Precedent Autonomy and Surrogate Decisionmaking After Severe Brain Injury

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 maki...

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Bibliographic Details
Published in:Cambridge quarterly of healthcare ethics 2020-10, Vol.29 (4), p.511-526
Main Author: GRAHAM, MACKENZIE
Format: Article
Language:English
Subjects:
Advance directives
Autonomy
Brain injuries
Brain research
Coma
Consciousness
Covert
Decision makers
Decision making
Disorders
Families & family life
Injuries
Magnetic resonance imaging
Medical ethics
Medical imaging
Patients
Preferences
Preservation
Quality of life
Recovery (Medical)
Recovery of function
Traumatic brain injury
Unconsciousness
Values
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Summary: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.
ISSN:0963-1801
1469-2147
1469-2147
DOI:10.1017/S0963180120000286