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. Torke
  • G. Caleb Alexander
  • John Lantos
Perspectives

Abstract

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.

KEY WORDS

decision making end-of life substituted judgement surrogate 

References

  1. 1.
    Arnold RM, Kellum J. Moral justifications for surrogate decision making in the intensive care unit: implications and limitations. Crit Care Med. 2003;31(5 Suppl):S347–53.PubMedCrossRefGoogle Scholar
  2. 2.
    Buchanan AE, Brock DW. Deciding For Others: The Ethics of Surrogate Decision Making. Cambridge: Cambridge University Press; 1990.Google Scholar
  3. 3.
    Emanuel EJ, Emanuel LL. Proxy decision making for incompetent patients. An ethical and empirical analysis. JAMA. 1992;267(15):2067–71.PubMedCrossRefGoogle Scholar
  4. 4.
    Miles SH, Koepp R, Weber EP. Advance end-of-life treatment planning. A research review. Arch of Intern Med. 1996;156(10):1062–8.CrossRefGoogle Scholar
  5. 5.
    Bailey S. Decision making in health care: limitations of the substituted judgment principle. Nurs Ethics. 2002;9(5):483–93.PubMedCrossRefGoogle Scholar
  6. 6.
    Dresser R. Precommitment: a misguided strategy for securing death with dignity. Tex Law Rev. 2003;81(7):1823–47.PubMedGoogle Scholar
  7. 7.
    Welie JV. Living wills and substituted judgments: a critical analysis. Med Health Care Philos. 2001;4(2):169–83.PubMedCrossRefGoogle Scholar
  8. 8.
    Burt RA. The End of Autonomy. In: Jennings B, Kaebnick GE, Murray TH, eds. Improving end of life care: Why has it been so difficult?: Hastings Center; 2005:9–13.Google Scholar
  9. 9.
    Sulmasy D, Sugarman J. Methods in Medical Ethics. Washington, D.C.: Georgetown University Press; 2001.Google Scholar
  10. 10.
    Weissman JS, Haas JS, Fowler FJ Jr., et al. The stability of preferences for life-sustaining care among persons with AIDS in the Boston Health Study. Med Decis Making. 1999;19(1):16–26.PubMedCrossRefGoogle Scholar
  11. 11.
    Emanuel LL, Emanuel EJ, Stoeckle JD, Hummel LR, Barry MJ. Advance directives. Stability of patients’ treatment choices. Arch of Intern Med. 1994;154(2):209–17.CrossRefGoogle Scholar
  12. 12.
    Carmel S, Mutran EJ. Stability of elderly persons’ expressed preferences regarding the use of life-sustaining treatments. Soc Sci Med. 1999;49(3):303–11.PubMedCrossRefGoogle Scholar
  13. 13.
    Danis M, Garrett J, Harris R, Patrick DL. Stability of choices about life-sustaining treatments. Ann Intern Med. 1994;120(7):567–73.PubMedGoogle Scholar
  14. 14.
    Coppola KM, Ditto PH, Danks JH, Smucker WD. Accuracy of primary care and hospital-based physicians’ predictions of elderly outpatients’ treatment preferences with and without advance directives. Arch of Internal Med. 2001;161(3):431–40.CrossRefGoogle Scholar
  15. 15.
    Druley JA, Ditto PH, Moore KA, et al. Physician’s predictions of elderly outpatients’ preferences for life-sustaining treatment. J Fam Pract. 1993;37:469–75.PubMedGoogle Scholar
  16. 16.
    Fischer GS, Tulsky JA, Rose MR, Siminoff LA, Arnold RM. Patient knowledge and physician predictions of treatment preferences after discussion of advance directives. J Gen Intern Med. 1998;13(7):447–54.PubMedCrossRefGoogle Scholar
  17. 17.
    Mattimore TJ, Wenger NS, Desbiens NA, et al. Surrogate and physician understanding of patients’ preferences for living permanently in a nursing home. J Am Geriatr Soc. 1997;45(7):818–24.PubMedGoogle Scholar
  18. 18.
    Ouslander JG, Tymchuk AJ, Rahbar B. Health care decisions among elderly long-term care residents and their potential proxies. Arch of Internal Med. 1989;149(6):1367–72.CrossRefGoogle Scholar
  19. 19.
    Pearlman RA, Starks H, Cain KC, Cole WG. Improvements in advance care planning in the Veterans Affairs System: results of a multifaceted intervention. Arch of Internal Med. 2005;165(6):667–74.CrossRefGoogle Scholar
  20. 20.
    Teno JM, Hakim RB, Knaus WA, et al. Preferences for cardiopulmonary resuscitation: physician-patient agreement and hospital resource use. J Gen Intern Med. 1995;10:179–86.PubMedCrossRefGoogle Scholar
  21. 21.
    Seckler AB, Meier DE, Mulvihill M, Paris BE. Substituted judgment: how accurate are proxy predictions?[see comment]. Ann of Intern Med. 1991;115(2):92–8.Google Scholar
  22. 22.
    Uhlmann F, et al. Understanding of elderly patients’ resuscitation preferences by physicians and nurses. West J Med. 1988;150:705–7.Google Scholar
  23. 23.
    Uhlmann RF, Pearlman RA, Cain KC. Physicians’ and spouses’ predictions of elderly patients’ resuscitation preferences. J Gerontol. 1988;43(5):M115–21.PubMedGoogle Scholar
  24. 24.
    Wilson IB, Green ML, Goldman L, Tsevat J, Cook EF, Phillips RS. Is experience a good teacher? How interns and attending physicians understand patients’ choices for end-of-life care. SUPPORT Investigators. Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments. Med Decis Making. 1997;17(2):217–27.PubMedCrossRefGoogle Scholar
  25. 25.
    Fagerlin A, Ditto PH, Danks JH, Houts RM, Smucker WD. Projection in surrogate decisions about life-sustaining medical treatments. Health Psychol. 2001;20(3):166–75.PubMedCrossRefGoogle Scholar
  26. 26.
    Fried TR, Bradley EH, Towle VR. Valuing the outcomes of treatment: do patients and their caregivers agree? Arch Intern Med. 2003;163(17):2073–8.PubMedCrossRefGoogle Scholar
  27. 27.
    Gerety MB, Chiodo LK, Kanten DN, Tuley MR, Cornell JE. Medical treatment preferences of nursing home residents: relationship to function and concordance with surrogate decision-makers. J Am Geriatr Soc. 1993;41(9):953–60.PubMedGoogle Scholar
  28. 28.
    Hare J, Pratt C, Nelson C. Agreement between patients and their self-selected surrogates on difficult medical decisions. Arch Intern Med. 1992;152(5):1049–54.PubMedCrossRefGoogle Scholar
  29. 29.
    Layde P. Surrogates’ predictions of seriously ill patients’ resuscitation preferences. Arch of Fam Med. 1995;4:518–24.CrossRefGoogle Scholar
  30. 30.
    Sulmasy DP, Haller K, Terry PB. More talk, less paper: predicting the accuracy of substituted judgments. Am J Med. 1994;96(5):432–8.PubMedCrossRefGoogle Scholar
  31. 31.
    Zweibel N, Cassel C. Treatment choices at the end of life: a comparison of decisions by older patients and their physician-selected proxies. Gerontologist. 1989;29:615–21.PubMedGoogle Scholar
  32. 32.
    Ditto PH, Danks JH, Smucker WD, et al. Advance directives as acts of communication: a randomized controlled trial. Arch of Intern Med. 2001;161(3):421–30.CrossRefGoogle Scholar
  33. 33.
    Shalowitz DI, Garrett-Mayer E, Wendler D. The accuracy of surrogate decision makers: a systematic review. Arch of Intern Med. 2006;166(5):493–7.CrossRefGoogle Scholar
  34. 34.
    Fins JJ, Maltby BS, Friedmann E, et al. Contracts, covenants and advance care planning: an empirical study of the moral obligations of patient and proxy. J Pain Symptom Manag. 2005;29(1):55–68.CrossRefGoogle Scholar
  35. 35.
    Hawkins NA, Ditto PH, Danks JH, Smucker WD. Micromanaging death: process preferences, values, and goals in end-of-life medical decision making. Gerontologist. 2005;45(1):107–17.PubMedGoogle Scholar
  36. 36.
    Kim SH, Kjervik D. Deferred decision making: patients’ reliance on family and physicians for CPR decisions in critical care. Nursing Ethics: an International Journal for Health Care Professionals. 2005;12(5):493–506.Google Scholar
  37. 37.
    Puchalski CM, Zhong Z, Jacobs MM, et al. Patients who want their family and physician to make resuscitation decisions for them: observations from SUPPORT and HELP. Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatment. Hospitalized Elderly Longitudinal Project. J Am Geriatr Soc. 2000;48(5 Suppl):S84–90.PubMedGoogle Scholar
  38. 38.
    Sehgal A, Galbraith A, Chesney M, Schoenfeld P, Charles G, Lo B. How strictly do dialysis patients want their advance directives followed? JAMA. 1992;267(1):59–63.PubMedCrossRefGoogle Scholar
  39. 39.
    In re Quinlan 70 N.J. 10, 355 A.2d 647 (1976).Google Scholar
  40. 40.
    Cruzan V. Director, Missouri Department of Health. 479 U.S. 261 (1990).Google Scholar
  41. 41.
    Butcher HK, Holkup PA, Park M, Maas M. Thematic analysis of the experience of making a decision to place a family member with Alzheimer’s disease in a special care unit. Res Nurs Health. 2001;24(6):470–80.PubMedCrossRefGoogle Scholar
  42. 42.
    Park M, Butcher HK, Maas ML. A thematic analysis of Korean family caregivers’ experiences in making the decision to place a family member with dementia in a long-term care facility. Res Nurs Health. 2004;27(5):345–56.PubMedCrossRefGoogle Scholar
  43. 43.
    Chambers-Evans J, Carnevale FA. Dawning of awareness: the experience of surrogate decision making at the end of life. J Clin Ethics. 2005;16(1):28–45.PubMedGoogle Scholar
  44. 44.
    Vig EK, Starks H, Taylor JS, Hopley EK, Fryer-Edwards K. Surviving surrogate decision-making: what helps and hampers the experience of making medical decisions for others. J Gen Intern Med. 2007;22(9):1274–9.PubMedCrossRefGoogle Scholar
  45. 45.
    Azoulay E, Pochard F, Kentish-Barnes N, et al. Risk of post-traumatic stress symptoms in family members of intensive care unit patients. Am J Respir Crit Care Med. 2005;171(9):987–94.PubMedCrossRefGoogle Scholar
  46. 46.
    Beach MC, Sugarman J, Johnson RL, Arbelaez JJ, Duggan PS, Cooper LA. Do patients treated with dignity report higher satisfaction, adherence, and receipt of preventive care? Ann Fam Med. 2005;3(4):331–8.PubMedCrossRefGoogle Scholar
  47. 47.
    National Commission for the Protection of Human Subjects of Biomedical and Behavioral Research. (April 18, 1979). The Belmont Report.Google Scholar
  48. 48.
    Blustein J. Choosing for others as continuing a life story: the problem of personal identity revisited. J Law Med Ethics. 1999;27(1):20–31.PubMedCrossRefGoogle Scholar
  49. 49.
    Kuczewski MG. Commentary: narrative views of personal identity and substituted judgment in surrogate decision making. J Law Med Ethics. 1999;27(1):32–6.PubMedCrossRefGoogle Scholar
  50. 50.
    Karlawish JH, Quill T, Meier DE. A consensus-based approach to providing palliative care to patients who lack decision-making capacity. ACP-ASIM End-of-Life Care Consensus Panel. American College of Physicians-American Society of Internal Medicine. Ann of Intern Med. 1999;130(10):835–40.Google Scholar

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