In 1989, Allen Buchanan and Dan Brock published their groundbreaking work on surrogate decision-making entitled: Deciding for Others: The Ethics of Surrogate Decision Making in which they developed a decision making framework that could apply to adults and children. 1 Buchanan A.E. Brock D.W. Deciding for others: the ethics of surrogate decision making. Cambridge University Press, New York1990 Crossref Google Scholar It entailed 4 principles: (1) underlying ethical values, (2) authority principle, (3) guidance principle, and (4) intervention principle. Whereas the underlying ethical values in adult decision-making are self-determination and well-being, in pediatrics they placed greater priority on well-being followed by self-determination and then added a third value—parental interests—because they understood that parents are not fiduciaries who always act in their child’s best interest, but must balance the child’s needs and interests with the needs and interests of other family members (including themselves). 2 Ross L.F. Children, families and health care decision making. Oxford University Press, Oxford UK1996 Google Scholar In fact, for each principle, Buchanan and Brock distinguished how the framework applied for adults vs pediatrics. Whereas adults could choose who would speak for them (authority principle), parents were presumed the decision-makers for their children. Surrogate decision-makers for adults were supposed to act (guidance principle) following the patient’s preferences (living will or advance directive) when available. If not, the surrogate was supposed to act according to the principle of substituted judgment, as if the surrogate were to walk in the other person’s shoes. If those preferences were not known, they were to make a best interest determination. In contrast, in pediatrics, the only guidance principle was to act in the child’s best interest, although Buchanan and Brock quickly stated that this was only “a regulative ideal.” The only principle in which Buchanan and Brock did not distinguish between adults and minors was when the state should intervene. They limited the intervention principle to 3 types of cases: (1) conditions that disqualify the family, (2) certain classes of cases deserving special scrutiny, and (3) decisions outside the range of medically sound alternatives. 1 Buchanan A.E. Brock D.W. Deciding for others: the ethics of surrogate decision making. Cambridge University Press, New York1990 Crossref Google Scholar
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