title: An ethical façade? Medical students' miscomprehensions of substituted judgment.
abstract: BACKGROUND
  We studied how well first-year medical students understand and apply the concept of substituted judgment, following a course on clinical ethics.
  
  
  METHODS
  Students submitted essays on one of three ethically controversial scenarios presented in class. One scenario involved a patient who had lost decisional capacity. Through an iterative process of textual analysis, the essays were studied and coded for patterns in the ways students misunderstood or misapplied the principle of substituted judgment.
  
  
  RESULTS
  Students correctly articulated course principles regarding patient autonomy, substituted judgment, and non-imposition of physician values. However, students showed misunderstanding by giving doctors the responsibility of balancing the interests of the patient against the interests of the family, by stating doctors and surrogates should be guided primarily by a best-interest standard, and by suggesting that patient autonomy becomes the guiding principle only when patients can no longer express their wishes.
  
  
  CONCLUSIONS
  Students did not appear to internalize or correctly apply the substituted judgment standard, even though they could describe it accurately. This suggests the substituted judgment standard may run counter to students' moral intuitions, making it harder to apply in clinical practice.
authors.affiliation: Department of Medicine, Section of General Internal Medicine, University of Chicago, Chicago, Illinois, United States of America. fcurlin@medicine.bsd.uchicago.edu
authors.forename: Farr A
authors.initials: FA
authors.lastname: Curlin
authors.forename: Ryan E
authors.initials: RE
authors.lastname: Lawrence
authors.forename: Julie
authors.initials: J
authors.lastname: Fredrickson
mesh_terms: D032882:Comprehension; D003657:Decision Making; D004992:Ethics, Medical; D006801:Humans; D007600:Judgment; D013337:Students, Medical