|
Volume 3 Number 28 November
4, 2005 |
|
Deciding for others Making surrogate decisions has its own
rules -- as well as pitfalls Who do you trust to salt your food at the dinner table? If you're like I am, you would really rather that other people leave your food alone, and leave the salting if necessary up to you. Only you know whether the food, as presented, meets your taste, and whether, and how much, extra salt is necessary. I use this example a lot when discussing the area of making decisions for other people. Even under the best of circumstances, and with the best directions, deciding for others is -- like salting someone else's food -- a tricky business and is fraught with danger. As I discussed last time, deciding for oneself is pretty straightforward. Questions of competence and public good aside, we're pretty much free to make decisions based on whatever criteria are important to us, no matter how risky or irrational they may seem to others. There are few rules. Deciding for others, despite the fact we can construct rules around it, is much trickier. Most of us end up making decisions for other people at some time or another. Those decisions can range from something as trivial as choosing a flavor of ice cream to something as weighty as end-of-life issues. And we can choose for children, spouses, friends, or the elderly. Generally, there are three mechanisms that govern deciding for others, more formally called "surrogate decision making." Under ideal conditions, we can work from an advance directive. That is, someone tells us in advance what it is they want us to do. Failing that, and depending on how well we know the other person, we may use "substituted judgment." If we know the person well enough, the theory goes, we can substitute our judgment for theirs with the hope that we would make the same decision that the other person would make if he or she were able. If we have no advance directive and we don't know what the other person would want, then we would be ethically required to make decisions based on what would be in the other person's best interests. One way I use to illustrate the difference among these three is to ask people to imagine they go into a restaurant with a spouse, a significant other, or a friend. Before the waiter comes, the other person goes to the restroom. Then, the waiter comes to take a drink order. It could have been the case that the other person has given you an advance directive. "If the waiter comes, order me a white wine." No problem. The waiter comes. You order a white wine. Suppose that hasn't happened. There is no advance directive. Then, it's Plan B substituted judgment. You've gone out to dinner with the other person a lot and know that she always orders a white wine before dinner. So you order a white wine. It's a good bet, although there is a remote possibility that the other person has decided to change from her "regular drink." Still, it works most of the time. But now suppose that you don't have an advance directive and the other person doesn't have a "usual" drink. At this point you're forced to operate on the other person's best interests. One approach might be to order a club soda and explain: "Gee, dear, I've noticed you've put on a little weight. So, I thought a club soda would be in your best interests." (Caution: This is for illustration purposes only, and I am a professional. Do not try this at home.) Seriously, in the third case, the other person's best interest is to exercise his or her own autonomy, and the solution that serves that interest is to ask the waiter to return in a few minutes to get the order directly from the other person. In reality, none of the three methods is perfect. In the first case, the waiter could ask whether the other person wanted the Chardonnay or the Pinot Grigio. You're limited because your instructions stated only "white wine," leaving you to now drop back to one of the other guidelines. We see this sort of situation a lot in medical advance directives. Very often, people making such directives are very specific in their desires, but are unclear about the exact options that will be available when the time comes. So, even with an advance directive, a surrogate decision maker has to use another mechanism to make decisions. Using substituted judgment is even trickier. It supposes that we know the other person well enough to substitute our judgment for theirs. I've had people tell me that their spouses enjoy possess this knowledge, and could make decisions without the benefit for any advance directives. I've even had people make the same claim about "good friends." I usually counter these claims by going back to the question at the top of the column. One problem with thinking that we know what people want, or would want, under certain circumstances is that very often the person himself really doesn't know. What you think today that you might want under Circumstance A might not be want you want at all tomorrow when Circumstance A comes about. So, for me to claim that I know what you want, based on a conversation we had a month ago, or a year ago, really doesn't capture your judgment on the issue. The most difficult mechanism to use is "best interests." It sounds simple on the face of it, and some people mistakenly think that it is, but it is a virtual minefield. What makes it so complicated is that we have many "interests." Some of them overlap and others are diametrically opposed to one another. Very often, surrogate decision makers will focus on one interest to the exclusion of the others. Only we can properly balance our own interests one against the other. We have medical interests, financial interests, spiritual or religious interests, and our interest in our families just to name a few. None of these is necessarily our supreme interest; at least as far as a third person can tell. For example, it may be in my medical best interest to have a heart transplant. But I also might be aware that the expense would financially devastate my family, eat up all our savings, and mean that my children might not be able to go to college something I desire very much. In that case, I might decide that I was willing to die a little earlier to ensure the future success and happiness of my children. Or, it might be in my medical best interest to have a blood transfusion, something that would be argued by medical staff. But I might have a greater personal interest in my religious beliefs, which forbid a transfusion, and I might place a greater weight on that. So, it's a tricky business to claim that we are acting in someone's best interests, unless we are aware of what all those interests are and have some idea on how the person balances those interests. I dont want to give the impression that we can't make decisions for other people, but want to point out that, under the best of circumstances, it's difficult. Most often, we're forced into the position by circumstances we'd rather not face. This is one reason why I'm such an advocate of advance directives, and the clearer and more comprehensive the better. I'm sure, however, that I'm preaching to the choir, because you all heeded my advice during the Terri Schiavo fiasco, and went out and drew up exemplary directives that would aid your surrogate decision maker should that become necessary. One thing that does stand out in all surrogate decision making, however, is the assumption of risk. When making decisions for ourselves, we can take chances. We can be as risky as we want to be. When making decisions for others, we cannot take risks. We must always even when acting from advance directives and substituted judgment take a conservative approach that preserves the interests of the other person as best we can. When investing my own money, for example, I can, if I so choose, put half of my life savings in my Uncle Hector's Tabbouleh-on-a-stick business, whether I do it because I think it's a good product or just because I think I owe it to my uncle. On the other hand, if I'm charged with investing your money, I must stay with investments that have a much greater chance of preserving your capital and providing some return. I cannot ethically put your money into Uncle Hector's business. Again, we see this in a medical context when it comes to how we decide for ourselves versus how we decide for children. I can choose to eschew traditional medical care and go to a faith healer, if I so desire. However, if I have a sick child, I must seek the most conventional treatment that will preserve the best interests of the child. My best interest might be my religious belief in the faith healer, but since we consider a child too young and inexperienced to make such a dramatic and risky choice, we must err on the side of conventional treatment. My interest in a religious belief isn't necessarily my child's interest as well. I realize I've packed a lot of information and theory into a small space, but I hope I've given a good enough outline of what's involved. Next time, as promised, I'll relate all this to making decisions for a very significant other. |
|
© Copyright 2005 Carlton Vogt |