Abstract
How should we respond to patients who do not wish to take on the responsibility and burdens of making decisions about their own care? In this paper, we argue that existing models of decision-making in modern healthcare are ill-equipped to cope with such patients and should be supplemented by an "appointed fiduciary" model where decision-making authority is formally transferred to a medical professional. Healthcare decisions are often complex and for patients can come at time of vulnerability. While this does not undermine their capacity, it can be excessively burdensome. Most existing models of decision-making mandate that patients with capacity must retain ultimate responsibility for decisions. An appointed fiduciary model provides a formalized mechanism through which those few patients who wish to defer responsibility can hand over decision-making authority. By providing a formal structure for deferring to an appointed fiduciary, the confusions and risks of the informal transfers that can occur in practice are avoided. Finally, we note how appropriate governance and law can provide safeguards against risks to the welfare of patients and medical professionals.
Highlights
According to a popular historical view of medical ethics, ultimate responsibility for healthcare decisionmaking has transferred over recent decades from doctors to patients.[1]
We have outlined an extension to the doctor–patient relationship that aims to respond to the possibility that some patients will feel overwhelmed by the responsibility involved in making treatment decisions
Since the appointed fiduciary relationship relies on patient choice to be activated, we have argued that it still sufficiently respects patient autonomy
Summary
According to a popular historical view of medical ethics, ultimate responsibility for healthcare decisionmaking has transferred over recent decades from doctors to patients.[1]. A theme of increasing prominence in discussions of the doctor–patient relationship is the idea of “shared decision-making,” described by the United Kingdom’s National Institute for Health and Care Excellence (NICE) as decisions where “health professionals and patients work together.”[13] As Cathy Charles et al note, the details of shared decision-making are not always made entirely clear by proponents.[14] Ezekiel and Linda Emmanuel propose two models in between absolute patient sovereignty and classical paternalism.[15] According to the “interpretive” model, the doctor helps the patient to work out the patient’s own values; on the deliberative model, of which liberal rationalism is an instance, the doctor aims to persuade the patient to adopt her favored course of action, though the decision is left up to the patient. It is doubtful that competent patients really do uniformly want to have decision-making power in all medical issues
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