When patients are too ill to make their own health care decisions and lack a previously designated decision maker, identifying the appropriate surrogate can be a complex process. For example, clinicians may use surrogacy ladders (hierarchical lists of individuals who could serve as decision makers), which are delineated in state statutes.1 Although patients with incapacitating illness are inherently vulnerable, there are additional considerations for people who are incarcerated, and these may not be addressed in state laws. We discuss the selection of surrogates for incarcerated patients and who should or should not serve in this role.