PHI 227 Biomedical Ethics

Some distinctions: three kinds of patients

1. Previously competent patients who expressed their wishes before they became incompetent.
2. Previously incompetent patients who did not express their wishes but whose general values are known.
3. Not previously competent patients and previously competent patients who did not express their views and whose values are not known.

Previously competent patients who expressed their wishes before they became incompetent.


The wishes of these patients ought to be respected.
1. Advance directives
   1. Instructional directives (What to do), e.g., living will or oral statements to family and friends.
   2. Proxy directives (Who is going to make health care decisions) for patients, durable attorney for health care.
   3. Combined (Appointing a proxy and providing instructions). This is the ideal as instructional directives may be ambiguous and a patient cannot foresee all the contingencies that might arise.
2. Advantages of advance directives
   1. Relieve family stress and anxiety
   2. Keep the patient in control of important decisions
   3. Provide a basis for debate on what to do on behalf of the patient
   4. Document unusual requests
Problems with Advance directives
1. Question of interpretation.
   1. Drafted in the past and difficult to know if patient changed his mind.
   2. Possibility that the patient would have changed his mind at the approach of death.
   3. Vague terms such a "heroic" and "extraordinary."
   4. The situation is different from what the patient anticipated.
2. Not informed
3. When ignoring advance directives may be justified
   1. Evidence that patient changed his mind
   2. The situation is not like anything the patient could have anticipated.

Previously incompetent patients who did not express their wishes but whose general values are known.

1. Substituted judgment
   1. Make the kind of decision the incapacitated patient would have made if he had been able to choose given his values and preferences.
   Based on the desire to respect the patient's autonomy
2. Problems with substituted judgment
   1. Disagreement about what the patient wanted
   2. Different people may interpret the values of the patient differently.

Not previously competent patients and previously competent patients who did not express their views and whose values are not known.

1. Best interest
   1. Make the kind of decision that best serves the interests of the patient.
   2. Based on the principle of beneficence
2. Problems with best interest
   1. Disagreement about what is in the best interest of the patient, whether it life or the quality of life that is important
   2. Surrogates may impose their own conception of what is valuable

Questions about the readings

1. Arras, "The Severely Demented, Minimally Functional Patient: An Ethical Analysis
   1. What does the "best interest" criterion lead to when appliedto patients in PVS? Why does Arras think that this criterion is not applicable to them?
   2. On what, according to Arras, should decisions in favor of patients in PVS be based?
   3. Why does he think that the objective standard is still applicable to patients to marginally functional patient?
   4. What is the problem with basing one's decisions on the previous preferences and attitudes of the patient? What about her aversive behavior? Is it an indication that she wants to die?
   5. Why does Arras think that the objective standard does not apply to the case of Arras's solution? What standard does he advocate? What does he include in the "quality of life" category?


2. Dresser and Robertson, " Quality of Life and Non-Treatment for Incompetent Patients: A Critique of the Orthodox Approach
   1. What is the orthodox approach Dresser and Robertson argue against?
   2. What are the conceptual flaws of this approach? What are its dangers?
   3. What is the "current interest" approach?