What ethical concept is represented when a healthcare power of attorney (HCPA) makes decisions based on what they think the patient with impaired cognitive capacity would have wanted?

Substituted Judgment in Healthcare Decision-Making

The ethical concept represented when a healthcare power of attorney makes decisions based on what they think the patient would have wanted is substituted judgment. This is clearly the correct answer (option C) to the question presented.

Understanding Substituted Judgment

Substituted judgment is a decision-making standard where a surrogate decision-maker attempts to make healthcare decisions that reflect what the incapacitated person would have chosen if they were able to decide for themselves. This ethical framework focuses on respecting the patient's autonomy by extending their values and preferences into decisions made during periods of incapacity 1.

Key characteristics of substituted judgment include:

• The surrogate attempts to make the decision the patient would have made if capable
• Decisions are based on the patient's previously expressed wishes, values, and beliefs
• The surrogate's own preferences are set aside in favor of what they believe the patient would want
• The goal is to respect the patient's personhood and autonomy even when decision-making capacity is lost

How Substituted Judgment Works in Practice

When applying substituted judgment, the healthcare power of attorney (in this case, the son) should:

1. Consider any advance planning documents completed by the patient (living will, etc.)
2. Reflect on previous conversations with the patient about their healthcare preferences
3. Consider the patient's known values, religious beliefs, and life priorities
4. Consult with family members and others who knew the patient well
5. Make decisions that align with what they believe the patient would have wanted 1

As explained in guidelines, "for previously competent adult patients the goal should be to enact the patient's previously stated treatment preferences if applicable and contemporary... If the patient did not express such preferences, the goal is to make decisions that are respectful of the patient as a person, generally by trying to make decisions the patient would make if she could speak for herself" 1.

Distinguishing Substituted Judgment from Other Ethical Concepts

Not Best Interests (Option B: Non-maleficence)

While non-maleficence (do no harm) is an important ethical principle, it differs from substituted judgment. A best interests standard focuses on what would objectively benefit the patient most, rather than what the patient would have chosen 1.

Best interests approaches "protect against exploitation, but they can be exclusionary, especially for nontherapeutic research" 1. In contrast, substituted judgment prioritizes the patient's own values even if they might not align with what others consider "best" for them.

Not Autonomy (Options A and D)

While substituted judgment aims to respect autonomy, it is not itself autonomy. Negative autonomy (freedom from interference) and positive autonomy (freedom to act) are principles that apply to patients with decision-making capacity. Substituted judgment is specifically a method for extending autonomy when capacity is lost 1, 2.

Challenges in Applying Substituted Judgment

Several challenges exist when applying substituted judgment:

• Surrogates may not accurately know what the patient would have wanted
• Surrogates sometimes make decisions based on their own values rather than the patient's (projection bias) 1
• The patient's preferences might have changed over time or with illness experience
• Patients may never have expressed clear values regarding certain medical scenarios 1

When Substituted Judgment Cannot Be Applied

When the patient's preferences cannot be determined, decision-makers may need to default to a best interests standard. This is particularly true for:

• Patients who never had decision-making capacity
• Patients who never articulated clear values or preferences
• Situations where the patient's wishes are completely unknown 1

In these cases, "the goal should be to make decisions that are in the patient's best interest" 1.

Conclusion

In the case presented, the son is acting as healthcare power of attorney and is attempting to make decisions based on what he believes his father would have wanted, which is a clear example of substituted judgment (option C).