The practice of using surrogate decision-makers in cases involving critically sick patients is marred with several ethical concerns. Surrogate decision-making involves individuals’ used to make healthcare decisions on other people’s behalf. The decision-making activity is done when the patient does not have the mental capacity to make better choices. Different people can act as a patient’s surrogate. However, the standard form of a surrogate involves an individual appointed by an attorney to make healthcare decisions on behalf of the patient (Bibas et al., 2019)(Surrogate decision-Making).
The procedure for the appointment of a surrogate agent involves proving one’s involvement with a patient to have decision-making challenges. The attorney requires that individuals demonstrate their understanding of the patient’s needs for appointment as surrogates. Most surrogates tend to be family members. Often, critically ill patients do not have the mental capacity to make better healthcare decisions.
Surrogate decision-makers, therefore, fill the void. The surrogate has the right to make healthcare decisions for patients who lack the mental capacity to make viable choices. Arguments emerges against the ethical nature of the practice. The understanding of the ethical issues that emerge in the use of surrogate decision-makers remain visible in the right to refuse treatment. Consequently, lack of advanced directives thereby violating the principle of informed consent, doubts about the quality of decisions, failure to determine right and wrong for patients, and contravening of values and beliefs.
The ethical debate surrounding the withdrawal of treatment remains challenged based on the patient’s right to refuse medical interventions to prolong lives. Moreover, the morality of using life-prolonging treatments remains a concern, knowing very well that the patient will not recover. The practice remains considerable to violate medical practitioners’ principles to ensure that no causing harm to their patients. While a patient in the right state of mind can refuse life-prolonging treatment, the situation becomes complicated during critical illnesses (Surrogate decision-Making).
It becomes challenging to ascertain whether the patient would have advocated for the treatment withdrawal. The 1990 Missouri Court ruling in Nancy Cruzan’s case depicts some of the concerns raised with the critical ill-treatment withdrawal. Cruzan went into a vegetative state after a car accident in 1983. Her parents decided to seek court approval to remove the feeding tubes that prolonged her life. The hospital had declined to adhere to the requirement. According to the hospital, withdrawing the life support machines amounted to a violation of their professional practice.
Cruzan’s parents hence granted the right to withdraw from the treatment. The ruling stated that every citizen has the constitutional right to refuse life-prolonging treatment (Flood, 2004). Therefore, in this particular case, Cruzan’s parents’ refusal to treatment took place on her behalf. The controversy surrounding the morality of withdrawing treatment for the critically ill depends on the provision of proof that the patients would have refused the administered interventions had they had the capacity to decide.
Physicians ought not to force patients to continue treatment interventions to prolong lives. Her roommate, recounted that the former having informed her of her intention not to forcefully continue to feed by hydration and tubes, proved Cruzan’s lack of desire for life-prolonging treatments. The ethical issue of surrogates withdrawing particular treatments remain proven. The surrogates’ withdrawal making is vital, proving that the patients would not have accepted to continue with the treatment if they could choose (Surrogate decision-Making).
Another ethical issue regarding surrogates’ role in making decisions for the critically ill involves the stoppage of treatment. In some cases, surrogate decision-makers involved at the end of life select the option to stop treatment. Surrogates view the patients as likely to have made the same decision if they had the right mental capacity. However, the withdrawal of treatment has attracted much backlash regarding its legality and moral view. Withdrawing treatment remains considered to violate patients’ right to life.
The clash on whether to withdraw treatment as stipulated by surrogates and thoughts of violation of the right to life questioning surrogates’ morality. The 1975 Quinlan case provides a perfect example of Surrogates’ treatment withdrawal’s morality issues. The 21-year-old Quinlan experienced breathing cessation twice for minutes. Moreover, It later emerged that she proceeded into a vegetative state. The family’s first ethical issue emerged when the family sought to withdraw treatment after an assured that no likelihood of improvement to her condition(Surrogate decision-Making).
The ethical obstacle emerged from the father’s religious belief as he saw the act as contravening his values. The next hurdle to withdrawing treatment emerged in the courts after the parents sought legal permission to go forward with the plans against the doctors’ wishes. Eventually, Quinlan’s family granted the right to cease the treatment.
The ethical issue of withdrawing treatment for a critically ill patient such as Quinlan remains enshrined in the constitution’s right to privacy. The law demands that a person stays granted the right to privacy without interference from other people. The court ruled that Quinlan’s father was in a position to exercise the right to privacy on her daughter’s behalf by removing her from the respirator (Flood, 2004).
Surrogate decision-making faces the ethical challenge of lack of advanced directives. The fact that surrogates have to make decisions that entail a patient’s wishes means that the former needs advanced information on the latter’s treatment preferences. However, this is not always the case. Not all patients provide their patients with directives on handling them when they having no mental capacity to make decisions(Surrogate decision-Making).
A 2017 study conducted by DeMartino et al. (2017) established that only a few numbers of people provide their patients with advanced directives on treatment proceeds when they no longer have the mental state to decide. The study investigating alternate patients’ decision-makers indicated that only 20 to 29% of surrogates receive prior directives. The figures supported by 2014 Pew Research findings pointed out that only 30% of Americans gave directives on treatment procedures during a state of lack of decision-making capacity (Wood, 2015).
The small number of critically ill patients with advanced directives presents ethical challenges regarding surrogates’ role in making treatment decisions for the latter. It paints an image of a violation of the patient’s consent to treatment. The ethical question arises from the surrogate’s role in deciding on behalf of the patient despite lacking knowledge of the patient’s preferred treatment method(Surrogate decision-Making).
Surrogates’ use for decision-making remain considered to violate the informed consent policy for medical practice. A 2019 study by Kwon et al. established that the informed consent policy remain often abused when surrogates are used in treatment. It emerged that cancer patients undergoing chemotherapy remain subjected to treatments they disagree with. The agreements often made between the physicians and the surrogates, thereby violating patients’ right to informed consent (Kwon et al., 2019).
Additionally, the use of surrogates in cases involving the critical has elicited ethical questions regarding the nature of decisions made and their impact on patient’s health. It remains the responsibility of medical practitioners to ensure that decisions remain undertaken to enhance patients’ well-being. Therefore, surrogates are required to make decisions that are considered in the best interest of the patients. However, the practical application of their choices may not reflect the patient’s best interest, thereby violating the ethical need to make better decisions for the critically sick(Surrogate decision-Making).
Diverse studies have established that surrogates often make poor judgment when determining what is right for their patients. The surrogates are often not accurate in describing the patients’ wishes. According to Fetherstonhaugh et al. (2017), surrogates’ substituted judgment approach may not reflect the actual choice. The findings established in a study investigating the effectiveness of surrogate decision-making among patients with dementia. The researchers recommended that healthcare workers should take an active role in helping surrogates make viable decisions on the patient’s behalf (Fetherstonhaugh et al., 2017).
The poor decision-making capabilities of surrogates stood reported by research findings conducted by Lord Livingston and Cooper (2015). The research focused on decision-making by surrogates handling patients who have dementia. The surrogates pointed out that they found it challenging to decide for the patients. The findings highlight the challenges of relying on surrogate decision-makers in end-of-life situations. Lack of ideal treatment for the critically ill due to poor choices by surrogates may lead to the emergence of questions regarding the violation of pursuit of decisions perceived as better for patients’ health(Surrogate decision-Making).
An ethical argument against surrogate decision-making entails the practice’s ability to adhere to patients’ beliefs, values, and preferences. Ethical healthcare requires that patients receive treatment using criteria they consider suitable for their health. Patients have the right to choose the correct remedy that appeals to them from a set of alternatives. Likewise, the treatment selected should be in line with the patient’s values and beliefs. The need to observe patients’ values stems from the fact that society comprises people from different communities with cultural diversities and beliefs(Surrogate decision-Making).
Some patients tend to avoid treatments that they consider to violate their cultural and religious beliefs (Siddiqui et al., 2018). Therefore, treatment options that give preference to the patient’s values must be considered to recover well. However, getting the goals, values, and treatment procedures for critically ill patients may be challenging. The fact that the patients cannot choose a treatment option that they view as good in terms of values and preference makes them vulnerable to wrong remedies.
The surrogate’s ethical duty is to ensure that the critically ill’s treatment values and priorities are not violated (Geros-Willfond et al., 2016). The ethical challenges of adhering to patients’ values and beliefs emerge when the involved parties’ cultural norms clash. The 1975 ruling by the New Jersey Supreme Court in Quinlan’s case explains the ethical concerns regarding surrogate decision-making regarding patient’s values. Quinlan’s father initially declined the family’s quest to withdraw her from the respirator as it violated his religious beliefs(Surrogate decision-Making).
The hospital also declined the idea as it amounted to a violation of its ethical code of operation. The matter was solved by witnesses who stated that it was against Quinlan’s wishes to be supported by a respirator despite no recovery signs. Therefore, the ethics of surrogate decision-making critically involves thoughts of violation of personal beliefs and values among the different parties involved(Surrogate decision-Making).
Additionally, ethical concerns have been raised regarding surrogates’ ability to know what is right and wrong for patients. According to Chaet (2017), physicians cannot decide on halting the treatment as doing so amounts to a violation of their professional duties. Therefore, the decision to select the next course of action is left to the surrogates. Besides the patient’s values and preferences, surrogates are forced to rely on their judgment on what is best. The decision should focus not only on the patient’s interest alone but also on the loved ones and the general population.
Patients’ interest is illustrated by thoughts of decisions they are perceived as likely to undertake should they be aware of their situation (Moss et al., 2019). The controversy with allowing surrogates to make decisions on patients’ behalf may lead to more harm. Withdrawing patients from critical treatments such as life support machines and medications leads to further deterioration of their health condition(Surrogate decision-Making).
While surrogates rely on physicians’ medical information, their decisions tend to be contested on ethical grounds. Withdrawing treatment is portrayed as unethical since it violates healthcare principles of acting in good faith. The concern comes despite knowing that the patient will not recover if still subjected to treatment. Surrogates’ decision to withdraw treatment is considered wrong as it causes adverse effects on the patient’s life.
In conclusion, surrogates play a critical yet controversial role during critically ill patients’ treatment. The right to refuse treatment as practiced by the surrogates is depicted as contravening medical practitioners’ conduct. The issue also takes into consideration the privacy rights of a patient. Also, patients’ lack of advanced directives led to questions regarding observation of the right to informed consent. Similarly, surrogates’ decisions may not reflect the patient’s real stand. Another issue of ethical attention is the failure to determine what is right and wrong for the patients effectively. Lastly, the patient’s values and parties may be violated under surrogate decision-making(Surrogate decision-Making).
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Kwon, J. H., Baek, S. K., Kim, B. S., Koh, S. J., Ahn, H. K., Lim, J. H., … & Kim, D. Y. (2019). Surrogate decision-making of chemotherapy consent: do we provide informed consent of chemotherapy for patients?. The Korean Journal of Internal Medicine, 34(3), 626.
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Moss, K. O., Douglas, S. L., Baum, E., & Daly, B. (2019). Family surrogate decision-making in chronic critical illness: a qualitative analysis. Critical care nurse, 39(3), e18-e26.
Siddiqui, S., Sureish, S., & Chia, A. (2018). Survey on the perceived impact of religion, culture, and social network information on surrogate decision-making in a South Asian developed country. Indian journal of critical care medicine: peer-reviewed, official publication of Indian Society of Critical Care Medicine, 22(9), 656.
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