Hostname: page-component-586b7cd67f-gb8f7 Total loading time: 0 Render date: 2024-11-26T06:15:42.311Z Has data issue: false hasContentIssue false
  • English
  • Français

Prospective Autonomy and Critical Interests: A Narrative Defense of the Moral Authority of Advance Directives

Published online by Cambridge University Press:  29 July 2009

Ben A. Rich
Ben A. Rich
Affiliation:
Assistant professor in the Department of Preventive Medicine and Biometrics, and assistant director of the program in Health Care Ethics, Humanities, and Law at the University of Colorado Health Sciences Center in Denver, Colorado.
Get access Rights & Permissions [Opens in a new window]

Extract

In the mid to late 1980s a debate arose over the moral and legal authority of advance medical directives. At the center of this debate were two point-counterpoint law journal articles by Rebecca Dresser and Nancy Rhoden. What appeared to have the makings of an ongoing critical dialogue ended with the untimely death of Nancy Rhoden. Rebecca Dresser, however, has continued her challenge of advance directives in numerous publications, most recently in a critique of Ronald Dworkin's Life's Dominion. Like Rhoden, Dworkin has been a staunch advocate of advance directives as an exercise of what has come to be referred to as prospective or precedent autonomy. In this paper I will consider a number of the issues that Dresser has repeatedly raised about the infirmities of advance directives, and suggest that it is from an understanding of and appreciation for the narrative dimension of the life of a person that advanced directives draw one of their most powerful justifications.

Type
Special Section: Alpha and Omega: Ethics at the Edges of Life
Information
Cambridge Quarterly of Healthcare Ethics , Volume 6 , Issue 2 , Spring 1997 , pp. 138 - 147
Copyright
Copyright © Cambridge University Press 1997

Access options

Get access to the full version of this content by using one of the access options below. (Log in options will check for institutional or personal access. Content may require purchase if you do not have access.)

References

Notes

1. Dresser, R. Life, death, and incompetent patients: conceptual infirmities and hidden values in the law. Arizona Law Review 1986;28:373–405.Google ScholarPubMed

2. Rhoden, N. Litigating life and death. Harvard Law Review 1988;102:375–446.CrossRefGoogle ScholarPubMed

3. Dresser, R. Advance directives, self-determination, and personal identity. In Hackler, C, Moseley, R, Vawter, D, eds. Advance Directives in Medicine. New York: Praeger Publishers, 1989.Google Scholar

4. Dresser, R. Relitigating life and death. Ohio State Law Journal 1990;51:425–437.Google ScholarPubMed

5. Dresser, R. Missing persons: legal perceptions of incompetent patients. Rutgers Law Review 1994;46:609–719Google ScholarPubMed

6. Dresser, R. Dworkin on dementia: elegant theory, questionable policy. Hastings Center Report 1995;25(6):32–38.CrossRefGoogle ScholarPubMed

7. Firlik, AD. Margo's logo. JAMA 1991;265:201.CrossRefGoogle ScholarPubMed

8. Parfit, D. Reasons and Persons. New York: Oxford University Press, 1984.Google Scholar

9. Rich, BA. The values history: a new standard of care. Emory Law Journal 1991;40:1109–81.Google ScholarPubMed

10. In the eleven years between Dresser's first and most recent articles, both of which espouse or at least rely upon Parfit's theory of personal identity, the problematic policy implications that it entails have been identified by a number of authors, perhaps most notably Buchanan, Allen and Brock, Dan, Deciding for Others—The Ethics of Surrogate Decisionmaking. Cambridge: Cambridge University Press, 1989, pp. 177–78. Her failure or refusal to acknowledge and address these points suggests that she is avoiding the implications of the theory rather than merely overlooking them.Google Scholar

11. Hume, D. A Treatise of Human Nature. London: Penguin Books, 1969.Google Scholar

12. Locke, J. An Essay Concerning Human Understanding. ed., Nidditch, PH. Oxford: Oxford University Press, 1975,II.xxvii.9.Google Scholar

13. See note 12. Locke, 1975:II.xxvii.9.Google Scholar

14. Buchanan, A. Advance directives and the personal identity problem. Philosophy & Public Affairs, 1988;17:277–302.Google ScholarPubMed

15. Kuczewski, M. Whose will is it, anyway? A discussion of advance directives, personal identity, and consensus in medical ethics. Bioethics 1994;8:27–48.CrossRefGoogle ScholarPubMed

16. Samuel Sheffler expresses a similar sentiment when he states, with regard to Parfit's view of personal identity: “I don't have the faintest idea how I am to conceive of myself if I am not to conceive of myself in the usual way, as an agent existing over time,” Ethics, personal identity, and the ideals of the person. Canadian Journal of Philosophy 1982;12:229–46, p. 238.Google Scholar

17. Locke, J. Second Treatise of Government. Cambridge: Cambridge University Press, 1960, Ch. II., Sect. 4.Google Scholar

18. See note 2. Rhoden, 1988:418.Google Scholar

19. See note 7.

20. Buchanan, JH. Patient Encounters: The Experience of Disease. Charlottesville, Va.: University of Virginia Press, 1989, p. 40.Google Scholar

21. See note 20. Buchanan, 1989:45.Google Scholar

22. Nozick, R. Anarchy, State, and Utopia. New York: Basic Books, 1974, pp. 42–3.Google Scholar

23. Feinberg, J. Harm To Self. New York: Oxford University Press, 1986, pp. 361–2.Google Scholar

24. Buchanan and Brock offer three generally acknowledged conditions precedent for personhood: (1) consciousness of self as a being that exists over time, i.e., someone with a past and a future as well as a present; (2) the capacity to understand and appreciate reasons for and against acting and to control one's impulses or inclinations in conjunction with such reasons, and (3) the ability to engage in purposeful actions. Persons such as Margo, in the later stages of Alzheimer's demen tia, seem to have permanently lost these attributes out of which enduring persons are constructed from momentary person slices or stages. See note 10. Buchanan, and Brock, 1989:160.Google Scholar