• Ethics

I am grateful to John Phillips and David Wendler as well as to The Journal of Medical Ethics for the opportunity to express some thoughts about surrogate decision-making. Current practices are just a few decades old. It would not be surprising if they need a bit of tweaking.

An earlier acceptance of the physician as the decision-maker at the bedside relied on the premise that, among those at the bedside, the physician was most likely to be a person of practical wisdom, what Aristotle called a phronimos. The premise was that, in the welter of medical and non-medical considerations, the doctor was the most likely to pick out the best available option for the patient, the option that would best advance the patient's interests.

Read this way, there are reasons for scepticism:

1. In an era of hospital medicine, the doctor is unlikely to be sufficiently well acquainted with the patient to know what is best for her, what is in her best interests.

2. If the decision is (non-medically) difficult, calling for sagacity and human insight, there is no reason to think that the doctor, through being selected, trained and put to work by the medical establishment, will have more of such qualities than the patient.

It is thus understandable why the premise of physician wisdom might no longer seem attractive with decisionally competent patients.

Turning to the surrogate context, three questions need answers: What did the patient say or indicate she wanted? What would the patient want? What is in the patient's best interests?

Let's examine them in reverse order. The above objections also apply to the issue of who is more likely to get the patients’ best interests right, the doctor or the surrogate. With the question of what the patient would have chosen, the scale tilts further …