Ethical and legal issues in the treatment of incompetent religious.

Medical technology has created dilemmas for those who make decisions regarding whether to prolong life in the face of severe, irreversible illness. Two questions usually arise: who should decide, and what standards should the decision makers use? These questions can be particularly difficult for members of religious institutes. The basic legal standard for such decisions is the patient's autonomy or self-determination; the patient's wishes are paramount. If the patient has been determined incompetent, a person who has the patient's best interests at heart should make the treatment decisions. Sometimes it may be necessary for the court to appoint a conservator. In California a recent law enables a person to create a Durable Power of Attorney--that is, to designate someone to make all health care decisions if the designator becomes incompetent. The surrogate can base decisions on either of two basic legal standards: substituted judgment or best interests. The substituted-judgment standard holds that the decision should be the one that the patient would have made if competent. The decision should be based on any available information about the patient's values and preferences. If these are not sufficiently known, the decision maker may have to resort to the best-interest standard, evaluating all options to determine what is "best" for the patient. In the case of a religious who becomes incompetent and has no family members, the physician probably will accept a member of the institute as a surrogate. If the incompetent religious has family, they and the institute should discuss who should be responsible for communicating with medical personnel. In California, a competent member of an institute should designate a surrogate in advance to avoid any confusion or conflict later.