Deconstructing and reconstructing 'best interests': deciding for legally incompetent patients

'Best interests' is a panacea within medico-legal decisions for incapacitated patients. Its scope is extensive and its range of application situationally diverse, yet the meaning of best interests remains relatively obscure. To clarify its character this thesis deconstructs best interests by critically examining current law regarding treatment decisions for incompetent patients (Chapters 1 and 2). The conceptual implications of using 'interests' are then considered through exploration of philosophical approaches to sources of interests (Chapter 3). Certain important distinctions are raised and the notion of an 'interest network' is mooted. The possibilities for reconstruction of best interests are considered in Chapters 4 and 5. The importance of autonomy, including competence construction and patient perspective in alternative decision-making mechanisms, is considered. The meaning of welfare, together with quality of life and personhood are also explored in the context of incapacitated persons. Reconstruction then begins in earnest. 'Respect' is proffered as the most suitable ethic for governing 'best interests'. A new synthesis of respect is developed through Chapters 6,7 and 8. It is argued (Chapter 6) that we should admit a wider range of interests, recognise the importance of relationship, and differentiate between input and decision-making authority. A 'whole life, over time' approach is proffered in Chapter 7, including a reclassification of incompetence, and a process for ascertaining interests outlined. The final chapter embraces ethical issues, conflict resolution and criteria for justified decision-making. Discussion concludes by developing a normative framework to legally represent the improved respect synthesis within 'best interests'