Proxy Consent in a High

Proxy Consent in a High Stakes and Time Sensitive Healthcare Situation: A Philosophical Analysis

In general, healthcare decisions should be made by the individual receiving the care, based on their personal values and beliefs as well as their medical best interests as determined with the help of healthcare professionals through honest and objective dialogue. There are times, however, when such decisions cannot be made by the individual receiving the care for one reason or another, and in these instances the decisions must be made by proxy -- in a manner that keeps the patients best interests according to both their personal values, beliefs, and concepts as well as their medical needs as the primary focus of the decision making. Such decisions can be highly complex given the nature of the different interests involved in their determination; this paper examines one relatively straightforward hypothetical case that illustrates the inherent complexities of proxy decision making ethical standards and philosophical considerations.

In the case, Jill must decide whether or not her husband Jack, who has just suffered a stroke, should be included in a phase III drug trial. She has only thirty minutes in which to make a decision, and Jack is too disoriented from the stroke (which occurred within an hour of the decision needing to be made) to assist in the decision. The doctor provided limited but (presumably) all of the necessary information regarding the alternatives to Jill, and she chose to have Jack included in the trial. A consideration of the practical and philosophical elements of the case reveals that this decision was largely correct, but also had significant flaws.

The Practicalities

There are several practical issues that have a large bearing on this case, and these must be assessed before an accurate philosophical understanding of the decision and the decision making process can be rendered. These practical issues have to do primarily with the properties and effects of the new drug being tested in the phase III trial. Though Jack ends up being placed on the standard treatment during the trial anyway, as part of the control group, this cannot enter into the consideration here because there was an equal likelihood that he would have received the new pharmaceutical option instead. Neither Jill nor the doctor -- and especially not Jack himself -- could have foreseen which treatment group Jack would be assigned to in the carefully structured research study prior to making the decision, so this determination was not a part of the decision making process.

Knowledge of the trial drug itself, however, did enter into Jill's decision; the doctor informed her that the drug was believed to have a lower incidence and/or extremity of side effects. The lack of information regarding the new drug's efficacy in comparison to the standard treatment can be assumed, especially as the drug is now in phase III trials, to imply that the drug is essentially as efficacious as the standard treatment. Essentially, then, Jill is being offered a choice between two drug treatment options for her husband that are both equally likely to improve his medical condition, and there is a possibility that the trial drug will also reduce his exposure to harmful side effects. This is the practical information with which she is armed when making her decision.

Philosophical/Ethical Implications

As straightforward as the practical considerations of this case may be, there are still great complexities in the philosophical and ethical considerations of the decision making process and the decision itself. Ignoring the fact that any newer drug has an increased potential for unforeseen effects when compared to an established treatment, the decision is still not clear cut because a consideration of Jack's best medical interests is not all that must be accounted for in the decision. If it were, then the decision would be incredibly simple -- a new drug with efficacy equal to that of the standard treatment and with a possibility of lower side effects would definitely be within any patient's best medical interests. In addition, if this were a question of Jack's overall competency, the best interests of the state -- and of Jill, as the presumed primary caregiver for her husband -- could be used in making a determination based on the decision in Eve v. Mrs. E (Kluge 2005, pp. 191).

This does not apply to this situation, however, as Jack's competency for decision making is only temporarily impaired, and he will still be caring for himself by and large for the foreseeable future. Thus, a consideration of his best interests must include a consideration of Jack's psychological, emotional, and religious/philosophical attitudes as well (Kluge 2005, pp. 191). Jill asserts that her husband feels very strongly that all individuals should contribute to the welfare and progress of the community, and she believes that medical progress through such things as successful drug trials are a part of this progress and contribution. It is from this stance that she decides to have Jack included in the trial.

There does not appear, at first glance, to be anything wrong with this assessment, yet it must be noted that it is Jill's opinion that medical testing and drug trials contribute to social welfare and progress, and this does not necessarily align with jack's values and beliefs. Love and trust do not necessarily indicate the appropriateness of proxy consent decisions with an individual's best personal interests at heart; Jill is including her own personal values and beliefs in the decision and the doctor is allowing her to do so. There is also an automatic conflict of interest in the doctor's ability to make an effective decision in jack's best interest, especially in a controlled and systematic trial. Though such trials are much safer than unsystematic uses of new treatments based on a "clinical hunch," there is a heightened symbolic importance to the informed consent of a patient in a controlled trial because "the patient is being used as a means to an end," and the patient's outcome is no longer the sole consideration of the physician in his or her treatment of the patient (Kluge 2005, pp. ).

These considerations being taken into account, it is still reasonable that Jill decided to have Jack included in the study. The physician should not be without some moral qualms, however, as there were certainly some pitfalls in the logic and standards of proxy consent that were applied here. The knowledge that Jill used her own personal values, in however limited a fashion, in helping her render her decision, should serve as a reminder to the physician that few cases of ethical decision making are as simple as they may appear. In addition, many patients prefer to have increased input from the physician when making proxy decisions, and though the doctor in this case was right to step back, more information regarding the trial drug could have been provided (Kluge 2005).