Veit, W., Earp, B.D., Browning, H., Savulescu, J.
American Journal of Bioethics
https://www.researchgate.net/publication/354327526
A core challenge for contemporary bioethics is how to address the tension between respecting an individual’s autonomy and promoting their wellbeing when these ideals seem to come into conflict (Notini et al. 2020). This tension is often reflected in discussions of the ethical status of guardianship and other surrogate decision-making regimes for individuals with different kinds or degrees of cognitive ability and (hence) decision-making capacity (Earp and Grunt-Mejer 2021), specifically when these capacities are regarded as diminished or impaired along certain dimensions (or with respect to certain domains). The notion or practice of guardianship, wherein a guardian is legally appointed to make decisions on behalf of someone with different/diminished capacities, has been particularly controversial. For example, many people see guardianship as unjust, taking too much decisional authority away from the person under the guardian’s care (often due to prejudiced attitudes, as when people with certain disabilities are wrongly assumed to lack decision-making capacity); and as too rigid, for example, in making a blanket judgment about someone’s (lack of) capacity, thereby preventing them from making decisions even in areas where they have the requisite abilities (Glen 2015).
It is against this backdrop that Peterson, Karlawish, and Largent (2021) offer a useful philosophical framework for the notion of ‘supported decision-making’ as a compelling alternative for individuals with ‘dynamic impairments’ (i.e., non-static or domain-variant perceived mpairments in decision-making capacity). In a similar spirit, we have previously argued that bioethics would benefit from a more case-sensitive rather than a ‘one-size-fits-all’ approach when it comes to issues of cognitive diversity (Veit et al. 2020; Chapman and Veit 2020). We therefore agree with most of the authors’ defence of supported decision-making, as this approach allows for case- and context-sensitivity. We also agree with the authors that the categorical condemnation of guardianships or similar arrangements is not justified, as this precludes such sensitivity. For instance, as the authors note, if a patient is in a permanent unaware/unresponsive state – i.e., with no current or foreseeable decision-making capacity or ability to exercise autonomy – then a guardianship-like regime may be the most appropriate means of promoting this person’s interests. A similar point can be made in relation to debates about intended human enhancement of embryos and children. Although some critics claim that such interventions violate the autonomy of the enhanced person, proponents may argue that respect for autonomy and consent do not apply in certain cases, for example, when dealing with embryos (see Veit 2018); alternatively, they may argue that interventions to enhance the (future) autonomy of a currently pre-autonomous (or partially autonomous) being can be justified on an enhancement framework without falling prey to such objections (see Earp 2019, Maslen et al. 2014).
