Physicians Making Decisions for Unconscious Patients Without Family, Friends or Surrogates (1): The Issue

What is in the patient’s best interest is a major and frequently encountered issue in medical ethics. A conscious patient can very likely be able to tell the physician what are their values, goals and wishes with respect to their lives. An unconscious patient obviously can’t. However, if there are family and friends or legal surrogate of an unconscious patient available to communicate with the physician, they may be able to relate what they knew about the patient in this regard. But what if there are no family or friends or legal surrogate and there is no record by the patient that tells about his/her desires, how does the doctor really know what treatment or termination of what treatment would be accepted by the patient if he/she was conscious? Examples of such patients could include “street people” or often nursing home patients whom haven’t been visited by a relative in many years and/or whose location is unknown.. Without the ability to obtain informed consent, the physician has a problem that even or particularly in these days of “high-powered” medicine where so much more is known about disease and treatment, there is very little help. As I have been mentioning in the previous postings, “patient’s best interest” has a number of connotations. One definition that is used in cases of an unconscious patient without a surrogate or an advance directive, either of which can shed some light on patient desires, is “what an average or ordinary person might decide is in his/her best interest.” And how do we know what an average or ordinary person might decide? Well, it ends up being the opinion of those making the decision for the patient!

And here is the ethical dilemma that faces virtually all hospitals and their medical staffs, what is the fairest and most ethical and legal way for a physician to start treatment or terminate treatment in such an unconscious patient? It should be noted that in an emergency where a person’s life might be at stake and the patient is not able to communicate, physicians have the right and duty to do what is necessary to preserve life even without informed consent. But what if the situation is not emergent? What if the situation is a patient in whom the physicians on the case find that further treatment will not accomplish the medical benefit or that it wouldn’t provide the quality of life that an average person might expect? What should the physician do? This is the area of ethics in medicine in which most hospitals are still contemplating and trying to figure out guidelines to help their physicians. What are your views on how to solve this problem? ..Maurice.