Choosing for Another: Beyond Autonomy and Best Interests (Report‪)‬

According to bioethics orthodoxy, when we ask, "What would the patient choose?" the patient's autonomy is at stake. In fact, what underpins the moral force of that question is a value different from either autonomy or best interests. This is the value of doing things in a way that is authentic to the person. Imagine a patient, Bill, who has lost decision-making capacity. An important treatment decision must be made, but Bill cannot make it. Assume there is no advance directive or anything equivalent. There is no way to take a statement made by Bill, when competent, and apply it to the current setting. A standard move in cases like this is to have the patient's surrogate decision-maker--Bill's life-partner, for example--enter the picture and answer the question, "In this situation, what would Bill choose?" Imagine that Bill is in his late sixties and has always prided himself on his mental acuity, that he has held a job with considerable decision-making responsibility and in his spare time would read voraciously and do crosswords and acrostics. The proposed lifesaving procedure has a 70 percent chance of leaving Bill with significantly decreased cognitive function. Bill's partner believes that she knows what Bill would choose: Bill would not want to live with severely limited mental capacities, and he would decline a procedure likely to leave him in this condition. The medical team is ready to accept her decision. Something seems very right about taking this route, but what makes this the right thing to do?