Virtue Ethics and Action Guidance

Theological ethicists rarely allow the virtues to perform the heavyweight work of guiding action. This article contests this tradition and argues that, and demonstrates how, virtue ethics provides a practicable method of normative action guidance. The article contends that there are five interrelated but distinct modes of virtue action guidance. The first three modes—dialogue, emulation, and substituted judgment—invite the agent to take counsel with moral exemplars. The interrogative and discovery modes direct agents to morally deliberate using thick accounts of the virtues.

Trial by Triad: substituted judgment, mental illness and the right to die

Substituted judgment has increasingly become the accepted standard for rendering decisions for incapacitated adults in the USA. A broad exception exists with regard to patients with diminished capacity secondary to depressive disorders, as such patients’ previous wishes are generally not honoured when seeking to turn down life-preserving care or pursue aid-in-dying. The result is that physicians often force involuntary treatment on patients with poor medical prognoses and/or low quality of life (PMP/LQL) as a result of their depressive symptoms when similarly situated incapacitated patients without such depressive symptoms would have their previous wishes honoured via substituted judgment. This commentary argues for reconsidering this approach and for using a substituted judgment standard for a subset of EMP/LQL patients seeking death.

The Legal Characteristics of the Patient’s «Living Will»: Doctrine and Jurisprudence

The advance of medical technologies since the mid-20th century has enabled to prolong a patient’s life in critical situations, though not all patients would tolerate to undergo such treatment. Therefore, the legal question encompass- ing the problem was to resolve the issue of a patient’s refusal of life-sustaining treatment. Since most of such patients are usually irresponsive and lack legal capacity, a solution featuring a legal document akin to a testament or trust has been proposed in the early 70s. Upon the gist of this document, a patient having full legal capacity would anticipate his/her further incapacitation and command to conduct or refuse medical treatment. His/her will, which is reflected in a «living will» has to be notarized, and upon the jurisprudence of various countries worldwide, though not omnipresently, affirmed by a court in order to avoid fraud and satisfaction of the illegitimate interests of third parties. Despite being introduced in the 1970s, living wills are still seldomly drafted by patients. In such case, when the patient lacking a living will falls incapaci- tated, his/her legal representatives and/or the healthcare institution commence civil proceedings so as to define the future fate of the patient using the concept of a substituted judgment, constructed by the courts upon the evidence of the past beliefs and habits of the said person, which requires extensive witness testimony. Resolving the presumed will of the patient is a very complicated issue, and in terms of lack of evidence, courts are not likely to authorize ter- minating the patient’s treatment, acting with a «negative» presumption to rule so. However, courts still may rule that futile treatment is not of the best interests of the patient (which is frequent in respect with minor patients who were born with major congenital ailments). Therefore, a living will, if legitimately drafted, is considered as a firm evidence of the will of the incapacitated person to continue, or to terminate treatment. The «living will» is an entirely voluntary-drafted document and is void upon the fact of undue influence, like an ordinary testament. The intro- duction of such document into the national legislation requires adopting vari- ous legislative acts, and such document is not legally valid unless provided by appropriate legislation. A living will reflects the will of the patient, not his/her legal representatives, and may not be drafted by them. In rare exemptions, the patient, unable of writing, may dictate the will’s content to a duly authorized person (e.g., a guardianship judge, like in Italy). Thus, the approval of the living will execution is the compliance with the will of the patient concerned: his/her guardian expresses his/her will, and the court affirms it. The control- ling function of the courts is hereby apparent. All in all, the «living will» is a considerable institute of private law, enacted in various countries worldwide and has its legal prospects in Ukraine, as well.

A new kind of paternalism in surrogate decision-making? The case of Barnsley Hospitals NHS Foundation Trust v MSP

The modern legal and ethical movement against traditional welfare paternalism in medical decision-making extends to how decisions are made for patients lacking decisional capacity, prioritising surrogates’ judgment about what patients would have decided over even their best interests. In England and Wales, the Mental Capacity Act 2005 follows this trend of prioritising the patient’s prior wishes, values and beliefs but the dominant interpretation in life-sustaining treatment cases does so by in effect calling those values the ‘best interests’ of the patient and focusing nearly exclusively on the ‘subjective’ viewpoint of the patient. In this article, we examine the recent Court of Protection judgment in Barnsley Hospitals NHS Foundation Trust v MSP [2020] EWCOP 26, which adhered closely to this approach, to suggest that it could have unexpected negative consequences. These include insufficient information gathering about and attention to patients’ objective medical interests, inadequacy of the evidentiary standard used for the substituted decision-making and, in some cases, even prioritising a surrogate’s current substituted judgment over the potential for an actual judgment by the patient.

Precedent Autonomy and Surrogate Decisionmaking After Severe Brain Injury

Patients with disorders of consciousness after severe brain injury need surrogate decision makers to guide treatment decisions on their behalf. Formal guidelines for surrogate decisionmaking generally instruct decision makers to first appeal to a patient’s written advance directive, followed by making a substituted judgment of what the patient would have chosen, and lastly, to make decisions according to what seems to be in the patient’s best medical interests. Substituted judgment is preferable because it is taken to preserve patient autonomy, by using a patient’s past wishes and values to reconstruct what they would have chosen for themselves. In this paper, the author argues that for a certain population of patients, the standard interpretation of substituted judgment cannot ensure the preservation of patient autonomy. Patients with “covert awareness” may continue to have values and an authentic sense of self, which may differ from their past values and wishes. Accordingly, surrogate decision makers should make decisions based on how the patient is likely to experience their condition in the present, rather than their past wishes and values.

On the Likelihood of Surrogates Conforming to the Substituted Judgment Standard When Making End-of-Life Decisions for Their Partner

A considerable proportion of end-of-life decisions are made by the patient’s next-of-kin, who can be asked to follow the substituted judgment standard and decide based on the patient’s wishes. The question of whether these surrogate decision makers are actually able to do so has become an important issue. In this study, we examined how the likelihood of surrogates conforming to the substituted judgment standard varies with individual differences in mortality acceptance and confidence in their decision making. We recruited 153 participants in romantic relationships between 18 and 80 years old from the general population. We asked them to make hypothetical end-of-life decisions for themselves and on behalf of their partner, as well as predict what their partner would do, and complete a series of questionnaires. Participants predicted that their partner would make similar decisions to their own but were more likely to accept a life-saving treatment that could result in reduced quality of life on their partner’s behalf than for themselves. Decisions made by older adults were more likely to conform to the substituted judgment standard, which is encouraging given that they are more likely to be confronted with these decisions in real life, although this was not due to differences in mortality acceptance. Older adults were also more likely to have had previous discussions with their partner and thereby know that person’s wishes and feel confident that they made the right decision, but these factors did not affect their likelihood of conforming to the substituted judgment standard. This shows that encouraging discussions about end of life among families would ease the decision process, but more work is needed to ensure that surrogates can adhere to the substituted judgment standard.

Advance Care Planning and Surrogate Decision-Making (DRAFT)

Adult patients are presumed to possess decision-making capacity, but when they are unable to make their own decisions—which is especially frequent in the context of serious illness—ideally a surrogate decision-maker will be able to determine what the patient would have wanted (i.e., substituted judgment). Only when this is not possible is it necessary to fall back on what seems to be in the patient’s best interests. To foster patient autonomy, goals and values should be identified and documented in advance, such as in an advance directive, as well as a surrogate decision-maker named. This helps guide the medical team in critical and often uncertain times, given the challenges in accurate prognostication (which are lessening with the advent of evidence-based tools).

Substituted decision making and the dispositional choice account

There are two main ways of understanding the function of surrogate decision making in a legal context: the Best Interests Standard and the Substituted Judgment Standard. First, we will argue that the Best Interests Standard is difficult to apply to unconscious patients. Application is difficult regardless of whether they have ever been conscious. Second, we will argue that if we accept the least problematic explanation of how unconscious patients can have interests, we are also obliged to accept that the Substituted Judgment Standard can be coherently applied to patients who have never been conscious at the same extent as the Best Interests Standard. We then argue that acknowledging this result is important in order to show patients respect.