Precedent Autonomy and Surrogate Decisionmaking After Severe Brain Injury

Abstract

Patients with disorders of consciousness after severe brain injury need surrogate decision makers to guide treatment decisions on their behalf. Formal guidelines for surrogate decisionmaking generally instruct decision makers to first appeal to a patient’s written advance directive, followed by making a substituted judgment of what the patient would have chosen, and lastly, to make decisions according to what seems to be in the patient’s best medical interests. Substituted judgment is preferable because it is taken to preserve patient autonomy, by using a patient’s past wishes and values to reconstruct what they would have chosen for themselves. In this paper, the author argues that for a certain population of patients, the standard interpretation of substituted judgment cannot ensure the preservation of patient autonomy. Patients with “covert awareness” may continue to have values and an authentic sense of self, which may differ from their past values and wishes. Accordingly, surrogate decision makers should make decisions based on how the patient is likely to experience their condition in the present, rather than their past wishes and values.

Well-Being After Severe Brain Injury: What Counts as Good Recovery?

“…The patient's previously expressed values and wishes may no longer reflect how they would evaluate their life in the present. 60 Yet even if surrogate decisionmakers are drawing on values and wishes that accurately represent the patient's evaluated well-being, they might still be neglecting the patient's experienced well-being. This is the second issue.…”