Abstract
Decision making for incompetent patients is a much-discussed topic in bioethics. According to one influential decision making standard, the substituted judgment standard, the decision that ought to be made for the incompetent patient is the decision the patient would have made, had he or she been competent. Although the merits of this standard have been extensively debated, some important issues have not been sufficiently explored. One fundamental problem is that the substituted judgment standard, as commonly formulated, is indeterminate in content and thus offers the surrogate little or no guidance. What the standard does not specify is just how competent one should imagine the patient to be, and what else one ought to envision about the patient’s hypothetical outlook and the circumstances surrounding his or her decision making. The article discusses this problem of underdetermined decision conditions.
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References
Appleton Consensus: 1992, ‘The Appleton International Conference: Developing Guidelines For Decisions to Forgo Life-Prolonging Medical Treatment’ Journal of Medical Ethics 18, 2–22.
Baergen R. (1995) Revising the Substituted Judgement Standard. The Journal of Clinical Ethics 6(1):30–38
Bailey S. (2002) Decision Making in Health Care: Limitations of the Substituted Judgement Principle. Nursing Ethics 9(5): 483–493
Barnbaum D. (1999) Interpreting Surrogate Consent Using Counterfactuals. Journal of Applied Philosophy 16(2):167–172
Berghmans R.L.P. (1997). Ethical Hazards of the Substituted Judgement Test in Decision Making Concerning the End of Life of Dementia Patients. International Journal of Geriatric Psychiatry 12:283–287
Blustein J. (1999) Choosing for Others as Continuing a Life Story: The Problem of Personal Identity Revisited. Journal of Law,Medicine and Ethics 27(1):20–32
Brock, D.W.: 2004, ‘Surrogate Decision-Making’ in: S.G. Post (ed.), Encyclopedia of Bioethics, 3rd edn. New York: Macmillan, pp. 2483–2486.
Broström, L. and M. Johansson: ‘A Case of Mistaken Identity’(in preparation).
Buchanan A., Brock D.W. (1990), Deciding for Others. Cambridge, Cambridge UP
Collopy B.J. (1999) The Moral Underpinning of the Proxy-Provider Relationship: Issues of Trust and Distrust. Journal of Law, Medicine and Ethics 27(1):37–46
Giesen D. (1988) International Medical Malpractice Law: A Comparative Law Study of Civil Liability Arising from Medical Care. J.C.B. Mohr, Tübingen
Kuczewski M.G. (1999) Commentary: Narrative Views of Personal Identity and Substituted Judgment in Surrogate Decision Making. Journal of Law, Medicine and Ethics 27(1):32–37
Lewis D. (1973) Counterfactuals. Blackwell, Oxford
Seckler A.B., Meier D.E., Mulvihill M., Paris B.E. (1991) Substituted Judgment: How Accurate are Proxy Predictions?. Annals of Internal Medicine 115:92–98
Welie J.V.M. (2001) Living Wills and Substituted Judgments: A Critical Analysis. Medicine, Health Care and Philosophy 4:169–183
Wierenga E. (1983) Proxy Consent and Counterfactual Wishes. The Journal of Medicine and Philosophy 8(4):405–416
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This work was generously supported by the Vårdal Foundation and the Vårdal Institute. Thanks also to Göran Hermerén, Marie Köhler, an anonymous referee, and the participants in the seminars in medical ethics and practical philosophy at Lund University, for helpful comments on previous versions of the paper.
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Broström, L., Johansson, M. & Nielsen, M.K. “What the patient would have decided”: A fundamental problem with the substituted judgment standard. Med Health Care and Philos 10, 265–278 (2007). https://doi.org/10.1007/s11019-006-9042-2
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DOI: https://doi.org/10.1007/s11019-006-9042-2