Journal of General Internal Medicine

, Volume 23, Issue 9, pp 1514–1517 | Cite as

Substituted Judgment: The Limitations of Autonomy in Surrogate Decision Making

  • Alexia M. TorkeEmail author
  • 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 



This work was supported by training grants from the Health Services and Resources Administration (Dr. Torke) and the Robert Wood Johnson Foundation (Dr. Alexander).

The authors would like to thank Mark Siegler, MD for comments on an earlier draft of this paper and Roberta Manns for assistance with manuscript preparation.

Conflicts of Interest

None disclosed.


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Copyright information

© Society of General Internal Medicine 2008

Authors and Affiliations

  • Alexia M. Torke
    • 1
    • 2
    • 3
    Email author
  • 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

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