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Licensing Surrogate Decision-Makers

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Abstract

As medical technology continues to improve, more people will live longer lives with multiple chronic illnesses with increasing cumulative debilitation, including cognitive dysfunction. Combined with the aging of society in most developed countries, an ever-growing number of patients will require surrogate decision-makers. While advance care planning by patients still capable of expressing their preferences about medical interventions and end-of-life care can improve the quality and accuracy of surrogate decisions, this is often not the case, not infrequently leading to demands for ineffective, inappropriate and prolonged interventions. In 1980 LaFollette called for the licensing of prospective parents, basing his argument on the harm they can do to vulnerable people (children). In this paper, I apply his arguments to surrogate decision-makers for cognitively incapacitated patients, rhetorically suggesting that we require potential surrogates to qualify for this position by demonstrating their ability to make reasonable and rational decisions for others. I employ this theoretical approach to argue that the loose criteria by which we authorize surrogates’ generally unchallenged power should be reconsidered.

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Notes

  1. One could possibly argue that a subcategory in this group—call it Class IIa – could be those patients who could be thought to have temporarily lost decision-making capacity, either due to medications, their illness process, “ICU Syndrome” (Ouimet et al. 2007), or some other co-morbidity. However, this can only be judged after the fact. If decisions must be made during this period, thus requiring the patient to have a surrogate, and without predictive accuracy about the probability of the patient regaining sufficient cognitive capacity to resume autonomous control of his medical care, then these patients may be considered similar to others in this Class.

  2. The only caveat is that physicians (and others) cannot refuse to provide an intervention that they would provide to another patient in a similar clinical situation, solely on the basis of morally irrelevant facts such as skin color, ethnicity, etc. Similarly, if a physician has such an idiosyncratic view of a widely accepted drug or treatment of some sort that places her far from the mainstream, the denial of it to patients would also be unacceptable. Refusals based on reasonable medical grounds could be prima facie legitimate, but the doctor may have the responsibility to offer the patient (or surrogate) a second opinion or to transfer him to the care of another physician who might provide the requested care, if there was reason to believe that others might think differently.

  3. For example, it is unlikely that it could prevent people dedicated to evading the strictures of the licensing procedure from devising strategies to cheat or otherwise deceive healthcare providers and/or those for whom they would serve as surrogates (i.e., patients). Similarly, there are adoptive parents who abuse their children despite having passed all the “tests”, and doctors with valid licenses who are incompetent (Hodgson et al. 2007; Papadakis et al. 2005).

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  1. Trent Center for Bioethics, Humanities and History of Medicine, Duke University Medical Center, 108 Seeley G. Mudd Building, Box 3040, Durham, NC, 27710, USA

    Philip M. Rosoff

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Rosoff, P.M. Licensing Surrogate Decision-Makers. HEC Forum 29, 145–169 (2017). https://doi.org/10.1007/s10730-016-9316-x

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