Summary of Patient Preferences in Clinical Ethics

Patient Preferences in Clinical Ethics: A Student Guide

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Introduction

Surrogate decision making arises when a patient lacks capacity to make or communicate medical choices. Clinicians rely on designated surrogates or legally recognized family members to authorize, withhold, or withdraw treatments. This material explains the ethical standards that guide surrogate decisions, practical approaches, and illustrative cases.

Definition: A surrogate decision maker is a person authorized to make health-care decisions for an incapacitated patient, using either the patient’s prior directives or standards that promote the patient’s welfare.

Core standards for surrogate decisions

Surrogates apply two principal standards depending on whether the patient’s preferences are known or not:

1. Substituted judgment

Purpose: To replicate the decision the patient would have made when competent.
When to use:
1. The patient expressly stated preferences in writing or orally; or
2. The surrogate can reasonably infer preferences from past statements, actions, or values.
Key requirement: Decisions should reflect the patient’s values, not the surrogate’s own values.

Definition: Substituted judgment is a method in which the surrogate uses the patient’s known wishes or inferred values to decide what the patient would have chosen.

Practical application and examples:

Case example: In In re Karen Quinlan, earlier statements by the patient that she would not want extraordinary means supported removal of a respirator under substituted judgment.
When preferences are partly known (e.g., broad statements like “I don’t want heroic measures”), the surrogate and clinicians should interpret these in the clinical context and discuss likely implications.
If surrogates disagree or their recollections are uncertain, seek corroborating evidence: written directives, multiple witnesses, or prior behavior.

Limitations and cautions:

Empirical studies show surrogate predictions are imperfect (e.g., about 68% accuracy in one study). Surrogates are often better than physicians but still fallible.
Clinicians should probe surrogate reports and check against other sources while presuming good faith.

💡 Did you know?Fun fact: High-profile cases such as Nancy Cruzan and Terri Schiavo shaped legal standards for substituted judgment in the United States and highlighted the need for clear evidence of prior patient wishes.

2. Best interests standard

Purpose: To protect and promote the welfare of a patient when prior preferences are unknown or unclear.
Core elements considered:
- Relief of suffering
- Preservation or restoration of function
- Extent and sustained quality of life that reasonable persons in similar circumstances would choose

Definition: The best interests standard directs surrogates to choose options that most benefit the patient’s welfare when the patient’s own preferences are not available.

Practical application and examples:

Use best interests when no advance directive or reliable substituted judgment evidence exists.
Decisions weigh benefits versus burdens, likely outcomes, and typical moral judgments about quality of life.

Who can serve as a surrogate?

Ordered preference:
1. A patient-designated agent (durable power of attorney for health care) supersedes others.
2. If none designated, many jurisdictions use statutory priority lists: spouse, parents, adult children, siblings, etc.
3. Courts can appoint guardians or conservators when necessary.
Practical notes:
- Appointed surrogates override default family lists.
- Statutes reduce conflict but can name an inappropriate person; clinicians should still assess suitability.

Advance planning and advance directives

Purpose: To communicate wishes in advance and nominate trusted decision makers.
Common forms:
- Durable (medical) power of attorney for health care
- Statutory directive to physicians (state-specific)
- Living will
- POLST (Physician Orders for Life-Sustaining Treatment) — described elsewhere

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Surrogate Decision Principles

Klíčové pojmy: Surrogates use substituted judgment when a patient’s prior preferences are known, Substituted judgment relies on written directives, prior statements, or reasonable inference from values, Avoid substituting the surrogate’s personal values for the patient’s values, Use the best interests standard when patient preferences are unknown or unclear, Best interests weigh relief of suffering, function, and sustained quality of life, A patient-designated agent (durable power of attorney) overrides default family surrogates, Advance directives need interpretation and should be discussed and documented with clinicians, Document surrogate decisions and the evidence or reasoning that supported them, When evidence is disputed, seek corroboration, ethics consult, or legal review, High-profile cases (Quinlan, Cruzan, Schiavo) shaped substituted judgment and evidentiary practices

## Introduction Surrogate decision making arises when a patient lacks capacity to make or communicate medical choices. Clinicians rely on designated surrogates or legally recognized family members to authorize, withhold, or withdraw treatments. This material explains the ethical standards that guide surrogate decisions, practical approaches, and illustrative cases. > Definition: A surrogate decision maker is a person authorized to make health-care decisions for an incapacitated patient, using either the patient’s prior directives or standards that promote the patient’s welfare. ## Core standards for surrogate decisions Surrogates apply two principal standards depending on whether the patient’s preferences are known or not: ### 1. Substituted judgment - Purpose: To replicate the decision the patient would have made when competent. - When to use: 1. The patient expressly stated preferences in writing or orally; or 2. The surrogate can reasonably infer preferences from past statements, actions, or values. - Key requirement: Decisions should reflect the patient’s values, not the surrogate’s own values. > Definition: Substituted judgment is a method in which the surrogate uses the patient’s known wishes or inferred values to decide what the patient would have chosen. Practical application and examples: - Case example: In In re Karen Quinlan, earlier statements by the patient that she would not want extraordinary means supported removal of a respirator under substituted judgment. - When preferences are partly known (e.g., broad statements like “I don’t want heroic measures”), the surrogate and clinicians should interpret these in the clinical context and discuss likely implications. - If surrogates disagree or their recollections are uncertain, seek corroborating evidence: written directives, multiple witnesses, or prior behavior. Limitations and cautions: - Empirical studies show surrogate predictions are imperfect (e.g., about 68% accuracy in one study). Surrogates are often better than physicians but still fallible. - Clinicians should probe surrogate reports and check against other sources while presuming good faith. Fun fact: High-profile cases such as Nancy Cruzan and Terri Schiavo shaped legal standards for substituted judgment in the United States and highlighted the need for clear evidence of prior patient wishes. ### 2. Best interests standard - Purpose: To protect and promote the welfare of a patient when prior preferences are unknown or unclear. - Core elements considered: - Relief of suffering - Preservation or restoration of function - Extent and sustained quality of life that reasonable persons in similar circumstances would choose > Definition: The best interests standard directs surrogates to choose options that most benefit the patient’s welfare when the patient’s own preferences are not available. Practical application and examples: - Use best interests when no advance directive or reliable substituted judgment evidence exists. - Decisions weigh benefits versus burdens, likely outcomes, and typical moral judgments about quality of life. ## Who can serve as a surrogate? - Ordered preference: 1. A patient-designated agent (durable power of attorney for health care) supersedes others. 2. If none designated, many jurisdictions use statutory priority lists: spouse, parents, adult children, siblings, etc. 3. Courts can appoint guardians or conservators when necessary. - Practical notes: - Appointed surrogates override default family lists. - Statutes reduce conflict but can name an inappropriate person; clinicians should still assess suitability. ## Advance planning and advance directives - Purpose: To communicate wishes in advance and nominate trusted decision makers. - Common forms: - Durable (medical) power of attorney for health care - Statutory directive to physicians (state-specific) - Living will - POLST (Physician Orders for Life-Sustaining Treatment) — described elsewhere