Search

Some of the concerns that have been raised in connection to the use of advance directives are of the epistemic variety. Such concerns highlight the possibility that adhering to an advance directive may conflict with what the author of the directive actually wants (or would want) at the time of treatment. However, at least one objection to the employment of advance directives is metaphysical in nature. The objection to be discussed here, first formulated by Rebecca Dresser and labeled by Allen Buchanan as the slavery argument and David DeGrazia the someone else problem, aims to undermine the legitimacy of certain uses of advance directives by concluding that such uses rest upon an incorrect assumption about the identity over time of those ostensibly governed by the directives. There have been numerous attempts to respond to this objection. This paper aims to assess two strategies that have been pursued to cope with the problem.

People with dementia who are no longer competent have limited control over how their lives end. But an advance directive to withhold food and water by mouth could be used to ensure that one does not live for years in severe dementia. Such directives are arguably already legal.

Philosophers have mostly advocated that advance directives should bear the same authority, with regard to refusal of life-extending treatment, as a patient's contemporaneous consent or refusal. Such authors typically support this position through a theory of persistent personal identity. I agree that the loss of mental competence does not render someone a moral stranger to their prior goal but argue that equating advance direction with consent is to ignore the capacity of nonpersons to attribute and withhold moral value. A distinction should be drawn between advance directives that seek to pursue deeply held goals and those that express contempt for the mentally incompetent.

After falling from a roof, an older man lost neurological function below his face. In two days, the patient regained consciousness, but it was unclear whether he could communicate his preferences, whether due to injuries or difficulties with language. His family believed he could communicate with them, and that he was capable of making treatment decisions. The staff did not think to contact the hospital's largely inactive ethics consultation service for assistance, and instead looked to the patient's living will for guidance, even though the patient was not terminally ill, and his lack of capacity had not been determined.

A commentary on a case of a man who is left a "high quad" (ventilator dependant as well as quadriplegic) after an accident discusses the following: The right of patients who sustain catastrophic injuries to choose to discontinue life-sustaining treatment, The role of capacity assessment in treatment decisions and in ethics consultations, The role of advance directives (ADs) for such patients if they lack capacity, Whether a do-not-resuscitate or do-not-attempt-resuscitation order should be seen as "a medical order" or an advance directive, Some hints about what might be intended when a patient refers to the criterion of having a "meaningful life."

This article concerns the issue of how an ethic of care perspective may contribute to both normative theory and mental health care policy discussions on so called Ulysses arrangements, a special type of advance directives in psychiatry. The debate on Ulysses arrangements has predominantly been waged in terms of autonomy conceived of as the right to non-intervention. On the basis of our empirical investigations into the experiences of persons directly involved with Ulysses arrangements, we argue that a care ethics perspective may broaden and deepen the debate on Ulysses arrangements, by introducing additional concepts, such as vulnerability, responsibility and mutuality, and by refining familiar concepts, such as autonomy.

The issue of patient autonomy in cases of permanent dementia has recently received a great deal of philosophical attention. Specifically, many have worried about ethical issues surrounding advance directives in which people specify how they shall be treated when they are no longer competent to make their own medical decisions. Ronald Dworkin has been a staunch defender of what he calls precedent autonomy in these cases, believing persons have a right to control, to some degree, how their lives will end, despite the common intuition that the principle of beneficence requires us to improve the experiential quality of patients' lives. Objections have been brought against Dworkin on a number of fronts, including worries about personal identity theory and informed consent. Here, I offer an objection to Dworkin's assessment of the nature of paternalism as it relates to cases of permanent dementia.

Most patients eventually must face the process of planning for their future medical care. However, few Americans have a living will or a durable power of attorney for health care. Although advance directives provide a legal basis for physicians to carry out treatment using a health care proxy or a living will, they also should reflect the patient's values and preferences. Family physicians are in a position to integrate medical knowledge, individual values, and cultural influences into end-of-life care. Family physicians can best respect the autonomy of patients by allowing the patient and family to prospectively identify relevant health care preferences, by sustaining an ongoing discussion about end-of-life preferences, and by abiding by the decisions their patients have made.

Pre-commitment directives or Ulysses contracts are often defended as instruments that may strengthen the autonomous self-control of episodically disordered psychiatric patients. Autonomy is understood in this context in terms of sovereignty ("governing" or "managing" oneself). After critically analyzing this idea of autonomy in the context of various forms of self-commitment and pre-commitment, we argue that what is at stake in using Ulysses contracts in psychiatry is not autonomy as sovereignty, but autonomy as authenticity. Pre-commitment directives do not function to protect autonomous self-control. They serve in upholding the guidance that is provided by one's deepest identity conferring concerns. We elucidate this concept of autonomy as authenticity, by showing how Ulysses contracts protect the possibility of being "a self."

Honoring a living will typically involves treating an incompetent patient in accord with preferences she once had, but whose objects she can no longer understand. How do we respect her "precedent autonomy" by giving her what she used to want? There is a similar problem with "subsequent consent": How can we justify interfering with someone's autonomy on the grounds that she will later consent to the interference, if she refuses now? Both problems arise on the assumption that, to respect one's autonomy, any preferences we respect must be among that person's current preferences. I argue that this is not always true. Just as we can celebrate an event long after it happens, so can we respect someone's wishes long before or after she has that wish. In the contexts of precedent autonomy and subsequent consent, the wishes are often preferences about which of two other, conflicting preferences to satisfy. When someone has two conflicting preferences, and a third preference on how to resolve that conflict, to respect his autonomy, we must respect that third preference. People with declining competence may have a resolution preference earlier, favoring the earlier conflicting preference (precedent autonomy), whereas those with rising competence may have it later, favoring the later conflicting preference (subsequent consent). To respect autonomy in such cases we must respect not a current, but a former or later preference.

This paper critically examines the liberal model of decision making for the terminally ill and contrasts it with the familial model that can be found in some Asian cultures. The contrast between the two models shows that the liberal model is excessively patient-centered, and misconceives and marginalises the role of the family in the decision making process. The paper argues that the familial model is correct in conceiving the last journey of one's life as a sharing process rather than a process of exercising one's prior or counterfactual choice, and concludes by suggesting a policy framework for the practice of familialism that can answer the liberal challenge that familialism cannot safeguard the patient from abuse and neglect.

This paper offers a philosophical consideration and evaluation of several different criteria of moral standing, and discusses their implications for persistent vegetative state (PVS) individuals who were once competent. It is argued that the only criterion PVS individuals meet is that of being human, which is not the best test of moral standing. Accordingly it is, in principle, morally acceptable to perform passive or active euthanasia on PVS individuals or to use their bodies for research or for organ harvest. Nevertheless, the autonomous choices made by the persons the PVS individuals used to be can still impose moral obligations. Indeed, it is argued that the capacity for autonomy is a particularly appealing criterion of moral standing, and that the implications of this standard for PVS individuals confirm that appeal.