Extending autonomy by substituting judgment: A case of mistaken identity

According to the so-called Substituted Judgment Standard, a surrogate decision maker, acting on behalf of an incompetent patient, ought to make that health care decision which the patient would have made, had the latter been competent. The most common way of justifying the Substituted Judgment Standard is to maintain that this standard extends patients’ opportunities for self-determination to situations where they are no longer able to exercise the right to autonomy on their own. In this paper we question this justification by arguing that the most frequently suggested moral reasons for allowing and encouraging people to make their own choices do not seem to apply when the patient’s decision-making is merely hypothetical. We end with some brief sketches of possible alternative ways of justifying the Substituted Judgment Standard