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.
Highlights
Frieda, a 32-year-old female, suffers a severe traumatic brain injury when she is struck by a motor vehicle while riding her bicycle
What reason do we have for thinking that patients with covert awareness continue to have the capacity to form new critical interests? As described above, the mental imagery task requires the exercise of a range of cognitive capacities: sustained attention, language comprehension, response selection, decisionmaking and execution skills, and working memory
I have argued that there is evidence to suggest that patients with covert awareness could retain the capacity for critical interests in the present, which may be different from their past critical interests
Summary
A 32-year-old female, suffers a severe traumatic brain injury when she is struck by a motor vehicle while riding her bicycle She is rushed to the hospital, and her condition is stabilized by emergency physicians, but she remains in a coma for 5 days. An electroencephalogram has detected a P300 signal in response to a recording of her name, which has been found to be predictive of recovery in posttraumatic VS.[1] At this stage after her injury, it remains unclear to what extent Frieda might recover. Her husband believes that she would not want to continue living in a severely disabled state, given the feelings she had expressed about the prolonged period of disability her grandmother experienced prior to her recent death. None of Frieda’s family is really sure how to proceed
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