Chest
ethics in cardiopulmonary medicinePulling the Plug on Living Wills: A Critical Analysis of Advance Directives
Section snippets
Autonomy in the Nonautonomous Individual
Both the popular and scholarly ethical support for advance directives spring from the increasing value placed on the autonomy of patients. Patients have asserted, and courts have supported, the competent adult's right to obtain all relevant information regarding a proposed treatment (informed consent)8 and to refuse any treatment, even if it is expected to be beneficial or life sustaining.9 Such assertions have implicitly or explicitly contained within them the notion of the patient as an
Practical Concerns
Advance directives are also severely limited by practical concerns about their use.17, 18 In the case of instructive directives, three limitations appear to be particularly problematic.
First, those who formulate advance directives, even with the aid of a medical professional, can have only incomplete information about the risks and benefits of any future medical treatments they might possibly face after becoming incompetent. The informed portion of the notion of informed consent will thus be
The Problem of Proxies
The problems with instructive directives have led some to argue that proxy directives, such as the durable power of attorney for health care, are preferable for most patients.22 Proxy directives are generally supported with the same ethical argument as instructive directives: they offer a tool for the continuance of autonomous choice for nonautonomous patients. To fulfill this goal, the decisions of surrogates must be consistent with those that would be made by the now incompetent patient. This
Effectiveness
Advance directives are put forth primarily as a method of ensuring patient autonomy. How well they serve this function can be investigated and several studies have attempted to assess whether patients’ wishes are more likely to be followed if they have written advance directives. Given the inherent difficulty of trying to measure directly whether individual preferences are followed, some studies looking at the impact of these documents have focused on indirect measurements of their effects.
In
Conclusion
Advance directives are designed as instruments by which a competent individual can continue to exercise autonomous control over health-care decisions in the event of future incompetence. They do not appear capable of fulfilling this task. Instructive directives, hobbled by uncertainty regarding identity, intention, and meaning, cannot be accepted as binding without an attempt to verify them independently. This process of validation, involving discussions with other physicians, surrogates, and
Acknowledgments
I would like to thank my colleagues Len Hudson, MD, David Ralph, MD, Tom McCormick, PhD, and, especially, Nancy Jecker, PhD, for their thoughtful review and criticism of earlier versions of this work.
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