Autonomy under uncertainty: the structural limits of substituted judgment in clinical practice

Area of Science:

• Bioethics
• Medical Law
• Philosophy of Medicine

Background:

• Informed consent traditionally assumes patient competence and adequate information.
• Clinical realities like incapacity, uncertainty, and time pressure complicate decision-making.
• Surrogate decision-making is often necessary but ethically complex.

Purpose of the Study:

• To examine the structural vulnerability of substituted judgment standards.
• To investigate how surrogate self-interest can undermine patient autonomy.
• To propose criteria for reconstructing autonomy in incapacitated patients.

Main Methods:

• Conceptual analysis of substituted judgment.
• Examination of a clinical case from interventional radiology.
• Philosophical inquiry into surrogate motivation and patient rights.

Main Results:

• Substituted judgment is structurally unstable when surrogate motives are suspect.
• Patient autonomy may be simulated rather than preserved under these conditions.
• Three criteria are proposed for autonomy reconstruction: evaluating surrogate testimony, understanding residual capacity, and defining the physician's role.

Conclusions:

• Autonomy in incapacitated patients is a normative task, not a recovered fact.
• Calibrated safeguards are needed to prevent misuse of surrogate decision-making.
• Reconstructing autonomy requires institutional changes, moving beyond default trust or suspicion.