Matched Preferences and Values: A New Approach to Selecting Legal Surrogates

Every day, hospitals are filled with incapacitated patients whose healthcare decisions are made by someone else. The law recognizes such decisions as the patient’s own, and accordingly, the primary purpose of surrogate decisionmakers is to make the decisions that patients would make if able. Unfortunately, surrogate decisionmakers frequently make choices for patients that are inconsistent with patient wishes. Indeed, social psychology literature on surrogate decisionmaking finds a stronger correlation between surrogates’ decisions for patients and what the surrogates would want for themselves, than between the surrogates’ decisions and what the patients actually would want. Although others have treated surrogates’ tendency to project their own preferences and values on patients as a barrier to appropriate decisionmaking, this Article shows how savvy patients, advocates, and policymakers can capitalize on this tendency to improve healthcare decisionmaking. Specifically, it proposes that surrogate decisionmakers for health care be selected based, at least in part, on the extent to which they share patients’ treatment preferences. Where it is not possible to compare treatment preferences, or where an individual cares less about individual treatment decisions than about consistency with a set of values, then surrogates should be selected based on shared values. Incorporating this approach into advance planning processes and the statutory law governing the selection of guardians and default surrogate decisionmakers could simultaneously increase the likelihood that decisions made are those patients want made, and facilitate more flexible, context-appropriate treatment decisions