Honoring Chosen Family: Revisiting the Doctor-Proxy Relationship

AbstractAmong her many scholarly contributions to the field of bioethics, Nancy Neveloff Dubler's exploration of the ethical, legal, and procedural dimensions of surrogate decision-making on behalf of persons who cannot make their own medical decisions has been the most impactful. In their 1999 publication "The Doctor-Proxy Relationship: An Untapped Resource," Dubler and coauthors Linda Farber Post and Jeffrey Blustein examined the decision-making paradigm of patients, their physicians, and trusted family and friends of patients.¹ The authors examined the historic dynamics supporting these collaborations and identified themes from focus groups with physicians and patient proxies. Recommendations put forth at the time to support patient proxies are reflected in well-established best practices and standards today. It is notable that there was no distinction made by the authors between those proxies related through kinship and those bonded through intimate relationships and friendships. Despite their appropriately inclusive recognition, many of the state guidelines establishing surrogate hierarchies systematically deprioritize friendships in favor of biological kinship or go so far as to exclude such individuals from being eligible to serve in these roles on behalf of patients, with whom they may have long-standing and well-established relationships defined by choice. Relying solely on traditional nuclear family structures denies the ethical legitimacy of chosen families and persons who may be best suited to make decisions for the patient.