Deciding for others

This article has offered a theoretical framework for addressing the distinctive problems that arise when treatment decisions must be made concerning elderly incompetent individuals. This framework includes two key elements. The first is an account of competence, including an analysis of the concept of competence (understood as decision-making capacity), an articulation of the fundamental ethical values that underlie the choice of standards for competence, and a discussion of operational measures for ascertaining whether those standards are met. The second element is a systematic explication and defense of a set of ethical principles for surrogate decision making. These include: the ethical value principles that motivate the enterprise as a whole, guidance principles that provide substantive direction as to how decisions are to be made, authority principles that specify who is to decide, and intervention principles describing the conditions under which the courts, representatives of public protective agencies, or others in various institutional roles are to intervene so as to take decisions out of the hands of those whose presumptive authority to decide is acknowledged in the authority principles. We have argued that the failure to distinguish these four types of principles, along with inadequate accounts of competence, have led not only to conceptual confusion but also to grave practical errors.