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J Med Philos. 2014 Apr;39(2):187-95. doi: 10.1093/jmp/jhu010. Epub 2014 Feb 19.

Improving medical decisions for incapacitated persons: does focusing on "accurate predictions" lead to an inaccurate picture?

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*Center for Bioethics and Social Sciences in Medicine, North Campus Research Complex, 2800 Plymouth Road, Building 16, Room 422W, Ann Arbor, MI 48109-2800, USA.


The Patient Preference Predictor (PPP) proposal places a high priority on the accuracy of predicting patients' preferences and finds the performance of surrogates inadequate. However, the quest to develop a highly accurate, individualized statistical model has significant obstacles. First, it will be impossible to validate the PPP beyond the limit imposed by 60%-80% reliability of people's preferences for future medical decisions--a figure no better than the known average accuracy of surrogates. Second, evidence supports the view that a sizable minority of persons may not even have preferences to predict. Third, many, perhaps most, people express their autonomy just as much by entrusting their loved ones to exercise their judgment than by desiring to specifically control future decisions. Surrogate decision making faces none of these issues and, in fact, it may be more efficient, accurate, and authoritative than is commonly assumed.


advance directive; decisional capacity; end of life decision making; surrogate

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