Advancing a Welfare-Based Model in Medical Decision

Why does family-centric decision-making, replete with the practices of collusion, familial determination and the circumnavigation of direct patient involvement in their own care decisions, continue to dominate end of life decision-making within the Singapore setting, particularly in light of the embrace of individualistic principlism? Received knowledge would point to the inherent dissonance in the manner in which familialism and principlism conceive the individual. Familialism envisages the individual as inextricably entwined with his/her family, leaving the interests of the family unit uppermost in any determination. This contrasts starkly with principlism, which sees the patient as a discrete individual who, though not entirely removed from his/her sociocultural surroundings, still places the interests of the individual at the centre of any decision-making process.

In this paper we will highlight the inherent flaws in the proposed Relational Autonomy (RA) framework as it attempts to bridge the differences between principlism and regnant familialism, and forward a flexible patient-centred, context-sensitive, welfare-based model of care that we believe will better address the clinical issues faced by local healthcare professionals. Guided by regnant sociocultural and professional standards, and employed under the aegis of a multidisciplinary palliative team approach to ensure transparency and accountability, the Welfare Model provides a clinically relevant, ethically sensitive, promising alternative to the present predicament.