Substituted Decision-making

Abstract

A core principle of medical ethics states that patients should be allowed to determine whether they wish to accept or refuse treatment, if they possess the relevant decision making capacity at the time treatment decisions need to be made. In cases where patients lack capacity to make decisions regarding their own treatment, substitute decision makers must make such decisions for them. This chapter begins with explication of criteria for decision making capacity and decision making incapacity. It then outlines the main standards of substituted decision making in the legal context: the Substituted Judgment Standard and the Best Interests Standard. It then discusses the moral groundings of these standards. The moral groundings are commonly understood to be two of the cornerstones of medical ethics: the principle of respect for patients’ autonomy and the principle of beneficence respectively. It then discusses how these standards apply to the formerly capacitated patient and the never-capacitated patient. It finally discusses conceptual, metaphysical, and moral challenges of substituted decision making. The chapter concludes with a summary of the most pressing issues of the contemporary debate on substitute decision making, and suggestions for fruitful future research focus.