An Ethical Façade? Medical Students' Miscomprehensions of Substituted Judgment

Farr A Curlin,Julie Fredrickson,Ryan E Lawrence,Erik Von Elm

doi:10.1371/journal.pone.0004374

Farr A Curlin, Julie Fredrickson + Show 2 more

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https://doi.org/10.1371/journal.pone.0004374

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Abstract

BackgroundWe studied how well first-year medical students understand and apply the concept of substituted judgment, following a course on clinical ethics.MethodStudents submitted essays on one of three ethically controversial scenarios presented in class. One scenario involved a patient who had lost decisional capacity. Through an iterative process of textual analysis, the essays were studied and coded for patterns in the ways students misunderstood or misapplied the principle of substituted judgment.ResultsStudents correctly articulated course principles regarding patient autonomy, substituted judgment, and non-imposition of physician values. However, students showed misunderstanding by giving doctors the responsibility of balancing the interests of the patient against the interests of the family, by stating doctors and surrogates should be guided primarily by a best-interest standard, and by suggesting that patient autonomy becomes the guiding principle only when patients can no longer express their wishes.ConclusionStudents did not appear to internalize or correctly apply the substituted judgment standard, even though they could describe it accurately. This suggests the substituted judgment standard may run counter to students' moral intuitions, making it harder to apply in clinical practice.

Highlights

Substituted judgment has become the normative criterion for making medical decisions when adult patients cannot express their wishes.[1,2,3] According to this standard, when a patient loses decisional capacity and has not provided doctors with sufficient guidance about what type of care he or she wishes to receive or forego, health care providers should identify an appropriate surrogate decision maker
Students did not appear to internalize or correctly apply the substituted judgment standard, even though they could describe it accurately. This suggests the substituted judgment standard may run counter to students’ moral intuitions, making it harder to apply in clinical practice
They should instruct the surrogate to make medical decisions based on their judgment of what the patient would most likely have chosen for himself or herself.[4]

Summary

Introduction

Substituted judgment has become the normative criterion for making medical decisions when adult patients cannot express their wishes.[1,2,3] According to this standard, when a patient loses decisional capacity and has not provided doctors with sufficient guidance about what type of care he or she wishes to receive or forego, health care providers should identify an appropriate surrogate decision maker They should instruct the surrogate to make medical decisions based on their judgment of what the patient would most likely have chosen for himself or herself.[4] The rationale for this, according to Beauchamp and Childress, is that it would be ‘‘unfair to deprive an incompetent patient of decision-making rights merely because he or she is no longer autonomous’’.[5] This emphasis on preserving patient selfdetermination emerged in the years following the Belmont Report, when the report’s principle of respect for persons was rearticulated as a mandate to respect a patient’s autonomy.[6] Since important court cases have advanced substituted judgment as a means for accomplishing this goal. We studied how well first-year medical students understand and apply the concept of substituted judgment, following a course on clinical ethics

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