HEC Forum

, Volume 28, Issue 1, pp 11–33 | Cite as

A Legal and Ethical Analysis of the Effects of Triggering Conditions on Surrogate Decision-Making in End-of-Life Care in the US

  • J. Clint Parker
  • Daniel S. Goldberg


The central claim of this paper is that American states’ use of so-called “triggering conditions” to regulate surrogate decision-making authority in end-of-life care leaves unresolved a number of important ethical and legal considerations regarding the scope of that authority. The paper frames the issue with a case set in a jurisdiction in which surrogate authority to withdraw life-sustaining treatment is triggered by two specific clinical conditions. The case presents a quandary insofar as the clinical facts do not satisfy the triggering conditions, and yet both the appropriate surrogates and the care team agree that withdrawal of life-sustaining treatment is in the best interest of the patient. The paper surveys applicable law across the 50 states and weighs the arguments for and against the inclusion of such triggering conditions in relevant legal regimes. The paper concludes by assessing the various legal and policy options states have for regulating surrogate decision-making authority in light of the moral considerations (including epistemic difficulties), and notes the possibility for conflict within ethics teams arising from the potential tension between prudence, risk-aversion, and moral obligation.


Triggering conditions End-of-life care Surrogate decision-making Obligation Safe harbors 


  1. Armstrong, E. M., & Abel, E. L. (2000). Fetal alcohol syndrome: The origins of a moral panic. Alcohol and Alcoholism, 35(3), 276–282.CrossRefGoogle Scholar
  2. Bachman, J. G., Alcser, K. H., Doukas, D. J., Lichtenstein, R. L., Corning, A. D., Brody H. (1996). Attitudes of Michigan physicians and the public toward legalizing physician-assisted suicide and voluntary euthanasia. New England Journal of Medicine, 334(5), 303–309.Google Scholar
  3. Bell, K., McNaughton, C., & Salmon, A. (2009). Medicine, morality and mothering: Public health discourses on foetal alcohol exposure, smoking around children and childhood overnutrition. Critical Public Health, 19(2), 155–170.CrossRefGoogle Scholar
  4. Benton, E. C. (1990). The constitutionality of pregnancy clauses in living will statutes. Vanderbilt Law Review, 43, 1821.Google Scholar
  5. Buchanan, A. E., & Brock, D. W. (1989). Deciding for others: The ethics of surrogate decision-making. New York: Cambridge University Press.Google Scholar
  6. Burch, T. J. (1995). Incubator or individual: The legal and policy deficiencies of pregnancy clauses in living will and advance health care directives. Maryland Law Review, 54, 528.Google Scholar
  7. Emanuel, E. J., & Emanuel, L. L. (1992). Proxy decision making for incompetent patients: An ethical and empirical analysis. Journal of the American Medical Association, 267(15), 2067–2071.Google Scholar
  8. Gill, C. J. (2004). Depolarizing and complicating the ethics of treatment decision making in brain injury: A disability rights response to Nelson and Frader. Journal of Clinical Ethics, 15(4), 277–288.Google Scholar
  9. Griffin, J. (1986). Wellbeing: It’s meaning, measurement and moral importance. New York: Oxford University Press.Google Scholar
  10. Heilborn, M. L., Brandão, E. R., & Cabral, C. D. S. (2007). Teenage pregnancy and moral panic in Brazil. Culture, Health & Sexuality, 9(4), 403–414.CrossRefGoogle Scholar
  11. Jerdee, A. L. (1999). Breaking through the silence: Minnesota’s pregnancy presumption and the right to refuse medical treatment. Minnesota Law Review, 84, 971.Google Scholar
  12. Kothari, S. (2004). Clinical (mis)judgments of quality of life after disability. Journal of Clinical Ethics, 15(4), 300–307.Google Scholar
  13. Kothari, S., & Kirschner, K. L. (2006). Abandoning the golden rule: The problem with “putting ourselves in the patient’s place”. Topics in Stroke Rehabilitation, 13(4), 68–73.CrossRefGoogle Scholar
  14. Longmore, P. K. (2005). Policy, prejudice, and reality: Two case studies of physician-assisted suicide. Journal of Disability Policy Studies, 16(1), 38–45.CrossRefGoogle Scholar
  15. Meisel, A., Cerminara, K. L., & Pope, T. M. (2013). Right-to-die: The law of end-of-life decision making. New York: Aspen Publishers.Google Scholar
  16. MO Rev. Stat. § 459.010 et. seq. (2012).Google Scholar
  17. Nagel, T. (1986). The view from nowhere. New York: Oxford University Press.Google Scholar
  18. North Carolina. Gen. Stat. § 14–17 (2012).Google Scholar
  19. North Carolina. Gen. Stat. § 90–322 (2012).Google Scholar
  20. Ouellette, A. (2013). Bioethics and disability: Toward a disability-conscious bioethics. Cambridge: Cambridge University Press.Google Scholar
  21. Pope, T. M. (2012). Physicians and safe harbor legal immunity. Annals of Health Law, 21, 121.Google Scholar
  22. President’s Commission for the Study of Ethical Problems in Medicine and Biomedical and Behavioral Research. (1982). Making health care decisions: The ethical and legal implications of informed consent in the patient-practitioner relationship. Washington, D.C.: U.S. Government Printing Office.Google Scholar
  23. Scully, J. L. (2008). Disability bioethics: Moral bodies, moral difference. Lanham: Rowman & Littlefield Publishers Inc.Google Scholar
  24. Sedwick, J. (2009). The health care risk management professional. In Roberta Carroll (Ed.), Risk management handbook for health care organizations (pp. 31–86). San Francisco: Wiley.Google Scholar
  25. Stabile, C. A. (1992). Shooting the mother: Fetal photography and the politics of disappearance. Camera Obscura, 10(1), 178–205.CrossRefGoogle Scholar
  26. Swinburne, R. (1989). Responsibility and atonement. New York: Oxford University Press.CrossRefGoogle Scholar
  27. Wardlaw, M. P. (2010). The right-to-die exception: How the discourse of individual rights impoverishes bioethical discussions of disability and what we can do about it. International Journal of Feminist Approaches to Bioethics, 3(2), 43–62.CrossRefGoogle Scholar
  28. Winslade, W., & Goldberg, D. S. (2007). Dying in America: Legal decisions, ethical conflicts, and the kinetics of cultural change. Annual Review of Law and Ethics, 13(2), 523–563.Google Scholar
  29. Wolff, K. B. (2011). Panic in the ER: Maternal drug use, the right to bodily integrity, privacy, and informed consent. Politics & Policy, 39(5), 679–714.CrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media Dordrecht 2015

Authors and Affiliations

  1. 1.The Brody School of MedicineEast Carolina UniversityGreenvilleUSA

Personalised recommendations