Clarifying substituted judgement: the endorsed life approach: Table 1

On substituted arguments

“…In their essay, “ Clarifying Substituted Judgment: the Endorsed Life Approach ,”1 Wendler and Phillips add to a growing body of literature that acknowledges what has been apparent to many clinicians and commentators for a long time: something is seriously wrong with the contemporary US approach to surrogate decision making. Their essay summarises background that has been more extensively reviewed elsewhere: the history of how we came to this impasse, and the many theoretical and empirical critiques of substituted judgement 2.…”

Whose decision? Whose practice?

“…The authors of this paper, Clarifying Substituted Judgment: The Endorsed Life Approach , alleged that respecting patient's autonomy is the primary goal of the current clinical practice 1. For incapacitated patients without definitive advance directives or with no advance directives at all, making decisions based on the substituted judgement standard (SJS) was regarded by the author as being widely accepted as the best way to pay due respect to the autonomy of such patients.…”

“…However, there are critics who have argued that it is practically difficult to follow SJS and that the standard is theoretically unsound. It follows that SJS may need to be “significantly revised or abandoned altogether”1, but it has already been a standard part of clinical practice. The author believed that the challenges of the critics do not stem from SJS itself but from how it has been interpreted, and that the challenges can be met by adopting a better interpretation that is the endorsed life approach (ELA).…”

“…According to this approach, the surrogate should make the decision in accordance with how to continue the course of life in the way endorsed by the incapacitated patient for herself. The author also alleged that the standard interpretation seems to imply that there is “a single correct choice in every case”1 (my emphasis) and that, in contrast, ELA may enable the surrogate to identify several options that may be equally consistent with the life endorsed by the patient for herself by drawing on wide information about the patient's “values and dreams” and preference for treatment 1…”

Patients, doctors and the good life (for the patient)

“…In one paper, I termed the first component ‘self-determination’ and in another paper (written with John Lantos) ‘agency’ 1 2. Phillips and Wendler seem to be referring to this element when they talk of ‘liberty’ 3. At stake is the capacity to make a choice, to act on the basis of reasons, the capacity to decide whether some reason for doing X—say, that I desire to do X—is a sufficient reason for doing X.…”