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Deciding on behalf of others: a population survey on procedural preferences for surrogate decision-making
  1. Renato Frey1,2,
  2. Stefan M Herzog2,
  3. Ralph Hertwig2
  1. 1 Center for Cognitive and Decision Sciences, Department of Psychology, University of Basel, Basel, Switzerland
  2. 2 Center for Adaptive Rationality, Max Planck Institute for Human Development, Berlin, Germany
  1. Correspondence to Dr Renato Frey; renato.frey{at}


Objectives To assess people’s procedural preferences for making medical surrogate decisions, from the perspectives of both a potential surrogate and an incapacitated patient.

Design Computer-assisted telephone interviews. Respondents were randomly assigned either the role of an incapacitated patient or that of a potential surrogate for an incapacitated family member. They were asked to rate six approaches to making a surrogate decision: patient-designated surrogate, discussion among family members, majority vote of family members’ individual judgements, legally assigned surrogate, population-based treatment indicator and delegating the decision to a physician.

Setting Germany and German-speaking and French-speaking parts of Switzerland.

Participants 2010 respondents were quota sampled from a panel (representative for the German and German-speaking and French-speaking Swiss populations, respectively, in terms of age, sex and regions).

Main outcome measures Endorsement of each approach (rated on a scale from 1 to 10). Degree to which preferences overlap between the perspective of potential surrogates and potential patients.

Results Respondents’ endorsement of the six different approaches varied markedly (from Mdn=9.3 to Mdn=2.6). Yet the preferences of respondents taking the perspective of incapacitated patients corresponded closely with those of respondents taking the perspective of a potential surrogate (absolute differences ranging from 0.1 to 1.3). The preferred approaches were a patient-designated surrogate (Mdn=9.3) and all family members making a collective decision by means of group discussion (Mdn=9.3). The two least-preferred approaches were relying on a statistical prediction rule (Mdn=3.0) and delegating the decision to a physician (Mdn=2.6).

Conclusions Although respondents taking the perspective of an incapacitated patient preferred a patient-designated surrogate, few people have designated such a surrogate in practice. Policy-makers may thus consider implementing active choice, that is, identifying institutional settings in which many people can be reached (eg, when obtaining a driver’s licence) and requesting them to complete advance directives and to designate a specific surrogate. Moreover, potential patients and surrogates alike highly valued shared surrogate decisions among family members. Policy-makers may consider acknowledging this possibility explicitly in future legislation, and caregivers and physicians may consider promoting shared surrogate decisions in practice.

  • substituted judgement
  • procedural preferences
  • population survey
  • advance directives
  • living will

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  • Contributors RF, SMH and RH designed the study. RF performed the analyses. RF wrote the manuscript and SMH and RH provided critical revisions. RF is the guarantor.

  • Funding This research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Patient consent Not required.

  • Ethics approval As this survey was a non-clinical study and did not involve any patients, it did not classify as requiring in-depth evaluation and approval by a cantonal review board according to Swiss federal law. The “Ethikkommission Nordwest- und Zentralschweiz”, EKNZ (i.e., the successor board to the “Ethikkommission beider Basel”, EKBB, which was operating at the time of the study) has subsequently issued a declaration of no objection.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data sharing statement The full dataset is available at

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