The elderly patient and the healthcare decision-making framework in Singapore
The legal decision-making framework supporting the needs of incapacitated patients is an important element of any eﬀective response to the challenges posed by healthcare for the elderly, particularly at the end of life. The problems posed by surrogate or proxy decision-making are signiﬁcant because under the conditions of modern medicine, many elderly patients with chronic illness lack decision-making capacity to some degree. Further, advances in medical technology oﬀer the potential to artiﬁcially prolong life with questionable compensating beneﬁt, which gives rise to greater uncertainty as to the ethical course of action in such situations (Buchanan and Brock, 1985). This has also spurred increasing reﬂection and debate in society on attitudes and preferences towards the dying process, responses to the aggressive intervention of medical technology and the concept of a ‘good’ death. An eﬀective decisionmaking framework is therefore a critical piece of legal infrastructure that assists healthcare professionals, administrators, family members and other interested persons in coming with reasonable certainty to the best decision that promotes the welfare and individual interests of each elderly patient. After a considerable period of legal uncertainty, the recently enacted Mental
Capacity Act (MCA 2008) in Singapore provides important clariﬁcations and institutions to facilitate the healthcare decision-making process, especially in respect of elderly patients who gradually or abruptly lose decision-making capacity as they age and their health deteriorates. This chapter will examine the key concepts and institutions that the MCA 2008 contributes to the legal infrastructure in the context of healthcare decision-making. In particular, it examines the statutory concepts of decision-making capacity and best interests, and considers continuing issues of implementation and interpretation of these concepts. It then considers responses to conﬂict in decision-making that are inevitable in any such system, and what can be done institutionally to respond eﬀectively to such potentialities. Finally, it proceeds to examine the extent to which patient autonomy is valued and incorporated within a proxy decision-making framework, and how this might be improved in order to facilitate better decision-making outcomes.