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The Substituted Judgment Standard. Studies on the Ethics of Surrogate Decision Making

Broström, Linus LU (2007) In Lund University, Faculty of Medicine Doctoral Dissertation Series 2007:134
Abstract
Patients who are incompetent need a surrogate decision maker to make treatment decisons on their behalf. One of the main ethical questions that arise in this context is what standard ought to govern such decision making. According to the Substituted Judgment Standard (SJS), a surrogate ought to make the decision that the patient would have made, had he or she been competent. Although this standard has sometimes been criticized on the grounds of being difficult to apply, it has found wide appeal, since it it is alleged to protect incompetent patients? right to autonomy. The main purpose of the thesis is to evaluate SJS, from a conceptual and ethical perspective. It argues that the traditional formulation of SJS is seriously incomplete, and... (More)
Patients who are incompetent need a surrogate decision maker to make treatment decisons on their behalf. One of the main ethical questions that arise in this context is what standard ought to govern such decision making. According to the Substituted Judgment Standard (SJS), a surrogate ought to make the decision that the patient would have made, had he or she been competent. Although this standard has sometimes been criticized on the grounds of being difficult to apply, it has found wide appeal, since it it is alleged to protect incompetent patients? right to autonomy. The main purpose of the thesis is to evaluate SJS, from a conceptual and ethical perspective. It argues that the traditional formulation of SJS is seriously incomplete, and discusses alternative ways of completing it. Moreover, it questions the received view on how SJS should be morally justified, by offering arguments against the view that decision making in accordance with this standard extends the patient's opportunities for self-determination. Instead it suggests a virtue-ethical approach according to which the moral point of SJS-based decision making is not to protect the patient's interests (in welfare or autonomy), but to express respect for person. The thesis also critically assesses empirical studies according to which surrogates often fail to correctly predict patients? actual treatment preferences. It is shown that such results cannot, for a number of reasons, support the conclusion drawn that surrogates are ill-equipped to make decisions that comply with SJS. (Less)
Popular Abstract (Swedish)
Beslutsinkompetenta patienter behöver en ställföreträdande beslutsfattare som kan fatta vårdbeslut för deras räkning. En av de etiska frågor som aktualiseras i detta sammanhang är vilka riktlinjer som bör gälla för sådant beslutsfattande. Enligt ?the Substituted Judgment Standard? (SJS) bör en ställföreträdare fatta det beslut som patienten själv hade fattat, om denne hade varit beslutskompetent. Trots att denna beslutsstandard ibland har kritiserats med hänvisning till att den kan vara svår att tillämpa, har den fått stor acceptans, eftersom den anses skydda patienters rätt till självbestämmande. Avhandlingens huvudsakliga syfte är att utvärdera SJS, från ett begreppsligt och etiskt perspektiv. Den argumenterar för att den traditionella... (More)
Beslutsinkompetenta patienter behöver en ställföreträdande beslutsfattare som kan fatta vårdbeslut för deras räkning. En av de etiska frågor som aktualiseras i detta sammanhang är vilka riktlinjer som bör gälla för sådant beslutsfattande. Enligt ?the Substituted Judgment Standard? (SJS) bör en ställföreträdare fatta det beslut som patienten själv hade fattat, om denne hade varit beslutskompetent. Trots att denna beslutsstandard ibland har kritiserats med hänvisning till att den kan vara svår att tillämpa, har den fått stor acceptans, eftersom den anses skydda patienters rätt till självbestämmande. Avhandlingens huvudsakliga syfte är att utvärdera SJS, från ett begreppsligt och etiskt perspektiv. Den argumenterar för att den traditionella formuleringen av SJS i viktiga avseenden är ofullständig, och den diskuterar olika sätt att fylla i det som saknas. Dessutom ifrågasätter avhandlingen den gängse synen på hur SJS ska rättfärdigas moraliskt, genom att argumentera mot tesen att SJS-baserat beslutsfattande ger patienter möjlighet till fortsatt självbestämmande. Istället föreslås en dygdetisk ansats enligt vilken det moraliska syftet med SJS-baserat beslutsfattande inte är att skydda patienters intressen (av välfärd eller autonomi), utan att uttrycka respekt för person. Avhandlingen gör också en kritisk granskning av de empiriska studier som tycks visa att ställföreträdare ofta misslyckas med att korrekt förutsäga patienters behandlingspreferenser. Granskningen visar att dessa resultat inte ger stöd åt den vanliga slutsatsen att ställföreträdare har dåliga förutsättningar att framgångsrikt följa SJS. (Less)
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author
supervisor
oppenent
  • Professor Inez de Beaufort, Dept. of Medical Ethics and Philosophy of Medicine, University Medical Center, Rotterdam
organization
year
type
Dissertation (Composite)
subject
keywords
Systematic philosophy, Medicin (människa och djur), Medicine (human and vertebrates), hypothetical consent, autonomy, incompetence, surrogate accuracy, surrogate decision making, substituted judgment, ethics, aesthetics, metaphysics, epistemology, ideology, Systematisk filosofi, etik, estetik, metafysik, kunskapsteori, ideologi
in
Lund University, Faculty of Medicine Doctoral Dissertation Series 2007:134
pages
140 pages
publisher
Department of Medical Ethics
defense location
Stora salen på D 15, BMC, D-huset, Klinikgatan 32, Lund.
defense date
2007-10-19 10:00
ISSN
1652-8220
ISBN
978-91-85897-12-4
language
English
LU publication?
yes
additional info
<div class="article_info">L Broström, M Johansson and M.K. Nielsen. <span class="article_issue_date">2007</span>. <span class="article_title">‘What the Patient Would Have Decided’: A Fundamental Problem with the Substituted Judgment Standard,</span> <span class="journal_series_title">Medicine, Health Care and Philosophy</span>, <span class="journal_volume">vol 10</span> <span class="journal_pages">pp 265-278</span>.</div> <div class="article_info">L Broström and M Johansson. <span class="article_issue_date"></span>. <span class="article_title">Extending Autonomy by Substituting Judgment: A Case of Mistaken Identity.</span> (submitted)</div> <div class="article_info">L Broström and M Johansson. <span class="article_issue_date"></span>. <span class="article_title">Surrogates Have Not Been Shown to Make Inaccurate Substituted Judgments.</span> <span class="journal_series_title">The Journal of Clinical Ethics</span>, (accepted)</div> <div class="article_info">L Broström and M Johansson. <span class="article_issue_date"></span>. <span class="article_title">A Virtue-Ethical Approach to Substituted Judgment.</span> (submitted)</div>
id
599023
date added to LUP
2007-11-13 07:21:27
date last changed
2010-09-23 18:37:35
@phdthesis{599023,
  abstract     = {Patients who are incompetent need a surrogate decision maker to make treatment decisons on their behalf. One of the main ethical questions that arise in this context is what standard ought to govern such decision making. According to the Substituted Judgment Standard (SJS), a surrogate ought to make the decision that the patient would have made, had he or she been competent. Although this standard has sometimes been criticized on the grounds of being difficult to apply, it has found wide appeal, since it it is alleged to protect incompetent patients? right to autonomy. The main purpose of the thesis is to evaluate SJS, from a conceptual and ethical perspective. It argues that the traditional formulation of SJS is seriously incomplete, and discusses alternative ways of completing it. Moreover, it questions the received view on how SJS should be morally justified, by offering arguments against the view that decision making in accordance with this standard extends the patient's opportunities for self-determination. Instead it suggests a virtue-ethical approach according to which the moral point of SJS-based decision making is not to protect the patient's interests (in welfare or autonomy), but to express respect for person. The thesis also critically assesses empirical studies according to which surrogates often fail to correctly predict patients? actual treatment preferences. It is shown that such results cannot, for a number of reasons, support the conclusion drawn that surrogates are ill-equipped to make decisions that comply with SJS.},
  author       = {Brostr\"o m, Linus},
  isbn         = {978-91-85897-12-4},
  issn         = {1652-8220},
  keyword      = {Systematic philosophy,Medicin (m\"a nniska och djur),Medicine (human and vertebrates),hypothetical consent,autonomy,incompetence,surrogate accuracy,surrogate decision making,substituted judgment,ethics,aesthetics,metaphysics,epistemology,ideology,Systematisk filosofi,etik,estetik,metafysik,kunskapsteori,ideologi},
  language     = {eng},
  pages        = {140},
  publisher    = {Department of Medical Ethics},
  school       = {Lund University},
  series       = {Lund University, Faculty of Medicine Doctoral Dissertation Series 2007:134},
  title        = {The Substituted Judgment Standard. Studies on the Ethics of Surrogate Decision Making},
  year         = {2007},
}