Substituted Judgment

The Limitations of Autonomy in Surrogate Decision Making

When seriously ill patients are unable to make health care decisions, surrogates assist in the decision-making process. Without advanced directives, substituted judgment is often used. Substituted judgment occurs when questions are asked to surrogates about their beliefs on what patients would want if they were able to detail them.

This article reviewed the concept of substituted judgment and highlighted alternative frameworks for health care decision-making.

Key Findings: 

  • Findings from research on substituted judgment highlighted the inaccuracy of substituted judgment for patients without living wills, the moderate concordance between patients and doctor or surrogates in decision-making, and questions as to whether patients want past wishes to be the basis for decision-making.
  • One alternative model to substituted judgment builds upon community standards in deciding the best interest of patients.
  • Another alternative model centers on a narrative approach to decision-making by surrogates where listening to and acting on a patient's account of their life, wishes, and role in their family and community grounds respect for individuals.

Community and narrative approaches are viable alternatives to substituted judgment in decision-making for seriously ill patients.