Abstract
When decisionally incapable patients need a surrogate to make medical decisions for them, sometimes
the patient has not appointed a healthcare agent and there is intractable disagreement among potential
surrogates of equal priority, legal rank, or relation to the patient (e.g., child vs. child, sibling vs. sibling). There
is no ethical, legal, or professional consensus about how to identify the appropriate surrogate in such circumstances.
This article presents a case study involving an elderly female patient whose four children disagree
about whether to continue life-sustaining treatment for their mother, along with an ethical analysis of various
strategies for selecting the appropriate surrogate in cases of conflicting equal-rank family members. It critically
examines three different strategies—chance, majority rules, and quality of relationship with the patient—and
defends the third approach.