Narrative review and criticize of surrogate decision-making in liberal medical ethics

Introduction:  Of the most important issues in medical ethics, one is the patient's right to make decisions about medical care. Making decisions based on informed consent needs to include three components: to have the capacity, to provide the information and to be voluntary. Based on the principle of “respect for autonomy”, patients have the right to freely choose their own medical care. In patients who cannot take the necessary decisions, such decisions are made by a surrogate. In consort with the advancement and development of health services and along with supportive organizations’ paying more attention to medical ethics and patient rights, the ambiguous problem of surrogate decision-making has become the center of medical ethics experts’ discussions. To tackle the challenges of this argument is to a large extent related to its ethical philosophy. As noted above, the patients’ right to make decisions about their medical care has been created based on the principle of respect for autonomy, which is rooted in the liberalism philosophy of ethics, as the dominant discourse in Western medical ethics is the philosophical school of liberalism. The present paper aims to review and criticize surrogate decision-making in liberal medical ethics. Methods:  In this narrative and critical review, library research method was firstly used to collect data. Then, stressing the principles of deductive reasoning in critical thinking, epistemic analyses were carried out. Avoiding prolonged discussions and abiding by the principle of brevity and usefulness, this study attempts to address, discuss, and criticize the most significant views of the liberal philosophical system in the analysis and criticism of the deductions. Results:  Theoretically, a patient without the decision-making capacity has the same right to give consent for diagnosis and treatment as people with such capacity. In practice, however, such patients cannot enjoy this right. All of the patient’s rights are, therefore, assigned to the surrogate decision-maker. The patients’ incapacity does not exempt the doctor from trying to consent them. The fundamental principle of respect for autonomy in medical ethics is the basis for such instructions as informed consent, information disclosure and voluntary decision making. An important reason for surrogate decision-making is this same principle. Autonomy is the product of Liberal thought, which was presented as a school of thought after the developments of the Renaissance in Europe. Allowing for almost all of the social, cultural, ethical and political structures, it put human life in the course of a series of changes. Rooted in humanistic thinking, it rose as an ideology across the Western globe instead of divine religions. In this current of thought, nothing other than individuals can stockade against individualism preventing them from achieving their natural demands. On the other hand, liberal thinking, theoretically or practically, does not adheres to some fixed ethics. Theoretically, from the perspective of liberalism, adherence to ethical values is justified and reasonable only if it is beneficial. Individualistically, logical conclusions and democracy provide the criteria for being considered as beneficial in ethical valuations. Selecting the surrogate depends on understanding the patient’s desires and beliefs, and is usually assigned to family and close relatives, which has been proposed prioritizing the following on liberal ethics: The most appropriate person to decide instead of the patient is the one whom the patients had chosen when s/he had had the capacity to do so, or the one who is his/her lawyer. Then one must refer to his/her spouse, children, parents, or next of kin. But if the patient has not designated any persons, or the designated person does not have decision-making capacity either, or the patient has been away from his/her spouse, parents, children or grandchildren for a long time, there will, of course, be cases which do not lead to any reliable results. The second question is how the surrogate will make the decisions. In liberal medical ethics, such cases of decision-making start with considering the patient's personal desires and wishes. Then, the patient’s manuscript drafts or will (if there are any) will be referred to. Finally, the patient's known values and beliefs will be taken into account. There exists the same challenge for this process. In addition, there is no real reference beyond these three stages. On the other hand, if a decision is taken based on the patient's desire to prevent his/her treatment, a conflict occurs among the quadruple principles. Medical ethics scholars have responded to the two aforementioned questions: in the process of selecting the surrogate, if the above-mentioned priorities are not met, the decision will be made by the protector or the legal authorities; and in the process of decision-making, if the surrogate cannot decide based on the patient’s values, or if there is discrepancy among family members’ decisions, the higher interests of the patient will be referred to. The main criticism is that in the liberal thought, one cannot be committed to some fixed ethical beliefs and to an excellent value system, and it is naturally pledged and committed to some sort of individual libertinage. In this ideology, there is no general ethical law to determine the does and don’ts; therefore, there is no place for higher interests of the person. Hence, the dilemma of the above questions in the liberal thought has no other solutions but to resort to other schools of thought. Even if they say that by higher interests of the person, they mean the mere benefits and harms of the treatment, not outside the excellent value system, another challenge will still be there: considering the mere benefits and harms of the treatment is a violation of individual autonomy. Conclusion:  Although designed to be well-structured as a way to resolve some issues and questions of ethical decisions in medicine, the medical ethics based on ideas and principles of liberalism is faced with serious challenges if it is bound to the philosophical foundations of liberal ethics. The dilemma of the liberal philosophical system is that it considers individualism and originality of the benefit as its ultimate goal. Nevertheless, if the drafter of the laws is the creator of the individual, the autonomy of the individual will then turn into self-governing, and it will be defined within the divine framework.  Please cite this article as:  Momeni N, Zamani M, Darvishi Tafvizi M. Narrative review and criticize of surrogate decision-making in liberal medical ethics. Med Ethics J 2016; 10(36): 15-24.