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  • Print publication year: 2016
  • Online publication date: February 2016

9 - Surrogate decision-making

from Part II - Moral foundations of the therapeutic relationship


Case example

Ms. Tina Cartrette is a 28-year-old woman with severe intellectual disability (also known as cognitive disability or mental retardation). Ms. Cartrette also has cerebral palsy and a seizure disorder. She has been a resident of a long-term care facility since she was 5 years old, and has never been able to sit up, walk, talk, dress, or bathe herself. Ms. Cartrette is fed through a tube inserted directly into her stomach. She has been hospitalized five times in the past year for urinary tract infections, which, in her case, cause high fever and seizures.

When Ms. Cartrette reached the age of 18, she was declared legally incompetent, and her mother, Ms. Diane Arnder, was appointed to serve as her legal guardian. Ms. Arnder lives in a distant city; she calls the residential care facility regularly to check on Ms. Cartrette and visits her daughter about twice a year.

Twelve days ago, Ms. Cartrette was hospitalized once again with a high fever and uncontrolled seizures. She received IV antibiotics and medications to control her seizures, but the medications led to respiratory depression, and, with Ms. Arnder's consent, Ms. Cartrette was intubated, placed on a mechanical ventilator, and transferred to the Medical Intensive Care Unit (MICU). She remains in the MICU on ventilator support. Dr. Friedland, Ms. Cartrette's attending physician, has discussed her treatment options with Ms. Arnder. Dr. Friedland told Ms. Arnder that continuing ventilator support could make Ms. Cartrette permanently ventilator-dependent, but removal of the ventilator would probably result in her death. After discussions with her husband and her pastor, Ms. Arnder has requested that the ventilator be withdrawn, explaining that she does not want to see her daughter suffer any longer. Most of the members of Ms. Cartrette's treatment team (including Dr. Friedland, several nurses, and a social worker) are willing to honor this request, but one of the residents disagrees. He points out that Ms. Cartrette is neither terminally ill nor unconscious, and he asserts that she should not simply be allowed to die. How should the team proceed?

The moral issue, and the available options

As noted in Chapter 8, a patient's lack of decision-making capacity is a generally recognized exception to the legal and moral duty to obtain the patient's informed consent to medical treatment.

Berger, Jeffrey T., DeRenzo, Evan G., and Schwartz, Jack. 2008. Surrogate decision making: reconciling ethical theory and clinical practice. Annals of Internal Medicine 149: 48–53.
Buchanan, Allen E. and Brock, Dan W. 1989. Deciding for Others: The Ethics of Surrogate Decision Making. Cambridge: Cambridge University Press.
Pope, Thaddeus Mason. 2013. Making medical decisions for patients without surrogates. New England Journal of Medicine 369: 1976–1977.
Rhodes, Rosamond and Holzman, Ian R. 2004. The not unreasonable standard for assessment of surrogates and surrogate decisions. Theoretical Medicine and Bioethics 25: 367–385.