AA

Capacity and Surrogacy

The History of Medicine

  • Medicine was paternalistic- concerned about patient well being, not autonomy
  • Then medicine became anti-paternalistic- try to maximize well being within constraints of patient’s autonomy

Capacity

  • Decision-making capacity (DMC)- present regarding a particular set of options if and only if they have the ability to
    • Understand the relative info (knowing objective facts from 3rd person POV)
    • Appreciate the situation (how the facts apply to their own life, 1st person POV)
    • Reason about their options
    • Communicate their choice
  • Characteristics of DMC
    • It’s autonomy tracking
    • Patient has DMC- do as they decide
    • Patient doesn’t have DMC- autonomy is not a concern
    • Requires ability thresholds because DMC is binary
    • Decision specific, relevant thresholds deermined by
    • Complexity- more complex decision requires a greater degree of abilities
    • Risk-relativity- higher stakes of decision, greater degree of abilities needed
  • Purpose of DMC- justifies patient’s authority (when a person’s choice determines which option is carried out)
  • Capacity not same as competency
    • Capacity determined by physician, competency determined by judge
  • Problem with DMC (according to Dr. Schwan)
    • The risks of the situation should not determine whether a person has autonomy or not

Surrogacy

  • Surrogate- a person who participates in decision making and speaks to pt’s medical wishes, values, and commitments
  • How to name a surrogate legally?
    • Legal guardian
    • Health care power of attorney
    • Psychiatric advance directive proxy- like HCPOA but specifically for psychiatric disorders
    • Next of kin (some states name this order)
  • Why use surrogates?
    • Promote patient well being
    • Best way to respect patient autonomy if they don’t have DMC
  • Surrogates only participate in decision making
  • These decisions should be made based on
    • Patient’s previously expressed wishes
    • Or substituted judgment
    • At least based on patient’s best interest
  • Surrogate is not a good surrogate if they don’t participate in decision making with these goals
  • Other sources of info about patient’s values/wishes
    • Advance directives
    • Living will, HCPOA, declaration for mental health treatment
    • Patient’s friends
    • Previous discussions w/ patient
    • Patient themselves