Surrogates and Uncertainty
Journal of Clinical Ethics. 1995 Winter; 6(4): 372-377.
It is often very difficult for surrogates to make appropriate decisions on behalf of incompetent patients, and the substituted-judgment standard (SJS) is one of several principles designed to provide guidance in this task. Typically, this principle is said to direct the surrogate to make the decision (about medical treatment) that the patient would have made, had the patient been competent to do so. I argued in an earlier article that this emphasis on hypothetical decisions the patient might have made in other circumstances is apt to yield trouble, and that these problems can be avoided by altering the structure of the principle. In a nutshell, my revised version of the SJS instructs the surrogate to use a practical syllogism to work out a decision by reasoning from what is known about the patient's goals and values (along with relevant facts about the medical situation). Although one's initial reaction to this may be that it is not significantly different from what the SJS has been saying all along, it turns out that the syllogistic approach eliminates an undesirable influence of depression, denial, and other factors. The response to my paper from Smith and Nunn challenges this proposed revision and raises questions about certainty and the autonomy of patients. My agreement with these commentators is extensive enough to suggest that my original article was unclear. I wish to clarify my position and comment on some of the issues raised in response to it.
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