## Facts

- Joseph Saikewicz, a 67-year-old resident of a state institution, had profound congenital intellectual disability and lacked capacity to provide informed consent.
- He was diagnosed with acute myeloblastic monocytic leukemia, an incurable condition.
- The institution’s superintendent and counsel petitioned the Probate Court to appoint a guardian and a guardian ad litem to address treatment decisions.
- Medical evidence showed chemotherapy was the medically indicated option but would cause substantial pain and adverse side effects, especially for a patient unable to understand or cooperate.
- Evidence also showed chemotherapy might produce remission in a minority of similar cases, typically for a limited period; without chemotherapy he would likely die sooner but without the added burdens of treatment.
- After receiving the guardian ad litem’s report and expert testimony, the Probate Court ordered that chemotherapy not be administered absent further court order, effectively authorizing nontreatment.
- Saikewicz died while appellate review was pending; the reviewing court proceeded to decide the legal issues because they were capable of repetition and important for future cases.

## Issues

1. Whether a person incompetent from birth has a right to refuse life-prolonging medical treatment, exercisable through a surrogate or court.
2. What decision-making standard governs refusal of treatment for an incompetent person: substituted judgment or a best-interests approach.
3. How to weigh the individual’s interests against asserted state interests in preserving life, preventing suicide, protecting third parties, and maintaining medical ethics.

## Decision

- The Supreme Judicial Court approved the Probate Court’s order withholding chemotherapy.
- The court held that a person incompetent from birth is not required to undergo life-prolonging treatment and is entitled to the same right to refuse treatment recognized for competent persons.
- The court adopted substituted judgment as the governing standard and treated the Probate Court as the appropriate forum to supervise such determinations.
- The court concluded the relevant state interests did not justify overriding the refusal of chemotherapy in these circumstances.

## Legal Principles

- The right to refuse medical treatment is grounded in informed consent and the constitutional right of privacy.
- Incompetency does not eliminate the right to refuse treatment; it shifts decision-making to a surrogate process supervised by the court.
- Substituted judgment requires deciding, as nearly as possible, what the particular patient would choose if competent, using patient-specific factors rather than a generalized best-interests calculus.
- State interests that may limit refusal include preservation of life, protection of innocent third parties, prevention of suicide, and maintaining the ethical integrity of the medical profession; their weight depends on the facts of the case.
- For profoundly incompetent institutionalized persons, judicial oversight—through appointment of a guardian/guardian ad litem, evidentiary hearing, and explicit findings—serves as a safeguard when withholding or withdrawing life-prolonging treatment.

## Conclusion

The court held that lifelong incompetent persons possess the same fundamental right as competent persons to refuse extraordinary or burdensome medical treatment, and that courts should implement this right through a substituted-judgment determination balancing patient-specific factors against any countervailing state interests.


Superintendent of Belchertown State Sch. v. Saikewicz, 373 Mass. 728, 370 N.E.2d 417 (1977)