The (In)Capacity to Exclude: The Normative Value of Preferences in Surrogate Exclusion

Area of Science:

• Bioethics
• Medical Law
• Patient Autonomy

Background:

• Medical teams rely on surrogate decision-makers when patients lack capacity.
• Statutory hierarchies often prioritize legal/biological ties for surrogate selection.
• Patients may wish to exclude designated legal surrogates from medical decisions.

Purpose of the Study:

• Distinguish the decision to exclude a surrogate from appointing one.
• Argue for respecting an incapacitated patient's exclusion of a surrogate.
• Address potential harms of current surrogate inclusion practices.

Main Methods:

• Conceptual analysis of patient autonomy and surrogate decision-making.
• Ethical examination of excluding surrogates.
• Review of legal hierarchies and patient rights.

Main Results:

• The decision to exclude a surrogate is distinct from appointing one.
• Current practice may not respect incapacitated patients' wishes to exclude surrogates.
• Excluding surrogates can be harmful and violate patient preferences.

Conclusions:

• Respecting an incapacitated patient's exclusion of a surrogate is morally appropriate.
• Current blanket inclusion of surrogates can be detrimental.
• Develop methods to honor exclusion preferences while managing risks.