The Problem of Proxies with Interests of Their Own: Toward a Better Theory of Proxy Decisions

Abstract

A seventy-eight-year-old married woman with progressive Alzheimer’s disease was admitted to a local hospital with pneumonia and other medical problems. She was able to recognize no one, and she had been incontinent for about a year. Despite aggressive treatment, the pneumonia failed to resolve, and it seemed increasingly likely that this admission was to be for terminal care. The patient’s husband (who had been taking care of her in their home) began requesting that the doctors be less aggressive in their treatment and, as the days wore on, he became more and more insistent that they scale back their aggressive care. The physicians were reluctant to do so, due to the small but real chance that the patient could survive to discharge. The husband was the patient’s only remaining family, so he was the logical proxy decision maker. Multiple conferences ensued; finally a conference with a social worker revealed that the husband had recently proposed marriage to the couple’s housekeeper, and she had accepted. The Current Theory of Proxy Decisions Patient autonomy is the cornerstone of our medical ethics. Given this commitment to autonomy, proxy decisions will always strike us as problematic: it is always more difficult to ensure that the wishes of the patient are embodied in treatment decisions when someone else must speak for the patient. Proxy decisions are especially disturbing when we fear that the proxy’s judgment is tainted by his own interests, so that the proxy is covertly requesting the treatment he wants the patient to have, rather than the treatment the patient would have wanted. This problem of interested proxies is exacerbated by the fact that we seek out proxies who often turn out to have strong interests in the treatment of the patient. We do this for two reasons. (1) Those who care deeply for the patient are more likely than others to want what is best for the patient. (2) Those who are close to the patient are generally most knowledgeable about what the patient would have wanted. This familiarity allows us to apply the substituted-judgment standard of proxy decision making. Given a commitment to autonomy, substituted judgment is an ethically better basis for proxy decision making than the reasonableperson or best-interest standard. The apparent alternative would be proxy decisions made by out-siders--physicians, court-appointed guardians, or ethics committees. We must learn to recognize that such outsiders also have interests of their own, and that their proxy decisions may also be influenced by these interests. The more common worry about outsiders is that they rarely know the patient as well as members of the patient’s family do, and outsiders’