Rethinking Surrogate Decision-Making: Evidence from a Qualitative Study of Physicians
Journal of Clinical Ethics, Forthcoming
Posted: 13 Jan 2007 Last revised: 20 Oct 2007
Background The standard ethical approach to surrogate decision making is based on the principle of respect for autonomy, through the use of advance directives and substituted judgment, and on the principle of beneficence, or promoting and protecting the patient's interests. However, little attention has been given to how well these theoretical ethical standards are reflected in clinical practice.
Methods In-depth, semi-structured interviews about surrogate decision-making were conducted with 21 physicians in an academic medical center. Each physician was interviewed at the conclusion of a period of inpatient service. Physicians were asked to describe a situation in which a patient was unable to make a major medical decision regarding the use of life-sustaining therapy, , or placement in a long term care facility, and then to describe the ethical principles important in surrogate decision making. All factors that physicians used to explain or justify their medical decisions were included in the present analysis.
Results All but one of the physicians approached for the study had cared for a patient within the previous month who lacked decision making capacity and required a major medical decision. Physicians identified six major considerations that guided decision-making: the patient's wishes, the patient's interests, the surrogate's wishes, the surrogate's interests, clinical judgment and knowledge and authority.
Conclusion Although physicians engaged in surrogate decision making often rely on the traditional, patient-centered ethical principles of respect for autonomy and best interest, surrogate wishes and interest were also important to decision making. Moreover, physicians appeal to other sources of authority such as clinical judgment. Physicians' decision-making framework is broader and more complex than previously thought and may rely on factors that have been ignored in traditional ethical models. In order to be useful for practicing physicians, future guidelines must explicitly include these additional factors.
Keywords: medical decision making, surrogate decision-making, qualitative research, ethics, autonomy, best interests
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