## Facts

- Beth was born in 1986 to minor parents and was adjudicated in need of care and protection; the Department of Social Services (DSS) obtained legal and physical custody.
- DSS later returned physical custody to Beth’s mother while retaining legal custody.
- Beth suffered catastrophic brain injury in an automobile accident when car-seat straps obstructed her airway, leaving her in an irreversible coma described as a persistent vegetative state.
- Beth could not see, hear, or make purposeful movements; she had extremely limited independent respiration, required a tracheostomy and ventilator support, and received nutrition through a permanent gastric feeding tube.
- Beth experienced life-threatening aspiration events causing cardiopulmonary arrests, requiring extraordinary interventions including medication to restart her heart; surgery reduced but did not eliminate the risk of recurrence.
- DSS and Beth’s mother jointly sought appointment of a guardian ad litem (GAL) and a substituted-judgment determination addressing whether resuscitation should be withheld through a “no code” (DNR) order.
- Medical testimony stated Beth’s condition was irreversible with no possibility of recovery and that a DNR order was medically and ethically appropriate.

## Issues

1. Whether a court in a care-and-protection proceeding may apply substituted judgment to authorize a DNR order for an incompetent minor who is a ward of the state.
2. Whether the evidence supported the determination that Beth, if competent, would choose to forgo resuscitative measures despite the Commonwealth’s strong interest in preserving life.

## Decision

- The Supreme Judicial Court of Massachusetts affirmed the District Court’s substituted-judgment order directing placement of a DNR (“no code”) order on Beth’s medical chart.
- The court held substituted judgment may be used for an incompetent minor in state custody within a care-and-protection case.
- The court concluded the District Court properly weighed the relevant factors and interests and permissibly found that Beth, if competent, would decline resuscitation.

## Legal Principles

- Substituted judgment requires the court to determine what decision the incompetent person would make if competent under the present circumstances.
- In making that determination, the court considers medical condition and prognosis, the burdens and intrusiveness of treatment, and the person’s dignity and bodily integrity.
- The Commonwealth’s interests (including preservation of life, protection of vulnerable persons, and prevention of self-harm) are substantial but not absolute and must be weighed against the individual’s circumstances.
- For patients without prior expressed wishes (such as an infant), the court may rely on medical evidence and reasonable inferences about what a competent person would choose when treatment is burdensome and offers no meaningful prospect of recovery.
- State custody does not require continuation of life-prolonging interventions in all cases; judicial oversight through substituted judgment remains available to authorize withholding resuscitation when supported by the record.

## Conclusion

Massachusetts upheld a DNR order for an infant in an irreversible persistent vegetative state, ruling that substituted judgment can be applied in a care-and-protection proceeding for a ward of the state and that the Commonwealth’s interest in preserving life may yield where resuscitation would be invasive, recurrent, and offer no prospect of recovery.


Care & Prot. of Beth, 412 Mass. 188, 587 N.E.2d 1377 (Mass. 1992)