THE QUESTION

How ought decisions to be made for those who are not competent to decide for themselves? That is the question this book seeks to answer. Our focus will be on medical treatment decision making for incompetent patients. We will mention decisions about other matters such as financial affairs, living arrangements, or participation in research either to clarify our theory for medical decisions or to show important contrasts between medical decision making and these other areas.

The scope of the problem of decision making for incompetent individuals is vast. If one focuses only on the elderly who are incompetent and, among the elderly incompetent, only on those who are incompetent due to Alzheimer's dementia, the number may be as high as two million in this country alone, and increasing. But this is only one group. When all forms of dementia are included, the total is between three and six million. At the other end of life is the largest group of incompetents—those who are not competent to decide for themselves by virtue of their immaturity. In addition, there are those who are incompetent due to mental retardation, brain damage from trauma, stroke, and alcoholism, and those whose mental illness renders them incompetent to make at least some decisions, and in some cases all decisions.

Over 80 percent of Americans die in hospitals.