Student Activities 2009-2010

Alissa LaGesse

Against the Use of Advance Directives in Medical Decision Making

National Undergraduate Bioethics Conference

Thesis: This paper argues against the use of advance directives in medical decision making, arguing that a competent patient who drafts an advance directive is psychologically unable to comprehend the conditions of incompetency that she might be left in in the future, the very time when the she will depend on the advance directive to speak for her. That which renders a patient incompetent is the very thing that invalidates her ability to make her own healthcare decisions; incompetency leaves the patient unable to comprehend her medical condition, causing any previous assumptions and wishes regarding treatment to become futile.

Summary of Argument: The ability to exercise autonomy is considerably the most highly regarded value in Western healthcare. Advance directives developed from the importance placed on individual patient autonomy, and serve to provide autonomous decision making power to individuals who are unable to communicate their wishes. Yet, there are many practical difficulties associated with the use of advance directives, which include the fact that expressing future desires is easier to do in a vacuum, when considering hypothetical, future-oriented situations. A presently-competent patient has no way of estimating what treatments she might be eligible for or able to receive once incompetent. When treating an incompetent patient, the healthcare provider may not view the situation from the perspective of the terminally-ill patient, but rather from the patient’s values and interests as previously stated, presenting a conflict in objectively choosing a course of treatment. 

Rebecca Dresser and John Robertson, two critics of the use of advance directives in health care decision making, claim that it is a mistake to assume that a patient’s current interests are best indicated by any desires and preferences which may have existed prior to incompetency, because the situation which made the patient incompetent changed him or her so much that the patient is considerably a different person, and thus, may have a completely different world view, beliefs, values, and desires, which the advance directive would not accommodate for.

Conclusion: The use of advance directives seems, to a population that places high regard on autonomy, to be sensible preparation for a situation in which a patient is not able to express his or her healthcare decisions. Yet, the practicality of advance directives in the treatment of incompetent individuals does not hold against the problems that arise and the incorrect assumptions caused by the advance directive.