Since several landmark legal decisions in the 1970s and 1980s, substituted judgment has become widely accepted as an approach to decision‐making for incapacitated patients that incorporates their autonomy and interests. Two notable exceptions have been cases involving minors and those involving cognitively or psychiatrically impaired individuals who never previously possessed the ability to contemplate the medical decisions involved in their care. While a best interest standard may have universal merit in pediatric cases, this paper argues that substituted (...) judgement has been rejected too broadly for “never‐capacitated” patients. It then lays out a three‐condition test for using substituted judgment in these cases. For a subset of “never‐capacitated” patients who belong to distinctive religious or cultural communities with clear medical values and have an appropriate surrogate, these values may prove helpful in vindicating the interests of the never‐capacitated and should not be blanketly dismissed. (shrink)

A primary goal of clinical practice is to respect patient autonomy. To promote this goal for patients who have lost the ability to make their own decisions, commentators recommend that surrogates make their treatment decisions based on the substituted judgment standard. This standard is commonly interpreted as directing surrogates to make the decision the patient would have made in the circumstances, if the patient were competent. However, recent commentators have argued that this approach—attempting to make the decision the (...) patient would have made if competent—is theoretically problematic, practically infeasible, and ignores the interests of the patient9s family and loved ones. These commentators conclude that the substituted judgment standard should be revised significantly, or abandoned altogether. While this response would avoid the cited problems, it also would require substantial changes to clinical practice and would raise significant problems of its own. The present paper thus considers the possibility that the criticisms do not point to problems with the substituted judgment standard itself; instead, they point to problems with the way it is most commonly interpreted. This analysis suggests that the substituted judgment standard need not be dramatically revised or abandoned. Instead, it should be interpreted in a way that effectively promotes respect for the autonomy of incompetent patients. The ‘endorsed life’ interpretation described here helps clinicians and surrogates to achieve this important goal. To clarify this approach, we explain how it differs from three other recently proposed alternatives to the standard interpretation of the substituted judgment standard. (shrink)

It is commonly thought that when a patient is unable to make a treatment decision for herself, patient autonomy should be respected by consulting the views of a patient surrogate, normally either the next-of-kin or a person previously designated by the patient. On one view, the task of this surrogate is to make the treatment decision that the patient would have made if competent. But this so-called ‘substituted judgment standard’ (SJS) has come in for has come in for (...) a good deal of criticism recently. For instance, some question whether surrogates are able to reliably predict what the patient would have chosen. Others wonder how respecting a patient's counter-factual, rather than actual, choices is supposed to respect her autonomy. Such concerns have lead some to reject the SJS and argue for alternative characterisations of the role of surrogate decision-makers. (shrink)

Patients who are incompetent need a surrogate decision maker to make treatment decisons on their behalf. One of the main ethical questions that arise in this context is what standard ought to govern such decision making. According to the Substituted Judgment Standard, a surrogate ought to make the decision that the patient would have made, had he or she been competent. Although this standard has sometimes been criticized on the grounds of being difficult to apply, it has found (...) wide appeal, since it it is alleged to protect incompetent patients? right to autonomy. The main purpose of the thesis is to evaluate SJS, from a conceptual and ethical perspective. It argues that the traditional formulation of SJS is seriously incomplete, and discusses alternative ways of completing it. Moreover, it questions the received view on how SJS should be morally justified, by offering arguments against the view that decision making in accordance with this standard extends the patient's opportunities for self-determination. Instead it suggests a virtue-ethical approach according to which the moral point of SJS-based decision making is not to protect the patient's interests, but to express respect for person. The thesis also critically assesses empirical studies according to which surrogates often fail to correctly predict patients? actual treatment preferences. It is shown that such results cannot, for a number of reasons, support the conclusion drawn that surrogates are ill-equipped to make decisions that comply with SJS. (shrink)

Consensus is growing among ethicists and lawyers that medical decision making for incompetent patients who were previously competent should be made in accordance with that person's prior wishes and desires. Moreover, this legal and ethical preference for the substituted judgment standard has found its way into the daily practice of medicine. However, what appears on the surface to be an agreement between jurists, bioethicists, and clinicians obscures the very real differences between disciplines regarding the actual implementation of the (...) sub stituted judgment standard. Ethicists and judges have carefully outlined how substituted judgments ought to be made and evaluated. Although differences arise, especially at the state court level, regarding the scope of the substituted judgment standard and its relation to other standards of surrogate decision making, agreement is fairly widespread on the priority of substituted judgment and on the necessity of sufficient evidence being available in order to support a particular substituted judgment. (shrink)

Substituted judgment has increasingly become the accepted standard for rendering decisions for incapacitated adults in the USA. A broad exception exists with regard to patients with diminished capacity secondary to depressive disorders, as such patients’ previous wishes are generally not honoured when seeking to turn down life-preserving care or pursue aid-in-dying. The result is that physicians often force involuntary treatment on patients with poor medical prognoses and/or low quality of life as a result of their depressive symptoms when (...) similarly situated incapacitated patients without such depressive symptoms would have their previous wishes honoured via substituted judgment. This commentary argues for reconsidering this approach and for using a substituted judgment standard for a subset of EMP/LQL patients seeking death. (shrink)

On a traditional interpretation of the substituted judgement standard a person who makes treatment decisions on behalf of a non-competent patient ought to decide as the patient would have decided had she been competent. I propose an alternative interpretation of SJS in which the surrogate is required to infer what the patient actually thought about these end-of-life decisions. In clarifying SJS it is also important to differentiate the patient's consent and preference. If SJS is part of an autonomy ideal (...) of the sort found in Kantian ethics, consent seems more important than preference. From a utilitarian perspective a preference-based reading of SJS seems natural. I argue that the justification of SJS within a utilitarian framework will boil down to the question whether a non-competent patient can be said to have any surviving preferences. If we give a virtue-ethical justification of SJS the relative importance of consent and preferences depends on which virtue one stresses-respect or care. I argue that SJS might be an independent normative method for extending the patient's autonomy, both from a Kantian and a virtue ethical perspective. (shrink)

The substituted judgement principle is often recommended as a means of promoting the self-determination of an incompetent individual when proxy decision makers are faced with having to make decisions about health care. This article represents a critical ethical analysis of this decision-making principle and describes practical impediments that serve to undermine its fundamental purpose. These impediments predominantly stem from the informality associated with the application of the substituted judgement principle. It is recommended that the principles upon which decisions (...) are made about health care for another person should be transparent to all those involved in the process. Furthermore, the substituted judgement principle requires greater rigour in its practical application than currently tends to be the case. It may be that this principle should be subsumed as a component of advance directives in order that it fulfils its aim of serving to respect the self-determination of incompetent individuals. (shrink)

Decision making for incompetent patients is a much-discussed topic in bioethics. According to one influential decision making standard, the substituted judgment standard, the decision that ought to be made for the incompetent patient is the decision the patient would have made, had he or she been competent. Although the merits of this standard have been extensively debated, some important issues have not been sufficiently explored. One fundamental problem is that the substituted judgment standard, as commonly formulated, (...) is indeterminate in content and thus offers the surrogate little or no guidance. What the standard does not specify is just how competent one should imagine the patient to be, and what else one ought to envision about the patient’s hypothetical outlook and the circumstances surrounding his or her decision making. The article discusses this problem of underdetermined decision conditions. (shrink)

According to the Substituted Judgment Standard a surrogate decision maker ought to make the decision that the incompetent patient would have made, had he or she been competent. This standard has received a fair amount of criticism, but the objections raised are often wide of the mark. In this article we discuss three objections based on empirical research, and explain why these do not give us reason to abandon the Substituted Judgment Standard.

The standard by which we apply decision-making for those unable to do so for themselves is an important practical ethical issue with substantial implications for the treatment and welfare of such individuals. The approach to proxy or surrogate decision-making based upon substituted judgement is often seen as the ideal standard to aim for but suffers from a need to provide a clear account of how to determine the validity of the proxy's judgements. Proponents have responded to this demand by (...) providing the truth-conditions for the substituted judgement in terms of counterfactual reasoning using a possible worlds semantics. In this paper, I show how these underpinnings fail to support the substituted judgement approach as a reasonable standard for decision-making. Firstly, I show how this counterfactual element has been poorly interpreted. I then explain how various accounts have failed to reflect problems and limitations associated with providing an interpretation of their truth-conditions using counterfactuals. Finally, I argue that, even when we attend to the initial problems of providing a counterfactual analysis, it still deeply problematic as a means of determining the validity of substituted judgements for two main reasons. Firstly, making determinate judgements as to the truth-value of these judgements will often not be possible and, secondly, there is a strong requirement when interpreting many counterfactual claims to charitably accede to their being true. I conclude that substituted judgements, as interpreted through counterfactual reasoning and possible worlds semantics, do not therefore provide an adequate standard for surrogate decision-making. (shrink)

The urgency of the resuscitation and the impaired ability of the patient to make a reasonable autonomous decision both conspire against adequate consideration of the principles of medical ethics. Informed consent is usually not possible for these reasons and this leads many to consider that consent is not required for resuscitation, because resuscitation brings benefit and prevents harm and because the patient is not in a position to give or withhold consent. However, consent for resuscitation is required and the common (...) models employed for this purpose are presumed consent or consent from a patient proxy. However, if we are to honour the principles of respect for patient autonomy, as well as beneficence and non-maleficence, when starting and continuing resuscitation we must try and achieve the best balance between benefit and harm from the patient's perspective. The concept of professional substituted judgment involves the resuscitators gathering as much information about the patient as they possibly can, including any previously expressed attitudes towards such a situation, and combining this with their acquired professional knowledge of the likely benefits and harms of the resuscitation endeavour and then exercising their moral imagination, imagining themselves as the patient, and asking "would I want this treatment?" By employing professional substituted judgment resuscitators should recognise when the balance of benefit and harm becomes unfavourable from the patient's perspective and at this point they have a moral obligation to withdraw resuscitation as they can no longer presume the patient's consent. In this way the principles of beneficence, non-maleficence and respect for patient autonomy are more favourably balanced than under other resuscitation decision making processes. (shrink)

The American Journal of Bioethics, Volume 12, Issue 10, Page 45-47, October 2012.

The first section introduces a distinction between 2 families of cognitive operations, called System 1 and System 2. The second section presents an attribute-substitution model of heuristic judgment, which elaborates and extends earlier treatments of the topic. The third section introduces a research design for studying attribute substitution. The fourth section discusses the controversy over the representativeness heuristic. The last section situates representativeness within a broad family of prototype heuristics, in which properties of a prototypical exemplar dominate global judgments (...) concerning an entire set. (shrink)

There are two main ways of understanding the function of surrogate decision making in a legal context: the Best Interests Standard and the Substituted Judgment Standard. First, we will argue that the Best Interests Standard is difficult to apply to unconscious patients. Application is difficult regardless of whether they have ever been conscious. Second, we will argue that if we accept the least problematic explanation of how unconscious patients can have interests, we are also obliged to accept that (...) the Substituted Judgment Standard can be coherently applied to patients who have never been conscious at the same extent as the Best Interests Standard. We then argue that acknowledging this result is important in order to show patients respect. (shrink)

Substituted judgement is often used in the absence of advanced directives to guide decision-making when patients lack decisional capacity. We present a remarkable case of family members exercising substituted misjudgement for a 42-year-old man hospitalized with multiorgan failure on life support. Feeling that their loved one would rather die than face severe disability, they elected to withdraw life support. Although this was done, the patient remained alive and recovered enough to clearly indicate his preference for life, even with (...) severe disability. This case suggests that in instances of unusual quality-of-life judgements where the patient's wishes cannot be known with reasonable certainty, families and physicians should be very wary using substituted judgement to refuse life support. Unless there are strong considerations based on the patient's prior statements, actions and values to decline life support, it would seem ethically appropriate to continue treatment, even with substantial disability the likely outcome. (shrink)

The so-called Substituted Judgment Standard is one of several competing principles on how certain health care decisions ought to be made for patients who are not themselves capable of making decisions of the relevant kind. It says that a surrogate decision-maker, acting on behalf of the patient, ought to make the decision 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 protects patients’ right to autonomy, or self-determination, in the situation where they are no longer able to exercise this right on their own. In this paper we question this justification, by arguing that the most commonly suggested moral reasons for allowing and encouraging people to make their own choices seem not 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. (shrink)

ZusammenfassungEin Großteil der medizinisch und ethisch schwierigen Therapieentscheidungen betrifft kritisch kranke, einwilligungsunfähige Patienten und wird auf Basis des mutmaßlichen Patientenwillens getroffen. Das Gesetz kann hierzu nur allgemeine Vorgaben geben. Es ist für die behandelnden Ärzte essentiell, sich ein konkretes Vorgehen zu erarbeiten. Wie in der Praxis vorgegangen wird, ist bisher kaum untersucht. Ziel dieser Studie ist es, die Vielfalt der Herangehensweisen und Erfahrungen von Klinikern zum mutmaßlichen Patientenwillen zu erforschen. Wir führten semistrukturierte Interviews mit 18 Ärzten und elf Pflegekräften von (...) intensiv- und palliativmedizinischen Abteilungen eines Universitätsklinikums durch. Die Abschriften der Tonaufnahmen wurden mithilfe der Qualitativen Datenanalyse ausgewertet. Auf einer numerischen Ratingskala wurde erhoben, wie hilfreich die Kliniker das Konzept des mutmaßlichen Willens fanden. Die meisten Studienteilnehmer hielten das Konzept des mutmaßlichen Willens für sehr hilfreich. Zu ihrem Vorgehen berichteten sie, dass sie zumeist die nächsten Angehörigen befragen, zuweilen auch Professionelle und falls möglich die Patienten selbst. Gefragt werde nach früheren Äußerungen der Patienten, nach ihrer Lebenspraxis und -einstellung sowie ihrem aktuellen Verhalten. Benannt wurden auch zahlreiche Unsicherheiten und Schwierigkeiten psychologischer, sozialer, praktischer und konzeptioneller Natur. Der mutmaßliche Patientenwille wird, so unser Ergebnis, in der von uns untersuchten klinischen Praxis entsprechend den gesetzlichen Vorgaben ermittelt. Da jedoch zahlreiche Probleme berichtet werden, stellen wir konkrete Empfehlungen zur Ermittlung des mutmaßlichen Willens vor. (shrink)

In the literature three mechanisms are commonly distinguished to make decisions about the care of incompetent patients: A living will, a substituted judgment by a surrogate (who may or may not hold the power of attorney ), and a best interest judgment. Almost universally, the third mechanism is deemed the worst possible of the three, to be invoked only when the former two are unavailable. In this article, I argue in favor of best interest judgments. The evermore (...) common aversion of best interest judgments entails a risk that health care providers withdraw from the decision-making process, abandoning patients (or their family members) to these most difficult of decisions about life and death. My approach in this article is primarily negative, that is, I criticize the alleged superiority of the living will and substituted judgment. The latter two mechanisms gain their alleged superiority because they are supposedly morally neutral, whereas the best interest judgment entails a value judgment on behalf of the patient. I argue that on closer inspection living wills and substituted judgments are not morally neutral; indeed, they generally rely on best interest judgments, even if those are not made explicit. (shrink)

The Substituted Judgment Standard for surrogate decision-making dictates that a surrogate, when making medical decisions on behalf of an incapacitated patient, ought to make the decision that the patient would have made if the patient had decisional capacity. Despite its intuitive appeal, however, SJS has been the target of a variety of criticisms. Most objections to SJS appeal to epistemic difficulties involved in determining what a patient would have decided in a given case. In this article, I offer (...) an alternative standard for surrogate decision-making that avoids these difficulties. I then offer an account of its theoretical underpinnings which shows that it preserves the central moral justification for SJS, namely, respect for patient autonomy. (shrink)

Expressivism is a blossoming meta-semantic framework sometimes relying on what Carter and Chrisman call “the core expressivist maneuver.” That is, instead of asking about the nature of a certain kind of value, we should be asking about the nature of the value judgment in question. According to expressivists, this question substitution opens theoretical space for the elegant, economical, and explanatorily powerful expressivist treatment of the relevant domain. I argue, however, that experimental work in cognitive psychology can shed light on (...) how the core expressivist maneuver operates at the cognitive level and that this: raises worries about the aptness of the expressivist question substitution and supports an evolutionary debunking argument against expressivism. Since evolutionary debunking arguments are usually run in favor of expressivism, this creates an obvious puzzle for expressivists. I wrap up by briefly responding to the objection that the debunking argument against expressivism overgeneralizes and, therefore, should be rejected. (shrink)

When making substituted judgments for incapacitated patients, surrogates often struggle to guess what the patient would want if they had capacity. Surrogates may also agonize over having the (sole) responsibility of making such a determination. To address such concerns, a Patient Preference Predictor (PPP) has been proposed that would use an algorithm to infer the treatment preferences of individual patients from population-level data about the known preferences of people with similar demographic characteristics. However, critics have suggested that even if (...) such a PPP were more accurate, on average, than human surrogates in identifying patient preferences, the proposed algorithm would nevertheless fail to respect the patient’s (former) autonomy since it draws on the ‘wrong’ kind of data: namely, data that are not specific to the individual patient and which therefore may not reflect their actual values, or their reasons for having the preferences they do. Taking such criticisms on board, we here propose a new approach: the Personalized Patient Preference Predictor (P4). The P4 is based on recent advances in machine learning, which allow technologies including large language models to be more cheaply and efficiently ‘fine-tuned’ on person-specific data. The P4, unlike the PPP, would be able to infer an individual patient’s preferences from material (e.g., prior treatment decisions) that is in fact specific to them. Thus, we argue, in addition to being potentially more accurate at the individual level than the previously proposed PPP, the predictions of a P4 would also more directly reflect each patient’s own reasons and values. In this article, we review recent discoveries in artificial intelligence research that suggest a P4 is technically feasible, and argue that, if it is developed and appropriately deployed, it should assuage some of the main autonomy-based concerns of critics of the original PPP. We then consider various objections to our proposal and offer some tentative replies. (shrink)

In this paper I argue that a variety of consequence relations can be subsumed under a common core. The reduction proceeds by taking the unconditional consequence, or judgment, as basic and deriving the conditional consequence via a uniform abstraction scheme. A specific outcome is that it is better not to base such a scheme on the semantic notion of a matrix and valuation but rather on theories and substitutions. I will also briefly look at consequence relations that are not (...) reducible in this way. (shrink)

The program of research now known as the heuristics and biases approach began with a study of the statistical intuitions of experts, who were found to be excessively confident in the replicability of results from small samples. The persistence of such systematic errors in the intuitions of experts implied that their intuitive judgments may be governed by fundamentally different processes than the slower, more deliberate computations they had been trained to execute. The ancient idea that cognitive processes can be partitioned (...) into two main families--traditionally called intuition and reason--is now widely embraced under the general label of dual-process theories. Dual-process models come in many flavors, but all distinguish cognitive operations that are quick and associative from others that are slow and governed by rules. To represent intuitive and deliberate reasoning, we borrow the terms "system 1" and "system 2" from Stanovich and West. In the following section, we present an attribute-substitution model of heuristic judgment, which assumes that difficult questions are often answered by substituting an answer to an easier one. Following sections introduce a research design for studying attribute substitution, as well as discuss the controversy over the representativeness heuristic in the context of a dual-system view that we endorse. The final section situates representativeness within a broad family of prototype heuristics, in which properties of a prototypical exemplar dominate global judgments concerning an entire set. (shrink)

This article proposes a novel integrative approach to moral judgment and a related model that could explain how unconscious heuristic processes are transformed into consciously accessible moral intuitions. Different hypothetical cases have been tested empirically to evoke moral intuitions that support principles from competing moral theories. We define and analyze the types of intuitions that moral theories and studies capture: those focusing on agents (A), deeds (D), and consequences (C). The integrative ADC approach uses the heuristic principle of “attribute (...) substitution” to explain how people make intuitive judgments. The target attributes of moral judgments are moral blameworthiness and praiseworthiness, which are substituted with more accessible and computable information about an agent's virtues and vices, right/wrong deeds, and good/bad consequences. The processes computing this information are unconscious and inaccessible, and therefore explaining how they provide input for moral intuitions is a key problem. We analyze social heuristics identified in the literature and offer an outline for a new model of moral judgment. Simple social heuristics triggered by morally salient cues rely on three distinct processes (role-model entity, action analysis, and consequence tallying—REACT) in order to compute the moral valence of specific intuitive responses (A, D, and C). These are then rapidly combined to form an intuitive judgment that could guide quick decision making. The ADC approach and REACT model can clarify a wide set of data from empirical moral psychology and could inform future studies on moral judgment, as well as case assessments and discussions about issues causing “deadlocked” moral intuitions. (shrink)

Do the humanities have a future? In the face of an increased emphasis on the so-called practical applicability of education, some educators worry that the presence of humanistic study in schools and universities is gravely threatened. In the short-term, scholars have rallied to defend the humanities by demonstrating how they do, in fact, advance our practical interests. Martha Nussbaum, for example, argues that the humanities uniquely support democratic citizenship by cultivating critical thinking and narrative imagination — two skills needed for (...) the development of sympathetic and autonomous judgment. Defending the humanities in this manner, however, puts practitioners of the humanities in an impossible position. In this essay, Megan Laverty explains that while arguments such as Nussbaum's, which defend the instrumental value of the humanities, are persuasive and strategic, their use is double-edged. They belie the fact that the humanities are valuable for their own sake. Such arguments imply that the humanities derive their value from their ability to provide extrinsic benefits such as critical thinking and narrative imagination. Moreover, they can prevent individuals from discovering that the value of the humanities is revealed over time and from the inside out. In fact, having to answer the question of why the humanities matter puts us in an impossible position precisely because humanistic study is what Laverty describes, drawing upon the work of Talbot Brewer and R. F. Holland, as a form of dialectical activity: one in which the activity's constitutive ideals and internal goods are progressively clarified by means of the individual's ongoing engagement in the activity itself. Having redescribed the humanities as intrinsically valuable, Laverty goes on to distinguish humanistic study from other forms of dialectical activity, arguing that the humanities call upon students to imagine alternative linguistic and conceptual possibilities — thereby connecting us with others. It is in the pursuit of this question about the nature of our humanity — not its answer, but the question itself — that the meaning of humanistic study continues, indefinitely, to unfold. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Philosophy and Literature 25.1 (2001) 177-180 [Access article in PDF] Book Review How to Defend Humane Ideals: Substitutes for Objectivity How to Defend Humane Ideals: Substitutes for Objectivity, by James R. Flynn; ix & 212 pp. Lincoln: University of Nebraska Press, 2000, $40.00. James Flynn's search for non-objective grounds for humane ideals opens with an admission that the author spent decades searching for an "ethical truth-test" by which to (...) measure ideals. This truth-test would constitute a "higher court of appeals," a nonpartisan judgment of right and wrong that would grant objectivity to the winning belief. This is the stance of Socrates and Kant. What Flynn came to realize was that the truth-tests he sampled proved to be contradictory, easily exploited, and ineffectual in convincing people of the tests' warrant. For many this collapse of ethical truth leads to relativism, and a concomitant tolerance of the values of others, however repellant one finds them. This is the stance of the postmodernists, those dedicated to "building bonfires to celebrate the demise of the Enlightenment" (p. 181). But Flynn deems the anti-truth position just as contradictory and exploitable as the truth-test position. Instead, he proposes an intermediate stance, short of objective truth but more than relativist assertion, an outlook that takes the best of truth, beauty, diversity, perfectibility, utilitarianism, and justice and casts them in a relation of trade-off and compromise.To reach this negotiation model of humaneness, Flynn must dispense with [End Page 177] three faulty beliefs. The first mistake is the objective one, that is, the reliance on ethical truth-tests (chapters 2-4). The problem lies in their grounding in "a theory of being that posits something beyond the physical universe... or that asserts that the physical universe contains something not revealed by science, such as the purposes of nature" (pp. 47-48). Plato has his Forms, Rousseau his nature, Moore his "moral goodness." The difficulty with these criteria is that, granted their existence, we know not how to apply them to human affairs. We may appeal to God to justify our actions, but in doing so "we tend to assume that God's overriding criterion of moral rectitude is similar to our own. The humane posit a benevolent God, the not so humane a stern God" (p. 72). In other words, such criteria beg the question of their use. Their transcendence of the world renders them eminently adaptable to various worldly designs, for example, when Kant reads into nature "whatever content he needs to get decisions in favor of his own principles" (p. 77).When ethical truth-tests fail in their implementation, the temptation is to reject ethical grounds altogether. Flynn terms this the "nihilist fallacy," the notion that if there is no extra-human ground for ethics, no ethical truth-test, then no ethic is justified. Flynn counters that "Even in the absence of a truth-test, people may internalize ideals and be deeply committed to them" (p. 9). They believe in those ideals not because they think they are true, but because they think they are right. Only those who believe that ethical beliefs are an epistemological matter assume that ideals must be shored up by evidence and proven to be correct. It is ironic, Flynn notes, that it is anti-epistemologists like Nietzsche who make this argument, claiming that ethical believers fail a truth-test when in fact those believers are not interested in truth-testing at all.The flip side of this nihilism is postmodernism, another ethical outlook Flynn rejects. Nihilists and postmodernists share an epistemological skepticism, treating putatively objective ideals as disguised power plays concocted to promote certain interests. They differ in how they direct that skepticism. For the Nietzschean nihilist, the interests are those of the herd and its institutions (like the Church), and so he counsels great geniuses to use lesser persons as means to their ends (pp. 127-33). For the postmodernist, the interests are those of the Western male, the naive empiricist, the imperialist, and so he counsels those privileged individuals to examine themselves... (shrink)

Philosophers such as Dan Brock believe that surrogates who make health care decisions on behalf of previously competent patients, in the absence of an advance directive, should make these decisions based upon a substituted judgment principle. Brock favours substituted judgment over a best interests standard. However, Edward Wierenga claims that the substituted judgment principle ought to be abandoned in favour of a best interests standard, because of an inherent problem with the substituted (...) class='Hi'>judgment principle. Wierenga's version of the substituted judgment principle and his counterexample to the principle's successful interpretation of valid surrogate consent is presented. A new version of what is meant by the substituted judgment principle is advanced. The new version is not beset with the problems Wierenga initially ascribed to the substituted judgment principle. (shrink)