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Commentary on ‘Autonomy-based criticisms of the patient preference predictor’
  1. Collin O'Neil
  1. Philosophy Department, Lehman College, Bronx, NY 10468, USA
  1. Correspondence to Collin O'Neil, Philosophy Department, Lehman College, Bronx, NY 10468, USA; collin.oneil{at}

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When a patient lacks sufficient capacity to make a certain treatment decision, whether because of deficits in their ability to make a judgement that reflects their values or to make a decision that reflects their judgement or both, the decision must be made by a surrogate. Often the best way to respect the patient’s autonomy, in such cases, is for the surrogate to make a ‘substituted’ judgement on behalf of the patient, which is the decision that best reflects the patient’s values and identity-infused beliefs as they were when the patient last possessed capacity.

It is by now well-known that there is troubling evidence that surrogates do only slightly better than chance at making accurate substituted judgements. The use of a patient preference predictor (PPP), an algorithm that predicts patient preferences based on characteristics like the patient’s age, gender, socioeconomic status and education level, could help. Rid and Wendler have done important work making a moral case for using the PPP.1 If it were shown to enhance accuracy, it is not at all obvious what objections there could be to its use.

Yet several subtle criticisms of the PPP have emerged in the literature.

In their feature article, Jardas, Wasserman and Wendler select six of the most prominent objections to the PPP in the literature and defend (very convincingly, in my view) the PPP against them.2 Along the way they make significant contributions to broader issues concerning the proper uses of statistical evidence and limits on the kinds of preferences there can be reasons of autonomy to respect. Since I found the authors’ answers to the final two objections—that the PPP relies on naked statistical evidence and that it uses non-endorsed reasons—to be especially interesting and provocative, I will examine those answers and raise a few questions about …

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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.

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