After many years of discussion and debate, decisions on life-sustaining treatment for incompetent patients continue to pose profound ethical and policy questions. A controversial Michigan Supreme Court decision issued last August highlights four major unresolved issues. First, how specific must a patient's prior remarks be to provide and convincing of the individual's preferences on a current treatment question? Second, should competent persons be granted full control over their future care as incompetent patients? Third, in what situations does an objective benefit-burden analysis permit treatment to be withheld or withdrawn? And fourth, whose wishes should take priority when close family members disagree about life-sustaining measures for an incompetent relative? In re Martin[1] presents all these issues. In Martin, the Michigan Supreme Court by a vote of six to one refused to authorize removal of an incompetent patient's gastrostomy tube. In February, the U.S. Supreme Court declined to review the decision. The patient, Michael Martin, suffered serious and permanent brain damage in a car accident. Though severely paralyzed and on a gastrostomy tube for nutrition, has no progressive terminal illness and retains some awareness of his environment. At the trial, witnesses gave differing accounts of his cognitive capacities. Although all agreed the patient could no longer make his own medical decisions, one expert testified lacked capacity for any meaningful interaction. Another claimed the patient could engage in limited voluntary movement, could recognize faces, respond emotionally, and communicate with others with head nods. According to this physician, when asked if experienced pain or suffering or did not want to continue living, the patient signaled no. Other testimony, both lay and professional, placed Mr. Martin's abilities somewhere in between. Most believed was able to respond appropriately to commands and to answer simple yes or no questions. His responses were sometimes inconsistent, however, and at times was unresponsive to external stimuli. Besides the patient's current capacities, court proceedings focused on his prior statements as a competent individual. His wife, who was also his legal guardian, initiated the request to withdraw the gastrostomy tube. According to Mary Martin, her husband had frequently and emphatically asserted that would not want to live if became incompetent and dependent on people and machines. According to her, he was always bothered by, and intolerant of, people who were disabled and on others. Other witnesses reported conversations in which Mr. Martin said would not want to be maintained in an unconscious state. What Qualifies as Clear and Convincing Evidence? Many courts have ruled that life-sustaining treatment may be forgone if an incompetent patient's previous statements provide clear and convincing evidence of a competent desire to refuse such treatment. Courts have disparate views on what kinds of statements satisfy this evidentiary standard, however. Some courts have accepted relatively general statements; others have demanded that the patient's prior refusal expressly encompass his or her current condition, current treatment intervention, or both. In Martin, the Michigan Supreme Court adopted the latter approach. Although a hospital ethics committee and two lower courts found and convincing that this patient sought to refuse treatment in his current circumstances, the higher court disagreed. The supreme court noted that most of the witnesses referred to Mr. Martin's prior remarks on coma or unconsciousness, which was not his current condition. The judges also were unpersuaded by Mrs. Martin's account of numerous conversations in which her husband asserted that life would be unacceptable if became on other people and machines to perform basic functions such as eating and dressing. …