What is the moral basis of the authority of family members to act as surrogates for incompetent patients?

...The authority of family members should be understood as presumptive; that is, there is a moral presumption that a close family member should serve as surrogate for an incompetent patient. That presumption can be overcome or rebutted in a particular case, either when there is sufficient evidence that the usual reasons supporting this presumption do not hold or when the surrogate's decision exceeds appropriate limits of surrogates' decision-making discretion. In order to clarify these hard cases and appropriate public policy, we need a much deeper and more complex analysis than either the conventional view, or the alternative account that Pearlman and colleagues provide. I have sought here only to point toward some of the other grounds that a full account of family members' authority as surrogates would have to develop and explore in much more detail....     

Projection in surrogate decisions about life-sustaining medical treatments.

To honor the wishes of an incapacitated patient, surrogate decision makers must predict the treatment decisions patients would make for themselves if able. Social psychological research, however, suggests that surrogates' own treatment preferences may influence their predictions of others' preferences. In 2 studies (1 involving 60 college student surrogates and a parent, the other involving 361 elderly outpatients and their chosen surrogate decision maker), surrogates predicted whether a close other would want life-sustaining treatment in hypothetical end-of-life scenarios and stated their own treatment preferences in the same scenarios. Surrogate predictions more closely resembled surrogates' own treatment wishes than they did the wishes of the individual they were trying to predict. Although the majority of prediction errors reflected inaccurate use of surrogates' own treatment preferences, projection was also found to result in accurate prediction more often than counterprojective predictions. The rationality and accuracy of projection in surrogate decision making is discussed.     

Care versus treatment at the end of life for profoundly disabled persons

Individuals who are profoundly mentally handicapped do not have the capacity to make their own decisions and also do not have a past record of decisions, from when they had capacity, to guide us in making decisions for them. They represent a difficult group, ethically, for surrogate decision making. Here I propose some guidelines, distinguishing between these patients and patients in a persistent vegetative state (PVS). As the life span of patients becomes shorter, or their level of consciousness becomes permanently impaired, the presumption for comfort care should become an imperative, and the standard of evidence to justify any invasive intervention should become higher. For members of this population, who have no more ability to refuse treatment than to consent to it, protection of the vulnerable must mean allowing a peaceful death as well as a comfortable life. Reasonable legal safeguards are also proposed to allow improved end-of-life decisions to be made for this population.     

Do we make decisions for other people based on our predictions of their preferences? evidence from financial and medical scenarios involving risk

Abstract

The ways in which the decisions we make for others differ from the ones we make for ourselves has received much attention in the literature, although less is known about their relationship to our predictions of the recipient’s preferences. The latter question is of particular importance given real-world occurrences of surrogate decision-making which require surrogates to consider the recipient’s preferences. We conducted three experiments which explore this relationship in the medical and financial domains. Although there were mean discrepancies between surrogate predictions and choices, we identified a predictive relationship between the two. Moreover, when participants took high risks for themselves, it seems that they were not willing to do so for others, even when they believed that the recipient’s preferences were similar to their own. We discuss these findings relative to current theories and real-world instances of surrogate decision-making.     

False memories for end-of-life decisions

OBJECTIVE: To examine people's false memories for end-of-life decisions. DESIGN: In Study 1, older adults decided which life-sustaining treatments they would want if they were seriously ill. They made these judgments twice, approximately 12 months apart. At Time 2, older adults and their self-selected surrogate decision makers tried to recall the older adults' Time 1 decisions. In Study 2, younger adults made treatment decisions twice, approximately 4 months apart. At Time 2, younger adults tried to recall their Time 1 decisions. MAIN OUTCOME MEASURES: Percentage of participants who falsely remembered that their original treatment decisions were the same as their current decisions. RESULTS: In Study 1, older adults falsely remembered that 75% of their original decisions were the same as their current decisions; surrogates falsely thought that 86% of older adults' decisions were the same. In Study 2, younger adults falsely remembered that 69% of their original decisions were the same as their current decisions. CONCLUSION: Age alone cannot account for people's false memories of their end-of-life decisions; we discuss other mechanisms. The results have practical implications for policies that encourage people to make legal documents specifying their end-of-life treatment decisions.     

Surrogate consent to non-beneficial research: erring on the right side when substituted judgments may be inaccurate

Part of the standard protection of decisionally incapacitated research subjects is a prohibition against enrolling them unless surrogate decision makers authorize it. A common view is that surrogates primarily ought to make their decisions based on what the decisionally incapacitated subject would have wanted regarding research participation. However, empirical studies indicate that surrogate predictions about such preferences are not very accurate. The focus of this article is the significance of surrogate accuracy in the context of research that is not expected to benefit the research subject. We identify three morally relevant asymmetries between being enrolled and not being enrolled in such non-beneficial research, and conclude that when there is a non-negligible probability that surrogates’ predictions are wrong, it will generally be better to err on the side of not authorizing enrollment.     

Respect for the developmentally disabled and forgoing life-sustaining treatment

A developmentally disabled person should be treated at all times as a unique individual and not as some anonymous "disabled person." The developmentally disabled should not be subjected to invasive medical treatment that is unduly burdensome or nonbeneficial, or be forced to endure a quality of life not meaningful to them as individuals. They have a right to refuse or accept treatment that a surrogate must exercise on behalf of each individual in a responsible and careful manner. Three cases and a preliminary approach to the ethical analysis of decisions to allow developmentally disabled persons to die by forgoing medical treatment are offered. The "best interests" of a developmentally disabled individual, properly understood, can serve as a useful and ethically defensible standard for determining the ethical propriety of surrogate decision making about forgoing life-sustaining medical treatment of the disabled.     

A multidimensional framework for financial–economic decisions

Most financial–economic decisions are made consciously, with a clear and constant drive to ‘good’, ‘better’ or even ‘optimal’ decisions. Nevertheless, many decisions in practice do not earn these qualifications, despite the availability of financial economic theory, decision sciences and ample resources. We plea for the development of a multidimensional framework to support financial economic decision processes. Our aim is to achieve a better integration of available theory and decision technologies. We sketch (a) what the framework should look like, (b) what elements of the framework already exist and which not, and (c) how the MCDA community can co‐operate in its development. Copyright © 2003 John Wiley & Sons, Ltd.     

Information about expert decision and post‐decision distortion of facts of own decision

Cognitive representations of decision problems are dynamic. During and after a decision, evaluations and representations of facts change to support the decision made by a decision maker her‐ or himself (Svenson, 2003). We investigated post‐decision distortion of facts (consolidation). Participants were given vignettes with facts about two terminally ill patients, only one of whom could be given lifesaving surgery. In Study 1, contrary to the prediction, the results showed that facts were distorted after a decision both by participants who were responsible for the decisions themselves and when doctors had made the decision. In Study 2 we investigated the influence of knowledge about expert decisions on a participant's own decision and post‐decisional distortion of facts. Facts were significantly more distorted when the participant's decision agreed with an expert's decision than when the participant and expert decisions disagreed. The findings imply that knowledge about experts' decisions can distort memories of facts and therefore may obstruct rational analyses of earlier decisions. This is particularly important when a decision made by a person, who is assumed to be an expert, makes a decision that is biased or wrong.     

Turning failures into successes: a methodological shortcoming in empirical research on surrogate accuracy

Decision making for incompetent patients is a much-discussed topic in bioethics. According to one influential decision making standard, the substituted judgment standard, a surrogate decision maker ought to make the decision that the incompetent patient would have made, had he or she been competent. Empirical research has been conducted in order to find out whether surrogate decision makers are sufficiently good at doing their job, as this is defined by the substituted judgment standard. This research investigates to what extent surrogates are able to predict what the patient would have preferred in the relevant circumstances. In this paper we address a methodological shortcoming evident in a significant number of studies. The mistake consists in categorizing responses that only express uncertainty as predictions that the patient would be positive to treatment, on the grounds that the clinical default is to provide treatment unless it is refused. We argue that this practice is based on confusion and that it risks damaging the research on surrogate accuracy.

Responsive care management: family decision makers in advanced cancer

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.     

How do shy people expand their social networks? Using social surrogates as a strategy to expand one's network

The authors examined the use of social surrogates by shy people to expand their social network when entering a new environment, following Bradshaw's social surrogate hypothesis. The authors conducted a panel survey of 70 friendship pairs of students 7 months after they entered university. The results revealed that when a friend acted as a surrogate, the shy students extended their joint networks more. In contrast, not-shy students extended their networks regardless of whether a friend acted as a surrogate. These results indicate that even shy people can adjust indirectly to new social circumstances because they can expand their social networks by using a close friend as a surrogate.     

替代指标在心血管疾病临床决策中的正确认识

在心血管疾病临床试验中,替代指标常用于评价干预措施的疗效。但替代指标在心血管疾病临床试验中非常复杂,因此,心血管医生在解读和评价心血管疾病临床试验的结果时,应正确认识替代指标的内涵、应用背景及其局限性,同时,还应客观地评价相关替代指标的证据强度,以寻找最好的医学证据指导其临床决策和实践。     

Thinking about decisions: An integrative approach of person and task factors

Decisions vary. They may vary in both content and complexity. People also vary. An important way that people vary is how much they think. Some prior research investigating thinking and decision making largely conflicts with most traditional decision theories. For example, if considering an array of products to choose from, thinking more about the alternative's attributes should lead to a better decision. However, some research indicates that thinking more may also lead to focusing on irrelevant aspects of the decision and a less optimal outcome. We propose that this conflict in the literature exists because of a failure to consider the interaction between the individual and the decision task. To test this, we used separate methodologies that enhance or attenuate a person's thinking. In Study 1, we selected people who were especially high or low in need for cognition and had them complete a robust decision-making inventory, which included both complex and simple tasks. In Study 2, we manipulated participant's level of glucose, which acts as the brain's fuel to enhance or attenuate thinking ability. Both studies provide insight for understanding our central tenant that more thought leads to better decisions in complex tasks but does not influence simple decisions. These findings show how the individual's thinking can interact with the constructive elements of the task to shape decision choice.     

The Problem of Counterfactuals in Substituted Judgement Decision‐Making

The standard by which we apply decision‐making for those unable to do so for themselves is an important practical ethical issue with substantial implications for the treatment and welfare of such individuals. The approach to proxy or surrogate decision‐making based upon substituted judgement is often seen as the ideal standard to aim for but suffers from a need to provide a clear account of how to determine the validity of the proxy's judgements. Proponents have responded to this demand by providing the truth‐conditions for the substituted judgement in terms of counterfactual reasoning using a possible worlds semantics. In this paper, I show how these underpinnings fail to support the substituted judgement approach as a reasonable standard for decision‐making. Firstly, I show how this counterfactual element has been poorly interpreted. I then explain how various accounts have failed to reflect problems and limitations associated with providing an interpretation of their truth‐conditions using counterfactuals. Finally, I argue that, even when we attend to the initial problems of providing a counterfactual analysis, it still deeply problematic as a means of determining the validity of substituted judgements for two main reasons. Firstly, making determinate judgements as to the truth‐value of these judgements will often not be possible and, secondly, there is a strong requirement when interpreting many counterfactual claims to charitably accede to their being true. I conclude that substituted judgements, as interpreted through counterfactual reasoning and possible worlds semantics, do not therefore provide an adequate standard for surrogate decision‐making.     

Interpreting Surrogate Consent using Counterfactuals

Philosophers such as Dan Brock believe that surrogates who make health care decisions on behalf of previously competent patients, in the absence of an advance directive, should make these decisions based upon a substituted judgment principle. Brock favours substituted judgment over a best interests standard. However, Edward Wierenga claims that the substituted judgment principle ought to be abandoned in favour of a best interests standard, because of an inherent problem with the substituted judgment principle. Wierenga's version of the substituted judgment principle and his counterexample to the principle's successful interpretation of valid surrogate consent is presented. A new version of what is meant by the substituted judgment principle is advanced. The new version is not beset with the problems Wierenga initially ascribed to the substituted judgment principle.     

Bailing and jailing the fast and frugal way

Legal decisions such as the decision to bail upon adjourning a case have major consequences for both defendants and society. In the English system, magistrates, most of whom are lay people, are afforded considerable discretion and must work under constraints such as time pressure. Judgment analysis of the bail decision making policies of 81 magistrates from 44 courts throughout England and Wales revealed intra‐ and inter‐magistrate inconsistency in bail decisions, discrepancies between stated and elicited cue use, and high levels of post‐decisional confidence. Furthermore, magistrates' policies were better described and predicted by a fast and frugal model characterized by noncompensatory cue use, than by either of two compensatory integration models. The fast and frugal model portrays a picture of bail decision making that conflicts with the ideal practice as defined by the due process model of justice. We discuss the implications of these findings for judgment and decision making research and criminal justice policy. Copyright © 2001 John Wiley & Sons, Ltd.     

Pervasiveness of framing effects among physicians and medical students

Researchers have been documenting the influence of framing upon decision making for more than two decades; decisions appear to change in response to superficial changes in the presentation of possible outcomes. Several studies of medical decision making have revealed; for instance, that clinical decisions differ when options are presented as gains (survival rates) rather than losses (mortality rates). However, most studies of framing effects in the medical domain have utilized a very limited number of clinical problems that have not allowed an adequate test of the prevalence of the phenomena. To extend previous studies, we presented three groups of subjects (experienced internists, residents, and third-year medical students) with booklets containing twelve hypothetical medical cases. Half of the subjects received gain versions and half received loss versions of the same cases. Chi-square analyses revealed that framing did not influence any of the decisions of medical students and influenced the decisions of residents and experienced physicians on only two of the clinical problems (the same two problems). It appears that the prevalence of framing effects in the clinical domain may be limited.     

心理距离与后果严重性对人身安全决策的影响

已有研究发现决策者在为自己与不同他人决策时,其风险偏好存在差异。但是当对后果严重性不同的事件进行决策时,上述结果也并不总是如此。为了探究在人身安全情境中决策者面对后果严重程度不同的任务时,为自己和为他人决策时风险偏好的差异,实验一采用人际亲密度和决策所带来消极结果的严重程度分别操纵心理距离与后果严重性,结果发现决策者在后果严重任务中的决策比后果不严重任务更保守,为自己和为陌生人决策均比为最好朋友决策更冒险。这可能是由于决策者知觉到的决策责任不同所致。因此在实验一的基础上实验二引入决策责任这一变量,考察其在心理距离对风险决策影响中的作用,研究结果证明了我们的假设。     

Caring for decisionally incapacitated elderly

Although treating the elderly occasion the same kinds of ethical issues as treating other patients, specific problems do arise when making decisions for persons, once competent, who no longer can express their values. I examine the problem of decisional incapacity and offer a critique of the principles, such as substituted judgment, and the instruments, such as advance directives, living wills, other instructional directives, as well as surrogate decision-makers.