Even if a person has an advance directive, it is frequently written in general terms.  The living will only provide a blueprint of the person’s preferences on end-of-life care. It is not possible to cover all aspects and specifics of care or interventions in the living will. There are hosts of medical conditions, treatments or procedures that may arise when the patient becomes incompetent or incapacitated.

A surrogate steps in when the person is no longer capable of making healthcare decisions. If there are situations and medical interventions that may be needed, the surrogate would decide based on his/her knowledge of the patient’s values and beliefs.

The Ethical and Religious Directives reiterates that surrogates should make decisions that are in line with the Catholic moral principles and to the person’s intentions and values or to the person’s best interests if intentions are unknown.[1]

The surrogate would act as the patient would act if he/she is competent to choose even if what the patient has requested is not what the surrogate would choose for himself. This is called the substituted judgment standard.[2] When the surrogate is not sure what the patient would want, he/she should follow the “best interests” standard on the patient’s behalf. The best interest standard considers the entire physical, moral, emotional and spiritual good of the patient.[3]

A healthcare surrogate should be familiar with the principal’s values, principles, and beliefs.

It is important to identify a healthcare surrogate, who is familiar with the patient and who has the moral and legal authority to address or interpret vague issues not specified in the declaration of living will.

The age and maturity of the designated surrogate must be considered.

The principal must appoint a surrogate with care. It is important to choose a person who truly knows you.  They must have shared a significant time to know the person’s values and preferences. The surrogate should be 18 years of age or older and should be accessible, at least by a phone call. It is important that the principal must choose a person of character, maturity since he/she may be going to make a difficult decision on behalf of the patient.

Appoint only one surrogate.

It is recommended to appoint only one surrogate to avoid conflict. An alternate surrogate needs to be identified in an event that the primary may no longer be capable to discharge surrogate duties.[4]

Surrogates cannot act whatever they wanted for the patient.

The surrogate does not have a blank check to decide whatever he/she wants for the patient. Those who provide care have legal as well as moral responsibilities to follow the advance directive unless there is a convincing proof that a certain preference or request may not serve the patient’s interest, or when it violates the rights of others.  The Hasting’s Center clarifies the limitations of surrogates in its guidelines for end-of-life decisions:

If the responsible professional has concerns about the ability of a surrogate to make treatment decisions in keeping with the standards for surrogate decision-making, the professional may seek an ethics consultation to determine whether the surrogate understands the obligations of surrogate decision making and can discharge them. On occasion, judicial review may be necessary.[5]



[1] USCCB, Ethical and Religious Directives, No. 25.

[2] Matthew P. Lomanno, ”Healthcare Proxy and Advance Directives,” in Catholic Healthcare Ethics: A Manual for Practitioners, 216.

[3] Matthew Lomanno, “Healthcare Proxies and Advance Directives,” 216.

[4] Virginia Catholic Conference, Catholic Advance Medical Directive,5.

[5]  Berlinger, Jennings and Wolf, The Hastings Center Guidelines, 64.

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