Surrogate Wars: The “Best Interest Values” Hierarchy & End-of-Life Conflicts with Surrogate Decision-Makers

Abstract Conflicts involving end-of-life care between healthcare providers (HCPs) and surrogate decision-makers (SDMs) have received sustained attention for more than a quarter of a century, with early studies demonstrating a frequency of HCP-SDM conflict in ICUs ranging from 32–78% of all admissions (Abbott et al. 2001; Breen et al. 2001; Studdert et al. 2003; Azoulay et al. 2009). More recent studies not only acknowledge the persistence of clinical conflict in end-of-life care (Leland et al. 2017), but they have begun to focus on the ways in which these conflicts escalate to verbal or physical violence in the ICU (Slack et al. 2023; Bass et al. 2024; Berger et al. 2024; Sjöberg et al. 2024). I will argue that part of the explanation for the persistence–and even escalation–of ICU disputes is the incommensurable value systems held by many conflicting HCPs and SDMs. I will argue that a common value system among HCPs can be understood as a “Best Interest Values” (BIV) hierarchy, which I will argue is irreconcilable with the set of “Life-Continuation Values” (LCV) held by a sizable minority of families in the United States. I argue this values-conflict undergirds many ICU disputes. If I am correct that an incommensurable value system underlies many ICU conflicts, then it is not just ineffectual for HCPs to impose their BIV system on LCV families, but also wrong given the American commitment to values pluralism. I conclude that the way to navigate continuous ICU surrogate wars is for BIV-focused healthcare institutions to engage more constructively with LCV stakeholders.