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Anosognosia in Hemiplegia: Toward a Process of Surrogate Decision-Making

Nutter, Gabriella Paige (2023) Anosognosia in Hemiplegia: Toward a Process of Surrogate Decision-Making. Master's Thesis, University of Pittsburgh. (Unpublished)

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Anosognosia is a condition in which patients lack awareness of their illness or impairment. Anosognosia in hemiplegia (AHP)—an unawareness of one’s one-sided paralysis—can occur following stroke. Without the ability to appreciate their paralysis and its consequences, patients with AHP lack the capacity to make certain decisions surrounding their stroke. However, AHP compromises patients’ ability to appreciate their paralysis without necessarily restricting other cognitive capacities. As a result, AHP raises questions regarding whether and how patients may be allowed to authorize or refuse treatment or enroll in research. For incapacitated patients without an advance directive, decision making authority is transferred to patients’ surrogates who would make decisions according to the substituted judgement standard. The outcome of employing this standard is only as reliable as the evidence on which is it based. Though patients with AHP fail to appreciate the experience and implications of paralysis, patients may retain specialized knowledge of their values and preferences that they can share with their surrogates even in their anosognosic state. This paper will demonstrate that patients with AHP can be involved in the decision-making process and that doing so assists surrogates in reconstructing these patients’ values and preferences. The first section will introduce anosognosia and some barriers to its classification before focusing on AHP. In the second section, I will argue that patients with AHP who lack decisional capacity can nevertheless be engaged in questioning involving hypothetical situations to solicit their view of their interests thereby contributing to decisions to manage their stroke in the acute setting. While surrogate decision-making is an appropriate strategy in the clinical setting, it is less justifiable in research owing to the added risks and burdens of participation for the benefit of others. The third section will demonstrate how engaging prospective subjects with AHP in the decision-making process may expand the range of research in which it is ethically justifiable for surrogate decision-makers to enroll people with AHP, if such enrollment is in line with the subjects’ values and preferences, or health-related interests.


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Item Type: University of Pittsburgh ETD
Status: Unpublished
CreatorsEmailPitt UsernameORCID
Nutter, Gabriella Paigegpn5@pitt.edugpn50009-0004-3662-1105
ETD Committee:
TitleMemberEmail AddressPitt UsernameORCID
Committee ChairParker, Lisa
Committee MemberWicclair, Mark
Committee MemberRosenstock, Jason
Date: 6 September 2023
Date Type: Publication
Defense Date: 8 May 2023
Approval Date: 6 September 2023
Submission Date: 18 June 2023
Access Restriction: No restriction; Release the ETD for access worldwide immediately.
Number of Pages: 131
Institution: University of Pittsburgh
Schools and Programs: Dietrich School of Arts and Sciences > Bioethics
Degree: MA - Master of Arts
Thesis Type: Master's Thesis
Refereed: Yes
Uncontrolled Keywords: Anosognosia in hemiplegia; Stroke; Surrogate decision-making; Informed consent
Date Deposited: 07 Sep 2023 01:37
Last Modified: 07 Sep 2023 01:37


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