As medical technology continues to improve, more people will live longer lives with multiple chronic illnesses with increasing cumulative debilitation, including cognitive dysfunction. Combined with the aging of society in most developed countries, an ever-growing number of patients will require surrogate decision-makers. While advance care planning by patients still capable of expressing their preferences about medical interventions and end-of-life care can improve the quality and accuracy of surrogate decisions, this is often not the case, not infrequently leading to (...) demands for ineffective, inappropriate and prolonged interventions. In 1980 LaFollette called for the licensing of prospective parents, basing his argument on the harm they can do to vulnerable people. In this paper, I apply his arguments to surrogate decision-makers for cognitively incapacitated patients, rhetorically suggesting that we require potential surrogates to qualify for this position by demonstrating their ability to make reasonable and rational decisions for others. I employ this theoretical approach to argue that the loose criteria by which we authorize surrogates’ generally unchallenged power should be reconsidered. (shrink)

The computer revolution has had an enormous effect on all aspects of the practice of medicine, yet little thought has been given to the role of social media in identifying treatment choices for incompetent patients. We are currently living in the?Internet age? and many people have integrated social media into all aspects of their lives. As use becomes more prevalent, and as users age, social media are more likely to be viewed as a source of information regarding medical care preferences. (...) This article explores the ethical and legal issues raised by the use of social media in surrogate decision making. (shrink)

It is usually taken for granted, in discussions about fiction, that real things or events can occur as referents of fictional names . In this paper, I take issue with this view, and provide several arguments to the effect that it is better to take the names in fiction to refer to fictional surrogates of real objects. Doing so allows us to solve a series of problems that arise on the reference-continuity view. I also show that the arguments philosophers usually (...) rely on in order to ban surrogates are not as serious as they have been taken to be. In the first part of the paper, I describe the two conflicting views. In the second part, I discuss several specific arguments in favor of surrogates. In the third part I take up the kind of reasons ordinarily offered against them. (shrink)

A diagnosis of fetal abnormality presents parents with a difficult – even tragic – moral dilemma. Where this diagnosis is made in the context of surrogate motherhood there is an added difficulty, namely that it is not obvious who should be involved in making decisions about abortion, for the person who would normally have the right to decide – the pregnant woman – does not intend to raise the child. This raises the question: To what extent, if at all, (...) should the intended parents be involved in decision-making? In commercial surrogacy it is thought that as part of the contractual agreement the intended parents acquire the right to make this decision. By contrast, in altruistic surrogacy the pregnant woman retains the right to make these decisions, but the intended parents are free to decide not to adopt the child. We argue that both these strategies are morally unsound, and that the problems encountered serve to highlight more fundamental defects within the commercial and altruistic models, as well as in the legal and institutional frameworks that support them. We argue in favour of the professional model, which acknowledges the rights and responsibilities of both parties and provides a legal and institutional framework that supports good decision-making. In particular, the professional model acknowledges the surrogate's right to decide whether to undergo an abortion, and the intended parents' obligation to accept legal custody of the child. While not solving all the problems that arise in surrogacy, the model provides a framework that supports good decision-making. (shrink)

The increasing accuracy of algorithms to predict values and preferences raises the possibility that artificial intelligence technology will be able to serve as a surrogate decision-maker for incapacitated patients. Following Camillo Lamanna and Lauren Byrne, we call this technology the autonomy algorithm. Such an algorithm would mine medical research, health records, and social media data to predict patient treatment preferences. The possibility of developing the AA raises the ethical question of whether the AA or a relative ought to serve (...) as surrogate decision-maker in cases where the patient has not issued a medical power of attorney. We argue that in such cases, and against the standard practice of vesting familial surrogates with decision making authority, the AA should have sole decision-making authority. This is because the AA will likely be better at predicting what treatment option the patient would have chosen. It would also be better at avoiding bias and, therefore, choosing in a more patient-centered manner. Furthermore, we argue that these considerations override any moral weight of the patient’s special relationship with their relatives. (shrink)

Surrogate motherhood (a.k.a. gestational surrogacy or surrogacy) refers to a process in which a woman becomes pregnant on behalf of someone else and gives birth to that person’s child. Surrogacy can either be biological (when the oocyte is not from the gestational mother but from the woman who will raise the child and who is indeed the child’s biological mother) or legal (when irrespective of whether there is a biological tie there is a formal contract attributing maternal rights and (...) duties to another woman other than the gestational woman). (shrink)

Part of the standard protection of decisionally incapacitated research subjects is a prohibition against enrolling them unless surrogate decision makers authorize it. A common view is that surrogates primarily ought to make their decisions based on what the decisionally incapacitated subject would have wanted regarding research participation. However, empirical studies indicate that surrogate predictions about such preferences are not very accurate. The focus of this article is the significance of surrogate accuracy in the context of research that (...) is not expected to benefit the research subject. We identify three morally relevant asymmetries between being enrolled and not being enrolled in such non-beneficial research, and conclude that when there is a non-negligible probability that surrogates’ predictions are wrong, it will generally be better to err on the side of not authorizing enrollment. (shrink)

Conflicts involving end-of-life care between healthcare providers (HCPs) and surrogate decision-makers (SDMs) have received sustained attention for more than a quarter of a century, with early studies demonstrating a frequency of HCP-SDM conflict in ICUs ranging from 32–78% of all admissions (Abbott et al. 2001; Breen et al. 2001; Studdert et al. 2003; Azoulay et al. 2009). More recent studies not only acknowledge the persistence of clinical conflict in end-of-life care (Leland et al. 2017), but they have begun to (...) focus on the ways in which these conflicts escalate to verbal or physical violence in the ICU (Slack et al. 2023; Bass et al. 2024; Berger et al. 2024; Sjöberg et al. 2024). I will argue that part of the explanation for the persistence–and even escalation–of ICU disputes is the incommensurable value systems held by many conflicting HCPs and SDMs. I will argue that a common value system among HCPs can be understood as a “Best Interest Values” (BIV) hierarchy, which I will argue is irreconcilable with the set of “Life-Continuation Values” (LCV) held by a sizable minority of families in the United States. I argue this values-conflict undergirds many ICU disputes. If I am correct that an incommensurable value system underlies many ICU conflicts, then it is not just ineffectual for HCPs to impose their BIV system on LCV families, but also wrong given the American commitment to values pluralism. I conclude that the way to navigate continuous ICU surrogate wars is for BIV-focused healthcare institutions to engage more constructively with LCV stakeholders. (shrink)

This paper accomplishes two tasks. First, I examine in detail Edmund Husserl’s earliest philosophy of surrogates, as it is found in his 1890 “On the Logic of Signs ”. I analyze his psychological and logical investigations of surrogates, where the former is concerned with explaining how these signs function and the latter with how they do so reliably. His differentiation of surrogates on the basis of their genetic origins and degrees of necessity is discussed. Second, the historical importance of this (...) text is disclosed by showing how Semiotic serves as both the inspiration for, and the foil to, Husserl’s 1901 First Logical Investigation. Husserl not only adopts the idea that linguistic signs can function via association, but also maintains that such signs can motivate me to execute one of two experiences. The key difference between the texts is that Husserl abandons his theory of surrogates in 1901, instead holding that I can experience absent objects by means of empty intentions. The reasons why Husserl found it necessary to transform this tenet of his philosophy are discussed at length. (shrink)

This chapter contains sections titled: Moral Arguments against and for Surrogate Motherhood Legal Remedies for Surrogate Motherhood Perspectives of Health‐care Practitioners on Surrogate Motherhood Perspectives of Society on Surrogate Motherhood Conclusion.

In the past 15 years, trauma-informed care (TIC) has evolved as a new paradigm in healthcare that recognizes the impact of past traumas on patients’ and families’ healthcare experience while seeking to avoid inducing new trauma during clinical care. A recent paper by Lanphier and Anani extends TIC principles to healthcare ethics consultation (HEC) in what they label “trauma-informed ethics consultation” (TIEC), which calls for the “addition of trauma informed awareness, training, and skill in clinical ethics consultation.” While Lanphier and (...) Anani claim that TIEC is “novel, but not radical” because it builds on the approach to HEC endorsed by the American Society for Bioethics and Humanities, I believe that TIEC has radical implications, particularly regarding ethical obligations to surrogate decision makers (SDMs). Given what I call the SDM’s “trauma capacity,” I argue that TIEC accords moral priority to SDMs over patients in certain types of end-of-life cases, particularly futility disputes, which is a radical departure from the conventional HEC approach to SDMs. (shrink)

Surrogate decision-making refers to authorizing a third person (a proxy) to make decisions about the healthcare treatment provided by a professional to a patient who is unable to express his or her wishes as a result of being, say, a minor, mentally incapacitated, senile, or no longer self-aware. Such a proxy can be a close family member biologically (parents and children), legally (spouses), or affectively (a close family member or friend). The proxy can perform this role informally or when (...) legally designated formally. (shrink)

Background: Current practice frequently fails to provide care consistent with the preferences of decisionally-incapacitated patients. It also imposes significant emotional burden on their surrogates. Algorithmic-based patient preference predictors (PPPs) have been proposed as a possible way to address these two concerns. While previous research found that patients strongly support the use of PPPs, the views of surrogates are unknown. The present study thus assessed the views of experienced surrogates regarding the possible use of PPPs as a means to help make (...) treatment decisions for decisionally-incapacitated patients. -/- Methods: This qualitative study used semi-structured interviews to determine the views of experienced surrogates [n=26] who were identified from two academic medical centers and two community hospitals. The primary outcomes were respondents’ overall level of support for the idea of using PPPs and the themes related to their views on how a PPP should be used, if at all, in practice. -/- Results: Overall, 21 participants supported the idea of using PPPs. The remaining five indicated that they would not use a PPP because they made decisions based on the patient’s best interests, not based on substituted judgment. Major themes which emerged were that surrogates, not the patient’s preferences, should determine how treatment decisions are made, and concern that PPPs might be used to deny expensive care or be biased against minority groups. -/- Conclusions: Surrogates, like patients, strongly support the idea of using PPPs to help make treatment decisions for decisionally-incapacitated patients. These findings provide support for developing a PPP and assessing it in practice. At the same time, patients and surrogates disagree over whose preferences should determine how treatment decisions are made, including whether to use a PPP. These findings reveal a fundamental disagreement regarding the guiding principles for surrogate decision-making. Future research is needed to assess this disagreement and consider ways to address it. (shrink)

In the natural and social sciences, it is common to use toy models—extremely simple and highly idealized representations—to understand complex phenomena. Some of the simple surrogate models used to understand opaque machine learning (ML) models, such as rule lists and sparse decision trees, bear some resemblance to scientific toy models. They allow non-experts to understand how an opaque ML model works globally via a much simpler model that highlights the most relevant features of the input space and their effect (...) on the output. The obvious difference is that the common target of a toy and a full-scale model in the sciences is some phenomenon in the world, while the target of a surrogate model is another model. This essential difference makes toy surrogate models (TSMs) a new object of study for theories of understanding, one that is not easily accommodated under current analyses. This paper provides an account of what it means to understand an opaque ML model globally with the aid of such simple models. (shrink)

> Stephan, a middle-aged immigrant, presents with acute sepsis from his diabetic foot ulcer and confusion that significantly diminishes his capacity. His attending physician, Marta, has initiated an aggressive antibiotic regime but is considering amputation. Unsure, whether this aligns with the preferences of Stephan, his family, and his devoted support worker, Emily, she is considering using a P4 AI for substituted judgment using a corpus of Stephan’s emails and online posts. > > When diagnosed with diabetes shortly after immigrating seventeen (...) years ago, Stephan railed against the disease’s ravages online, declaiming that he would rather be dead than blind or immobile. Five years ago, anxiety over disturbing trends in online discourse led to his abruptly ceasing all online communication, turning increasingly to Emily as a confidant and guide to advances in vision treatment and prosthetics. And two years ago, Stephan gained significantly new purpose and joy with the birth of his first grandchild Anya. This case, following Annoni,1 helps illustrate the potential use of P4 artificial intelligence (AI) to advance moral goods in a substituted judgement setting by (1) honouring the patient’s unique identity and past agency and (2) reducing the burdens on human surrogate decision-makers. However, against (2), we argue that decision-making discourse …. (shrink)

In this commentary, I argue that while the value-systems of healthcare providers and surrogate decision-makers might appear to be incommensurable, they share enough common ground over high-level principles that meaningful engagement between the two groups is possible. This engagement can happen through incompletely theorized agreements that allow discussants to focus on shared values while adhering to competing value-systems. Nonetheless, I argue that the privileging of both healthcare providers and their best interest value system within healthcare creates a continued and (...) unjustified subordination of surrogate decision-makers that threatens to undermine the possibility of meaningful engagement between the two groups. As a solution, I suggest that end-of-life policies be structured in ways that emphasize common ground between healthcare providers and surrogate decision-makers while allowing the dissent of surrogate decision-makers to be a genuinely viable option whenever possible. (shrink)

BackgroundFunctional neurodiagnostics could allow researchers and clinicians to distinguish more accurately between the unresponsive wakefulness syndrome and the minimally conscious state. It remains unclear how it informs surrogate decision-making.ObjectiveTo explore how the next of kin of patients with disorders of consciousness interpret the results of a functional neurodiagnostics measure and how/why their interpretations influence their attitudes towards medical decisions.Methods and SampleWe conducted problem-centered interviews with seven next of kin of patients with DOC who had undergone a functional HD-EEG examination (...) at a neurological rehabilitation center in Germany. The examination included an auditory oddball paradigm and a motor imagery task to detect hidden awareness. We analyzed the interview transcripts using structuring qualitative content analysis.ResultsRegardless of the diagnostic results, all participants were optimistic of the patients’ meaningful recovery. We hypothesize, that participants deal with the results of examinations according to their belief system. Thus, an unfavorable evaluation of the patient’s state had the potential to destabilize the participant’s belief system. To re-stabilize or to prevent the destabilization of their belief system, participants used different strategies. Participants accepted a “positive” HD-EEG result since it stabilized their belief system.ConclusionWe hypothesize, that a group of next of kin of patients with DOC deals with functional neurodiagnostics results on the basis of the result’s value and their high hope that the patient will recover meaningfully. A psychological mechanism seems to moderate the impact of functional neurodiagnostics on surrogate treatment decisions. (shrink)

Chapter 19 of the Children’s Act No. 32 of 2005 regulates the practice of surrogate motherhood in South Africa and provides legal certainty regarding the rights of the children born as a result of surrogacy, including the rights of the different parties involved. Despite the clarity regarding the legal consequences of human reproduction by artificial fertilisation of women acting as surrogate mothers, some legal gaps and inconsistencies regarding certain medical and ethico-legal issues remain. The purpose of this article (...) is to critically examine selected provisions whose implementation is hampered by a lack of detail or clarity, compromising compliance by the different parties to the surrogate motherhood agreement. The article concludes with recommendations on how some of these issues may be addressed to provide for legal certainty and transparency. (shrink)

When patients are unable to make decisions for themselves, medical teams often turn to surrogate decision makers to help identify what the patient would have wanted. Unless a patient has designated a surrogate, teams must rely on statutory hierarchies that often prioritize legal and biological ties. When cases arise in which patients do not want their legal surrogate to be their medical decision maker, they must take steps to exclude that person. Unfortunately, people often are not aware (...) of this until they are unable to make complex medical decisions for themselves. While much has been said about the capacity to appoint surrogates, comparatively little has been said about excluding surrogates. In current practice, a patient’s decision to exclude a surrogate would not be respected when they do not have capacity. It is our view that this blanket inclusion of surrogates can be seriously harmful and potentially violating. Our goals in this article are twofold. First, we aim to carve out the decision to exclude a surrogate as distinct from the decision to appoint one. Second, we argue that respecting an incapacitated patient’s exclusion to some degree is morally appropriate. We will conclude by offering suggestions about how to respect the preference to exclude while considering the risks that may come with exclusion. (shrink)

In clinical research, decision-making capacity is often equated with unspecified conceptions of autonomy, and autonomy is often equated with personhood. On this view, the loss of decision-making capacity is seen as a loss of autonomy, and the loss of autonomy subsumes a loss of personhood. An ethical concern arises at the intersection of those philosophical considerations with the legal considerations in informed consent. Because persons with inadequate decision-making capacity cannot provide legally effective consent, enrollment in research can occur only if (...) a surrogate gives permission on the person’s behalf. Federal regulations and resulting institutional policies allow permission from surrogates empowered under state law to consent to medical treatment procedures, typically in a hierarchy of legislatively prioritized relationships lacking regard for what the surrogate actually knows about the current research-related values and preferences of the potential subject. As a result, the research enterprise often countenances reliance on surrogates who have no relational or informational basis for an enrollment decision that aligns with the values and preferences of the subject. Arguing from the perspective that losing decision-making capacity does not alter the moral status of persons, and that respect for persons rather than respect for autonomy is the central ethical obligation, I assess the ethical implications of allowing persons with no knowledge of the values and preferences of the potential subject to make enrollment decisions, concluding that reliance on uninformed surrogates is not an ethically defensible approach to enrolling subjects in clinical research. (shrink)

How shall we decide for others who cannot decide for themselves? And who—or what, in the case of artificial intelligence — should make the decision? The present issue of the journal tackles several interrelated topics, many of them having to do with surrogate decision making. For example, the feature article by Jardas et al 1 explores the potential use of artificial intelligence to predict incapacitated patients’ likely treatment preferences based on their sociodemographic characteristics, raising questions about the means by (...) which we come to decide for others. And a clinical ethics round table led by Wilkinson and Pillay2 examines the case of a premature baby on life support whose primary surrogate is herself incapacitated. Together, these examples force us to think more deeply about the meaning and significance of taken-for-granted concepts: respect for autonomy, substituted judgement, best interests. We’ll consider the baby first and then turn to AI. “Baby T” is a critically ill newborn delivered prematurely by emergency caesarean section. The mother had entered into a surrogacy arrangement with a same-sex male couple, the intended parents, who were to take over the baby’s care after birth—just as soon as a formal parental order could be obtained through the court. Until then, the birth mother, who had used her own eggs to conceive Baby T along with sperm from an unidentified donor, would have legal and ethical responsibility to decide about the baby’s care. Unfortunately, she too was in critical condition, having fallen unconscious prior to delivery due to a sudden brain haemorrhage. She remained unconscious, and thus incapacitated, during a crucial period in which time-sensitive decisions about Baby T’s care needed to be made, including whether to continue life support. Given the mother’s incapacity, who should …. (shrink)

We advocate for a change in the way individuals with cognitive impairment are enrolled in minimal risk clinical research. We do so in the hope that such a change will lead to more cognitively impaired individuals being enrolled in research. Our proposal applies only to cases where would-be participants retain some interest in decision-making as well as the ability to express a decision. In these cases, we argue that the common practice whereby researchers either obtain consent from the individual or (...) consent from a surrogate and assent from the individual, is ethically unnecessary. Instead, a process of facilitated decision-making based on SDM (supported decision-making) should be employed. Although it is possible that this process of facilitation will enable some individuals to make a capacitated choice who would not otherwise have done so, this should not be a requirement of getting to choose. In those cases where a would-be participant, despite support, fails to make a capacitated choice, the individual should still have the final say about participation. In this respect, our proposal deviates from standard practice. However, we argue that our proposal offers participants as much ethical protection as the more common procedures involving surrogates. (shrink)

The capacity to designate a surrogate (CDS) is not simply another kind of medical decision-making capacity (DMC). A patient with DMC can express a preference, understand information relevant to that choice, appreciate the significance of that information for their clinical condition, and reason about their choice in light of their goals and values. In contrast, a patient can possess the CDS even if they cannot appreciate their condition or reason about the relative risks and benefits of their options. Patients (...) who lack DMC for many or most kinds of medical choices may nonetheless possess the CDS, particularly since the complex means-ends reasoning required by DMC is one of the first capacities to be lost in progressive cognitive diseases (eg, Alzheimer’s disease). That is, patients with significant cognitive decline or mental illness may still understand what a surrogate does, express a preference about a potential surrogate, and be able to provide some kind of justification for that selection. Moreover, there are many legitimate and relevant rationales for surrogate selection that are inconsistent with the reasoning criterion of DMC. Unfortunately, many patients are prevented from designating a surrogate if they are judged to lack DMC. When such patients possess the CDS, this practice is ethically wrong, legally dubious and imposes avoidable burdens on healthcare institutions. (shrink)

Shared decision-making (“SDM”) has increased in acceptance and become a gold standard in medical decision-making over the last two decades. Despite this, there continues to be disagreement about several facets of SDM that many existing models or versions do not sufficiently address, including: that there is a lack of agreement about which version or model of SDM to utilize in practice; that there are practical limitations on when SDM ought to be utilized; that SDM may be required to use different (...) “harm thresholds” when making decisions for patients who have lost decision-making capacity or competence, or for those who have never had such capacity in the first place; and that many existing models of SDM succumb to what is known as the “framing problem,” among other concerns. Elsewhere, this author presented a model of SDM titled, the Professionally-Driven Zone of Patient or Surrogate Discretion (or, Professionally-Driven ZPSD) as a more comprehensive and defensible way forward. This article sets out to expand on the expected benefits of the model, and apply it to several case studies in the acute-care setting in order to demonstrate its functionality as a model of SDM. (shrink)

The Substituted Judgment Standard for surrogate decision-making dictates that a surrogate, when making medical decisions on behalf of an incapacitated patient, ought to make the decision that the patient would have made if the patient had decisional capacity. Despite its intuitive appeal, however, SJS has been the target of a variety of criticisms. Most objections to SJS appeal to epistemic difficulties involved in determining what a patient would have decided in a given case. In this article, I offer (...) an alternative standard for surrogate decision-making that avoids these difficulties. I then offer an account of its theoretical underpinnings which shows that it preserves the central moral justification for SJS, namely, respect for patient autonomy. (shrink)

Topic modelling is a popular unsupervised method for text processing that provides interpretable document representation. One of the most high-level approaches is additively regularized topic models (ARTM). This method features better quality than other methods due to its flexibility and advanced regularization abilities. However, it is challenging to find an optimal learning strategy to create high-quality topics because a user needs to select the regularizers with their values and determine the order of application. Moreover, it may require many real runs (...) or model training which makes this task time consuming. At the current moment, there is a lack of research on parameter optimization for ARTM-based models. Our work proposes an approach that formalizes the learning strategy into a vector of parameters which can be solved with evolutionary approach. We also propose a surrogate-based modification which utilizes machine learning methods that makes the approach for parameters search time efficient. We investigate different optimization algorithms (evolutionary and Bayesian) and their modifications with surrogates in application to topic modelling optimization using the proposed learning strategy approach. An experimental study conducted on English and Russian datasets indicates that the proposed approaches are able to find high-quality parameter solutions for ARTM and substantially reduce the execution time of the search. (shrink)

The rise in the recent Western pattern of surrogate decision making is not a necessary result of an increase in the number of elderly with decreased competence; it may rather manifest the dominant Western vision of human life and relations. From a comparative philosophical standpoint, the Western pattern of medical decision making is individualistic, while the Chinese is familistic. These two distinct patterns may reflect two different comprehensive perspectives on human life and relations, disclosing a foundational difference that can (...) be seen in the Aristotelian account of friendship and the Confucian account of humanity. The contemporary development of surrogate decision making in the West may illustrate a general tendency toward the Aristotelian account, while the Chinese approaches are congruent with the Confucian view. Also explored are some merits of the Chinese approach to family decision making for health care. (shrink)

To what extent are people able to make predictions about other people’s preferences and values? We report two experiments that present a novel method assessing some of the basic processes in surrogate decision-making, namely surrogate-utility estimation. In each experiment participants formed dyads who were asked to assign utilities to health related items and commodity items, and to predict their partner’s utility judgments for the same items. In experiment one we showed that older adults in long-term relationships were able (...) to accurately predict their partner’s wishes. In experiment two we showed that younger adults who were relatively unfamiliar with one another were also able to predict other people’s wishes. Crucially we demonstrated that these judgments were accurate even after partialling out each participant’s own preferences indicating that in order to make surrogate utility estimations people engage in perspective-taking rather than simple anchoring and adjustment, suggesting that utility estimation is not the cause of inaccuracy in surrogate decision-making. The data and implications are discussed with respect to theories of surrogate decision-making. (shrink)

In Speaking for the Dying: Life‐and‐Death Decisions in Intensive Care, Susan Shapiro attempts to penetrate and organize the chaotic communications between physicians and family members who are making medical decisions for people who have lost the capacity to make their own medical decisions. The work is based on observations undertaken by Shapiro and a coresearcher of one thousand encounters between physicians and the family members of two hundred patients too sick to participate. Their ethnographic work, which is both traditional and (...) innovative, leads to stunning findings. They reveal an inadequacy among surrogates that is undeniable, vast, and potentially tragic—if measured by the questionable standard of adhering to the patient's preferences. Further confirming research would be helpful, but what Shapiro has recognized already should shake the foundations of advance care planning. (shrink)

When decisionally incapable patients need a surrogate to make medical decisions for them, sometimes the patient has not appointed a healthcare agent and there is intractable disagreement among potential surrogates of equal priority, legal rank, or relation to the patient (e.g., child vs. child, sibling vs. sibling). There is no ethical, legal, or professional consensus about how to identify the appropriate surrogate in such circumstances. This article presents a case study involving an elderly female patient whose four children (...) disagree about whether to continue life-sustaining treatment for their mother, along with an ethical analysis of various strategies for selecting the appropriate surrogate in cases of conflicting equal-rank family members. It critically examines three different strategies—chance, majority rules, and quality of relationship with the patient—and defends the third approach. (shrink)

Because it is often argued that surrogacy should not be treated as contractual, the question arises in which terms this practice might then be couched. In this article, I argue that a phenomenology of surrogacy centering on the notion of trust provides a description that is illuminating from the moral point of view. My thesis is that surrogacy establishes a complex and extended reproductive unit––the “surrogacy triad” consisting of the surrogate mother, the child, and the intending parents––whose constituents are (...) bound together by mutual trustful commitments. Even though a trust-based approach does not provide an ultimate answer to whether surrogacy should be sanctioned or prohibited, it allows for at least some practical suggestions. In particular, I will argue that, under certain conditions, surrogacy is tenable within familial or other significant relationships, and I will stress the necessity of acknowledging the new relationships and moral commitments that result from this practice. (shrink)

BackgroundDuring a commercial surrogacy arrangement, the event of embryo transfer can be seen as the formal starting point of the arrangement. However, it is common for surrogates to undergo a failed attempt at pregnancy conception or missed conception after an embryo transfer. This paper attempts to argue that such failed attempts can be understood as a loss. It aims to reconstruct the experiences of loss and grief of the surrogates and the intended parents as a consequence of their collective failure (...) to conceive a surrogate pregnancy.MethodsDrawing on a qualitative study conducted over a period of eight months between 2014 and 2015 at two fertility clinics in Delhi and two in Kolkata, India, this paper examines the experiences of the surrogates and the intended parents when faced with missed conceptions or failed conceptions during a surrogacy arrangement.ResultsWe argue that while the surrogate grieves the non-arrival of a ‘good news’ as an uncertain loss, the intended parents experience yet another, failure in addition to the losses they might have incurred during their previous fertility treatments. The body of the surrogate becomes a site of ‘a lost opportunity’. The surrogate embodies a loss in her quest to achieve social mobility and the intended parents experience a disembodied pregnancy loss. This very emotional experience stands in stark contrast to the conceptualisation of such failed attempts as non-events within the discourse of the surrogacy industry. The experience of loss of the intended parents is recognised but their grief is given no space. We argue that such ambiguity around the nature of losses resulting out of a missed or failed conception during surrogacy is an outcome of lack of interpersonal relationship between the surrogate and the intended parents.ConclusionsSince commercial surrogacy is a relational process, the only way in which the experiences of losses and failures of the actors at the preconception stage can be better addressed is through developing close sharing and understanding between each other through an ethics of care. Therefore, to nurture caring relationships, surrogacy needs to be understood as a moral commitment by –the surrogates and intended parents. To enable such a commitment, there is a need to reconsider the pre-defined and legally regulated professional duty of the doctors, agents and agencies. It cannot be a one-sided commitment, but has to have elements of mutuality. (shrink)

Patients with mental illness, and depression in particular, present clinicians and surrogate decision-makers with complex ethical dilemmas when they refuse life-sustaining non-psychiatric treatment. When treatment rejection is at variance with the beliefs and preferences that could be expected based on their premorbid or “authentic” self, their capacity to make these decisions may be called into question. If capacity cannot be demonstrated, medical decisions fall to surrogates who are usually advised to decide based on a substituted judgment standard or, when (...) that is not possible, best interest. We propose that in cases where the patient meets the widely accepted cognitive criteria for capacity but is making decisions that appear inauthentic, the surrogate may best uphold patient autonomy by following a “restorative representation” model. We see restorative representation as a subset of substituted judgement in which the decision-maker retains responsibility for deciding as the patient would have, but discerns the decision their “truest self” would make, rather than inferring their current wishes, which are directly influenced by illness. Here we present a case in which the patient’s treatment refusal and previously undiagnosed depression led to difficulty determining the patient’s authentic wishes and placed a distressing burden on the surrogate decision-maker. We use this case to examine how clinicians and ethicists might better advise surrogates who find themselves making these clinically and emotionally challenging decisions. (shrink)

This article aims to present a Free Dialogic Logic [FDL] as a general framework for hypothesis generation in the practice of modelling in science. Our proposal is based on the idea that the inferential function that models fulfil during the modelling process (surrogate reasoning) should be carried out without ontological commitments. The starting point to achieve our objective is that the scientific consideration of models without a target is a symptom that, on the one hand, the Applicability of Logic (...) should be considered among the conditions of adequacy that should take into account all modeling process and, on the other, that the inferential apparatus at the base of the surrogate reasoning process must be rid of realistic assumptions that lead to erroneous conclusions. In this sense, we propose as an alternative an ontologically neutral inferential system in the perspective of dialogical pragmatism. (shrink)

This article examines pregnancy as a dyadic body-project within surrogate motherhood arrangements. In gestational surrogacy arrangements, the surrogate mother agrees to have an embryo that has been created using IVF, with the genetic materials of the intended parents or of anonymous donors, surgically implanted in her womb. Based on anthropological fieldwork among Jewish-Israeli surrogates and intended mothers involved in these arrangements, this article focuses upon the interactive identity management practices that the women jointly undertake during the pregnancy. For (...) each side, creating an unambiguous definition of motherhood was central to their individual identity-work. For surrogates, the possible imputations of immorality required redefining pregnant embodiment as separate from maternal identity, while for intended mothers, the surrogate’s embodiment of the pregnancy represented competing claims to their own maternity. Through verbal communication and through practices of disembodiment and vicarious embodiment, the women construct a ‘shifting body’ which they use to designate the social label of pregnancy, identity-building processes associated with pregnant embodiment, and even the lived experience of pregnancy. This example of a dyadic body-project contributes to the existing scholarship on the role of the body in the management of identity. While previous works have examined projects of the body as individualistic pursuits, the shifting body exemplifies that body-projects can be collaborative, dual forms of identity-work and that pregnancy can be the site of these projects. (shrink)

Surrogates introduces an important new philosophic topic: the pervasive ways that things stand for one another in nature and human experience. Going beyond semiotic theory, Paul Weiss interprets surrogacy in terms of metaphysical, epistemological, ethical, and religious dimensions of life, integrating the concept into a systematic way of regarding reality. Just as philosophy brings a systematic set of questions to the issue of surrogate reality, Weiss’s investigation of the topic raises new questions for philosophy itself, manifesting his great concern (...) for philosophy’s freedom and creativity. The author concludes each chapter with a provocative set of questions and answers that engage imagined critics in a dialogue. Together with his previous book, Emphatics, Surrogates constitutes a richly textured phenomenology of human experience with important ramifications for contemporary pragmatism. The wit and intelligence of this volume are a delight for any reader. (shrink)

The case states that a male same-sex couple entered into a surrogacy arrangement with an unrelated surrogate using donor sperm and the surrogate’s eggs. M is the legal mother pursuant to s33 of the Human Fertilisation and Embryology Act 2008. Though the facts tell us that there was no legally binding arrangement, this is in fact the position of the law: under s1A Surrogacy Arrangements Act, no surrogacy arrangements can ever be binding on the parties. It is not (...) clear whether the donor sperm is from one of the same-sex couple or not. If it was donor sperm and not from either intended father, this is not an arrangement that would be recognised in law, as one of the men must be genetically related to the child in order for them to obtain legal parenthood via a parental order, under s54 HFEA 2008. They could apply to adopt the child, although they may fall foul of adoption legislation1 if any money has moved between them and M and they do not fall within an exemption.2 In any event, an adoption cannot be achieved in time for them to obtain legal parenthood in a crisis situation. In the absence of a biological connection and the resulting legal parenthood, in order to obtain parental responsibility for the child to allow them to make decisions about Baby T’s care, the men would need to apply for leave to apply for a child arrangements order pursuant to s10 Children Act 1989. However, in the …. (shrink)

The "surrogate colonization" of Palestine had a foreign power giving to a nonnative group rights over land occupied by an indigenous people. It thus brought into play the complementary and conflicting agendas of three culturally distinguishable parties: British, Jews and Arabs. Each party had both "externalist" [those with no sustained practical experience of day to day life in Palestine] and "internalist" representatives. The surrogate idea was based on a "strategic consensus" involving each party's externalist camp: the British ruling (...) elite, the leadership of the World Zionist Organization and the Hashemite Dynasty of Arabia. The collapse of this triangular consensus, which put an end to the policy but not the process of surrogate colonization, resulted from irreconcilable antagonisms within and between the major currents of each internalist camp. A focus on the land problem in Palestine highlights contradictions in each party's internalist agenda, which forestalled a rift between the Jewish and British sides of the consensus long enough for the Zionist settlement in Palestine to acquire territory and to develop a largely self-sufficient economic, cultural, political and military infrastructure. (shrink)

Computer simulations are widely used for surrogative reasoning in scientific research. They also play a crucial role in engineering, more specifically in the design of new robotic systems, yet the nature of this role has been little discussed so far in the philosophy of technology literature. The main claim made in this article is that the notion of surrogative reasoning is central to understanding how computer simulations can serve the purpose of designing new robots. More specifically, it is argued that (...) computer simulations can support two forms of surrogative reasoning, which are called model-oriented and prediction-oriented, whose inferential structure is reconstructed to some extent. And it is argued that, when computer simulations are used to design new robots, they are distinctively used in the model-oriented way. By unravelling the structure of the computer simulation-supported methods adopted in robotic design, this article may contribute to a finer-grained understanding of the epistemic processes involved in technological research. (shrink)

Historically, individuals with disorders of consciousness (DoC) have often been subject to prognostic pessimism and therapeutic nihilism, leading to clinical decisions that became self-fulfilling prophecies. Recent advances in neurodiagnostics -particularly multimodal assessments of consciousness- offer new opportunities to reduce diagnostic ambiguity and to potentially improve rehabilitation outcomes. These developments have the potential to support more effective care planning. Given their central role in surrogate decision-making, informal caregivers are increasingly recognised as key participants in this evolving process. Yet, little is (...) known about the distribution of their preferred roles in decision-making, especially in light of emerging, technology-informed models of diagnosis. Two research questions guided a multicenter study within the PerBrain project: (1) To what extent do informal caregivers differ in their preferences regarding control over decision-making and (2) does a majority of informal caregivers prefer a collaborative model over other forms of decision-making? A cross-sectional survey using a modified version of the Control Preferences Scale (CPS) -which measures a person’s preferred level of control in medical decision-making- was conducted with informal caregivers of persons with DoC in three medical units in Italy and Germany between March 2021 and June 2023. The participating medical centers were part of the PerBrain project, which investigates multimodal consciousness assessment. Caregivers were recruited consecutively, and data were analysed using descriptive statistics, chi-square tests, and t-tests to assess cross-national differences. Seventy caregivers completed the survey. Preferences regarding decision-making roles varied: 34 (48.6%) favoured a passive role, 26 (37.1%) preferred a shared or collaborative role, and 10 (14.3%) expressed a preference for an active role. When ranked across all six possible positions (from active to passive options), the collaborative approach was most frequently among the top three choices: 26 (37.1%) ranked it first, 20 (28.6%) second, and 19 (27.1%) third. Statistically significant cross-country differences emerged (χ²(2) = 7.408, p =.025), with German caregivers demonstrating a stronger preference for active participation than their Italian counterparts. Healthcare professionals should be attentive to the diversity of decision-making preferences expressed by family caregivers of patients with DoC shortly after the transition from intensive to rehabilitation care. Although SDM is widely regarded as the normative standard in clinical practice, our findings reveal a discrepancy between this standard and the actual preferences of informal caregivers in two similar care settings in two different European countries. The findings add to the literature on uncertainty in surrogate health-care decision-making for people with DoC and raise questions of whether SDM should even be implemented, when it is not the preferred approach of (future) surrogate decision-makers. The study protocol was registered at ClinicalTrials.gov (identifier: NCT04798456). The study was retrospectively registered on 15 March 2021 for the purpose of transparency. The protocol had been finalized before the start of the data collection. Further details can be accessed at https://clinicaltrials.gov/ct2/show/NCT04798456. (shrink)

Philosophers such as Dan Brock believe that surrogates who make health care decisions on behalf of previously competent patients, in the absence of an advance directive, should make these decisions based upon a substituted judgment principle. Brock favours substituted judgment over a best interests standard. However, Edward Wierenga claims that the substituted judgment principle ought to be abandoned in favour of a best interests standard, because of an inherent problem with the substituted judgment principle. Wierenga's version of the substituted judgment (...) principle and his counterexample to the principle's successful interpretation of valid surrogate consent is presented. A new version of what is meant by the substituted judgment principle is advanced. The new version is not beset with the problems Wierenga initially ascribed to the substituted judgment principle. (shrink)

During an outbreak or pandemic involving a novel disease such as COVID-19, infected persons may need to undergo strict medical isolation and be separated from their families for public health reasons. Such a practice raises various ethical questions, the characteristics of which are heightened by uncertainties such as mode of transmission and increasingly scarce healthcare resources. For example, under what circumstances should non-infected parents be allowed to stay with their infected children in an isolation facility? This paper will examine ethical (...) issues with three modes of “family presence” or “being there or with” a separated family member during the current COVID-19 pandemic: physical, virtual, and surrogate. Physical visits, stays, or care by family members in isolation facilities are usually prohibited, discouraged, or limited to exceptional circumstances. Virtual presence for isolated patients is often recommended and used to enable communication. When visits are disallowed, frontline workers sometimes act as surrogate family for patients, such as performing bedside vigils for dying patients. Drawing on lessons from past outbreaks such as the 2002-2003 SARS epidemic and the recent Ebola epidemic in West Africa, we consider the ethical management of these modes of family presence and argue for the promotion of physical presence under some conditions. (shrink)

Background Shared decision-making (SDM) requires bidirectional communication between medical staff and patients (or their surrogates) to ensure treatment aligns with patients’ values and preferences. In the intensive care unit (ICU), critically ill patients often lose decision-making capacity, placing surrogate decision-making responsibilities on family members. However, surrogates face significant challenges due to restricted information access, communication barriers, and decision-making delays. The impact of ICU spatial isolation, restricted visitation policies (RVP), and information flow on the decision-making process remain underexplored. This study (...) examines how these factors shape surrogate decision-making and affect its effectiveness. Methods A focused ethnographic study was conducted in the ICU of a tertiary hospital in China over 6 months. Data were collected through participant observation and semi-structured interviews with 9 ICU physicians, 6 nurses, and 10 family surrogates. Thematic content analysis was used to systematically code and synthesize data, identifying key challenges within the ICU decision-making ecosystem. Results ICU spatial isolation and RVP placed surrogates at the periphery of the information network, where they receive only fragmented and unidirectional updates. Medical staff predominantly relied on one-way, ad-hoc communication, preventing surrogates from fully understanding patient conditions. Additionally, discussions often neglected patients’ values, impeding substituted judgment. The resulting information deficit led surrogates to seek external sources, exacerbating trust issues with medical staff. This dual-layered isolation—spatial and informational—and distrust increased the influence of non-medical factors such as financial constraints, emotional distress, and sociocultural pressures, potentially leading to decisions misaligned with patient interests. The study proposes a staged visitation and structured communication model to address these challenges and enhance surrogate decision-making quality. Conclusions Future research should assess the effectiveness of this model and explore strategies to balance ICU staff workload with surrogate informational needs in high-stress environments. Ethical considerations The study was approved by the Institutional Review Board of Dalian Medical University (Approval No. BECDMU 2024-008). Written informed consent was obtained from all formal interview participants, while oral informed consent was secured for ethnographic observations. Confidentiality and anonymity were strictly maintained. (shrink)

In this issue, Leah Eisenberg and I present two cases involving commonplace scenarios that clinical ethicists confront when called in to address conflicts with surrogate decision-making. In the cas...

Cochrane has developed a linked data infrastructure to make the evidence and data from its rich repositories more discoverable to facilitate evidence-based health decision-making. These annotated resources can enhance the study and understanding of biomarkers and surrogate endpoints.

Medical decision-making for individuals lacking the capacity to consent often involves ethically and emotionally challenging deliberations, how to make appropriate surrogate decisions in acute settings, and how to plan in advance. This is particularly true for two patient populations: (1) adults who have lost their decision-making capacity and whose presumed wishes are unknown, and (2) individuals with congenital incapacity due to lifelong cognitive impairments. This study aimed to critically synthesize the existing literature on surrogate decision-making and advance care (...) planning (ACP) for these populations, as there are currently no detailed national guidelines for navigating such complex situations. A scoping review was conducted in accordance with PRISMA-ScR guidelines. Four databases (PubMed, Scopus, Web of Science, and Google Scholar) were searched. Eligible articles included those published in English or German since 2010 that addressed decision-making and documentation for adults lacking judgement capacity and whose preferences are unknown. 15 relevant publications were included. These addressed key concepts such as the best interest standard, substituted decision-making and quality of life, and reflected on the use of tools like Patient Preference Predictors. However, none offered detailed guidance on how to implement surrogate decision-making or ACP in practice for cognitively impaired individuals. Surrogate decision-making for individuals without known preferences or a living will remains insufficiently structured and ethically ambiguous. While the need for national guidelines is widely recognized, existing frameworks fail to translate ethical principles into practical, actionable steps. The development of detailed, transparent, and ethically grounded guidelines is urgently required to support decision-making in clinical practice. (shrink)

While patients have the right to control who has access to their health information and designate visitors, it is not always clear whether—when a patient lacks capacity—their surrogate also exercises such rights. States and federal laws are often vague about the limits of surrogate authority. Even where legal or institutional guidance on this issue is clear, requests by surrogates to withhold information or restrict visitation with a patient can be a source of ethical uncertainty and distress on the (...) part of the clinical team. This paper explores the ethical issues raised by such requests. To date, there has been little exploration of this issue in the clinical ethics literature. First, we summarize the scant existing ethical and legal guidance on this issue. Second, we present two potential approaches to navigating requests from surrogates to withhold information or restrict visitation. Third, we discuss the merits and limitations of both approaches, and introduce some additional considerations that further complicate the picture. We argue for a flexible restrictive approach to information-sharing, and a constrained permissive approach to visitation. Finally, we propose several considerations that clinicians and clinical ethicists might think through in these situations to help guide their practice. (shrink)

As large language model (LLM) interfaces, such as ChatGPT, move into everyday communicative practice, they increasingly occupy roles once reserved for human interlocutors—drafting, advising, and explaining—without clearly signaling when communicative delegation becomes substitution. This paper conceptualizes such systems as communicative surrogates: nonhuman actors that assume communicative labor, while destabilizing the ontological assumptions that ordinarily ground responsibility, authority, and care. Drawing on semi-structured interviews with academic knowledge workers during the early public uptake of ChatGPT, we adopt an abductive, STS-informed analytic orientation (...) that treats participants’ narratives and affective recalibrations—including moments of hesitation, projection, and boundary-setting—as diagnostic signals of sociotechnical instability. Participants were less concerned with correctness than with difficulty determining what kind of communicative participant ChatGPT had become. We show how frictionless usability enables LLMs to drift across communicative contexts, producing ambivalence and unease that undermine the conditions under which ethical accountability can be clearly assigned. Synthesizing these accounts, we identify four figures of communicative surrogacy and argue that communicative ethics is downstream of ontology: ethical concern emerges when it becomes unclear who or what is participating in communication. (shrink)

Decisions at the end of life often result in conflicting opinions between medical and nursing professionals and the people concerned themselves. Especially when different beliefs and values clash, it can be difficult to understand each other's situation. Appropriate communication, with the necessary respect for the opinions and interests of other individuals, seems to be crucial here. However, if the person concerned is no longer able to express their own views on further treatment or possible withdrawal, support is often needed in (...) the form of a surrogate decision maker, which poses specific challenges. This article deals with the ethically relevant difference between conscience and conscientiousness in the context of surrogate decision making. In the first step, due to the multitude of different views, it is shown what can be understood by conscience. By differentiating between building conscience, formation of conscience, and conscience conformity, a distinction is made between conscience and conscientiousness. In the second step, representatives are placed in relation to the concept established so far, and ethical implications are pointed out. The final step attempts not only to bring together the previous considerations and present suggestions for action but also to clarify common misunderstandings regarding the two terms. The ethical relevance of conscientiousness and the willingness of representatives to be open to other views on the one hand and to remain true to their own values on the other appear to be essential. (shrink)