Morally mandatory

Physicians generally carry out negotiations about incompetent patients with surrogate decision makers.

If the incompetent patient has advance directives which include the appointment of a health care proxy, then the proxy acts as surrogate. In regard to infants and children, parents are legally responsible to act in the role of surrogate. As children mature through the adolescent years, their input into treatment decisions is routinely requested. However, until youngsters reach the age of 18, only a parent or guardian can authorize procedures.There are some cases in which surrogates are appointed by the courts. These cases include situations in which an incompetent person has no relatives, cases in which there is a question as to whether or not a surrogate is acting in a responsible manner, and circumstances of family disagreement in which the relatives of an incompetent patient cannot arrive at the same conclusion.

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Since court involvement in the clinical setting is slow, costly, and cumbersome, there is general agreement among health care professionals, ethicists, and the public that such involvement should be kept to a minimum.What responsibilities do surrogates take on in behalf of incompetent persons? Incompetent persons do not surrender their rights through being/becoming incompetent; instead, they lack the means to exercise their rights and surrogates provide this means. Rights are constituent parts of human nature so that all human persons have rights.

Rights are powers and privileges to which persons are entitled simply because they are human. These rights include access to and provision of proper medical care.Surrogates act for incompetents, in a sense enabling the incompetents to exercise their choice, by authorizing various treatments and programs of medical care. This is consistent with the obligations we experience as members of the human community, while following from the entitlement of all persons, including the vulnerable, to medical care. Given the sophistication of medical technology and the compromised status of many types of incompetent patients, ethical issues have arisen around cessation of treatment and forgoing of treatment for incompetents.

In regard to both forgoing and withdrawing, the predictable result is frequently the death of the patient. Since death is a negative event and since incompetent patients are also vulnerable, a cautiousness has often become manifest in regard to doing anything which might not be justifiable. As physicians, surrogates, judges, and the public grappled with cases of this kind, some principles began to take shape to give direction for decision making. One principle is the quality of life concept which considers the patient’s level of satisfaction or comfort with or without medical treatment.

The emerging consensus is that treatments which will enhance the quality of an incompetent patient’s life are morally mandatory and should be chosen. On the other hand, treatments which would cause the patient pain and suffering, and thus diminish the quality of his life, need not be prescribed. Another standard which is taking shape is known as the best-interest standard. This requires an analysis of the benefits and burdens of treatment, with treatments which are clearly beneficial being required while those which will likely add to the patient’s burdens not being morally mandatory.