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Sovereignty, authenticity and the patient preference predictor
  1. Ben Schwan
  1. Department of Bioethics, Case Western Reserve University, Cleveland, OH 44106, USA
  1. Correspondence to Ben Schwan, Department of Bioethics, Case Western Reserve University, Cleveland, OH 44106, USA; ben.schwan{at}

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The question of how to treat an incapacitated patient is vexed, both normatively and practically—normatively, because it is not obvious what the relevant objectives are; practically, because even once the relevant objectives are set, it is often difficult to determine which treatment option is best given those objectives. But despite these complications, here is one consideration that is clearly relevant: what a patient prefers. And so any device that could reliably identify a patient’s preferences would be a promising tool for guiding the treatment of incapacitated patients.

The patient preference predictor (PPP) is just such a tool—an algorithm that takes as inputs a patient’s sociodemographic characteristics, and outputs a reliable prediction about that patient’s treatment preferences.1 But some have worried that the use of such a tool would violate or fail to appropriately respect patients’ autonomy. There are, I think, two ways to understand this kind of criticism. First, globally—as a worry that any systematic implementation of the PPP would be problematic on the grounds that it would result in significant or pervasive autonomy violations. Second, locally—as a worry that in some important (but possibly narrow) range of cases, certain uses of the PPP would be problematic on autonomy grounds.

Jardas et al, as I read them, address global autonomy-based criticisms, arguing—convincingly, in my view—that there’s no reason to suspect the autonomy concerns raised by the PPP would be so significant and pervasive as to render any implementation of it generally problematic.1 But even with the global criticisms rebuffed, there remains work to be done. Any ethically acceptable implementation of the PPP must be sensitive to the more local autonomy-based criticisms, with restrictions and safeguards in place to ensure respect for autonomy in the kinds of cases in which the use of the PPP might otherwise threaten …

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  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Provenance and peer review Not commissioned; internally peer reviewed.

  • As Jardas et al.1 note, the PPP has kin. But the differences among the various prediction algorithms aren’t relevant for what follows. So, following their lead, I focus just on the PPP.

  • Admittedly, Jardas et al gesture at some such restrictions and safeguards, but it’s not the primary focus of their project.

  • For a more in-depth discussion of this distinction as it applies to incapacitated patients, see Schwan2. For a helpful application to patient decision-making more generally, see Brudney and Lantos3. For a recent philosophical discussion of the distinction, see Enoch4.

  • An agent’s sovereign domain is the space of decisions that are properly theirs to control and hence generate autonomy-as-sovereignty considerations. See Feinberg5 for an early and influential discussion.

  • For more on the sovereignty considerations at stake for borderline incapacitated patients, see Schwan2.

  • Note that this concern is distinct from—though often coincidental with—sovereignty considerations that arise when a patient decides against the use of the PPP.

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