for not reversing the trial court on the basis

of HRS § 327E-13.      In addition, Abella urges us to hold that the

trial court’s failure to instruct the jury “regarding the causal

connection[,] or lack thereof, between Abella’s conduct and

Higa’s death” constituted plain error.

                         II.   STANDARDS OF REVIEW

A.   Statutory Interpretation

           “Questions of statutory interpretation are questions of

law to be reviewed de novo under the right/wrong standard.”

Nakamoto v. Kawauchi, 142 Hawai i 259, 268, 418 P.3d 600, 609

(2018).

B.   Jury Instructions

           “When jury instructions . . . are at issue on appeal,

the standard of review is whether, when read and considered as a

whole, the instructions given are prejudicially insufficient,

erroneous, inconsistent, or misleading.”           State v. Nichols, 111

Hawai i 327, 334, 141 P.3d 974, 981 (2006).



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                              III.   DISCUSSION

A.   HRS § 327E-13 Does Not Prevent a Jury from Convicting Abella
     of Homicide

           We first consider whether HRS § 327E-13 applies to this

case, which is a matter of statutory interpretation.              We hold

that it does not.

           When construing a statute, “our foremost obligation is

to ascertain and give effect to the intention of the legislature,

which is to be obtained primarily from the language contained in

the statute itself.”      Nakamoto, 142 Hawai i at 268, 418 P.3d at

609 (quoting Lingle v. Hawai i Gov’t Emps. Ass’n, AFSCME, Local

152, AFL-CIO, 107 Hawai i 178, 183, 111 P.3d 587, 592 (2005)).

“A ‘cardinal’ canon of statutory interpretation is that this

court ‘cannot change the language of the statute, supply a want,

or enlarge upon it in order to make it suit a certain state of

facts.’”   State v. Haugen, 104 Hawai i 71, 75, 85 P.3d 178, 182

(2004) (quoting State v. Dudoit, 90 Hawai i 262, 271, 978 P.2d

700, 709 (1999)).

           Nevertheless, statutory language is read “in the

context of the entire statute” and interpreted “in a manner

consistent with its purpose.”         Haugen, 104 Hawai i at 76, 85 P.3d

at 183 (quoting Gray v. Admin. Dir. of the Court, 84 Hawai i 138,

148, 931 P.2d 580, 590 (1997)).         We construe statutes “to avoid,

if possible, inconsistency, contradiction, and illogicality.”

Id. (quoting State v. Cornelio, 84 Hawai i 476, 484, 935 P.2d

1021, 1029 (1997)) (emphasis omitted).           If a literal construction


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of statutory language would produce an absurd result, we presume

that result was not intended and construe the statute in accord

with its underlying legislative intent.          See id. at 77, 85 P.3d

at 184 (citing Dudoit, 90 Hawai i at 270, 978 P.2d at 708).

          Abella argues that he was entitled to an acquittal

based on HRS § 327E-13(b), a provision in the Uniform Health-Care

Decisions Act (Modified).       HRS § 327E-13(b) provides:

          (b) Death resulting from the withholding or withdrawal
          of health care in accordance with this chapter shall
          not for any purpose constitute a suicide or homicide
          or legally impair or invalidate a policy of insurance
          or an annuity providing a death benefit,
          notwithstanding any term of the policy or annuity to
          the contrary.

(Emphasis added.)

          In effect, Abella interprets this statute to supply a

general defense to criminal liability whenever a crime victim is

allowed to die from their injuries due to “the withholding or

withdrawal of health care.”       HRS § 327E-13(b).       He contends that

because Higa died from the decision by Daughter and the medical

team to withdraw care, his death “shall not for any purpose

constitute a . . . homicide[.]”        According to Abella, the terms

“for any purpose” plainly and unambiguously prevent the State

from holding anyone criminally liable for Higa’s death.              Thus, he

argues, the statute absolves him of criminal liability, and he

was accordingly entitled to a judgment of acquittal.

          However, we conclude that HRS § 327E-13(b), when read

in context, applies only to the persons involved in making and

carrying out health-care decisions.         Chapter 327E codifies in

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Hawai i the right to refuse life-sustaining medical treatment, a

right that is incident to the rights to privacy, bodily autonomy,

and self-determination.         The parameters of the right to refuse

life-sustaining treatment have common law origins and may be

traced to the seminal case In re Quinlan, 355 A.2d 647 (N.J.

1976), cert. denied sub nom. Garger v. New Jersey, 429 U.S. 922

(1976).

             In Quinlan, the Supreme Court of New Jersey recognized

that “the State’s interest [in the preservation of life] weakens

and the individual’s right to privacy grows as the degree of

bodily invasion increases and the prognosis dims.”                 355 A.2d at

664.    The court held that under the circumstances, Ms. Quinlan’s

right to refuse further life-sustaining medical treatment

outweighed the State’s interests.            Id.   Recognizing that Ms.

Quinlan was no longer competent to assert this right, the court

also held that the only practical way to protect it would be to

permit her family to assert it on her behalf.               Id.     Further, the

court considered the relationship between this right and the

criminal law.       The Quinlan court made clear that physicians who

carry out these wishes would not be held criminally liable for

terminating life-sustaining treatment, consequently accelerating

the patient’s death.        Id. at 669–70.

             Since this 1976 decision, state courts and the United

States Supreme Court have recognized the right to refuse

treatment, and developed tests for determining how and when this

right may be asserted in specific circumstances.                  See, e.g.,

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Cruzan v. Director, Missouri Dep’t of Health, 497 U.S. 261 (1990)

(recognizing that a competent person has a Fourteenth Amendment

liberty interest in refusing medical treatment); Matter of

Welfare of Colyer, 660 P.2d 730 (Wash. 1983); In re Conroy, 486

A.2d 1209 (N.J. 1985) (holding that an incompetent, but not

necessarily comatose, patient has the right to refuse life-

sustaining treatment).      Recognizing the issue as a fundamental

societal concern, state legislatures have passed laws addressing

the right to refuse life-sustaining medical treatment,

established procedures for creating and implementing advance

directives (i.e. “living wills”), and enabled surrogate decision-

makers to exercise authority on another’s behalf.             See, e.g.,

N.J.S.A. 26:2H-54a (“New Jersey Advance Directives for Health

Care Act”); GA Code Ann. § 31-32-1 (“Georgia Advance Directive

for Health Care Act”); Cal. Prob. Code §§ 4600-4660 (“Health Care

Decisions Law”).

          In 1986, the Hawai i legislature followed suit,

enacting HRS chapter 327D.       1986 Haw. Sess. Laws. Act 338.          This

act, among other things, recognized the right to individual

autonomy in medical choices and protected medical providers from

criminal prosecution.      See, e.g., HRS § 327D-1 (1993) (“The

legislature finds that all competent persons have the fundamental

right to control the decisions relating to their own medical

care, including the decision to have medical or surgical means or

procedures calculated to prolong their lives provided, continued,

withheld, or withdrawn.”); id. § 327D-14 (“Death resulting from

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the withholding or withdrawal of life-sustaining procedures from

a patient under this chapter does not, for any purpose,

constitute a suicide.”); id. § 327D-18 (“In the absence of actual

notice of the revocation of a declaration, no health care

provider, health care facility, physician, or any other person

acting under the direction of an attending physician shall be

subject to criminal prosecution . . . as a result of the

withholding or the withdrawal of life-sustaining procedures from

a patient in accordance with this chapter[.]”).

          In 1999, the Hawai i legislature replaced chapter 327D

with chapter 327E, the Uniform Health-Care Decisions Act.               1999

Haw. Sess. Laws Act 169.      Standing Committee Report No. 1600 from

the Senate Committee on the Judiciary stated:

                The purpose of this measure is to enact the Uniform
          Health-Care Decisions Act.
                Your Committee finds that since the Supreme Court's
          decision in Cruzan v. Commissioner, Missouri Department of
          Health, 497 U.S. 261 (1990), significant changes have
          occurred in state legislation on health care decision
          making. Nearly all states have statutes authorizing the use
          of powers of attorney for health care. In addition, a
          majority of states have statutes allowing family members,
          and in some cases close friends, to make health care
          decisions for adult individuals or emancipated minors who
          lack capacity.
                However, your Committee recognizes that there is a
          greater need for uniformity among advance directives for
          health care and believes that this Uniform Health Care
          Decisions Act will simplify and facilitate the making of
          advance health care directives. . . . .
                Your Committee intends that this measure replace
          chapter 327D, Hawaii Revised Statutes, relating to medical
          treatment decisions which was first enacted in 1986 and has
          not been revised since 1992. In the intervening years,
          medical science has advanced tremendously and medical ethics
          has developed correspondingly. This measure brings medical
          treatment decisions into today's world of advances in
          medicine, patient rights, and attitudes toward dying. Your


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          Committee notes that this measure is not intended to disrupt
          the existing surrogate law and practices in acute care and
          long-term care settings.

S. Stand. Comm. Rep. No. 1600, in 1999 Senate Journal, at 1657.

          HRS § 327E-13(b) closely tracks           13(b) of the Uniform

Health-Care Decisions Act (1993).         See Unif. Health-Care

Decisions Act § 13(b) (“Death resulting from the withholding or

withdrawal of health care in accordance with this [Act] does not

for any purpose constitute a suicide or homicide or legally

impair or invalidate a policy of insurance or an annuity

providing a death benefit, notwithstanding any term of the policy

or annuity to the contrary.”).        HRS § 327E-13(b) is also

substantively the same as other state statutes derived from the

uniform law.   See, e.g., Cal. Prob. Code § 4656; Me. Rev. Stat.

Ann. tit. 5, § 813(b); Miss. Code. Ann. § 41-41-227(2); see also

N.M. Stat. Ann. § 24-7A-13(B) (“Death resulting from the

withholding or withdrawal of health care in accordance with the

Uniform Health-Care Decisions Act does not for any purpose: (1)

constitute a suicide, a homicide, or other crime[.]”).

          In declaring that “[d]eath resulting from the

withholding or withdrawal of health care in accordance with this

chapter shall not for any purpose constitute a suicide or

homicide,” HRS § 327E-13(b), the Hawai i legislature adopted the

well-recognized principle that persons properly involved in

making and carrying out decisions to terminate life-support,

including patients, surrogates, and doctors, should be free of

criminal and civil liability for their involvement.             See, e.g.,

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Matter of Farrell, 529 A.2d 404, 415–16 (N.J. 1987); 11 In re

Quinlan, 355 A.2d at 669.        There is no indication in either the

language or legislative history of HRS chapter 327E, or in case

law related to the right to refuse treatment, that the exercise

of this right protects any person from criminal liability.

            The statute’s language should not be taken out of

context; rather, it should be read to protect only those whose


      11
            For example, in the New Jersey case Matter of Farrell, the
plaintiff petitioned to the New Jersey Chancery Court to be appointed the
special medical guardian for his wife, who had amyotrophic lateral sclerosis
(more commonly known as Lou Gehrig’s disease), and had expressly granted
permission to remove a respirator that had been keeping her alive for the past
three years. 514 A.2d 1342, 1343 (N.J. Ch. 1986). The court recognized Mrs.
Farrell’s right to discontinue this life-sustaining treatment, found that Mrs.
Farrell was competent and capable of making this decision, and appointed the
plaintiff, her husband, as her guardian ad litem to carry out her wishes. Id.
at 1347. In addition, the court ordered “that [Mr.] Farrell, or any physician
or other person involved in the removal of said respirator from [Mrs.] Farrell
pursuant to the terms of this judgment, will be free from any criminal and
civil liability.” Id. In a footnote, the court explained:

            This finding is made in accordance with In The Matter
            of Quinlan, 70 N.J. 10, 51-52, 355 A.2d 647[, 669]
            (1976), where the New Jersey Supreme Court stated that
            upon the termination of life support systems, “the
            ensuing death would not be homicide but rather
            expiration from existing natural causes. Secondly,
            even if it were to be regarded as homicide, it would
            not be unlawful.” The Quinlan Court added that there
            is a “real” and “determinative distinction between the
            unlawful taking of the life of another and the ending
            of artificial life support systems as a matter of
            self-determination.” Id. at 52, 355 A.2d 647. The
            Court clearly established that the exercise of this
            constitutional right is protected from criminal
            prosecution, which “extends to third parties whose
            action is necessary to effectuate the exercise of that
            right.” Ibid.

Id. at 1347 n.3 (emphasis added).

            The New Jersey Supreme Court affirmed the chancery court’s
decision, and, in addition to providing guidance for when a patient requests
“the discontinuance of life-sustaining medical treatment,” Matter of Farrell,
529 A.2d at 413, it held that “no civil or criminal liability will be incurred
by any person who, in good faith reliance on the procedures established in
this opinion, withdraws life-sustaining treatment at the request of an
informed and competent patient[.]” Id. at 415–16 (emphasis added).

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conduct “in accordance with [chapter 327E]” leads to the

patient’s death.       Chapter 327E specifically enumerates and

defines people who are relevant to its provisions.                This list

includes agents (someone who has “power of attorney for health

care to make a health-care decision for the individual granting

the power”); guardians (“a judicially appointed guardian having

authority to make a health-care decision for an individual”);

health-care providers (“an individual licensed, certified, or

otherwise authorized or permitted by law to provide health care

in the ordinary course of business or practice of a profession”);

and others.      HRS § 327E-2.      Those corresponding people in Higa’s

life acted “in accordance with” Chapter 327E-2 when they decided

to remove his ventilator.          HRS § 327E-13(b).      Abella, when he

allegedly set into motion the events leading to Higa’s death, did

not.

             Accordingly, we hold that HRS § 327E-13(b) does not

shield from criminal liability for homicide those actors whose

conduct caused another to require life-saving medical

intervention if the victim’s medical care is subsequently

withdrawn, causing death.          To hold otherwise would lead to

absurdity.      Haugen, 104 Hawai i at 76–77, 85 P.3d at 183–84

(“Every construction which leads to an absurdity shall be

rejected.”) (citation omitted).           Interpreting HRS § 327E-13(b) to

apply to any actor would insulate from liability the very person

who caused Higa to require life support technology to stay alive.

In other words, the legislature could not have intended for a

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statute designed to protect an individual’s right to bodily

autonomy in the age of medical advancement to be used as a shield

for a wrongdoer who caused the need for medical intervention in

the first place - and did so by severe physical intrusion into

someone else’s bodily autonomy, the very right enshrined in the

statute.

            The above analysis supports the conclusion that HRS

§ 327E-13(b) of the Uniform Health-Care Decisions Act shields

family members and medical professionals from criminal liability

for death resulting from the withdrawal of medical care, but it

does not extend its protections to actors whose conduct rendered

medical care necessary in the first instance.             Thus, we hold that

HRS § 327E-13(b) does not bar Abella, an actor whom the statute

does not contemplate protecting, from being convicted of a

homicide.    Therefore, Abella’s motion for a judgment of acquittal

was properly denied.

B.   The Circuit Court Should Have Instructed the Jury on
     Causation Pursuant to HRS §§ 702-215 and 702-216

            We next consider whether Abella was entitled to jury

instructions on causation and intervening action under HRS

§§ 702-21512 and 702-216.13      We hold that the circuit court


     12
            HRS § 702-215 provides:

            In the following instances intentionally or knowingly
            causing a particular result shall be deemed to be
            established even though the actual result caused by the
            defendant may not have been within the defendant's intention
            or contemplation:

            (1)   The actual result differs from that intended or
                                                                (continued...)

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plainly erred by failing to include instructions pursuant to

those provisions.

              In a jury trial, it is the court’s responsibility to

ensure that the jury is properly instructed on the law and the

questions the jury is to decide.             See Nichols, 111 Hawai i at

334-35, 141 P.3d at 981-82.          The State must prove “[e]ach element

of the offense” beyond a reasonable doubt.             HRS § 701-114.

Causation is a question of fact (and an element of the offense of


     12
          (...continued)
                     contemplated, as the case may be, only in the respect
                     that a different person or different property is
                     injured or affected or that the injury or harm
                     intended or contemplated would have been more serious
                     or more extensive than that caused; or

              (2)   The actual result involves the same kind of injury or
                    harm as the intended or contemplated result and is not
                    too remote or accidental in its occurrence or too
                    dependent on another's volitional conduct to have a
                    bearing on the defendant's liability or on the gravity
                    of the defendant's offense.

              (Emphasis added.)
     13
              HRS § 702-216 provides:

              In the following instances, recklessly . . . causing a
              particular result shall be deemed to be established even
              though the actual result caused by the defendant may not
              have been within the risk of which the defendant was . . .
              aware:

              (1)   The actual result differs from the probable result
                    only in the respect that a different person or
                    different property is injured or affected or that the
                    probable injury or harm would have been more serious
                    or more extensive than that caused; or

              (2)   The actual result involves the same kind of injury or
                    harm as the probable result and is not too remote or
                    accidental in its occurrence or too dependent on
                    another's volitional conduct to have a bearing on the
                    defendant's liability or on the gravity of the
                    defendant's offense.

              (Emphasis added.)

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manslaughter) and is therefore reserved for the jury as fact

finder to determine.

            The Hawai i Penal Code addresses causation in HRS

§§ 702-214, 702-215, and 702-216, which are derived from the

Model Penal Code (MPC) § 2.03. 14      HRS § 702-214 supplies the test

     14
          MPC § 2.03 provides:

            (1) Conduct is the cause of a result when:

                  (a) it is an antecedent but for which the result in
                  question would not have occurred; and

                  (b) the relationship between the conduct and result
                  satisfies any additional causal requirements imposed
                  by the Code or by the law defining the offense.

            (2) When purposely or knowingly causing a particular result
            is an element of an offense, the element is not established
            if the actual result is not within the purpose or the
            contemplation of the actor unless:

                  (a) the actual result differs from that designed or
                  contemplated, as the case may be, only in the respect
                  that a different person or different property is
                  injured or affected or that the injury or harm
                  designed or contemplated would have been more serious
                  or more extensive than that caused; or

                  (b) the actual result involves the same kind of injury
                  or harm as that designed or contemplated and is not
                  too remote or accidental in its occurrence to have a
                  [just] bearing on the actor's liability or on the
                  gravity of his offense.

            (3) When recklessly or negligently causing a particular
            result is an element of an offense, the element is not
            established if the actual result is not within the risk of
            which the actor is aware or, in the case of negligence, of
            which he should be aware unless:

                  (a) the actual result differs from the probable result
                  only in the respect that a different person or
                  different property is injured or affected or that the
                  probable injury or harm would have been more serious
                  or more extensive than that caused; or

                  (b) the actual result involves the same kind of injury
                  or harm as the probable result and is not too remote
                  or accidental in its occurrence to have a [just]
                  bearing on the actor's liability or on the gravity of
                                                                (continued...)

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for “actual causation” and “is commonly called the ‘but for’

test.”      HRS § 702-214 cmt. (2014).       Like subsection 1(a) of MPC

§ 2.03, it provides: “Conduct is the cause of a result when it is

an antecedent but for which the result in question would not have

occurred.”       HRS § 702-214.     According to the Commentary to this

statute, once actual causation is established, “causality in its

strict sense is finished and attention must then shift to §§ 702-

215 and 216 which deal with the defendant’s culpability with

respect to the result.”         HRS § 702-214 cmt. (2014).       But:

              The difficulty of the problem of causation does not lie in
              making a determination of actual causation, but rather in
              setting the appropriate standard for determining those
              instances in which the defendant will not be held liable for
              the result of the defendant's conduct because the defendant
              did not intend or contemplate the result or was unaware of
              the risk that it would obtain.

HRS § 702-214 cmt. (2014).

              To address that difficulty, the Hawai i legislature

adopted the “culpability” assessment in HRS §§ 702-215 and 216 as

the proper inquiry for determining whether it would be unjust to

attribute the result that occurred to the defendant’s conduct,

even if the conduct was a cause-in-fact of that result.                 See HRS

§ 702-214 cmt. (2014).         This test derives from subsections (2)

and (3) of MPC § 2.03, but clarifies the MPC in an important

respect: HRS §§ 702-215 and 216 make explicit that “another’s


     14
          (...continued)
                     his offense.

              (4) When causing a particular result is a material element
              of an offense for which absolute liability is imposed by
              law, the element is not established unless the actual result
              is a probable consequence of the actor's conduct.

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volitional conduct” may be a factor to consider in the

“culpability” analysis.       See HRS § 702-215 cmt. (2014).15          In

State v. Pelham, the dissent recognized that Hawai i and New

Jersey are the only two states “that have adopted MPC § 2.03 and

explicitly added the intervening volitional conduct of others as

a factor to be considered in determining causation.” 16             824 A.2d

1082, 1097 (N.J. 2003) (Albin, J., dissenting)

            As noted in the Commentary to the HRS, the

“culpability” standard relates to the idea of “proximate cause”

in that “culpability” captures when the law will “allow the just

imposition of liability” for causing a particular result.                HRS

§ 702-214 cmt. (2014).       However, the culpability standard

            departs from the common-law concept of ‘proximate cause’ (at
            best a poor label for a host of largely unarticulated
            considerations) and analyzes the question of whether a
            defendant will be held liable for having caused a particular
            result not in terms of factual or “scientific” causation
            (which has to be resolved according to the test set forth in
            § 702-214) but in terms of those factors which properly bear
            on the defendant's culpability with respect to a result



      15
            The Commentary explains:

            The Code follows the Model Penal Code1 as supplemented by
            the suggestion of Hart and Honore that provisions regarding
            liability for unintended or uncontemplated results must be
            separately stated for those instances when the difference in
            result is due to natural events and those instances when it
            is due to the volitional conduct of another. Although the
            commentary to the Model Penal Code would suggest that
            volitional conduct of another is adequately covered as a
            factor which might make the actual result “too remote or
            accidental,” greater clarity is achieved by the language of
            this Code.

HRS § 702-215 cmt. (2014) (footnotes omitted) (citing H.L.A. Hart & A.M.
Honore, Causation in the Law (1959)).
      16
            For this reason, we consider case law from New Jersey interpreting
similar causation principles as persuasive authority on these provisions.

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          other than one which the defendant intended or contemplated.
          The factors to be considered are, as stated, whether the
          actual result is more serious or extensive than the intended
          or contemplated result and whether the actual result is too
          remote or accidental in its occurrence or too dependent on
          another's volitional conduct to have a bearing on
          defendant's liability (or the gravity of the defendant’s
          offense).

HRS § 702-215 cmt. (2014); see id. § 702-216 cmt. (2014).

          The culpability standard for causation comes into play

when the actual result can be “contrasted with the designed or

contemplated (or in the case of subsection (3), the probable)

result in terms of its specific character and manner of

occurrence.”     State v. Martin, 573 A.2d 1359, 1364 (N.J. 1990)

(emphasis added) (quoting Model Penal Code and Commentaries

§ 2.03 comment at 260 n.13 (1985)).         Subsection (1) of both HRS

§§ 702-215 and 216 refer to differences in the character of the

actual result.    See, e.g., HRS § 702-215(1) (considering when “a

different person or different property is injured or affected” or

when the injury or harm is more or less serious than

contemplated).    Subsection (2) of both statutes refers to

differences in the manner of the result’s occurrence.              See, e.g.,

HRS § 702-215(2) (considering whether the result is “too remote

or accidental in its occurrence” or whether its occurrence is

“too dependent on another’s volitional conduct”).

          Specifically, subsection (2) concerns the concept of

intervening causation.      In a case involving reckless

manslaughter, the Supreme Court of New Jersey addressed the

concept of intervening causation under N.J.S.A. 2C:2-3(c), a


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statutory provision that is substantially identical to HRS § 702-

216, as follows:

          [W]hen permitted by the law, “‘it is for the jury to
          determine whether intervening causes or unforeseen
          conditions lead to the conclusion that it is unjust to find
          that the defendant's conduct is the cause of the actual
          result.’” Pelham, supra, 176 N.J. at 461, 824 A.2d [at 1089-
          90] (quoting Martin, supra, 119 N.J. at 13, 573 A.2d [at
          1365]). The Code “does not identify what may be an
          intervening cause,” ibid., but “‘deals only with the
          ultimate criterion by which the significance of such
          possibilities ought to be judged,’” Martin, supra, 119 N.J.
          at 13, 573 A.2d [at 1365] (quoting [The New Jersey Penal
          Code: Final Report of the New Jersey Criminal Law Revision
          Commission], commentary to § 2C:2–3, at 50). An
          “‘intervening cause’” occurs when an event “‘comes between
          the initial event in a sequence and the end result, thereby
          altering the natural course of events that might have
          connected a wrongful act to an injury.’” Pelham, supra, 176
          N.J. at 461, 824 A.2d [at 1090] (quoting Black's Law
          Dictionary 212 (7th ed. 1999)). “Generally, to avoid
          breaking the chain of causation for criminal liability, a
          variation between the result intended or risked and the
          actual result of [the] defendant's conduct must not be so
          out of the ordinary that it is unfair to hold [the]
          defendant responsible for that result.” Id. at 461–62, 824
          A.2d [at 1090] (citing Martin, supra, 119 N.J. at 14, 573
          A.2d [at 1365]; Wayne R. LaFave & Austin W. Scott, Jr.,
          Handbook on Criminal Law § 35, at 246 (1972)). Thus, an
          “intervening cause” denotes an event or condition which
          renders a result “too remote, accidental in its occurrence,
          or dependent on another’s volitional act” to fairly affect
          criminal liability or the gravity of the offense. See
          N.J.S.A. 2C:2–3(c); Pelham, supra, 176 N.J. at 461–62, 824
          A.2d [at 1090].

State v. Buckley, 78 A.3d 958, 968 (N.J. 2013).

          In the instant case, the circuit court instructed the

jury only as to “but for” causation under HRS § 702-214.              At the

time, Abella did not request a causation jury instruction based

on the culpability standard relating to intervening causation in

subsection (2) of HRS §§ 702-215 and -216.           As such, he asks this

court to recognize plain error in omitting such an instruction.

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He asserts:

          Here, there was an intervening act by numerous persons,
          other than Abella, i.e., medical treatment, and a decision
          made that terminated Higa's life. In other words, the
          result caused was “too remote” or “too dependent on
          another's volitional conduct to have a bearing on the
          defendant's liability or on the gravity of the defendant's
          offense.” § 702-215(2), HRS [2014]; see also § 702-216(2),
          HRS [2014] (reckless or negligent causation).

          In this case, the court’s instruction on causation was

an incomplete and a misleading statement of the law - and thus

plain error - because it omitted any reference to the

“culpability” standard in HRS §§ 702-215(2) and –216(2).

Evidence was adduced at trial of intervening events, from which a

jury could have inferred that Abella’s culpability was

diminished.   Specifically, jurors could have considered evidence

of Higa’s daily improvements after his surgery, showing that Higa

could reach toward stimuli and open his eyes in response to

voice, that he was becoming more alert, and that his condition

was not worsening.     Jurors also could have considered Dr.

Oshiro’s testimony that it was “probably possible” that Higa

could have regained independent breathing.           Moreover, jurors

could have also fairly considered the circumstances surrounding

the decision to withdraw Higa’s life support, including that

Higa’s daughter was not informed of the progress he had been

making since the surgery.

          This evidence could enable a jury to conclude that

intervening volitional conduct caused Higa’s death such that it

would be unjust to convict Abella of a homicide.            “When the


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actual result is of the same character, but occurred in a

different manner from that designed or contemplated, it is for

the jury to determine whether intervening causes or unforeseen

conditions lead to the conclusion that it is unjust to find that

the defendant’s conduct is the cause of the actual result.”

Martin, 573 A.2d at 1365.       Indeed, in his closing argument before

the jury, defense counsel specifically urged the jurors to draw

this conclusion:

          One more thing. Remember I asked the doctor, I said what if
          you didn't pull the tubes out, would he have survived
          another day? He said yeah. Would you survive another day?
          Said yeah. Would you survive another day? Yeah. So they
          don't really know to this day whether that guy would still
          be alive and what kind of progress he would have been making
          over this past year. They really don't know, and they made
          a judgment call, and in making that judgment call, they want
          you to hold my client responsible for that, and that's just
          not right. That's just not right.

          In light of the evidence, whether it would be unjust to

hold Abella accountable for the result he in fact caused is

precisely the inquiry the legislature intended for a jury to

consider per subsection (2) of HRS §§ 702-215 and -216.              In this

instance, by limiting the jurors’ understanding of legal

causation to the “but for” rule under HRS § 702-214, the circuit

court prevented the jurors from meaningfully considering the

issue of whether it would be unjust to consider Abella criminally

liable for causing Higa’s death on July 29, 2014 based on

evidence of intervening events.        For this reason, the circuit

court plainly erred in omitting a jury instruction based on

subsection (2) of HRS §§ 702-215 and -216.


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           In reaching this conclusion, we disagree with the ICA’s

holding that, as a matter of law, removal of life support cannot

constitute an intervening cause that may absolve a defendant from

liability for causing death.        See Abella, 144 Hawai i at 148-49,

438 P.3d at 280-81.      Thus, we also disagree with the New Jersey

Supreme Court majority in Pelham, relied upon by the ICA.

           Pelham is the only case cited by the ICA that is

directly relevant to the instant case, given the unique statutory

definitions of causation in New Jersey and Hawai i.17             In Pelham,


      17
            In addition to Pelham, the ICA cited People v. Bowles, 607 N.W.2d
715 (Mich. 2000), State v. Yates, 824 P.2d 519 (Wash. App. 1992), and People
v. Funes, 28 Cal.Rptr.2d 758 (Cal. App. 1994). See Abella, 114 Hawai i at
148-49. The majority in Pelham also favorably cited these cases. See Pelham,
824 A.2d at 1091-92. However, the Pelham dissent persuasively observed:

           New Jersey is only one of two states that have adopted MPC
           § 2.03 and explicitly added the intervening volitional
           conduct of others as a factor to be considered in
           determining causation. . . .
                 [T]he majority’s heavy reliance on other states’
           common-law proximate causation jurisprudence as support for
           its position is misplaced. Not one case cited by the
           majority interprets a causation provision similar to our
           own. Only twelve states have codified general statutory
           causation provisions. Three states have adopted the
           essential elements of MPC § 2.03 verbatim, and do not
           include N.J.S.A. 2C:2–3’s additional requirements that the
           actual result of a defendant’s conduct not be “too . . .
           dependent on another’s volitional act to have a just
           bearing” on his liability or on the gravity of the offense.
           Three states have wholly rejected the MPC causation
           provision on which ours was patterned and instead rely
           solely on a draft provision of the Final Report of the
           National Commission on Reform of Federal Criminal Laws
           (Brown Commission) that “deals with only one aspect of the
           traditional problem of causation, indicating that if an act
           is a but-for’ or concurrent cause of a result causation ‘may
           be found.’” See MPC, supra, § 2.03 cmt. 5 at 264–65 & n.
           23. Two states have adopted provisions incorporating the
           Brown Commission draft provision, along with provisions
           analogous to MPC § 2.03(3)(a), supra note 2.6. Two states
           have adopted the MPC tentative draft alternative that the
           ALI ultimately rejected, and thus couch causation
           culpability in terms of whether the actual result was
                                                                (continued...)

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the victim suffered “catastrophic injuries” after a car accident,

including a spinal column fracture paralyzing him from the chest

down, multiple broken ribs, a punctured lung, and head injury,

among other things.         824 A.2d at 1084.      He required a vena cava

filter, a surgical airway through his neck and into his windpipe,

a feeding tube inserted directly to his stomach, and a catheter.

Id.   Despite his brain injuries, he “was aware of his physical

and cognitive disabilities” and occasionally “tried to remove his

ventilator” during lucid moments.             Id. at 1085.    About five

months after the accident, “[b]ecause of his brain damage, his

lack of improvement, and his severe infections[,] [his] family

decided to act in accordance with his wishes and remove the

ventilator.”        Id.   He was pronounced dead within two hours of the

ventilator’s removal.          Id.

               The defendant, who was charged with aggravated

manslaughter and convicted of second-degree vehicular homicide,

argued on appeal that the trial court committed reversible error

in instructing the jury that “the removal of life supports, in

this case a ventilator, is not a sufficient intervening cause to



      17
           (...continued)
                “foreseen or foreseeable as a substantial probability.” See
                MPC, supra, § 2.03 cmt. 3 at 261 n. 17. The majority’s
                reliance on other jurisdictions' law of causation is thus
                not persuasive because those cases do not interpret our
                unique provision, which explicitly incorporates both the
                intervening volitional conduct of others and the jury’s
                sense of justice as factors to be considered in determining
                a defendant's liability.

Id. at 1097, 1099 (Albin, J., dissenting) (footnotes omitted) (emphasis
added).

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relieve the defendant of criminal liability.”            Id. at 1086.        The

court of appeals agreed and vacated the conviction, concluding

that “the trial judge’s instructions on intervening cause

deprived defendant of the opportunity to have the jury decide the

essential issue of causation.”        State v. Pelham, 801 A.2d 448,

456 (N.J. App. 2002).       The court of appeals thus held that the

instruction “deprived defendant of his constitutional right to

have the jury in a criminal trial to decide all elements of the

charged offense.”     Id.

          On further review, the Supreme Court of New Jersey

upheld the conviction.       See Pelham, 824 A.2d at 1092.         The court

held that “removal of life support, as a matter of law, may not

constitute an independent cause for purposes of lessening a

criminal defendant’s liability.”          Id.   The majority reasoned:

          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 the defendant.

Id. at 1093.

          The court’s decision in Pelham turned largely and, in

our view, incorrectly, on the importance of upholding a person’s

right to refuse life-sustaining medical treatment and “the effect

to be given to a victim’s exercise of that right in the context

of a homicide trial.”       Id. at 1089.    As the dissent pointed out,

Pelham was “not about a patient’s right to self-determination”


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and the majority’s ruling, in essence, “conflates the right of

the patient to self-determination with the right of the accused

to have his case decided by a jury.”          Id. at 1095-96 (Albin, J.,

dissenting).

            The dissent focused on N.J.S.A. 2C:2-3c, the criminal

causation provision patterned on the MPC, which provides for the

consideration of whether a result is “too remote, accidental in

its occurrence, or dependent on another’s volitional act to have

a just bearing on the actor’s liability or on the gravity of his

offense.”18    Id. at 1095 (Albin, J., dissenting).           The dissent

observed that this “general and broad language . . . was intended

to apply to the infinite number of variables that arise in the

unique circumstances of each case, including that of this

defendant.”    Id. (Albin, J., dissenting).          The dissent also

emphasized, “Causation was a matter that the jury should have

been trusted to decide correctly” and that the majority “ignores

the statutory language that governs this case[.]”              Id. (Albin,

J., dissenting).     Further, the dissent noted:

            the drafters of our Code clearly contemplated, as previously
            recognized by this Court, that “[w]hen the actual result is
            of the same character, but occurred in a different manner
            . . ., it is for the jury to determine whether intervening
            causes or unforeseen conditions lead to the conclusion that
            it is unjust to find that the defendant's conduct is the
            cause of the actual result.” Martin, supra, 119 N.J. at 13,
            573 A.2d [at 1366-67] (emphasis added). This is just such a
            case.
                  Here, . . . defendant does not dispute that his



      18
            Although HRS §§ 702-215(2) and 702-216(2) differ from the New
Jersey provision because they do not include the word “just,” this does not
bear on our analysis.

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           conduct was a “but-for” cause of the victim's death.
           Instead, he claims that the State must prove the additional
           requirement of N.J.S.A. 2C:2–3c that he recklessly caused
           the actual result, i.e., the victim's death, five months
           after the accident and two hours after the victim and his
           family elected to disconnect his ventilator. In order for
           this defendant to be guilty of vehicular homicide, the State
           must prove that the specific character and manner of the
           victim's death was either: (1) within the risk of which
           defendant was aware; or, (2) if not, then not “too remote,
           accidental in its occurrence, or dependent on another's
           volitional act to have a just bearing” on defendant's
           liability or the gravity of his offense. N.J.S.A. 2C:2–3c;
           Martin, supra, 119 N.J. at 12, 573 A.2d [at 1364].

Id. at 1098 (Albin, J., dissenting) (emphasis in original).

           We adopt the reasoning of the dissent in Pelham.               To

hold as a matter of law that the removal of life support cannot

constitute an intervening cause ruling interferes with the role

of the jury in finding the essential element of causation.               See

id. at 1098 (Albin, J., dissenting) (“The majority holds, in

essence, that the risk that a victim will elect to reject or

terminate some life-sustaining measure as a result of his

injuries is, as a matter of law, within the risk of which

defendants are aware.      I part with the majority on this point.

Whether defendant was aware of the risk was a question for the

jury.”).   Moreover, we agree that

           [i]n making no allowance for the varied circumstances in
           which life support may be terminated by a victim, the
           majority does not permit the jury to consider the level of
           medical assistance required to sustain life, for example,
           whether the medical regimen is so burdensome as to deny even
           a minimal quality of life, or is relatively benign in
           comparison. The nature and scope of the medical care and
           the quality of life of the victim are factors that should be
           considered along with remoteness in determining whether
           intervening circumstances — the voluntary termination of
           life support — should have a just bearing on the outcome of
           the case.


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Id. at 1100 (Albin, J., dissenting).

            In adopting this analysis, we in no way diminish the

importance of the right to refuse medical treatment as provided

in Chapter 327E.     However, we cannot infringe on a defendant’s

right in a criminal case to have the jury determine causation, an

element of the crime, beyond a reasonable doubt.             The choices of

patients or their families do not affect that right.              This is

particularly so when, as was the case here, there was evidence

suggesting that the prognosis for the victim was uncertain at the

time the life support was discontinued.           We at once respect the

difficult, highly personal, and protected decision made by Higa’s

family while recognizing our responsibility to ensure that Abella

receives a fundamentally fair trial. 19

            For the above reasons, we hold that the trial court

should have instructed the jury on intervening causation pursuant

to HRS §§ 702-215 and 702-216, and its failure to do so was

“prejudicially insufficient,” requiring a new trial.              Nichols,

111 Hawai i at 334, 141 P.3d at 981.20

                              IV.   CONCLUSION

            For the foregoing reasons, we vacate the ICA’s May 7,



      19
            We note that on remand, a jury might well come to the same
verdict, and nothing in this decision should be read to foreclose that
possibility. But that must be a decision left to the jury. Pelham, 824 A.2d
at 1100 (Albin, J., dissenting).
      20
            The circuit court should be mindful of administering jury
instructions consistent with this opinion such that the jury is informed
whether the causation instructions discussed herein apply to a lesser-included
offense.

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2019 judgment on appeal and vacate the circuit court’s

December 16, 2015 judgment of conviction.           The case is remanded

to the circuit court for proceedings consistent with this

opinion.

Dana S. Ishibashi                     /s/ Mark E. Recktenwald
for petitioner
                                      /s/ Paula A. Nakayama
Chad M. Kumagai                       /s/ Sabrina S. McKenna
(Brandon H. Ito
                                      /s/ Richard W. Pollack
on the brief)
for respondent                        /s/ Michael D. Wilson




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