Substituted Judgment Standard is Best Associated with Surrogate Decision-Making
The substituted judgment standard is the term most strongly associated with surrogate decision-making discussions, as it represents the most widely accepted ethical-legal framework for surrogates to make decisions based on what the incapacitated patient would have wanted. 1
Understanding the Substituted Judgment Standard
The substituted judgment standard directs surrogates to base their decisions on what the patient would have wanted if they were competent, rather than what others believe is best. 1 This approach:
- Prioritizes patient autonomy by attempting to honor the patient's previously expressed values, preferences, and wishes 1
- Serves as the primary legal and ethical framework for surrogate decision-making in medical treatment contexts, even though it may be imperfect 1
- Requires surrogates to act as interpreters of the patient's prior preferences rather than independent decision-makers 2, 3
Why Other Options Are Less Appropriate
Best Interest Standard
The best interest standard is problematic as the primary framework for surrogate decision-making because it shifts focus away from patient autonomy to what others determine is beneficial. 1 This standard:
- May be appropriate only when patient preferences are unknown or when direct health benefits are clearly at stake 1
- Represents a secondary approach used when substituted judgment cannot be applied 4, 5
- Focuses on welfare rather than respecting the patient's autonomous choices 4
Autonomy
While autonomy is the underlying ethical principle that justifies surrogate decision-making, it is not itself the decision-making standard. 1 Autonomy is the value being protected, whereas substituted judgment is the mechanism for protecting it. 3
Non-maleficence
Non-maleficence ("do no harm") is a general ethical principle in medicine but does not specifically characterize the surrogate decision-making process. 1 It applies broadly to all medical care, not specifically to how surrogates should make decisions.
Clinical Application
When serving as or working with surrogate decision-makers:
- Elicit what the patient would have wanted based on prior conversations, advance directives, or the patient's known values and life goals 1
- Recognize that surrogates using substituted judgment are "reporting" rather than "deciding" when they can accurately convey patient preferences 2
- Document any previously expressed patient preferences to support the surrogate's ability to apply substituted judgment 1
- Reserve the best interest standard for situations where the patient's preferences are truly unknown or were never expressed 1, 5
Important Caveats
Research demonstrates that surrogate accuracy in predicting patient preferences is imperfect, with mixed results regarding congruence between patients' actual preferences and surrogates' estimations. 1 Despite this limitation, substituted judgment remains the most widely accepted standard because it best honors patient autonomy. 1
The American College of Critical Care Medicine and American Thoracic Society support flexible approaches to surrogate decision-making that match the surrogate's preferred style, but these variations still fundamentally rely on understanding and implementing patient values. 1