Philosophy East and West

Recent decades have witnessed the rapid development of surrogate decision making in clinical medicine in Western countries, especially the United States.¹ Various advance-care documents such as "living wills," "advance directives," and "durable power of attorney" have been accepted in law and have become frequently used in hospitals. Increasingly patients come to adopt such documents to designate other persons as their surrogate decision makers in the event that the patients become incompetent. A surrogate decision maker (or proxy) is designated to make medical decisions for the patient in accordance with the patient's previously expressed wishes. Thus, only a person who is familiar with the patient's own values and expectations and is willing to follow them should be appointed surrogate decision maker. In practice, it is usually either family members or friends who are appointed to be proxies.

No doubt this practice has arisen against the background of increased life expectancy, made possible primarily by progress in medical science and technology. Almost all societies today are experiencing an increase in the number of aged members in their population.² Among the elderly with chronic diseases, reduced competence often accompanies dementia or other cognitive disorders. As a result, there is a growing need to provide for making surrogate health-care decisions for incompetent elderly patients who in the past would have died before reaching this condition.

However, it would be misleading to see the rise of this recent Western pattern of surrogate decision making as necessarily a result of an increase in the number of elderly with declining competence. This increase certainly necessitates a concomitant increase in surrogate decision making in clinical practice. But this need should not be seen as the sole determinant of the norms regarding who is to be appointed surrogate as well as the way in which surrogate decisions are made. There must be other, broader and deeper cultural as well as scientific and technological factors underlying the particular method by which surrogates are designated and decisions made in Western society. It is my view that the pattern of surrogate decision making in any society is determined first and foremost by the dominant perspective on human life and relations that is accepted by that society. The current American model of surrogate decision making, in my view, is best seen as a manifestation of the dominant overall Western perspective on human life and relations as it relates to current medical practice. [End Page 346]

This should become clearer if we compare the American approach to surrogate decision making with what is practiced in China. Although specialists in bioethics have introduced the formal arrangement of "advance directives" to Chinese society in the hope of facilitating medical decision making for incompetent patients in that community, very few Chinese have shown an interest in this arrangement. Chinese patients take it for granted that it is the whole family, rather than the patient alone, that should make medical decisions. When the whole family makes medical decisions for the patient—even when the patient is competent—it is only logical that the family should continue to take responsibility when the patient becomes incompetent. In this cultural context there is virtually no room for the patient to prepare formal advance directives or employ durable power of attorney regarding his or her health care.

Some would argue that the contemporary Western pattern of surrogate decision making is an indicator of moral progress in medical practice. In the West, it is seen as admirable when the patient is able to exercise control over what happens to his or her body, health, and life when he or she is competent to do so. And it is even more empowering to know that one can extend this control at a stage when one is no longer competent. The formal arrangement of surrogate decision making provides such an opportunity in a way that is legally explicit. Thus, according to this view, the practice of surrogate decision making represents a real triumph in the movement toward patients' rights. Indeed, some believe that Western society has experienced a revolutionary change in its medical ethics with the...