Advance directives for withholding life-saving treatment are controversial for dementia patients whose previously expressed wishes conflict with their currently expressed desires. To illustrate this ethical dilemma, McMahan conceives a hypothetical case in which an intellectually proud creative woman signs an advance directive stipulating her refusal to receive life-saving treatment if she contracts a fatal condition with dementia. However, when she develops dementia and forgets this advance directive, she contracts pneumonia and now expresses a desire to live. In response to such (...) dilemmas, scholars like Norman Cantor have defended the moral authority of advance directives by giving credence to one’s prior competent wishes over one’s current incompetent preferences. I argue that their arguments, which are rooted in the principle of respect for autonomy, operate under ableist assumptions about incompetent persons and exclude other important features of respect. I propose an ethics of care model as an alternative moral approach that reconceptualises respect as a matter of caring about people’s contemporaneous interests, even if they are not competently conceived. It fosters the virtues of care by encouraging healthcare providers to recognise dementia patients as legitimate narrative agents capable of authoring their own evolving life story. I argue that the ethics of care model not only provides an ethical defence of the creative woman’s current incompetent desire to live despite her advance directive, but also vindicates our moral intuitions about what it means to demonstrate respect to dementia patients. (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)

What justifies our holding a person morally responsible for some past action? Why am I justified in having a special prudential concern for some future persons and not others? Why do many of us think that maximizing the good within a single life is perfectly acceptable, but maximizing the good across lives is wrong? In these and other normative questions, it looks like any answer we come up with will have to make an essential reference to personal identity. So, for (...) instance, it seems we are justified in holding X responsible for some past action only if X is identical to the person who performed that action. Further, it seems I am justified in my special concern for some future person only if he will be me. Finally, many of us think that while maximization within a life affects only one person, a metaphysical unity, maximization across lives affects many different, metaphysically distinct, persons, and so the latter is wrong insofar as it ignores this fundamental separateness of persons. (shrink)

A persistent question in discussions of the ethics of advance directives for euthanasia is whether patients who go through deep psychological changes retain their identity. Rather than seek an account of identity that answers this question, I argue that responsible policy should directly address indeterminacy about identity directly. Three sorts of indeterminacy are distinguished. Two of these—epistemic indeterminacy and metaphysical indeterminacy—should be addressed in laws/policies regarding advance directives for euthanasia.

Within the Western bioethical framework, we make adistinction between two dominant interpretations of the meaning of moral personhood: thenaturalist and the humanist one. While both interpretations of moral personhood claim topromote individual autonomy and rights, they end up with very different normativeviews on the practical and legal measures needed to realize these values in every daylife. Particularly when we talk about the end of life issues it appears that in general thearguments for euthanasia are drawn from the naturalist interpretation of (...) moral personhoodwhile the arguments against euthanasia, for their part, are derived from the idealistand/or humanist understanding of the same concept. This article focuses onexamining the metaphysical assumptions and internal contradiction found behind the opposingarguments presented by two prominent philosophers of these two traditions:Peter Singer and Ludger Honnefelder. The author claims that neither side of thedebate succeeds in defending its normative position without reconsidering how to takethe social aspects of moral personhood into account. The author holds that, despite ourneed to set individual's decision making into social context, the currentcommunitarian narrative concept of personhood fails to offer a convincing alternative.Instead of merely trying to replace psychological and atomistic view of personhood with acollective understanding of an individual's moral identity, we need to discuss thenormative relation between the concept of `moral personhood' and the demand for respect ofindividual autonomy in Western bioethics within a wider philosophical perspective. (shrink)

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. (shrink)