Friday, September 26, 2008

Substituted Judgment and the Limits of Autonomy

Rosemary Flanigan
Program Associate
Center for Practical Bioethics

Our own John Lantos co-authored an article in the 2008 Journal of General Internal Medicine (23(9):1514-7) entitled Substituted Judgment: The Limitations of Autonomy in Surrogate Decision Making.

The authors make an interesting point: that there is "a compelling argument against substituted judgment. . .based on empirical evidence," and alternative models do a better job of respecting the patient as a person.

(I'm sure you know the arguments against: patients change their minds over time; predictions by surrogates are correct about 68% of the time; research shows that patients themselves do not want decisions made on their behalf to be based solely on their prior statements (!)

So what models to use?

1)Best-interest standards based on community norms (but that is unwieldy. Think of the time it would take to reach those "norms" and, once reached, how do we know they apply to "this" patient?)
2) The patient's life story: respect for persons approach. Here, decisions are not made by trying to predict the actual choices that an incapacitated loved one would have made; instead, decision-makers consider the individual's interests and values in the context of the current situation.

It is an interesting paper. Perhaps ethics committees could consider how surrogate decision making occurs in institutions.

Has anyone done so recently?

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