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Choosing for Another: Beyond Autonomy and Best Interests
Abstract
According to bioethics orthodoxy, when we ask, "What would the patient choose?" the patient's autonomy is at stake. In fact, what underpins the moral force of that question is a value different from either autonomy or best interests. This is the value of doing things in a way that is authentic to the person.
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“The sense of authenticity employed in Dutch concurrent request EAS cases seems to be in its second sense, namely, authenticity that is normally sought in surrogate decision-making after a person has lost decision-making capacity.(34)”
From Euthanasia and Assisted Suicide of Persons With Dementia in the Netherlands (2020) · cites this paper as [34]
Citations
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Shared Decision Making in ICUs
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“First, doing so allows clinicians to learn of and incorporate patients’ values and previously expressed treatment preferences, thereby manifesting respect for the patient as a person (18).”
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Sulmasy, D. P., & Snyder, L. (2010) · JAMA · doi:10.1001/jama.2010.1595 · Cited by 157
Reframing Consent for Clinical Research: A Function-Based Approach
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“Processes designed to identify and incorporate those values, such as conversations with family or research advance directives, may advance the extent to which enrollment decisions cohere with them in circumstances in which the individual cannot achieve this alone (Jaworska 1999; Kim and Karlawish 2003; Brudney 2009).”
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“…or authentic to the patient in this way is perhaps most clearly seen in a context where informed consent is not possible: In cases of surrogate decision- making, when needing to make a decision for a temporarily incompetent relative, we naturally ask “what would they choose” (Brudney, 2009).”
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Euthanasia and Assisted Suicide of Persons With Dementia in the Netherlands
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Giving Voice to Patient Values Throughout Cancer: A Novel Nurse-Led Intervention
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Wiener, L. S., Bedoya, S. Z., Battles, H. B., Sender, L. S., Zabokrtsky, K. B., Donovan, K. A., Thompson, L. M. A., di Ciccone, B. L., Babilonia, M. B., Fasciano, K. M., et al. (2021) · Palliative & Supportive Care · doi:10.1017/s1478951521001462 · Cited by 49
“…ACP discussions often occur too late or during an acute clinical deterioration where there is insufficient time to consider goals and values (Snaman et al., 2020) and when a patient ’ s incapacity may leave family members and clinicians struggling to make patient-centered decisions (Brudney, 2009).”
Who should make the decision on the use of GPS for people with dementia?
Landau, R., Auslander, G. K., Werner, S., Shoval, N., & Heinik, J. (2010) · Aging & Mental Health · doi:10.1080/13607861003713166 · Cited by 49
“In a similar way, in an article exploring the moral bases of the different questions a patient’s surrogate decision-maker might have to answer, Brudney (2009) argues that although one’s ‘authenticity’ or will may be important, in some cases other values might override it.”
ResultSurrogate Decision Makers Need Better Preparation for Their Role: Advice from Experienced Surrogates
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Clarifying substituted judgement: the endorsed life approach
Phillips, J., & Wendler, D. S. (2014) · Journal of Medical Ethics · doi:10.1136/medethics-2013-101852 · Cited by 47
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“Apparently, the participants were also considering the patients’ family interests (Brudney, 2009).”
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The Evolution of Advance Directives
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A conceptual model of the role of communication in surrogate decision making for hospitalized adults
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“reflect the actual wishes of the patient, asking what the patient would have wanted may reflect other key values, such as respecting the patient as a person [78] or making a decision that is an authentic reflection of the patient [79].”
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“The former invokes notions of self-control, freedom of choice, and self-rule,(7) whereas the latter provides a basis for making informed projections about courses of treatment consistent with the individual’s wishes.(10) Cognitively impaired individuals may gradually lose the capacity for self-determination.”
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“The rights-based framework that has evolved in end-of-life law and policy, founded upon theories that give primacy to the pursuit of self-interest and exercise of rational choice in transactional exchanges in the market, has been challenged on many fronts as inadequate (Brudney, 2009; Burt, 2005; Fins, 2006).”
BackgroundSurrogates and Artificial Intelligence: Why AI Trumps Family
Hubbard, R. K., & Greenblum, J. (2020) · Science and Engineering Ethics · doi:10.1007/s11948-020-00266-6 · Cited by 24
“Others argue that the principle is responding to the patient’s authenticity or dignity (Brudney 2009).”
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“This recommendation is supported by literature which suggests that families know patients’ preferences the best, [6–10] and seeking patients’ preferences from others is a way of extending patients’ autonomy [11, 12].”
Shepherd, V., Sheehan, M., Hood, K., Griffith, R., & Wood, F. (2020) · Journal of Medical Ethics · doi:10.1136/medethics-2019-106042 · Cited by 21
“Indeed, at times a person’s best interests might be considered to be at odds with their authenticity [Brudney D. “Choosing for Another: Beyond Autonomy and Best Interests,” Hastings Centre Report 39, no. 2 (2009): 31–37].”
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Autonomy, Respect, and the Rights of Persons with Disabilities in Crisis
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Bedoya, S. Z., Fry, A., Gordon, M. L., Lyon, M. E., Thompkins, J. D., Fasciano, K. M., Malinowski, P. K., Heath, C. L., Sender, L. S., Zabokrtsky, K. B., et al. (2022) · Frontiers in Psychology · doi:10.3389/fpsyg.2022.871042 · Cited by 16
“…when ACP discussions do take place, they often occur too late and typically during an acute clinical crisis, when there is insufficient time to consider individual goals and values (Davidson et al., 2007; Brudney, 2009; Durall et al., 2012; Snaman et al., 2020; Pennarola et al., 2021).”
BackgroundWithdrawal of Life-Sustaining Treatment
Hinderer, K. A., Friedmann, E., & Fins, J. J. (2015) · Dimensions of Critical Care Nursing · doi:10.1097/dcc.0000000000000097 · Cited by 15
“Decisions are made in context; the proxy must consider what the patient would have wanted in his/her current condition.(19) There is discrepancy in the literature related to patient and proxy agreement in EOL decisions.”
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“39 However, signi fi cant discrepancies often exist between patients ’ and families ’ treatment preferences; 40,41 studies in China similarly highlight this gap, especially regarding goals of care and preferences for life-sustaining interventions.”
A narrative approach to the ethical dilemmas of surrogate decision making
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Empirical Fallacies in the Debate on Substituted Judgment
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“While some commentators, ourselves included, have suggested that giving consideration to what the patient would have done might serve some other purpose than to respect self-determination [5, 6], much of the discussion concerns whether surrogates really can be expected to know what the patient would have decided [7].”
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“She explains that other scholars, namely Brudney (2009), suggest that authenticity is a more important right than autonomy and that authenticity promotes integrity. According to Dresser (2009), Brudney’s argument concludes that surrogate decision making, without an advance directive, promotes authenticity in the absen…”
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The protection of unrepresented patients in emergency care research
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“7There are, however, several alternative views on the ethical foundation of surrogate decision-making (Broström and Johansson 2009; Brudney 2009; Yarborough 2015).”
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Howard, D. (2017) · The Journal of Law Medicine & Ethics · doi:10.1177/1073110517737541 · Cited by 5
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“An “altered” consent would have respected participants’ values regarding how they interact with the medical profession and enhanced the extent to which their decisions reflected “who they are” and “what they care about” (Brudney 2009).”
BackgroundEthical Aspects of Dementia Care
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““substituted interests” model (4), whereas Brudney refers to this concept as authenticity (5).”
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“Surrogates may also incorporate their own preferences and personal factors in decisionmaking, aside from simply exercising substituted judgment on behalf of the incapacitated patient.(12) The fact that ICU clinicians work with surrogate decision makers on a daily basis does not necessarily mitigate the practical chall…”
BackgroundEthical reflection support for potential organ donors' relatives: A narrative review
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“Three types of narrative approaches – which could be three levels and steps of the relatives’ analysis – were found in the literature: The ‘authentic life’ approach promotes the authenticity of the patient’s life in the sense of continuing the life that the individual lived and maintaining the coherence of the patient…”
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Hammami, M., Al-Balkhi, A., De Padua, S. S., & Abuhdeeb, K. (2020) · Figshare · doi:10.6084/m9.figshare.12904674
Hammami, M., Al-Balkhi, A., De Padua, S. S., & Abuhdeeb, K. (2020) · Figshare · doi:10.6084/m9.figshare.12904671
Hammami, M. M., Al-Balkhi, A., De Padua, S. S., & Abuhdeeb, K. (2020) · Figshare · doi:10.6084/m9.figshare.12904665
Metadata
- Authors
- Brudney, D.
- Corresponding author
- Daniel Brudney
- ORCID
- Daniel Brudney
- Venue
- Hastings Center Report
- Publisher
- Project MUSE
- Published
- 2009
- Volume
- 39
- Issue
- 2
- Pages
- 31-37
- ISSN
- 0093-0334 (ISSN-L)
- 1552-146X
- OpenAlex
- W2004981452
- Cited by
- 101
- References
- 17
- Citations by year
- 2026: 1 · 2025: 6 · 2024: 6 · 2023: 3 · 2022: 8 · 2021: 2 · 2020: 15 · 2019: 10 · 2018: 4 · 2017: 6 · 2016: 5 · 2015: 6 · 2014: 6 · 2013: 5 · 2012: 8
- FWCI
- 6.02
- Type
- journal article
- Language
- en
- Open access
- closed
- Locations
- The Hastings Center Report (publishedVersion)
- PubMed (publishedVersion)
- Project Muse (Johns Hopkins University) (submittedVersion)
- National University of Singapore (submittedVersion)
- DigitalGeorgetown (Georgetown University Library) (submittedVersion)
- Topics
- Health Sciences › Medicine › Public Health, Environmental and Occupational Health › Ethics and bioethics in healthcare
- Health Sciences › Medicine › Pediatrics, Perinatology and Child Health › Ethics and Legal Issues in Pediatric Healthcare
- Social Sciences › Arts and Humanities › Philosophy › Philosophical Ethics and Theory
- Keywords
- patient autonomy, best interests, surrogate decision-making, patient choice, authenticity, bioethics, moral values in medicine
- MeSH terms
- Attitude to Death, Decision Making, Ethics, Medical, Humans, Mental Competency, Proxy, Personal Autonomy
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