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The capacity to designate a surrogate is distinct from decisional capacity: normative and empirical considerations
  1. Mark Navin1,
  2. Jason Adam Wasserman2,
  3. Devan Stahl3,
  4. Tom Tomlinson4
  1. 1 Department of Philosophy, Oakland University, Rochester, Michigan, USA
  2. 2 Department of Foundational Medical Studies and Department of Pediatrics, Oakland University William Beaumont School of Medicine, Rochester, Michigan, USA
  3. 3 Department of Religion, Baylor University, Waco, Texas, USA
  4. 4 Center for Ethics and Humanities in the Life Sciences, Michigan State University, East Lansing, Michigan, USA
  1. Correspondence to Dr Mark Navin, Oakland University, Rochester, MI 48309-4401, USA; navin{at}


The capacity to designate a surrogate (CDS) is not simply another kind of medical decision-making capacity (DMC). A patient with DMC can express a preference, understand information relevant to that choice, appreciate the significance of that information for their clinical condition, and reason about their choice in light of their goals and values. In contrast, a patient can possess the CDS even if they cannot appreciate their condition or reason about the relative risks and benefits of their options. Patients who lack DMC for many or most kinds of medical choices may nonetheless possess the CDS, particularly since the complex means-ends reasoning required by DMC is one of the first capacities to be lost in progressive cognitive diseases (eg, Alzheimer’s disease). That is, patients with significant cognitive decline or mental illness may still understand what a surrogate does, express a preference about a potential surrogate, and be able to provide some kind of justification for that selection. Moreover, there are many legitimate and relevant rationales for surrogate selection that are inconsistent with the reasoning criterion of DMC. Unfortunately, many patients are prevented from designating a surrogate if they are judged to lack DMC. When such patients possess the CDS, this practice is ethically wrong, legally dubious and imposes avoidable burdens on healthcare institutions.

  • clinical ethics
  • decision-making
  • dementia
  • informed consent

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  • Twitter @MarkCNavin, @JasonWassermanPhD, @DevanStahl

  • Contributors MN conceptualised and designed the study, carried out the initial analyses, drafted the initial manuscript, and reviewed and revised the manuscript. JAW, DS and TT conceptualised and designed the study, carried out the initial analyses and reviewed and revised the manuscript. All authors approved the final manuscript as submitted and agree to be accountable for all aspects of the work.

  • 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.

  • Patient consent for publication Not required.

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

  • Data availability statement There are no data in this work.

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