Surrogate Wars: The "Best Interest Values" Hierarchy & End-of-Life Conflicts with Surrogate Decision-Makers

Area of Science:

• Medical Ethics
• Critical Care Medicine
• Sociology of Healthcare

Background:

• End-of-life care conflicts between healthcare providers (HCPs) and surrogate decision-makers (SDMs) are persistent in ICUs.
• These conflicts have escalated to verbal and physical violence in recent years.
• Previous research highlights the frequency of these disputes, ranging from 32-78% of ICU admissions.

Purpose of the Study:

• To explore the underlying reasons for persistent and escalating conflicts in end-of-life care within ICUs.
• To propose a framework for understanding these conflicts based on differing value systems.
• To offer recommendations for navigating and resolving these disputes.

Main Methods:

• Conceptual analysis of value systems in end-of-life care decision-making.
• Argumentation based on existing literature regarding HCP-SDM conflicts.
• Ethical analysis grounded in American values pluralism.

Main Results:

• A core explanation for ICU conflicts lies in the incommensurable value systems of HCPs and SDMs.
• HCPs often operate under "Best Interest Values" (BIV), which conflict with families' "Life-Continuation Values" (LCV).
• This values-conflict is a fundamental driver of many ICU disputes.

Conclusions:

• Imposing a BIV system on LCV families is ineffective and ethically problematic in a pluralistic society.
• Healthcare institutions must engage constructively with LCV stakeholders to navigate end-of-life care conflicts.
• Addressing the root cause of value system differences is crucial for resolving "surrogate wars" in the ICU.