Valuing for Others: Centring Values in Proxy Decision Making

Abstract

Advance directives have proven inadequate as an advance care planning tool, largely because they fail to adequately anticipate and address relevant clinical scenarios. The primary response has been to turn to proxy decision-makers. Under the standard view, proxies are tasked with making the same decisions the patient would have chosen under the circumstances based upon their intimate familiarity with the patient and their wishes. However, it is now well established that proxies fail to accurately replicate decisions, only performing slightly above random chance. Given this, some have suggested that we should give up on advance care planning altogether in favour of alternatives, such as attending to the patient’s best interests.

My goal in this thesis is to provide an alternative model of proxy decision making, which I dub the ‘value proxy account’. It proceeds in two parts.

In the first part, I argue that the standard view of proxy appointments is mistaken in claiming that knowledge of the patient’s wishes suffices to provide insight into what they would value. Instead, in line with the work of R. M. Veatch, I argue that the only way to have this kind of insight is via the appointment of proxies who share patient values, and value in the same manner as the patient. This allows value proxies to decide based upon their own values, in the knowledge that their decision will respect or further the values of the patient.

However, a key problem remains: the individual value proxy remains an individual, with all the problems that this entails. As I show, individual proxies, qua individual reasoners, are beset by myriad biases which invariably influence their decisions beneath the level of conscious awareness. As a corrective, a body of empirical literature suggests that group deliberation, under felicitous conditions, produces better decisions than individual reasoning. This licenses the conclusion that our reasoning capacities are much improved when they are embedded in a dialogical context. I therefore argue that patients, in most cases, would be better served by appointing multiple value proxies who deliberate together to determine what is best, all things considered. My account will demonstrate that, despite the possibility of deadlock, the group value proxy account offers the best model of substitute decision making available.