By issuing an advance treatment directive, an autonomous person can formally express what kinds of treatment she wishes and does not wish to receive in case she becomes ill or injured and unable to autonomously decide about her treatment. While many jurisdictions and medical associations endorse them, advance treatment directives have also been criticized. According to an important criticism, when a person irreversibly loses her autonomy what she formerly autonomously desired ceases to be of importance in deciding about her treatment. (...) The medical ethical debate regarding different possible ways of solving the problem on which the criticism is based has grown exceedingly intricate. Instead of assessing the developments made in the debate so far, I present a thought experiment—built around a suicide case—which suggests that the problem is not as intractable as it has generally been deemed to be. (shrink)

Background Best interests is a ubiquitous principle in medical policy and practice, informing the treatment of both children and adults. Yet theory underlying the concept of best interests is unclear and rarely articulated. This paper examines bioethical literature for theoretical accounts of best interests to gain a better sense of the meanings and underlying philosophy that structure understandings. Methods A scoping review of was undertaken. Following a literature search, 57 sources were selected and analysed using the thematic method. Results Three (...) themes emerged. The first placed best interests within the structure of wider theory, noting relationships with consequentialism, deontology, prudential value theory, rights and political philosophy. The second mapped a typology of processes of decision-making, among which best interests was ambiguously positioned. It further indicated factors that informed best interests decision-making, primarily preferences, dignity and quality of life. The final theme considered best interests from a relational perspective. Conclusions Characterisation of best interests as strictly paternalist and consequentialist is questionable: while accounts often suggested a consequentialist basis for best interests, arguments appeared philosophically weak. Deontological accounts, found in law and Kantianism, and theories of political liberalism influenced accounts of best interests, with accounts often associating best interests with negative patient preferences (i.e. individual refusals). There was much more emphasis on negative interests than positive interests. Besides preference, factors like dignity and quality of life were held to inform best interests decisions, but generally were weakly defined. To the extent that preferences were unable to inform decision making, decisions were either made by proxy authority or by an intersubjective process of diffuse authority. Differing approaches reflect bifurcations in liberal philosophy between new liberalism and neo-liberalism. Although neither account of authority appears dominant, bias to negative interests suggests that bioethical debate tends to reflect the widespread ascendancy of neo-liberalism. This attitude was underscored by the way relational accounts converged on private familial authority. The visible connections to theory suggest that best interests is underpinned by socio-political trends that may set up frictions with practice. How practice negotiates these frictions remains a key question. (shrink)

Next SectionThe personal identity problem expresses the worry that due to disrupted psychological continuity, one person’s advance directive could be used to determine the care of a different person. Even ethicists, who strongly question the possibility of the scenario depicted by the proponents of the personal identity problem, often consider it to be a very potent objection to the use of advance directives. Aiming to question this assumption, I, in this paper, discuss the personal identity problem’s relevance to the moral (...) force of advance directives. By putting the personal identity argument in relation to two different normative frameworks, I aim to show that whether or not the personal identity problem is relevant to the moral force of advance directives, and further, in what way it is relevant, depends entirely on what normative reasons we have for respecting advance directives in the first place. (shrink)

It has often been claimed that orthodox thinking about personal identity undermines the moral authority of advance directives in dementia by implying that the signer of the directive is numerically different from the severely demented patient. This is the ‘identity problem'. I introduce the problem, outline some well‐known solutions, and explain why they might be deemed unattractive. I then propose an alternative solution. It promises to be compatible with orthodox thinking about personal identity. I discuss three ways in which it (...) might be challenged and find that none is convincing. Personal identity is no bar to the moral authority of advance directives. (shrink)

ZusammenfassungAusgehend von den Positionen Ronald Dworkins, Rebecca Dressers und Agnieszka Jaworskas untersucht der Beitrag das Spannungsverhältnis zwischen vorgängigem und aktualem Selbstbestimmungsrecht demenzkranker Patienten und verbindet die Diskussion über das Autonomiepotential der Betroffenen mit einer Theorie praktischer Selbstverhältnisse, die die Patienten zumindest in den Anfangs- und den mittleren Stadien der Krankheit aufrechterhalten können. Theoretisches Grundgerüst für die Auseinandersetzung mit den Möglichkeiten und Grenzen der Patientenautonomie Demenzkranker ist dabei zunächst die Opposition zwischen Äquivalenz- und Nichtäquivalenztheorien der Personalität, in die sich auch die (...) divergierenden Positionen von Dworkin und Dresser einordnen lassen. Durch Einbeziehung des Ansatzes von Jaworska, die Demenzbetroffenen eine sogenannte capacity to value zuschreibt, versucht der Beitrag zu zeigen, dass strikte Äquivalenz- oder Nichtäquivalenztheorien der Personalität, die wiederum für ein umfassendes oder stark limitiertes Verständnis der Patientenautonomie Demenzkranker argumentieren, zu kurz greifen. Im Anschluss an die von Jaworska herausgestellte Fähigkeit der Betroffenen, Wertungen und Wertschätzungen vorzunehmen, kann stattdessen ein Verständnis der Personalität Demenzkranker erarbeitet werden, das mit geringeren Rationalitätsannahmen operiert als strikte Nichtäquivalenztheorien und das auch die Bedingungen für die Ausübung von Patientenautonomie weiter fasst, ohne vollständig in einer Konzeption relationaler Autonomie aufzugehen. Darüber hinaus ermöglicht dieser Ansatz, erste Grundzüge einer Theorie praktischer Selbstverhältnisse bei Demenzbetroffenen zu skizzieren. (shrink)

There are two contrasting views on the decision-making for life-sustaining treatment in advanced stages of dementia when the patient is deemed incompetent. One is to respect the patient's precedent autonomy by adhering to advance directives or using the substituted judgement standard. The other is to use the best-interests standard, particularly if the current judgement on what is best for the incapacitated patient contradicts the instructions from the patient's precedent autonomy. In this paper, I argue that the protracted clinical course of (...) dementia over many years requires the extended perspective of a progressive decision-making process—extended in both social space and time. The ongoing debate between these two competing views has missed this perspective by focussing on an exclusive disjunction between the competent former self and the incompetent current self. Drawing on theories of situated cognition in cognitive science, I will show that the cognition of a demented patient can be viewed as extended and embodied by her supportive social environment. As the disease progresses, the content of the mind of a demented person becomes partially constituted by such external resources along with her diminishing intrinsic mind. With this understanding, medical decision-making for a demented patient can be construed as a temporally and socially extended practice. A collective decision-making body consisting of the patient, her family and surrogates, and the clinician, should make progressive decisions as a whole over years of the disease course. Finally, I will provide a practical example of how this proposal can be applied in clinical practice. (shrink)