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Trial by Triad: substituted judgment, mental illness and the right to die
  1. Jacob M Appel
  1. Psychiatry, Icahn School of Medicine at Mount Sinai, New York, New York, USA
  1. Correspondence to Dr Jacob M Appel, Psychiatry, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA; jacobmappel{at}


Substituted judgment has increasingly become the accepted standard for rendering decisions for incapacitated adults in the USA. A broad exception exists with regard to patients with diminished capacity secondary to depressive disorders, as such patients’ previous wishes are generally not honoured when seeking to turn down life-preserving care or pursue aid-in-dying. The result is that physicians often force involuntary treatment on patients with poor medical prognoses and/or low quality of life (PMP/LQL) as a result of their depressive symptoms when similarly situated incapacitated patients without such depressive symptoms would have their previous wishes honoured via substituted judgment. This commentary argues for reconsidering this approach and for using a substituted judgment standard for a subset of EMP/LQL patients seeking death.

  • capacity
  • psychiatry
  • clinical ethics
  • end-of-life
  • living wills/advance directives

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  • Contributors JMA is the sole contributor to this paper and takes full responsibility for its contents.

  • Funding The author has 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; externally peer reviewed.

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