1.4 Substitute Decision-Making
George C. Webster and Pat Murphy
- To appreciate the basis of substitute decision-making in health care.
- To appreciate how substitute decision-makers may be identified in a health care context.
- To appreciate the scope of substitute decision-making.
- To appreciate the circumstances under which a health care team may seek to limit a substitute decision-maker's authority to make health care decisions.
Case: "No Pain Medication for Mother, Thank you Very Much!"1
We have secured permission from University Publishing Group to re-print the case study. An elderly woman suffering from shortness of breath was brought to the emergency department by her daughter. She had an elevated temperature and seemed confused and disoriented. Her medical history indicated that she had suffered a cerebrovascular accident approximately one year ago. On admission, it was noted that the woman had a gangrenous foot and ankle and a mottled leg up to, and above, her knee. Later, on the ward, the nursing staff noticed that when they moved the patient she appeared to be in considerable pain. They recommended analgesia and the attending physician concurred. The patient's daughter, however, who was her only child and only living relative, refused to allow any pain medication. The daughter was the patient's legally recognized substitute decision-maker. The daughter, a retired pharmacist, said that analgesia would shorten her mother's life. Further, she informed the staff that her mother had an unusually high pain threshold. She noted that her mother had never used any freezing at the dentist and when she had suffered a bad burn on her arm she never took anything for the pain. Caregivers tried to negotiate with the daughter, but to no avail. She emphatically stated: "No pain medication for Mother, thank you very much!"
The patient's condition deteriorated. The daughter met with her mother's surgeon and was told that her mother's gangrenous leg was reaching a critical point (i.e., sepsis). The daughter agreed to amputation surgery to prolong her mother's life. Following the amputation surgery, the anaesthetic was wearing off and staff approached the patient's daughter about giving the patient post-surgical analgesia. Once again, the daughter adamantly refused.
- What ethical foundation or principles underlie health care decisions made by a substitute decision-maker?
- In practice, how are substitute decision-makers identified?
- What is the scope of the task undertaken by substitute decision-makers?
- When may a health care team seek to interfere with or limit a substitute decision-maker’s authority to make health care decisions?
- Santurri E, Werpehowski W. Substituted judgment and the terminally-ill incompetent. Thought 1982; 57: 484–501.
- Dickens BM. The role of the family in surrogate medical consent. Health Law in Canada 1980; autumn: 49–52.
- Back AL, Arnold RM. Dealing with conflict in caring for the seriously ill: "it was just out of the question". Journal of the American Medical Association 2005; 293: 1374-81.
- Brock DW. What is the moral basis of the authority of family members to act as surrogates for incompetent patients? The Journal of Clinical Ethics 1992; 3: 121-3.
- Forrow L, Arnold RM, Parker LS. Preventive ethics: Expanding the horizons of clinical ethics. The Journal of Clinical Ethics 1993; 4: 287-94.
- Lazar NM, Greiner GG, Robertson G, Singer PA. Bioethics for clinicians: 5. Substitute decision-making. Canadian Medical Association Journal