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Correspondence |

Resolving Conflicts With Surrogate Decision Makers FREE TO VIEW

Thaddeus M. Pope, JD, PhD
Author and Funding Information

From Widener University School of Law.

Correspondence to: Thaddeus Pope, Widener University, 4601 Concord Pike, Wilmington, DE 19803; e-mail: tmpope@widener.edu


Financial/nonfinancial disclosures: The author has reported to CHEST that no potential conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article.

Reproduction of this article is prohibited without written permission from the American College of Chest Physicians (www.chestjournal.org/site/misc/reprints.xhtml).


© 2010 American College of Chest Physicians


Chest. 2010;137(1):238-239. doi:10.1378/chest.09-1637
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To the Editor:

I read with interest the report in CHEST (July 2009) by Zier et al1 in which they examine surrogate decision makers’ responses to physicians’ predictions of medical futility. Futility disputes cause significant staff distress and consume prodigious palliative care and ethics consultation resources. Fortunately, most futility disputes are resolved collaboratively by providers and surrogates.2 And increasingly, with findings like those offered by Zier et al,1 the already high rate of resolution and consensus can be further improved. With a better understanding of surrogates’ motivations and rationales for resisting provider recommendations to discontinue life support, the development of empirically derived interventions can be enhanced. Process-based approaches can then incorporate targeted interventions and deploy them according to the precise basis for surrogate dissent.

Unfortunately, Zier et al1 fail to recognize some rather significant implications of their key finding that “surrogates with religious objections to the futility rationale were more adamant about continuing life support.” Prima facie, a surrogate’s own religious beliefs are wholly irrelevant to the treatment decision. Surrogates must exercise “substituted judgment” and make the medical choice that the patient, if competent, would have made. If there is insufficient evidence of what the patient would have wanted, then the surrogate must act in the patient’s “best interests.”3 But whichever standard is employed, the surrogate’s decision must reflect only patient-centered considerations.

Zier et al1 ask “whether it is appropriate to override a surrogate’s deeply held religious belief.” The answer to this question depends on data that Zier et al1 did not collect or report. Specifically, does the patient share the surrogate’s religious beliefs?4 Did the patient specifically grant the surrogate unusually wide discretion to consider her preferences as not binding but merely informative?5 To be sure, it is controversial whether a provider should override a patient’s own deeply held religious belief. But a surrogate stands in the shoes of the patient. Without evidence of patient authorization, it is not only permissible, but mandatory, that the surrogate’s deeply held religious beliefs be excluded and eliminated from the decision-making process.

Zier LS, Burack JH, Micco G, Chipman AK, Frank JA, White DB. Surrogate decision makers’ responses to physicians’ predictions of medical futility. Chest. 2009;1361:110-117. [CrossRef] [PubMed]
 
Pope TM. Medical futility statutes: no safe harbor to unilaterally refuse life-sustaining medical treatment. Tenn Law Rev. 2007;711:1-81
 
Meisel A, Cerminara KL. The Right to Die: The Law of End-of-Life Decisionmaking. 2009;3rd ed New York, NY Aspen Publishers chapter 3.
 
HE v A NHS Hosp TrustHE v A NHS Hosp Trust EWHC [England and Wales High Court of Justice] 1017 (Fam.) (2003).
 
Berger JT, DeRenzo EG, Schwartz J. Surrogate decision making: reconciling ethical theory and clinical practice. Ann Intern Med. 2008;1491:48-53. [PubMed]
 

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References

Zier LS, Burack JH, Micco G, Chipman AK, Frank JA, White DB. Surrogate decision makers’ responses to physicians’ predictions of medical futility. Chest. 2009;1361:110-117. [CrossRef] [PubMed]
 
Pope TM. Medical futility statutes: no safe harbor to unilaterally refuse life-sustaining medical treatment. Tenn Law Rev. 2007;711:1-81
 
Meisel A, Cerminara KL. The Right to Die: The Law of End-of-Life Decisionmaking. 2009;3rd ed New York, NY Aspen Publishers chapter 3.
 
HE v A NHS Hosp TrustHE v A NHS Hosp Trust EWHC [England and Wales High Court of Justice] 1017 (Fam.) (2003).
 
Berger JT, DeRenzo EG, Schwartz J. Surrogate decision making: reconciling ethical theory and clinical practice. Ann Intern Med. 2008;1491:48-53. [PubMed]
 
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