Historical Context
Also known as a “living will”, “declaration of determining the termination of life”, and “testament permitting death,” the idea behind this document was derived from the common law premise that a patient may not be subjected to treatment without their consent.
By this standard, advanced directives are useful mechanisms for reconstructing what the patient would have wanted, in the circumstances at hand, if they had decision-making capacity, with the underlying moral principle being respect for autonomy.
What is the Substituted Judgement standard?
This approach attempts to establish priority between the former and current self's interests by claiming once the current self falls below a certain capacity, their current interests are so marginal as to no longer be authoritative for how they should be cared for, and therefore the interests of the former self come first.
What is the Threshold of Authority approach?
A TIME review from 1975 stated “Many doctors... are taught to regard death as an enemy and to do all they can to defeat it... Many regard “pulling the plug” as an act akin to euthanasia, which is forbidden by both law and the medical code.” This sentiment is contrary to Paul Kalanithi's claim that this act should not be the goal of physicians.
What is saving lives?
This model does not champion an absolute defense of all incompetent preferences, but rather challenges the moral authority of advance directives by exposing their roots in overemphasized notions of rational autonomy in Western bioethics.
What is the Ethics of Care Model?
For the first time in the 1960/70s, these developments in medicine made it difficult to distinguish saving a life from prolonging suffering and death.
What are technological developments?
Used when there is little or no information about the patient's specific values and preferences, this standard uses the underlying moral principle of beneficence to decide, in general, what would be good for the patient.
What is the Best Interests standard?
American philosopher Ronald Dworkin argued that in crossing the threshold of a global loss of capacity, one ceases to be a being of this certain kind, thereby defending the capacity for autonomy as the relevant threshold.
What is a morally privileged kind?
Dworkin draws a distinction between experiential interests and critical interests, which are similar to this type of desire discussed in class which make one's life good as a whole when satisfied.
What are second order desires?
In reference to dementia patients, Rebecca Dresser's response to Cantor's arguments highlights how advance directives fail to capture interests as they evolve over time, and that when we dichotomize the identities of the patient before and after dementia, advance directives risk perpetuating this type of discrimination against post-dementia persons.
What is ableist discrimination?
What are proxy provisions?
By the Orthodox Legal view, the use of advanced directives is appropriate for patients who are classified as this, meaning they once had relevant decision-making capacity (ex. those with Alzheimer's).
What is formerly competent?
An alternative argument to Dworkin's defense of autonomy as the relevant threshold claims so long as an individual still has these, they remain a being of a morally privileged type, and interests stemming from these have authority in determining how the individual is treated.
What are values?
This author, whose work was read in class, would argue a patient's advanced directive requesting to die should be honored once they reach a point of such unbearable pain that they are no longer their rational self, can no longer act autonomously, and therefore can no longer live with dignity.
Who is Velleman?
A patient in the middle stages of Alzheimer's disease may retain genuine values (ex. family ties, or the conviction that helping others is good), yet due to a rapid deterioration of short-term memory, they may be perpetually confused and unable to figure out how to enact these values in the concrete circumstances of life. The set of values such a patient retains would typically be a curtailment of the original set, introducing the potential for conflict between the interests of the earlier and current self. By this previously mentioned philosopher's arguments, the patient's current interests should not override their earlier interests because they have lost their standing as an autonomous agent.
Who is Dworkin?
In the absence of advance directives, 46 states have these: laws that create a list of permissible replacements for medical decisions, ranging from only close immediate family to “close friend.”
What are default surrogate consent laws?
Patients who never had relevant decision-making capacity, because either it did not develop or because of permanent brain deficiency, are considered this. The Orthodox Legal view says the Best Interests standards is most applicable in these cases.
What is never-been competent?
One challenge to the threshold of capacity principle says in the wake of a drastic transformation of one's psychology, one does not survive as numerically the same individual, and the interests of the current self overrule those of the former. However, philosophers Buchannan and Brock argue if one ceases to exist by turning into a nonperson, they retain this type of right to control the resulting nonperson.
What is a quasi-property right?
Author Norman Cantor argued administering life-saving treatment against a dementia patient’s advance directive violates the prior rational autonomy of the patient, an argument resisted by some because, similar to arguments highlighted in the RadioLab podcast for class, of the reliance on these characteristic notions of autonomy and dignity.
What are Western notions?
Consider the hypothetical case of a creative woman whose life has been devoted to intellectual work, and believes that living with dementia would be horribly degrading for her life as a whole. The creative woman signs an advance directive stipulating her refusal to receive life-saving treatment if she contracts a fatal condition while mentally incompetent. She eventually enters the late stages of dementia and contracts pneumonia, which is fatal without penicillin. However, she no longer remembers her advance directive and appears content with her life, now expressing a desire to live when asked. A proponent of the Ethics of Care Model might respond this way when asked if the woman's healthcare provider should honor her advance directive or administer treatment to satisfy her current desire to live.
A patient's life should not be prematurely ended without further narrative investigation solely on the basis of an advanced directive. Showing respect for a patient's autonomy does not mean listening only to their current desires. However, sometimes caring for a patient requires revisiting their advanced directive to understand the prior values a patient seeks to retain, as well as critically assessing whether current requests/choices stem from values that are important to the patient’s ongoing narrative.
While advance directives offer patients a standardized tool to express their wishes about life-sustaining treatment in the event of a terminal condition or permanent unconsciousness, they offer providers this form of protection for complying with a patient's wishes in good faith.
What is statutory immunity?
Because the Orthodox Legal view overlooks the possibility of this between the earlier competent self and the current incompetent self, advance directives are arguably best suited for the contexts they were originally developed for — conditions involving loss of consciousness such as persistent vegetative state.
What are conflicting interests?
Arguments in favor of the threshold of capacity principle claim the former self is one of these, and that their interests are associated with the dominant, more substantial and lengthy part of life which creates one unified life-segment.
What is a higher self?
This methodology acts as an alternative to the traditional emphasis on rational autonomy in addressing conflicts between past and current desires of dementia patients, and calls for an intimate understanding of a patient's identity to inform a treatment plan that addresses the plot twists of unexpected illness or loss, similar to how in When Breath Becomes Air, Paul worked closely with his doctor to find new meaning and purpose with the time he had left.
What is narrative methodology?
Jaworska, Agnieszka, "Advance Directives and Substitute Decision-Making", The Stanford Encyclopedia of Philosophy (Summer 2017 Edition), Edward N. Zalta (ed.), URL = <https://plato.stanford.edu/archives/sum2017/entries/advance-directives/>.
Sabatino CP. The evolution of health care advance planning law and policy. Milbank Q. 2010;88(2):211-239. doi:10.1111/j.1468-0009.2010.00596.x
Choi WJ. Ethics of care challenge to advance directives for dementia patients. J Med Ethics. 2022. https://link.ezproxy.neu.edu/login?url=https://www.proquest.com/scholarly-journals/ethics-care-challenge-advance-directives-dementia/docview/2724373040/se-2. doi: https://doi.org/10.1136/jme-2022-108475.
What are Works Cited?