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Reassessing the Reliability of Advance Directives

Published online by Cambridge University Press:  29 July 2009

Thomas May
Thomas May
Affiliation:
Clinical Ethicist in the Clinical Ethics Center at Memorial Medical Center, Springfield, Illinois, and Adjunct Assistant Professor in the Department of Medical Humanities, Southern Illinois University School of Medicine, Springfield.
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Extract

A competent patient has the right to refuse treatment necessary to sustain life. However, for many end-of-life decisions, we lack direct access to the wishes of a competent patient. Some treatment decisions near the end of life involve patients with severely diminished mental capacity (for example, Alzheimer's patients), some involve patients who are unable to communicate (for example, some stroke victims), and some involve patients who are simply unable or unwilling to participate in decisionmaking due to the nature or severity of their illness.

Type
Articles
Information
Cambridge Quarterly of Healthcare Ethics , Volume 6 , Issue 3 , Summer 1997 , pp. 325 - 338
Copyright
Copyright © Cambridge University Press 1997

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References

Notes

1. See Buchannan, A. Advance directives and the personal identity problem. Philosophy and Public Affairs 1988;17:277–302.Google Scholar

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12. See note 11. Raz, 1990:39.Google Scholar

13. I have also discussed the concept of second-order reasons in a medical context in May, T. The nurse under physician authority. Journal of Medical Ethics 1993;19(4):223–7.CrossRefGoogle ScholarPubMed

14. See note 11. Raz, 1990:37.Google Scholar

15. See note 11. Raz, 1990:39.Google Scholar

16. These similarities include the fact that in neither case is the subject acting on “the balance of reasons,” and in each case, the second-order reason operates by affecting the weight of first-order reasons, making at least some irrelevant to the subject's determination of action.

17. Ohio State Bar Association, Ohio State Medical Association. Advanced directives for health care: standard forms (special insert). Ohio Lawyer 1991.

18. See our earlier discussion concerning the role of autonomy in structuring society, especially its role in facilitating the effectiveness of attempts to regulate behavior; and the reasons we believe autonomous decisions will best advance the welfare of individuals.

19. Emanuel, L et al. Advance directives for medical care—a case for greater use. New England Journal of Medicine 1991;324(13):889–95.CrossRefGoogle ScholarPubMed

20. It should be noted, however, that in the absence of direct discussion with patients, substituted decisionmaking is not likely to correspond with the patient's preferences. This may be relevant to the criteria we wish to impose on the recognition of a chosen surrogate's decisions.

21. See, for example, the various standards of competency offered by Drane, J. The many faces of competency. Hastings Center Report 1985;15(2):17–21.CrossRefGoogle ScholarPubMed

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23. May, T. Assessing competency without judging merit. Journal of Clinical Ethics, forthcoming.Google Scholar

24. Lynn, Joanne and Teno, Joan M. have discussed the lack of adequate empirical research on how advance directives might best incorporate a patient's values and preferences in their paper, After the Patient Self-Determination Act: the need for empirical research on formal advance directives (Special Supplement). Hastings Center Report 1993;23(1):520–24.Google Scholar