IEEE Technology and Society Magazine - June 2015 - 49

saw physicians assuming decision-making authority in
healthcare both in ordinary contexts involving capable
patients and contexts involving incapacitated patients
[5]. That trend has been reversed. Despite physicians'
considerable knowledge and expertise regarding medical options, family members and next-of-kin are once
again viewed as the most ethically appropriate proxy
decision-makers.
Because healthcare decisions are among the most
intimate and private decisions one can make, few people would easily give up the power to make their own
healthcare decisions. In practice, turning decision-making authority over to a moral proxy tends to be a last
resort only after every effort made to engage the patient
in his or her own decision-making has failed.
Proxy decision-making is not without controversy. In
Canada and the U.S., courts have found that moral proxies must strive to make proxy healthcare decisions in the
best interests of the patient [5], [6]. Those are decisions
that "[the patient] would choose, if he were in a position
to make a sound judgment" autonomously [7]. Thus, the
ideal proxy decision-maker makes no decisions at all: the
ideal proxy acts merely as a conduit for communicating
the precise wishes of the patient given the current circumstances. Typically, however, proxy decision-makers
find themselves in a position of partial ignorance with
respect to the patient's wishes, which complicates the
decision-making process. Expectations are such that the
proxy, often a family member, is required to disentangle
his own preferences from those of the ailing loved one, a
difficult requirement [8]. It is equally if not more difficult
to determine, as an outside observer, whether or not
the proxy has met this requirement. In Re S.D., the case
quoted above, parents acting as proxy to their severely
disabled seven year old boy refused consent for a routine surgery to unblock a shunt that drained spinal fluid
from the brain. In their estimation, their son was enduring a life of suffering that the surgery would only act to
prolong. Family and Child Service petitioned the courts
on behalf of the boy. Their dispute was over whether or
not the parents were able to separate their own interests
sufficiently from that of the child's, casting doubt on
whether or not their decision was in the best interests
of the patient. The parents argued that it was, while the
Supreme Court of British Columbia found that it was not.
So go the controversies surrounding moral proxies.
Pointing out that proxy decision-making is difficult
and controversial is not meant to suggest that there
is no good way of doing proxy decision-making, or of
resolving controversies over what is in a patient's best
interests. In the context of this argument, the controversial nature of moral proxies is meant to underscore
the moral complexities associated with delegating proxy
decision-making powers to someone other than the
june 2015

∕

patient. Though not without its own controversies [9],
having the competent patient make her own healthcare
decisions is broadly accepted by healthcare professionals, patients and the courts, as morally preferable to
having another decide on her behalf.

Technology as Moral Proxy
Consider the following scenario, which is adapted from
first-person accounts of living with an Internal Cardiac
Defibrillator (ICD). Though Jane is a fictional character,
her experiences as described are consistent with those
accounts [10]. Jane is at high risk of ventricular arrhythmias, a condition that causes her to unexpectedly experience life-threatening abnormal cardiac rhythms. She
found this out a decade ago after having being admitted
via ambulance to the emergency room, suffering a heart
attack. Jane's cardiologist told her that she was lucky to
be alive, and that the symptoms could recur unexpectedly
at any time. To increase her chances of surviving similar
future cardiac events, her cardiologist recommended that
Jane be fitted with an ICD. An ICD is a small implantable
device consisting of a power source, electrical leads that
are fixed to the heart, and a small processor that monitors
the heartbeat to deliver electrical stimuli (shocks) whenever a dangerously abnormal rhythm is detected. The ICD is
a small version of the larger defibrillator that the paramedics had used to save Jane's life. Otherwise healthy at the
time, Jane agreed to the surgery.
Three uneventful years after her ICD implantation,
Jane recalls being in a meeting at work and suddenly
feeling lightheaded. She recalls experiencing a sudden
"jolt" in her chest, which according to her was the rough
equivalent of being kicked in the chest by a horse. The
first jolt was followed in quick succession by several others, though she cannot recall how many, each one as
traumatic as the first. After several of these shocks her coworkers called an ambulance. Paramedics arrived to find
Jane conscious but in shock. In the hospital she was told
that her ICD had saved her life after delivering a total of
seven series of shocks to her heart. "The ICD performed
perfectly," her doctors told her, "it saved your life."
Without the ICD the efforts of several people, and
some luck, are required to prevent disaster. Jane could
only hope to be in the company of others during a cardiac episode, for starters someone would need to call the
paramedics to come help her. The paramedics, assuming Jane is near enough that they are able to arrive in
time, must assess the situation, perhaps without the
benefit of knowledge of her preexisting heart condition.
(Do those who called in the emergency happen to be
privy to Jane's heart condition? Is Jane conscious and
alert enough to tell the paramedics of her condition
when they arrive?) Assuming the paramedics are able
to assess her condition accurately they must then prep

IEEE Technology and Society Magazine

Table of Contents for the Digital Edition of IEEE Technology and Society Magazine - June 2015