The care of adult patients without decision-making abilities is a routine part of medical practice. Decisions for these patients are typically made by surrogates according to a process governed by a hierarchy of 3 distinct decision-making standards: patients' known wishes, substituted judgments, and best interests. Although this framework offers some guidance, it does not readily incorporate many important considerations of patients and families and does not account for the ways in which many patients and surrogates prefer to make decisions. In this article, the authors review the research on surrogate decision making, compare it with normative standards, and offer ways in which the 2 can be reconciled for the patient's benefit.

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Moral distress is the experience of cognitive-emotional dissonance that arises when one feels compelled to act contrary to one's moral requirements. Moral distress is common, but under-recognized in medical education and training, and this relative inattention may undermine educators' efforts to promote empathy, ethical practice, and professionalism. Moral distress should be recognized as a feature of the clinical landscape, and addressed in conjunction with the related concerns of negative role modeling and the goals and efficacy of medical ethics curricula.