Managing Conflicts between Physicians and Surrogates

Two articles in this issue of the Hastings Center Report explore two sides of the same problematic coin. In "The Limits of Surrogates' Moral Authority and Physician Professionalism," Jeffrey Berger discusses the moral problem of a surrogate refusing a treatment, palliative sedation, on behalf of a patient whose suffering is refractory to intensive palliative efforts provided by a multidisciplinary team. In "After the DNR: Surrogates Who Persist in Requesting Cardiopulmonary Resuscitation," Ellen Robinson and her colleagues analyze data from a study of cases in which physicians wished not to perform cardiopulmonary resuscitation on patients whom they thought it would harm. Both articles begin from the idea of a professional determination about a physician's duty to a patient that conflicted with a surrogate's determination about what should or should not be done for that patient. Berger's argument stops just short of a solution, however, because a physician's professional obligation to help patients, even within guidelines set by other professionals, is insufficient protection for patients. But if Berger's theory is right-that sometimes surrogates lack moral authority to make decisions on behalf of patients-then the Robinson team has developed a careful and public process for attending to that conflict.