Journal of General Internal Medicine

, Volume 23, Issue 9, pp 1514–1517

Substituted Judgment: The Limitations of Autonomy in Surrogate Decision Making

  • Alexia M. Torke
  • G. Caleb Alexander
  • John Lantos


Substituted judgment is often invoked as a guide for decision making when a patient lacks decision making capacity and has no advance directive. Using substituted judgment, doctors and family members try to make the decision that the patient would have made if he or she were able to make decisions. However, empirical evidence suggests that the moral basis for substituted judgment is unsound. In spite of this, many physicians and bioethicists continue to rely on the notion of substituted judgment. Given compelling evidence that the use of substituted judgment has insurmountable flaws, other approaches should be considered. One approach provides limits on decision making using a best interest standard based on community norms. A second approach uses narrative techniques and focuses on each patient’s dignity and individuality rather than his or her autonomy.


decision making end-of life substituted judgement surrogate 

Copyright information

© Society of General Internal Medicine 2008

Authors and Affiliations

  • Alexia M. Torke
    • 1
    • 2
    • 3
  • G. Caleb Alexander
    • 4
    • 6
  • John Lantos
    • 5
    • 6
    • 7
  1. 1.Indiana University Center for Aging ResearchIndianapolisUSA
  2. 2.Regenstrief Institute, Inc.IndianapolisUSA
  3. 3.Fairbanks Center for Medical EthicsIndianapolisUSA
  4. 4.Department of MedicineUniversity of Chicago HospitalsChicagoUSA
  5. 5.MacLean Center for Clinical Medical EthicsChicagoUSA
  6. 6.Department of PediatricsUniversity of Chicago HospitalsChicagoUSA
  7. 7.Center for Practical BioethicsKansas CityUSA

Personalised recommendations