Two standards should guide surrogate decision making. In chapter 2 of buchanan and brock blog 5 in chapter 2. Physicians can engage patients about decision making in ways that are inclusive of family input, and help consider possible roles of surrogate decision makers for patients who do not have decision making capacity. Third, appeals to the best interest standard are often vague and indeterminate. First, reliance on the best interest standard is subjective.
Withholding or withdrawing lifesustaining treatment. Scope and outcomes of surrogate decision making among. These findings suggest a discrepancy between the normative ethical framework of surrogate decision making and the descriptive reality of how it is actually being carried out. This fact leads to situations where surrogate decision makers must fill the role of the patient in terms of making preferencebased treatment decisions, oftentimes in challenging situations where prognosis is uncertain. Most participants reported that there was not an advance care plan in place for the person living with dementia. Study shows longterm emotional impact for people who make treatment decisions for ill loved ones. Best interests, dementia and the mental capacity act 2005. In the neuroscience intensive care unit nicu, most patients lack the capacity to make their own preferences known. Advance directives, substituted judgment, and the bestinterest standard all have limitations that constrain their usefulness in making medical decisions for patients who. Evaluating medical decisionmaking capacity in practice. Although the code of medical ethics does not have much to say about mental health. A surrogate decision maker is the individual legally authorized to make decisions on behalf of the patient. After the cruzan decision and the patient selfdetermination act of 1990, many states enacted proxy statutes specifically for health.
Decision making for incompetent elderly people is an increasingly serious issue. Second, it leads to behavior that is intolerant and polarizing. Recently, proxy or surrogate decision making regarding the termination of lifesustaining interventions for incompetent patients has been widely endorsed and promoted. A surrogate decision maker, also known as a health care proxy or as agents, is an advocate for incompetent patients. Privileging advance directives and recreating the judgment of the earlier self via substituted judgment are no longer the obvious solutions, given this conflict. The act does not provide an account of the underlying concept of best.
If the patient is not capable of giving consent, and time permits, the medical team will seek a surrogate. Learn vocabulary, terms, and more with flashcards, games, and other study tools. Four theoretical ethical perspectives on professionalpatient relationshipsautonomy, justice, virtue ethics, and the ethic of careare surveyed, and some of their implications for the informed consent requirement in health care are sketched out. Surrogate decisionmaker an overview sciencedirect topics. Alternative models of surrogate decision making may mitigate this disparity by employing a valuebased approach over a strict prioritization of patient preferences. Importance hospitalized older adults often lack decisional capacity, but outside of the intensive care unit and endoflife care settings, little is known about the frequency of decision making by family members or other surrogates or its implications for hospital care objective to describe the scope of surrogate decision making, the hospital course, and outcomes for older adults. Parents or other surrogate decision makers provide informed permission for diagnostic procedures and medical treatment for their children. If there is a durable power of attorney for health care, the agent appointed by that document is authorized to make health care decisions within the scope of. Such scenarios raise difficult questions of how the interests of the earlier and current self ought to be balanced in surrogate decision making. Using substituted judgment, doctors and family members try to make the decision that the patient would have made if he or she were able to make decisions. It also makes an enormous contribution to current scholarly debates regarding surrogate decision making in medicine, law, and ethics. Decisionmaking on behalf of people living with dementia.
Deciding for others studies in philosophy and health policy. Bioethics research library of the kennedy institute of ethics. Moreno, ethics deciding for others has much to teach the general reader who may have read press coverage of major court descisions such as cruzan. Drawing on their extensive experience in philosophy, medical ethics, and public policy. Even when the prior wishes of the person with dementia were known, the process of decision. Use the approach of ethical principlism in nursing practice. Pdf on feb 1, 1999, mark g kuczewski and others published commentary. It provides an indepth analysis of competence, articulates and defends a coherent set of principles to specify suitable surrogate.
On abortion, capital punishment, surrogate decisionmaking. However, patients frequently are unable to participate in decision making about their treatment because of the effects of the illness, treatment, or underlying condition. The ethics of surrogate decision making, the authors do a thorough job of describing a framework to consider how to ethically treat incompetent patients and honor their selfdetermination. The ethics of surrogate decision making as want to read. When a patient chooses a surrogate, he or she must have capacity to make that decision and be free of coercion.
Advance directives ad and surrogate decisionmaking. He taught at the university of arizona, the university of wisconsinmadison, and the university of. One is brought back to questions such as, does what occurs at fertilization make a moral difference, and if so, why. If a patient is conscious, competent, and has reached the age at which the law of the jurisdiction permits medical decision making, then there is no need for a surrogate decision maker. By incompetent, this chapter is referring to decision making competence as is necessary for the idea of informed consent. Advanced directives and surrogate decision making case. A general theory for treatment decisions for incompetent patients, especially minors, the elderly, and psychiatric patients. Should age be a deciding factor in ethical decision making. After all, cases are usually controversial precisely because reasonable.
Patient autonomy, assessment of competence and surrogate decision making. The substituted judgment standard sjs for surrogate decision making dictates that a surrogate, when making medical decisions on behalf of an incapacitated patient, ought to make the decision that the patient would have made if the patient had decisional capacity. Respecting autonomy necessarily means respecting patients decisions. Stressful choices for surrogate treatment decision makers. Deciding for others studies in philosophy and health. In this book, the authors, both professors of philosophy and members of the presidents commission on medical ethics, set out a theoretical framework for deciding who is competent to make his own life. Competence, capacity, and surrogate decisionmaking the. New issues and arguments, all published here for the first time, focus on recent thinking in this important area, helping initiate issues and lines of argument that have not been explored previously. The ethics of surrogate decision making paperback jan 26 1990. Surrogate decisionmaking it is well established in medical ethics, practice, and law that the informed consent of competent patients must be secured before treatment. Ama code of medical ethics opinions on patient decisionmaking. Get your kindle here, or download a free kindle reading app. Reconceptualizing the experience of surrogate decision.
There is no surrogate available and willing to make decisions on behalf of a patient who does not have decision making capacity or no surrogate can be identified. Pdf legal fundamentals of surrogate decision making. He received his phd from the university of north carolina at chapel hill in 1975. Part i develops a general theory for making treatment and care decisions for patients who are not competent to decide for themselves. In this book, the authors, both professors of philosophy and members of the presidents commission on medical ethics, set out a theoretical framework for deciding who. Limitations of advance directives, substituted judgment, and best interest, commentary 1. However, empirical evidence suggests that the moral basis for substituted judgment is. Results analysis revealed three main themes associated with the process of surrogate decision making in dementia. Autonomy, beneficence, and the rights of parents and. Surrogates commonly face a broad range of decisions in both the icu and the hospital ward setting. The patient or surrogate and the health care team cannot reach agreement about a decision to withhold or withdraw lifesustaining treatment. Pdf the four previous articles in this series have traced the history of patient autonomy and have identified its ethical and legal foundations. This substitute judgment is used when the patient has previously expressed preferences, or when the surrogate can reasonably infer what the. Some features of this site may not work without it.
How to help a patient choose a surrogate decision maker pcnow. This issue brings together essays on topics that have been the subject of longstanding debate in the journal of medicine and philosophyabortion, capital punishment, surrogate decisionmaking, and genetic enhancement. The mental capacity act 2005 is an impressive piece of legislation that deserves serious ethical attention, but much of the commentary on the act has focussed on its legal and practical implications rather than the underlying ethical concepts. Because decision making capacity is decision specific, a patient may have capacity to assign a surrogate which is in general felt to be a lowrisk medical decision even if they lack capacity for more complex. In the vast majority of cases of surrogate decision making, the legal system is. The substituted judgment standard of surrogate decision making determines whether or not the life lived and to be lived by. A physician may determine that a patient does not have the capacity to make a decision for or against surgery for a hip fracture, but she may have the capacity to decide if she wants a sleeping pill or a laxative. We argue that the best interest standard for surrogate decision making is problematic for a number of reasons. How to help a patient choose a surrogate decision maker. Thus, attribution of competence in the context of medical decisionmaking.
Decision making capacity, on the other hand, is a clinical term that is taskspecific. If a patient is unable to make decisions for themselves about personal care, some agent must make decisions for them. The goal of surrogate decision making is to reflect what the individual would have decided, if able to speak for him herself. Autonomy is the right of children to decide what is best for their parents. Substituted judgment is often invoked as a guide for decision making when a patient lacks decision making capacity and has no advance directive. This paper examines the approach that the act takes to best interests. In chapter 2 of buchanan and brocks deciding for others. Narrative views of personal identity and substituted judgment in surrogate decision making find, read and cite all the. Surrogate decision making occurs for nearly half of hospitalized older adults and includes both complete decision making by the surrogate and joint decision making by the patient and surrogate. Obtenez votre kindle ici, or download a free kindle reading app. Duke professor of philosophy at duke university and also professor of the philosophy of international law at the dickson poon school of law at kings college, london. Generally, patients are free to exercise their autonomy in making decisions about.
Medical decision making capacity is the ability of a patient to understand the benefits and risks of, and the alternatives to, a proposed treatment or intervention including no treatment. Professionalpatient relationships and informed consent. Patient preferences and surrogate decision making in. Users may download and print one copy of any publication from the public. Ama code of medical ethics opinions on patient decision.
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