Sign Up Submit Enquiry

The volitional approach to surrogate decision making

Home The volitional approach to surrogate decision making

Related Articles

Contact us

Article Content

Abstract

When a patient lacks capacity, medical decisions on their behalf are made according to an advance directive or by surrogate decision making. Often, however, patients’ previously expressed wishes are ambiguous, vague, inconsistent, or fail to anticipate the patient’s current condition. In this paper, we argue that when patient’s wishes are not clear, surrogates must utilize interpretative principles to reach a decision regarding treatment. We identify three such principles: the value-substitution, value-coherence, and volitional principles. We argue that the volitional principle is the most reliable way of capturing what the patient would have wanted when they no longer possess decisional capacity. This approach tasks the surrogate with identifying a medical choice close to what the patient would have agreed to based on previously expressed wishes without attributing the surrogate’s own values to the patient or attempting to provide an interpretation consistent with the patient’s other values. This approach is best positioned to support patients’ sovereignty for those who were previously able to express wishes for or against life-sustaining treatment.

 This is a preview of subscription content, log in via an institution  to check access.

Licensing Surrogate Decision-Makers

Article 23 December 2016

Explore related subjects

Discover the latest articles and news from researchers in related subjects, suggested using machine learning.

  • Bioethics
  • Decision Making
  • Medical Ethics
  • Palliative Care
  • Philosophical Methods
  • Utilitarianism

Notes

  1. We would like to thank an anonymous reviewer for suggesting this concern.

  2. We would like to thank an anonymous reviewer for this insight.

  3. This may especially be true when surrogates are not explicitly selected by the patient using an advance directive or healthcare proxy, but are determined based on state surrogacy laws.

  4. We concede that a degree of logical consistency is necessary for sound deliberation, so we are not suggesting that it plays no role in interpreting a patient’s stated wishes for care. But practical deliberation—deliberating about what to do—does not require the same high degree of consistency with one’s professed values in the way that logical consistency in forming judgments often is. Often, people make decisions by shifting the weight of their value-commitments—e.g., between fidelity to their religious and moral beliefs on the one hand and their interests in avoiding pain or inconvenience on the other. For example, a Christian Scientist may be committed to the tenants of their religion, but also liable to choose medical treatment forbidden by their faith if the alternative would involve dying. Such a person may be ‘weak-willed,’ but their choice need not involve practical irrationality. For this example, see [34]. Instead, they may not see their commitments to their religious values as so strong that they override their interest in staying alive. This kind of openness to revision regarding one’s deep commitments seems both rationally permissible and not exceedingly rare. In such cases, it would be a failure of substituted judgment for a surrogate to apply value-coherence as an interpretive principle to ascertain a patient’s wishes, i.e., to reason from a patient’s general value commitments to what they would decide in a particular case. To do so would be both to inaccurately predict what the patient would want and fail to correct for any obvious irrationality on the part of the patient.

References

  1. Seckler, Allison B., Dianne E. Meier, Michael Mulvihili, and Barbara E. Cammer Paris. 1991. Substituted judgment: How accurate are proxy predictions? Annals of Internal Medicine. https://doi.org/10.7326/0003-4819-115-2-92.

  2. Thompson, Trevor, Rosaline Barbour, and Lisa Schwartz. 2003. Adherence to advance directives in critical care decision making: Vignette study. British Medical Journal. https://doi.org/10.1136/bmj.327.7422.1011.

    Article Google Scholar

  3. Pope, Thaddeus Mason, and Melinda Hexum. 2012. POLST: Physician orders for life-sustaining treatment. Journal of Clinical Ethics. https://doi.org/10.1086/JCE201223410.

    Article Google Scholar

  4. Buchanan, Allen E., and Dan W. Brock. 1989. Deciding for others: The ethics of surrogate decision making. Cambridge: Cambridge University Press.

    Google Scholar

  5. Code of Federal Regulations. N.d. Title 42, Chapter IV, Subchapter G, Part 489, Subpart I: Advance Directives. https://www.ecfr.gov/current/title-42/chapter-IV/subchapter-G/part-489/subpart-I. Accessed 24 January 2025.

  6. Black, Betty S., Linda A. Fogarty, Hillary Phillips, Thomas Finucane, David J. Loreck, Alva Baker, David M. Blass, and Peter V. Rabins. 2009. Surrogate decision makers’ understanding of dementia patients’ prior wishes for end-of-life care. Journal of Aging and Health. https://doi.org/10.1177/0898264309333316.

    Article Google Scholar

  7. New York State Attorney General’s Office. N.d. Instructions for Completing Your New York Living Will. https://ag.ny.gov/sites/default/files/livingwill-template-fillin.pdf. Accessed 24 January 2025.

  8. Baeke, Goedele, Jean-Pierre. Wils, and Bert Broeckaert. 2011. Orthodox Jewish perspectives on withholding and withdrawing life-sustaining treatment. Nursing Ethics. https://doi.org/10.1177/0969733011408051.

    Article Google Scholar

  9. Stich, Stephen P. and Shaun Nichols. 2003. Folk psychology. In The Blackwell guide to philosophy of mind, ed. Stephen P. Stich and Ted A. Warfield, 235–55. Malden, MA: Blackwell. https://doi.org/10.1002/9780470998762.ch10.

  10. Gligorov, Nada. 2016. Neuroethics and the scientific revision of commonsense. Dordrecht: Springer.

    Book Google Scholar

  11. Gligorov, Nada. 2018. The cognitive basis of commonsense morality. Journal of Cognitive Enhancement. https://doi.org/10.1007/s41465-018-0098-8.

    Article Google Scholar

  12. Persson, Ingmar, and Julian Savulescu. 2012. Unfit for the future: The need for moral enhancement. Oxford: Oxford University Press. https://doi.org/10.1093/acprof:oso/9780199653645.001.0001.

    Book Google Scholar

  13. Gordon, Robert M. 1992. The simulation theory: Objections and misconceptions. Mind & Language. https://doi.org/10.1111/j.1468-0017.1992.tb00195.x.

    Article Google Scholar

  14. Godfrey-Smith, Peter. 2005. Folk psychology as a model. Philosopher’s Imprint 5:1–16.

    Google Scholar

  15. Andrews, Kristen. 2007. It’s in your nature: A pluralistic folk psychology. Synthese. https://doi.org/10.1007/s11229-007-9230-5.

    Article Google Scholar

  16. Fritsch, Jenna, Sandra Petronio, Paul R. Helft, and Alexia M. Torke. 2013. Making decisions for hospitalized older adults: Ethical factors considered by family surrogates. Journal of Clinical Ethics 24:125–134.

    Article Google Scholar

  17. Shalowitz, David I., Elizabeth Garrett-Mayer, and David Wendler. 2016. The accuracy of surrogate decision makers. Archives of Internal Medicine. https://doi.org/10.1001/archinte.166.5.493.

    Article Google Scholar

  18. Marks, Melissa A. Z., and Hal R. Arkes. 2008. Patient and surrogate disagreement in end-of-life decisions: Can surrogates accurately predict patient preferences? Medical Decision Making. https://doi.org/10.1177/0272989X08315244.

    Article Google Scholar

  19. Torke, Alexia M., Greg A. Sachs, Paul R. Helft, Kianna Montz, Siu L. Hui, James E. Slaven, and Christopher M. Callahan. 2014. Scope and outcomes of surrogate decision making among hospitalized older adults. JAMA Internal Medicine. https://doi.org/10.1001/jamainternmed.2013.13315.

    Article Google Scholar

  20. Ozar, David. 2019. Who are “unrepresented” patients and what counts as “important” medical decisions for them? AMA Journal of Ethics. https://doi.org/10.1001/amajethics.2019.611.

    Article Google Scholar

  21. Curlin, Farr A., John D. Lantos, Chad J. Roach, Sarah A. Sellergren, and Marshall H. Chin. 2005. Religious characteristics of US physicians. Journal of General Internal Medicine. https://doi.org/10.1111/j.1525-1497.2005.0119.x.

    Article Google Scholar

  22. Coppola, Kristen M., Peter H. Ditto, Joseph H. Danks, and William D. Smucker. 2001. Accuracy of primary care and hospital-based physicians’ predictions of elderly outpatients’ treatment preferences with and without advance directives. Archives of Internal Medicine. https://doi.org/10.1001/archinte.161.3.431.

    Article Google Scholar

  23. Danis, Marion, Martha Susan Gerrity, Leslie Irene Southerland, and Donald Lee Patrick. 1988. A comparison of patient, family, and physician assessments of the value of medical intensive care. Critical Care Medicine. https://doi.org/10.1097/00003246-198806000-00006.

    Article Google Scholar

  24. Kristen, Halvorsen, Reidun Førde, and Per Nortvedt. 2008. Professional challenges of bedside rationing in intensive care. Nursing Ethics. https://doi.org/10.1177/0969733008095383.

    Article Google Scholar

  25. Wyller, Vegard Bruun. 2015. Give the doctor what is due to the doctor! Why “fair rationing at the bedside” is impossible. In Fair resource allocation and rationing at the bedside, ed. Marion Danis, 253–62. Oxford: Oxford University Press. https://doi.org/10.1093/acprof:oso/9780199989447.003.0015.

  26. Oh, Hyeyoung. 2017. Resisting throughput pressures: Physicians’ and patients’ strategies to manage hospital Discharge. Journal of Health & Social Behavior. https://doi.org/10.1177/0022146517691090.

    Article Google Scholar

  27. Sharp, Shane, Deborah Carr, and Cameron Macdonald. 2012. Religion and end-of-life treatment preferences: Assessing the effects of religious denomination and beliefs. Social Forces. https://doi.org/10.1093/sf/sos061.

    Article Google Scholar

  28. Heyland, Daren K., Rebecca Heyland, Peter Dodek, John J. You, Tasnim Sinuff, Tim Hiebart, Xuran Jiang, and Andrew G. Day. 2017. Discordance between patients’ stated values and treatment preferences for end-of-life care: Results of a multicentre survey. British Journal of Supportive & Palliative Care. https://doi.org/10.1136/bmjspcare-2015-001056.

    Article Google Scholar

  29. Kunda, Ziva. 1999. Social cognition: Making sense of people. Cambridge, MA: MIT Press. https://doi.org/10.7551/mitpress/6291.001.0001.

    Book Google Scholar

  30. Harman, Gilbert. 2009. Skepticism about character traits. Journal of Ethics. https://doi.org/10.1007/s10892-009-9050-6.

    Article Google Scholar

  31. Paul, L. A. 2014. Transformative experience. New York: Oxford University Press. https://doi.org/10.1093/acprof:oso/9780198717959.001.0001.

    Book Google Scholar

  32. Walsh, Emily. 2020. Cognitive Transformation, dementia, and the moral weight of advance directives. American Journal of Bioethics. https://doi.org/10.1080/15265161.2020.1781955.

    Article Google Scholar

  33. Davidson, Donald 2001. Psychology as philosophy. In Essays on actions and events, 2nd ed., 229–44. Oxford: Oxford University Press.

  34. Enoch, David. 2017. Hypothetical consent and the value(s) of autonomy. Ethics. https://doi.org/10.1086/692939.

    Article Google Scholar

  35. Robertson, John. 1975. Involuntary euthanasia of defective newborns: A legal analysis. Stanford Law Review. https://doi.org/10.2307/1228265.

    Article Google Scholar

  36. Hobbes, Thomas. 1996 [1651]. Leviathan. Ed. R. Tuck. Cambridge: Cambridge University Press.

  37. Scanlon, T. M. 1998. What we owe each other. Cambridge: Harvard University Press.

    Google Scholar

Download references

Author information

Authors and Affiliations

  1. Alden March Bioethics Institute, Albany Medical College, 47 New Scotland Ave., Albany, NY, 12210, USA

    Pierce Randall & Nada Gligorov

Corresponding author

Correspondence to Pierce Randall.

Additional information

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Springer Nature or its licensor (e.g. a society or other partner) holds exclusive rights to this article under a publishing agreement with the author(s) or other rightsholder(s); author self-archiving of the accepted manuscript version of this article is solely governed by the terms of such publishing agreement and applicable law.

Reprints and permissions

About this article

Cite this article

Randall, P., Gligorov, N. The volitional approach to surrogate decision making. Theor Med Bioeth (2025). https://doi.org/10.1007/s11017-025-09720-7

Download citation

  • Accepted
  • Published
  • DOIhttps://doi.org/10.1007/s11017-025-09720-7

Keywords

  • Surrogate decision-making
  • Substituted judgment
  • Advance directives
  • Theory of mind
  • Hypothetical consent

Copyright © All rights reserved Designed and Developed by Digital Flavers

WhatsApp