LAUSR

The question of how to treat an incapacitated patient is vexed, both normatively and practically—normatively, because it is not obvious what the relevant objectives are; practically, because even once the relevant objectives are set, it is often difficult to determine which treatment option is best given those objectives. But despite these complications, here is one consideration that is clearly relevant: what a patient prefers. And so any device that could reliably identify a patient’s preferences would be a promising tool for guiding the treatment of incapacitated patients. The patient preference predictor (PPP) is just such a tool—an algorithm that takes as inputs a patient’s sociodemographic characteristics, and outputs a reliable prediction about that patient’s treatment preferences. But some have worried that the use of such a tool would violate or fail to appropriately respect patients’ autonomy. There are, I think, two ways to understand this kind of criticism. First, globally—as a worry that any systematic implementation of the PPP would be problematic on the grounds that it would result in significant or pervasive autonomy violations. Second, locally—as a worry that in some important (but possibly narrow) range of cases, certain uses of the PPP would be problematic on autonomy grounds. Jardas et al, as I read them, address global autonomybased criticisms, arguing—convincingly, in my view—that there’s no reason to suspect the autonomy concerns raised by the PPP would be so significant and pervasive as to render any implementation of it generally problematic. But even with the global criticisms rebuffed, there remains work to be done. Any ethically acceptable implementation of the PPP must be sensitive to the more local autonomybased criticisms, with restrictions and safeguards in place to ensure respect for autonomy in the kinds of cases in which the use of the PPP might otherwise threaten it. Here, drawing on a distinction between two types of autonomy considerations, I’ll raise some of these more local autonomybased criticisms and use them to motivate some restrictions on the PPP’s use. As Jardas et al note, there are (at least) two ways in which autonomy is morally important. An autonomous agent is capable of governing her life, in accordance with her commitments. And, as such, we can respect an autonomous agent’s autonomy in two distinct ways: we can allow or ensure that they are the one that does their life’s governing, or we can allow or ensure that their life goes in a way that (best) accords with their commitments. Call the former autonomyassovereignty and the latter autonomyasauthenticity. Clearly distinguishing between these two types of autonomy considerations can (1) help us to more readily identify the kinds of cases in which the PPP might undermine patient autonomy; (2) allow us to more precisely state exactly how the PPP undermines patient autonomy in such cases and (3) facilitate the development of targeted restrictions and safeguards to protect patient autonomy in such cases. To start, consider autonomyassovereignty. Jardas et al mention it, then quickly set it aside: “use of the PPP cannot fail to respect patient autonomy in this [sovereignty] sense” because it “is intended for patients who lack the capacity to determine the course of their lives.” But this is too quick. First, a small but important point: decisionmaking capacity is decision specific, and a patient might lack the capacity to make many medical decisions while retaining the capacity to decide whether the PPP is