Substituted Judgment and The Paradigm Case Mistake.

Abstract

Substituted judgment is widely used at the bedside, but the moral value that underpins its use needs examination. I argue that this value is the value of leading an authentic life. I then argue that an authentic life has multiple axes and that patients (like all human beings) vary widely in how they score on these axes. This entails that the moral weight of the value of authenticity in bedside decision-making also varies widely. And that means that, at the bedside, substituted judgment should not be seen as a moral trump. Put differently, when a surrogate must make a bedside decision, the answer to the "What would the patient choose?" question should not be morally decisive for that decision. The answer to that question should be a part, but only a part, of a more complex decision-making process.