Against Consistency when Making Medical Decision for Others

Abstract: Medical decision-making sometimes requires interpreting incomplete information about what a patient would have wanted when that patient no longer has capacity to make decisions for themselves. For example, a son might have to make decisions on behalf of his mother regarding end-of-life care knowing that she was a devout Catholic but not her views about particular interventions such as a feeding tube. In such a case, he might look toward his mother’s faith for guidance and assume that she would have wanted what is broadly consistent with Catholic teaching.

This approach to making decisions on behalf of others makes what I will call the assumption of consistency: that what a patient wanted, or would have wanted, regarding their medical care is normally consistent with their other rational commitments. This assumption might be understood as an empirical regularity—people tend to want treatment that is consistent with their religious and ethical beliefs—or as capturing the idea that autonomy or rational agency presuppose a certain degree of consistency in living up to one’s rational commitments.

This paper argues that we should reject the assumption of consistency when making decisions on behalf of patients. Empirically, patients often revise their commitments about what is important to them through their encounters within the medical system. Additionally, there is nothing irrational about holding preferences and commitments that are inconsistent across time. Finally, we should reject thick conceptions of autonomy that require patients retain their rational commitments when they experience life-changing medical conditions.

Keywords: Advance directives, Surrogate decision-making, Religion