IntroductionExtended decision -making through the use of proxy decision -makers has been enshrined in a range of International Codes, Professional Guidance and Statute,For example, the UK Mental Capacity Act section 9.1; The General Medical Council ; the US National Guardianship Association ; Nuffield Council on Bioethics ; CIOMS-WHO section 6. Court cases such as Re Quinlan in the US have also contributed to establishing the groundings for the legal status of the proxy, albeit in terms of (...) who might be suitable as a proxy in cases where there was no clear appointment of them by a still competent individual. and is now widely seen as a useful means through which we can exercise control over decisions that affect our lives when we have lost capacity to make these decisions for ourselves.I will here limit myself to discussion of proxy consent for adults appointed prior to the loss of competence by the person they are acting as proxy for. The issue of p. (shrink)

Background: Research involving adults lacking mental capacity relies on the involvement of a proxy or surrogate, although this raises a number of ethical concerns. Empirical studies have examined attitudes towards proxy decision-making, proxies’ authority as decision-makers, decision accuracy, and other relevant factors. However, a comprehensive evidence-based account of proxy decision-making is lacking. This systematic review provides a synthesis of the empirical data reporting the ethical issues surrounding decisions made by research proxies, and the (...) development of a conceptual framework of proxy decision-making for research. Methods: A systematic review was conducted according to PRISMA guidelines. Databases including MEDLINE, EMBASE, and CINAHL were searched using a combination of search terms, and empirical data from eligible studies were retrieved. The review followed the framework synthesis approach to refine and develop a conceptual framework. Results: Thirty-four studies were included in the review. Two dimensions of proxy decision-making emerged. The ethical framing criteria of decision-making used by proxies: use of a substituted judgement, use of a best interests approach, combination of substituted judgement and best interests, and ‘something else’, and the active elements of proxy decision-making: ‘knowing the person’, patient-proxy relationship, accuracy of the decision, and balancing risks, benefits and burdens, and attitudes towards proxy decision-making. Interactions between the framing criteria and the elements of decision-making are complex and contextually-situated. Conclusions: The findings from this systematic review challenge the accepted reductionist account of proxy decision-making. Decision-making by research proxies is highly contextualized and multifactorial in nature. The choice of proxy and the relational features of decision-making play a fundamental role: both in providing the proxy’s authority as decision-maker, and guiding the decision-making process. The conceptual framework describes the relationship between the framing criteria used by the proxy, and the active elements of decision-making. Further work to develop, and empirically test the proposed framework is needed. (shrink)

Surrogate (proxy) decision makers must make research decisions for people with dementia who lack decision-making capacity. Proxies’ decision-making processes are minimally understood. We randomly assigned 82 proxies of AD patients to informed consent for one of three hypothetical protocols with differing levels of risk and benefit. Proxies answered questions about potential benefits of the described research to the patient and society, as well as about whether they would enroll their relative and why or why not. Proxies (...) interested in enrolling their relative cited the potential for direct benefit to their relative, altruism, and trust in researchers. Those declining cited risks, inconvenience, and stage of illness. Proxies weighed numerous factors, incorporating both substituted judgment and best interests standards in their decision-making processes. Although further empirical work is needed to understand the influences on and adequacy of proxies’ decision making regarding research, these findings can help inform policy regarding surrogate consent. (shrink)

We aim to establish the following claim: other factors held constant, the relative weights of the epistemic burdens of competing treatment options serve to determine the options that patient surrogates pursue. Simply put, surrogates confront an incentive, ceteris paribus, to pursue treatment options with respect to which their knowledge is most adequate to the requirements of the case. Regardless of what the patient would choose, options that require more knowledge than the surrogate possesses (or is likely to learn) will either (...) be neglected altogether or deeply discounted in the surrogate’s incentive structure. We establish this claim by arguing that the relation between epistemic burdens and incentives in decision-making is a general feature of surrogate decision-making. After establishing the claim, we draw out some of the implications for surrogate decision-making in medicine and offer philosophical and psychological explanations of the phenomenon. (shrink)

ZusammenfassungIm Gesetzentwurf des Bundesrates zur Änderung des Betreuungsrechts ist eine regelhafte Stellvertretung durch Angehörige für zur Entscheidung unfähige Patienten vorgesehen. Mithilfe eines strukturierten Fragebogens wurden die Einstellungen von Tumorpatienten, gesunden Kontrollpersonen, Pflegenden und Ärzten zur Präferenz der zu bevollmächtigenden Personen ermittelt. Nur 10–20% der Befragten haben eine Patientenverfügung verfasst. Als Entscheidungbefugte im Falle akuter Erkrankung werden Angehörige und Ärzte gemeinsam genannt. Als Gesundheitsbevollmächtigte werden Ehepartner/lebenspartner bevorzugt und nichtangehörige Personen nur von einer Minderheit genannt. Die grundsätzliche Bereitschaft, als Gesundheitsbevollmächtigte Verantwortung zu (...) übernehmen, ist hoch, erstreckt sich jedoch überwiegend auf Angehörige. Nur Ärzte sind in bis zu 50% auch für nichtangehörige Personen bereit, als Bevollmächtigte zu entscheiden. Die regelhafte Stellvertretung in Gesundheitsfragen durch Angehörige entspricht den Wünschen der Mehrheit von Tumorpatienten, gesunden Vergleichspersonen und medizinischem Personal. (shrink)

Mary Ann Meeker’s article admirably reminds readers that family members are involved in—or “responsively manage”—the care of relatives with severe illness in ways that run considerably beyond the stereotypes at play in many bioethical discussions of advance directives. Her observations thus make thinking about the role of families in healthcare provision more adequate to the facts, and this is an important contribution. There’s reason to be worried, however, that one explicit aim of the article—to ease the standing anxieties that many (...) clinicians and ethicists have about the reliability of family members as proxy decision makers—will be frustrated by its very success. Those already inclined to suspicion may tend to think that the more intricate and pervasive the ways in which families influence the healthcare decision making of their sick, the more chances they have for altering the connection between patients’ interests and the actions of professional providers.To determine whether and when such alterations are something to be concerned about, we’ll need to supplement a better grasp of the pertinent facts with a deeper sense of how human agency works and why we value it. We may also need some reminders about the defensibility of diverse moral understandings. Although both professionals and family members may profess an ethic that sets patients’ interests above those of non-patients—as Meeker’s own results suggest—any strict allegiance to such a framework may be more notional than normative—as her findings also hint. The actual working norms (among professionals, as well as within families) will likely be more complex, but not necessarily any the less defensible for that. (shrink)

The number of admissions to hospitals of patients without a proxy decision maker is rising. Very often these patients need fairly immediate medical intervention for which informed consent—or informed refusal—is required. Many have recommended that there be a process in place to make these decisions, and that it include a variety of perspectives. People are particularly wary of relying solely on medical staff to make these decisions. The University Hospitals Case Medical Center recruits community members from its (...) Ethics Committee to serve on a subcommittee, the Patients Without Proxies (PWP) Committee, which works with medical staff during the decision-making process for these patients. Generally, the community members go to the bedside to observe patients. This article looks at how those unused to observing hospitalized patients who are sick and/or dying are affected, comparing them to mock jurors in a research study who are exposed to graphic photographs related to a fabricated crime scene. Judgments made by the mock jurors are affected by viewing such images. The personal experience of witnessing unfamiliar and shocking scenes affects their subsequent judgments. While it may be difficult to tease out whether observing patients causes PWP members to be benefited or harmed, they are affected by what they see. If a variety of perspectives is desirable to reduce possible bias or error, this article argues that at least one community member should refrain from seeing the patient in order to add a different and valuable voice to the decision-making process. Members of the subcommittee base their judgments on the various kinds of information available. Sometimes the things they see, hear, or feel may affect them particularly deeply, and affect their judgments as well. In this article I explore the idea that something like this may be happening in a particular kind of clinical ethics case consultation. (shrink)

To date no one has identified or described the population of incapacitated patients being treated in an inpatient setting who lack proxy decision-makers. Nor, despite repeated calls for protocols to be developed for decision-making, has any institution reported on the utilization of such a protocol. In 2005, our urban tertiary care hospital instituted a protocol utilizing community members of the ethics committee to meet with the medical providers and engage in shared decision-making for patients without proxies. (...) We conducted a retrospective chart review and in this paper describe nearly 200 patients who were identified and treated according to the protocol over a 12 year period. After an aggressive search, family members were located for a surprising number of patients, leaving 80 patients who needed decisions to be made utilizing the PWP committee. We review the decisions required, the results of the shared decision-making meetings, and the patient outcomes. Our experience has shown that a protocol involving community volunteers to make decisions for PWPs in a timely manner is feasible and ethically defensible. The protocol has been accepted by physicians and utilized with increasing frequency. Because it was possible to gather at least minimal information on most patients, a standard of “informed best interest” was used to make decisions. PWP committee recommendations varied, but in all cases agreement was reached with the attending physicians. (shrink)

The Mental Capacity Act 2005 has provided unified scope in the British medical system for proxy consent with regard to medical decisions, in the form of a lasting power of attorney. While the intentions are to increase the autonomous decision making powers of those unable to consent, the author of this paper argues that the whole notion of proxy consent collapses into a paternalistic judgement regarding the other person’s best interests and that the new legislation introduces only (...) an advisor, not a proxy with the moral authority to make treatment decisions on behalf of another. The criticism is threefold. First, there is good empirical evidence that people are poor proxy decision makers as regards accurately representing other people’s desires and wishes, and this is therefore a pragmatically inadequate method of gaining consent. Second, philosophical theory explaining how we represent other people’s thought processes indicates that we are unlikely ever to achieve accurate simulations of others’ wishes in making a proxy decision. Third, even if we could accurately simulate other people’s beliefs and wishes, the current construction of proxy consent in the Mental Capacity Act means that it has no significant ethical authority to match that of autonomous decision making. Instead, it is governed by a professional, paternalistic, best-interests judgement that undermines the intended role of a proxy decision maker. The author argues in favour of clearly adopting the paternalistic best-interests option and viewing the proxy as solely an advisor to the professional medical team in helping make best-interests judgements. (shrink)

Many state laws specify procedures for determining surrogate or proxy decision-makers for end-of-life care in the absence of an advance directive, living will, or other designation. Some laws also set forth criteria that the decision-maker must follow when making medical decisions for an incapacitated patient and determining whether to withdraw life-sustaining treatment. This article provides analysis of a medical ethics case on the question of how to address family allegations that the proxy decision-maker (...) suffers from dementia and is unable to make decisions for the patient. Cases such as this involve interwoven legal and ethical considerations including: how to address concerns that the proxy is making questionable or unreasonable decisions, how to evaluate the proxy's decisional capacity, strategies for enhancing communication, and standards for removing a proxy. This article suggests that “surrogacy ladders” in state law serve not only as a procedural mechanism, but also protect important ethical values such as tiers of moral authority for decision-making, relational autonomy, and privacy. (shrink)

In 2016, the Colorado legislature passed an amendment to Colorado’s medical proxy law that established a process for the appointment of a physician to act as proxy decision maker of last resort for an unrepresented patient (Colorado HB 16-1101: Medical Decisions For Unrepresented Patients). The legislative process brought together a diverse set of stakeholders, not all of whom supported the legislation. Following passage of the statutory amendment, the Colorado Collaborative for Unrepresented Patients (CCUP), a group of (...) advocates responsible for initiating the legislative process, coordinated a unique effort to engage these stakeholders in the creation of a set of voluntary guidelines to assist facilities and individual careproviders in the implementation of policies and procedures enabled by the statute. This article delineates the questions and concerns of stakeholders, describes how those issues were addressed within the guidelines, and proposes additional opportunities for research to assess the impact of the legislation in Colorado. (shrink)

The substituted judgement principle is often recommended as a means of promoting the self-determination of an incompetent individual when proxy decision makers are faced with having to make decisions about health care. This article represents a critical ethical analysis of this decision-making principle and describes practical impediments that serve to undermine its fundamental purpose. These impediments predominantly stem from the informality associated with the application of the substituted judgement principle. It is recommended that the principles upon which (...) decisions are made about health care for another person should be transparent to all those involved in the process. Furthermore, the substituted judgement principle requires greater rigour in its practical application than currently tends to be the case. It may be that this principle should be subsumed as a component of advance directives in order that it fulfils its aim of serving to respect the self-determination of incompetent individuals. (shrink)

Unrepresented patients are some of the most vulnerable patients encountered in the healthcare system today. One of the challenges associated with healthcare for unrepresented patients is the lack of a standardized legal approach to decision making for this highly vulnerable population. Current statutory approaches vary widely without best practices or consensus guidelines. In 2016, Colorado passed a medical proxy law that established a process for the appointment of an independent physician to serve as a temporary proxy (...) class='Hi'>decision maker for an unrepresented patient. Although this approach helps to identify a decision maker when no proxy is available, the appropriate standards for decision making remain uncertain. A peer-to-peer session at the Clinical Ethics Unconference in 2022 approached this conundrum with a focus on the best interests standard and the appropriate use of patients’ context in decision making. (shrink)

Out of 288 Hong Kong cancer patients, 92.3% include themselves in decision-making, 71% prefer joint decision-making: with family, with doctor, with doctor plus family, with family minus doctor, and with doctor minus family. <5% want decision-making by “doctor-alone” and <1% desire decision-making by “family-alone”. Harmony, communication and responsibility are reasons for family participation. Most patients prefer “specialist” for information, followed by “family”, “friends”, and “GP”. Trust in doctors and prospects for controlling/curing disease are important factors in (...) decision-making. Patients want to participate and be listened to rather than make decisions. Doctors should not disclose information to family without patients’ permission, nor withhold information from patient [End Page 109] on family’s request. Only 25% of patients have discussed post-competent treatment with others and 7% have heard of Advance Directive ; 24% refuse to discuss it. After AD has been explained to them, 66% remain reluctant to sign one, preferring to leave oral instructions or appoint family as proxy decision-makers. The family’s decision-making role increases when patients become incompetent. The top reason for signing AD is to receive preferred post-competent treatments, and for not signing it, difficulty with making a prospective decision. The implications of these findings will be discussed. (shrink)

Much debate concerning ‘precedent autonomy’ – that is, the authority of former, competent selves to govern the welfare of later, non-competent selves – has assumed a radical discontinuity between selves, and has overlooked the ‘bridging’ role of intimate proxy decision-makers. I consider a recent proposal by Lynn et al. (1999) that presents a provocative alternative, foregrounding an imagined dialogue between the formerly competent patient and her/his trusted others. I consider what standards must be met for such dialogues to (...) have moral force, appealing to narrative and feminist ethics. I then critique the dualistic construction of selves implicit in much of the advance directive literature, noting the continuities of dependence, character, and body, as well as the social dimension of the construction of selves. (shrink)

Despite clear legislative and judicial support, a well established ethical consensus, and increased efforts at information dissemination and education, proxy decision making for incapacitated patients continues to produce moral muddle and poor resolutions in end-of-life care.In her analysis of the proxy-doctor relationship, Nancy Dubler spells out the institutionalized patterns that keep the promise of proxy directives so often unrealized. Facing medically complex care of an incapacitated patient, health care teams are apt to view the proxy (...) as a potentially indecisive or unrealistically demanding decision-maker, less a stand-in for the patient than an interloper whose improper, misguided, or self-interested decisions will work against the patient's best interests. So perceived, proxies are routinely relegated to the edges of care planning discussions, left relatively uninformed and unconsulted, and then suddenly thrust center stage to face decisions they find overwhelming. Confronting such decisions, proxies need support and compassion. What they often find is isolation and distrust, a web of professional and institutional practices that trammel their efforts to understand and execute their role. (shrink)

Despite clear legislative and judicial support, a well established ethical consensus, and increased efforts at information dissemination and education, proxy decision making for incapacitated patients continues to produce moral muddle and poor resolutions in end-of-life care.In her analysis of the proxy-doctor relationship, Nancy Dubler spells out the institutionalized patterns that keep the promise of proxy directives so often unrealized. Facing medically complex care of an incapacitated patient, health care teams are apt to view the proxy (...) as a potentially indecisive or unrealistically demanding decision-maker, less a stand-in for the patient than an interloper whose improper, misguided, or self-interested decisions will work against the patient's best interests. So perceived, proxies are routinely relegated to the edges of care planning discussions, left relatively uninformed and unconsulted, and then suddenly thrust center stage to face decisions they find overwhelming. Confronting such decisions, proxies need support and compassion. What they often find is isolation and distrust, a web of professional and institutional practices that trammel their efforts to understand and execute their role. (shrink)

Health care decision making for patients without decisional capacity is ethically and legally challenging. Advance directives (living wills) have proved to be of limited usefulness in clinical practice. Therefore, academic attention should focus more on substitute decision making by the next of kin. In this article, we comparatively analyse the legal approaches to substitute medical decision making in England and Germany. Based on the current ethico-legal discourse in both countries, three aspects of substitute decision making will (...) be highlighted: (1) Should there be a legally predefined order of relatives who serve as health care proxies? (2) What should be the respective roles and decisional powers of patient-appointed versus court-appointed substitute decision-makers? (3) Which criteria should be determined by law to guide substitute decision-makers? (shrink)

Purpose The debate about the end-of-life care decision is becoming a serious ethical and legal concern in the Far-Eastern countries of Korea, China and Japan. However, the issues regarding end-of-life care will reflect the cultural background, current medical practices and socioeconomic conditions of the countries, which are different from Western countries and between each other. Understanding the genuine thoughts of patients who are critically ill is the first step in confronting the issues, and a comparative descriptive study of these (...) perspectives was conducted by collaboration between researchers in all three countries. Methods Surveys using self-reporting paper questionnaire forms were conducted from December 2008 to April 2009 in Korea (six hospitals in two regions), China (five hospitals in four regions) and Japan (nine hospitals in one region). The subjects were patients who were critically ill who had been diagnosed as having cancer. A total of 235 participants (Korea, 91; China, 62; Japan, 52) were eventually recruited and statistically analysed. Results Most respondents had sometimes or often thought of their own death, mostly fear of ‘separation from loved ones’. They wanted to hear the news regarding their own condition directly and frankly from the physician. A quarter of them preferred making end-of-life care decisions by themselves, while many respondents favoured a ‘joint decision’ with their family members. The most favoured proxy decision maker was the spouse, followed by the children. Most admitted the necessity of ‘advance directives’ and agreed with artificial ventilation withdrawal in irreversible conditions. The most common reason was ‘artificial prolongation of life is unnecessary’. Most respondents agreed with the concept of active euthanasia; however, significant differences were sometimes observed in the responses according to variables such as patient's country of origin, age, gender and education level. Conclusion Patients in Far-Eastern countries gave various responses regarding end-of-life care decisions. Although familial input is still influential, most patients think of themselves as the major decision maker and accept the necessity of advance directives with Westernization of the society. Artificial ventilation withdrawal and even active euthanasia may be acceptable to them. (shrink)

Incompetent patients need to have someone else make decisions on their behalf. According to the Substituted Judgment Standard the surrogate decision maker ought to make the decision that the patient would have made, had he or she been competent. Objections have been raised against this traditional construal of the standard on the grounds that it involves flawed counterfactual reasoning, and amendments have been suggested within the framework of possible worlds semantics. The paper shows that while this approach (...) may circumvent the alleged problem, the way it has so far been elaborated reflects insufficient understanding of the moral underpinnings of the idea of substituted judgment. Proper recognition of these moral underpinnings has potentially far-reaching implications for our normative assumptions about accuracy and objectivity in surrogate decision making. (shrink)

Economic motivations are key drivers of human behavior. Unfortunately, they are largely overlooked in literature related to medical decisionmaking, particularly with regard to end-of-life care. It is widely understood that the directions of a proxy acting in bad faith can be overridden. But what of cases in which the proxy or surrogate appears to be acting in good faith to effectuate the patient’s values, yet doing so directly serves the decision-maker’s financial interests? Such situations are not (...) uncommon. Many patients care as deeply about economic wellbeing of their families as they do for their own lives and health. This brief work examines three scenarios that raise ethical issues regarding the role of pecuniary motives in making critical medical decisions. Each scenario presents a potential financial conflict of interest between an incapacitated patient and a third-party decision-maker and offers a framework for integrating ethical and legal concerns into clinical care. It is our hope that this work prepares physicians for unexpected ethical conflicts of interest and enables them to further the interests of his or her patients. (shrink)

An implicit ambiguity in the field of prediction-based decision-making concerns the relation between the concepts of prediction and decision. Much of the literature in the field tends to blur the boundaries between the two concepts and often simply refers to ‘fair prediction’. In this paper, we point out that a differentiation of these concepts is helpful when trying to implement algorithmic fairness. Even if fairness properties are related to the features of the used prediction model, what is more (...) properly called ‘fair’ or ‘unfair’ is a decision system, not a prediction model. This is because fairness is about the consequences on human lives, created by a decision, not by a prediction. In this paper, we clarify the distinction between the concepts of prediction and decision and show the different ways in which these two elements influence the final fairness properties of a prediction-based decision system. As well as discussing this relationship both from a conceptual and a practical point of view, we propose a framework that enables a better understanding and reasoning of the conceptual logic of creating fairness in prediction-based decision-making. In our framework, we specify different roles, namely the ‘prediction-modeler’ and the ‘decision-maker,’ and the information required from each of them for being able to implement fairness of the system. Our framework allows for deriving distinct responsibilities for both roles and discussing some insights related to ethical and legal requirements. Our contribution is twofold. First, we offer a new perspective shifting the focus from an abstract concept of algorithmic fairness to the concrete context-dependent nature of algorithmic decision-making, where different actors exist, can have different goals, and may act independently. In addition, we provide a conceptual framework that can help structure prediction-based decision problems with respect to fairness issues, identify responsibilities, and implement fairness governance mechanisms in real-world scenarios. (shrink)

Eye tracking is used to investigate human choice procedures. We infer from eye movement patterns in choice problems where the deliberation process is clear to deliberations in problems of choice between two lotteries. The results indicate that participants tend to compare prizes and probabilities separately. The data provide little support for the hypothesis that decision makers use an expected utility type of calculation exclusively. This is particularly true when the calculations involved in comparing the lotteries are complicated.

An agent's options in a decision problem are best understood as the decisions that the agent might make. Taking options this way eliminates the gap between an option's adoption and its execution.

The purpose of this study was to investigate the attitudes of decision-makers toward the use of care robots in welfare services. We investigated their knowledge regarding the use of care robots in welfare services as well as their attitudes toward using robots in their own care and in the care of various user groups, for example, children, youths, and older people. We conducted an online survey with a range of Finnish decision-makers as respondents. The respondents were divided into (...) two groups: service actors and research and development actors. The respondents did not regard themselves as having much knowledge about robotics; however, the results showed that the R&D actors had more overall knowledge of the use of robots than the service actors. The R&D actors were found to be more willing to accept a robot as part of their own care as well as part of the care for various user groups. The contribution of this study is a better understanding of the views of the decision-makers who are or will be in charge of the acquisition of technological devices in welfare services. (shrink)

People who are unable to make decisions about participating in research rely on proxies to make a decision based on their wishes and preferences. However, patients rarely discuss their preferences about research and proxies find it challenging to determine what their wishes would be. While the process of informed consent has traditionally been the focus of research to improve consent decisions, the more conceptually complex area of what constitutes ‘good’ proxy decision-making for research has remained unexplored. Interventions (...) are needed to improve and support proxy decision-making for research but are hampered by a lack of understanding about what constitutes decision quality in this context. A global increase in conditions associated with cognitive impairment such as dementia has led to an urgent need for more research into these conditions. The COVID-19 pandemic and subsequent necessity to conduct research with large numbers of critically ill patients has made this need even more pressing. Much of the empirical research centres on the desire to improve decision accuracy, despite growing evidence that authenticity is more reflective of the aim of proxy decisions and concerns about the methodological flaws in authenticity-focused studies. Such studies also fail to take account of the impact of decision-making on proxies, or the considerable body of research on improving the quality of healthcare decisions. This paper reports a concept synthesis of the literature that was conducted to develop the first conceptualisation of ‘good’ proxy decisions about research participation. Elements of decision quality were identified across three stages of decision-making: proxy preparedness for decision-making which includes knowledge and understanding, and values clarification and preference elicitation; the role of uncertainty, decisional conflict, satisfaction and regret in the decision-making process; and preference linked outcomes and their effect. This conceptualisation provides an essential first step towards the future development of interventions to enhance the quality of proxy decision-making and ensure proxy decisions represent patients’ values and preferences. (shrink)

Research involving adults who lack capacity to consent relies on proxy (or surrogate) decision making. Proxy decisions about participation are ethically complex, with a disparity between normative accounts and empirical evidence. Concerns about the accuracy of proxies’ decisions arise, in part, from the lack of an ethical framework which takes account of the complex and morally pluralistic world in which proxy decisions are situated. This qualitative study explored the experiences of family members who have acted as (...) a research proxy in order to develop an understanding of the ethical concepts involved, and the interactions between those concepts. Proxies described a complex process of respecting the wishes and preferences of the person they represented, whist integrating preferences with what they viewed as being in the interests of the person. They aimed to make a decision that was ‘best’ for the person and protected them from harm; they also aimed to make the ‘right’ decision, viewed as being authentic to the person’s values and life. Decisions were underpinned by the relationship between the person and their proxy, in which both trust and trustworthiness were key. Proxies’ decisions, based both on respect for the person and the need to protect their interests, arose out of their dual role as both proxy and carer. The findings raise questions about accounts which rely on existing normative assumptions with a focus on accuracy and discrepancy, and which fail to take account of the requirement for proxies to make authentic decisions that arise out of their caring obligations. (shrink)

Phytomass cultivation for energy use is increasingly popular in Europe for high profits guaranteed by subsidy. Although public interest in ecology is on an increasing level, direct combustion is still preferred even though scholars have been warning about formations of hazardous compounds for a long-time. However, the reduction of subsidies would negatively affect an already bad situation in Czech agriculture, since most farmers became fully dependent on subsidies due to quotas, restrictions, and other unequal business conditions in European Union. It (...) was proved in a commercial scale that an alternative phytomass energy utilizing technology consisting of steam explosion and subsequent anaerobic fermentation may be run solely on the waste heat without any further addition of chemicals. Behavior analysis of present and future agriculture decision-makers showed that none of the farmers who visited the facility cared about ecological consequences. On the other hand, ost students from the Faculty of Agriculture and the Faculty of the Economy answered the questionnaire with higher environmental responsibility. We assume this is caused by high average age of farmers in Czech Republic who are more aware of the ongoing economical difficulties and perceive differently the risk of higher acquisition costs. (shrink)

This paper investigates why some companies give to charity and others do not. The study uncovers a strong relationship between the personal attitudes of the charitable decision maker and the firm's giving behavior. This relationship indicates that the human element of personal attitudes may interact and play a very important role in a firm's decision to become involved with philanthropic activities. The study also shows that firms who have a history of giving to charity cite altruistic motives (...) for their behavior. On the other hand, firms that do not give to charity tend to use business reasons to explain their non-involvement. (shrink)

Laypersons serve at critical junctures in the legal process. This article provides an overview of research about layperson roles and draws attention to the research methodologies used in studying them. It also discusses the jury system because, in addition to the fact that this institution has attracted the greatest quantity of empirical research on lay participation in legal processes, the studies have also involved the greatest range of methodological approaches, thus allowing exploration of their various strengths and weaknesses. Research on (...) mixed tribunals, lay magistrates, justices of the peace and other forms of lay participation are also discussed in the article. There are literally hundreds of empirical studies bearing on jury competence and behavior. More systematic research surveying the extent of layperson roles in different cultures and countries is needed and studies of how laypersons actually perform in these roles is crucial. (shrink)

With the passage by virtually every state legislature of healthcare proxy laws, the medical profession increasingly can expect to rely on the participation of surrogates in making decisions on behalf of incompetent patients. Several concerns about the legitimacy of proxy decision making have been discussed in the ethical and general medical literature: the lack of concordance between the views of patients and their surrogates have been documented on multiple occasions, and cases of abuse by proxies or potential (...) conflict of interest have been reported. Another dilemma that deserves discussion arises when proxies demand withdrawal of treatment that physicians and nurses regard as essential to the wellbeing of the patient. The following case highlights this dilemma. (shrink)

Group decisions raise a number of substantial philosophical and methodological issues. We focus on the goal of the group decision exercise itself. We ask: What should be counted as a good group decision-making result? The right decision might not be accessible to, or please, any of the group members. Conversely, a popular decision can fail to be the correct decision. In this paper we discuss what it means for a decision to be "right" and (...) what components are required in a decision process to produce happy decision-makers. Importantly, we discuss how "right" decisions can produce happy decision-makers, or rather, the conditions under which happy decision-makers and right decisions coincide. In a large range of contexts, we argue for the adoption of formal consensus models to assist in the group decision-making process. In particular, we advocate the formal consensus convergence model of Lehrer and Wagner (1981), because a strong case can be made as to why the underlying algorithm produces a result that should make each of the experts in a group happy. Arguably, this model facilitates true consensus, where the group choice is effectively each person's individual choice. We analyse Lehrer and Wagner's algorithm for reaching consensus on group probabilities/utilities in the context of complex decision-making for conservation biology. While many conservation decisions are driven by a search for objective utility/probability distributions (regarding extinction risks of species and the like), other components of conservation management primarily concern the interests of stakeholders. We conclude with cautionary notes on mandating consensus in decision scenarios for which no fact of the matter exists. For such decision settings alternative types of social choice methods are more appropriate. (shrink)

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. 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. (shrink)

With the passage by virtually every state legislature of healthcare proxy laws, the medical profession increasingly can expect to rely on the participation of surrogates in making decisions on behalf of incompetent patients. Several concerns about the legitimacy of proxy decision making have been discussed in the ethical and general medical literature: the lack of concordance between the views of patients and their surrogates have been documented on multiple occasions, and cases of abuse by proxies or potential (...) conflict of interest have been reported. Another dilemma that deserves discussion arises when proxies demand withdrawal of treatment that physicians and nurses regard as essential to the wellbeing of the patient. The following case highlights this dilemma. (shrink)

The purpose of this prospective study was to develop a grounded theory explaining the process that family decision makers use to make care decisions with or for a family member with advanced cancer. Adult surrogate decision makers were recruited for multiple interviews over the patient’s care trajectory: 40 surrogates provided 80 semi-structured interviews. Analysis of these narratives revealed a process of responsive care management that is inclusive of, but not limited to, decision-making roles. Monitoring, buffering, and taking (...) over comprise the three phases of the process. Decision making was embedded within the family member’s broader relational and care responsibilities. (shrink)

Purpose The manner in which people, businesses and governments perform is changing because of the spread of technology. Digitalization of governments can be considered a necessity as we are now entering the era of the Internet-of-Things. The advantages and disadvantages of electronic governments have been examined in several research studies. This study aims to examine the attitudes of decision-makers towards e-government. The research aims are as follows: to determine the problems related with e-government usage, to establish the factors which (...) decrease the usage of e-government services and to propose recommendations for the effective application of e-government practices. Design/methodology/approach Qualitative research has been used for the study. Participants were chosen by the snowball sampling method, and face-to-face in-depth interviews were conducted with all decision-makers. In-depth interviews are more efficient and enable the acquisition of better qualitative information, in-depth knowledge and statistics, as the distance between the interviewer and interviewee is reduced. Questions asked can be categorized under two sections, where the questions in the first section are related to the decision-maker’s management style/managerial proposition, and in the second section, technological questions are asked in terms of the preferred communication method and the decision-makers’ attitudes towards e-government practices. Findings Decision-makers perceive electronic government to be important, while the level of importance is observed to be different among the decision-makers. Chronic problems exist in many countries, such as nepotism, where the decision-makers have conflicting arguments about e-government and the resulting effect on nepotism. Furthermore, the study also indicates that decision-makers are aware of the importance of mobile government, although they acknowledge that more time is required, as their country is still developing. Electronic voting is also perceived to be important, although the decision-makers believe that security and privacy issues need to be solved before related projects can be initiated. Originality/value This research can be a benchmark study for the decision-makers of small island developing states by means of e-government. The impediments preventing the effective application of e-government practices are also discussed in the study. This study will be useful to highlight the triggers and obstacles for e-government development in the context of a developing country. Internet penetration has increased significantly since the 2000s, and therefore, decision-makers need to consider the shift in citizens’ behaviour, such as the high usage of smartphones and the emergence of the Internet-of-Things. (shrink)

The dominant approach to the study of dynamic preference is to generate preference change by manipulating aspects of decision-problem presentation (problem description, task procedure, contextual options). The predisposing approach instead manipulates the decision maker’s mental state while holding problem presentation constant. Three illustrative studies are outlined here. The first modified preferences for ambitious consumption by manipulating subjects’ consumption energy. The second modified preferences for immediate consumption by manipulating subjects’ hedonic resources. The third modified preferences for consumption itself (...) by manipulating subjects’ desire proneness. Whereas framing is thought to affect perception, predisposing apparently can affect tastes and so involves a special kind of preference dynamism. (shrink)

I consider two puzzles in which an agent undergoes a sequence of decision problems. In both cases it is possible to respond rationally to any given problem yet it is impossible to respond rationally to every problem in the sequence, even though the choices are independent. In particular, although it might be a requirement of rationality that one must respond in a certain way at each point in the sequence, it seems it cannot be a requirement to respond as (...) such at every point for that would be to require the impossible. (shrink)

Amy E. Caruso Brown (2022) considers situations in which a minor child’s parent or legal guardian (the “marginalized decision-maker (MDM)”) defers to another individual (the “primary decision-maker...

Berger (2019) argues effectively that “representativeness is more aptly understood as a variable that is multidimensional and continuous based on relational moral authority,” and also makes some useful suggestions about how taking this observation seriously might require changes in current patterns of practice regarding surrogates. But the essay raises additional important questions about how the Best Interest Standard (BIS) should be used among unrepresented patients and other patients as well because many surrogates besides those who “have no actionable knowledge of (...) a patient’s preferences” find themselves in positions in which they need to determine, with the physician, what is in the patient’s best interests. In this commentary, we therefore provide support for the ethical superiority of BIS judgments made by a multi-stakeholder process (rather than solo decision-makers), and sketch a process by which such judgments might be made. (shrink)