Emotion by proxy: Some ethical considerations in the designation of a health care power of attorney
Rapaport, Elisa Ruhl
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In medical ethics the issue of autonomy has produced interesting questions about how to resolve conflicts, such as how to ensure that a patient's wishes are respected when he is no longer able to speak for himself. The choice of a health care proxy (a.k.a. health care power of attorney) is perhaps one of the single most important decisions that can be specified in advance directive planning. I confront here three main concerns. (1) A handful of ethicists ( e.g., Buchanan) have argued that advance directives violate autonomy, because the incapacitated patient's interests are no longer those of the earlier 'pre-patient' who anticipated his future preferences. The idea is that one person has no authority to make decisions for another, and that the later 'self' of the incapacitated patient is effectively a different 'self' than the former person. (2) Some legal experts ( e.g., Cebuhar) purport that a living will trumps a living proxy and that the more specifically detailed the preferences provided in a living will, the better. (3) There remains a push amongst some ethicists and medical professionals ( e.g., Savulescu; Ardagh), for a modern, modified 'paternalism' whereby physicians and emergency rescuers make decisions for their incapacitated patients, rather than involving the patients' family, friends, or designated health care proxies. Loved ones, this approach claims, are too emotionally involved and medically uninformed to serve as effective proxies. I argue against these claims in this dissertation. It is precisely their emotional involvement that makes intimate acquaintances (or what we might call 'partner' proxies) the appropriate choice: who better could understand a patient's life-long values and anticipate the sorts of decisions he would make? For many patients, their social circles matter more than do ideological concepts like self-determination; it may be (as in a communitarian critique) that the well-being of patients' loved ones is integral to their own personal interests. Furthermore, reliance on overly-specific, binding living wills is problematic from an epistemological point of view. Despite our best efforts, we can guarantee neither the details of our future predicaments nor our reactions to them, but the proxy has the benefit of weighing contemporaneous information into medical decisions. The concern about directives being problematic for autonomy is avoided when the patient, while still competent, (a) appoints a benevolent acquaintance or partner proxy and (b) gives her the discretionary authority to make decisions in real time and in a manner that respects the general spirit of the patient's expressed values. An appropriately-chosen proxy is more useful than binding directives that cannot accommodate technological advancement, prognostic considerations, and experiential interests on behalf of the patient. Examinations of de Sousa's emotion theory and of Goldie's analysis of the ways in which we can understand and appreciate the emotions of others, both further demonstrate the unique advantage of partner proxies in ethically carrying through the decision-making process that is demanded of them.