Advance directives, future selves and decision-making

Medical Law Review

Volumn 14, Issue 3, 2006, Pages 291-320

  MacLean, Alasdair R ^a  

^a UNIVERSITY OF DUNDEE   (United Kingdom)

Author keywords

[No Author keywords available]

Indexed keywords

ARTICLE; CUSTODY; DECISION MAKING; HUMAN; INFORMED CONSENT; LEGAL ASPECT; LIVING WILL; MENTAL CAPACITY; MORALITY; PERSONAL AUTONOMY; PERSONHOOD; PHILOSOPHY;

ADVANCE DIRECTIVES; DECISION MAKING; HUMANS; INFORMED CONSENT; LEGAL GUARDIANS; MENTAL COMPETENCY; MORALS; PERSONAL AUTONOMY; PERSONHOOD; PHILOSOPHY, MEDICAL;

EID: 33750442145     PISSN: 09670742     EISSN: 14643790     Source Type: Journal    
DOI: 10.1093/medlaw/fwl009     Document Type: Article

References (123)

1. See S v. McC; W v. W [1972] A.C. 24 at 43, HL
2. Nancy B v. Hotel-Dieu de Quebec (1992) 86 D.L.R. (4th) 385 at 391 (Quebec Superior Court).
3. Unless otherwise stated, the legal claims in this article refer to the lawin England and Wales.
4. Re T (Adult: Refusal of Treatment) [1992] 3 W.L.R. 782 at 786, CA
5. Airedale NHS Trust v. Bland [1993] 1 All E.R. 821 at 860 per Lord Keith. There are exceptions under mental health and public health legislation.
6. Or Living Will.
7. Re T (Adult: Refusal of Treatment) [1992] 3 W.L.R. 782
8. Re AK (Medical Treatment: Consent) [2001] 1 F.L.R. 129
9. Airedale NHS Trust v. Bland [1993] A.C. 789 at 864 (per Lord Goff), 891-894 (per Lord Mustill)
10. Re C (Adult: Refusal of Treatment) [1994] 1 W.L.R. 290
11. HE v. A Hospital NHS Trust [2003] E.W.H.C. 1017.
12. The Act is not expected to come into force until 2007.
13. In one study, the authors found that five of 12 healthcare professionals interviewed justified treatment contrary to an advance directive on the basis of the patient's best interests: T. Thompson, R. Barbour, L. Schwartz, 'Adherence to Advance Directives in Critical Care Decision Making: Vignette Study' (2003) 327 British Medical Journal 1011.
14. See Report of the House of Lords Select Committee on Medical Ethics, HL Papers 21-I. (HMSO 1994) at para 181.
15. R (on the application of Burke) v. GMC [2004] E.W.H.C. 1879 at para 169.
16. R (Burke) v. GMC [2005] E.W.C.A. Civ 1003. The Mental Capacity Act 2005 also restricts binding directives to advance refusals.
17. A.M. Capron, 'Advance Directives' in H. Kuhse and P. Singer (eds.), A Companion to Bioethics (Blackwell Publishing 1998) at 261-271.
18. See e.g. G. Dworkin, The Theory and Practice of Autonomy (Cambridge University Press 1988) at 5.
19. R. Dworkin, Life's Dominion (Harper Collins 1993) at 223.
20. Ibid. at 224.
21. Ibid.
22. M. Quante, 'Precedent Autonomy and Personal Identity' (1999) 9 Kennedy Institute of Ethics Journal 365 at 372.
23. B.A. Rich, 'Personhood, Patienthood and Clinical Practice: Reassessing Advance Directives' (1998) 4 Psychology, Public Policy, and Law 610 at 614.
24. Supra, n.13, at 227.
25. Supra, n.16, at 367.
26. A.D. Firlik, 'Margo's logo' (1991) 265 Journal of the American Medical Association 201. Supra, n.13 at 226.
27. Critical interests are those that reflect the person's autonomously determined goals and life-plan; experiential interests are those that reflect the more immediate gratification of pleasurable activities.
28. Sisyphus was condemned by the Gods to push a rock up to the top of mountain only for the rock to roll down to the bottom. Thus, his task was repetitive and futile. For an argument that draws an analogy between man, particularly the 'workman', and Sisyphus, see: A. Camus, The Myth of Sisyphus, Transl. J. O'Brien (Penguin 1983).
29. Supra, n.13 at 226.
30. Ibid. at 221, 226
31. supra, n.17.
32. For a discussion of what constitutes 'precedent autonomy' see, J.K. Davis, 'The Concept of Precedent Autonomy' (2002) 16 Bioethics 114 at 127.
33. R. Dresser, 'Dworkin on Dementia: Elegant Theory, Questionable Policy' (1995) 25 Hastings Center Report 32 [reprinted in H. Kuhse and P. Singer (eds.), Bioethics: An Anthology (Blackwell Publishers Ltd. 1999) at 312-320]
34. R. Dresser, 'Missing Persons: Legal Perceptions of Incompetent Patients' (1994) 46 Rutgers Law Review 609.
35. R. Dresser, 'Dworkin on Dementia: Elegant Theory, Questionable Policy' in H. Kuhse and P. Singer (eds.), Bioethics: An Anthology (Blackwell Publishers Ltd. 1999) at 316.
36. Ibid. at 317.
37. D. Parfit, Reasons and Persons (Oxford University Press 1986).
38. D. Parfit, 'Personal Identity' (1971) 80 The Philosophical Review 3 at 16.
39. Ibid. at 14-15.
40. Ibid. at 10.
41. Ibid. at 11.
42. Ibid. at 21.
43. Ibid. at 21-22.
44. Ibid. at 25.
45. Ibid.
46. Ibid.
47. A. Buchanan, 'Advance Directives and the Personal Identity Problem' (1988) 17 Philosophy and Public Affairs 277 at 280.
48. N.K. Rhoden, 'The Limits of Legal Objectivity' (1990) 68 North Carolina Law Review 845 at 852.
49. B.A. Rich, 'Prospective Autonomy and Critical Interests: A Narrative Defense of the Moral Authority of Advance Directives' (1997) 6 Cambridge Quarterly of Healthcare Ethics 138 at 146.
50. See also, J.K. Davis, 'The Concept of Precedent Autonomy' (2002) 16 Bioethics 114 at 127.
51. Supra, n.38 at 293.
52. J. Locke, An Essay on Human Understanding (1690) Book Two, Chapter XXVII at 7. Available at: http://www.class.uidaho.edu/mickelsen/ToC/ Locke%20Essay%20ToC.htm, last accessed 2 January 2006.
53. E.T. Olson, 'Relativism and Persistence' (1997) 88 Philosophical Studies 141 at 157.
54. A distinction is usually made between numerical identity and qualitative identity. While normative identity may coincide with one or other of these types of identity, there is no prima facie reason, other than convention, why this should be so.
55. Supra, n.42, Book Two, Chapter XXVII at 8.
56. In addition to three spatial dimensions, there is a fourth temporal dimension.
57. Supra, n.42, Book Two, Chapter XXVII at 9.
58. See also H. Kuhse, 'Some Reflections on the Problem of Advance Directives, Personhood, and Personal Identity' (1999) 9 Kennedy Institute of Ethics Journal 347 at 356.
59. Supra, n.40, Rich at 141.
60. C.M. Korsgaard, 'Personal Identity and the Unity of Agency: A Kantian Response to Parfit' (1989) 18 Philosophy and Public Affairs 101 at 115.
61. C.M. Korsgaard, 'Self-Constitution in the Ethics of Plato and Kant' (1998) 3 The Journal of Ethics 1 at 7.
62. Ibid. at 22.
63. Supra, n.49 at 119.
64. Supra, n.49 at 123.
65. Supra, n.38 at 277-278.
66. T.L. Beauchamp, J.F. Childress, Principles of Biomedical Ethics 5th edition (Oxford University Press 2001) at 166-167.
67. See the discussion in A. Maclean, 'Canaries in the Mine' (2002) 5 Critical Review of International Social and Political Philosophy 164.
68. A competent person's refusal of treatment acts, in principle, as an absolute veto: Re T (Adult: Refusal of Medical Treatment) [1992] W.L.R. 782 at 786 per Lord Donaldson MR
69. Airedale NHS Trust v. Bland A.C. 789 at 864 per Lord Goff.
70. See infra nn.93-95.
71. Supra, n.38 at 286ff.
72. Supra, n.47, Kuhse at 357ff.
73. Supra, n.38 at 286.
74. Ibid. at 287.
75. Supra, n.47, Kuhse at 357.
76. See also, M.G. Kuczewski, 'Whose Will is it Anyway? A Discussion of Advance Directives, Personal Identity, and Consensus in Medical Ethics' (1994) 8 Bioethics 27 at 35-40.
77. Supra, n.47, Kuhse at 357-358.
78. Ibid. at 358.
79. See Harris' argument that critical interests that survive death are not 'person affecting' and are, therefore, not as weighty as 'person affecting' (including experiential) interests: J. Harris, 'Organ Procurement: Dead Interests, Living Needs' (2003) 29 Journal of Medical Ethics 130 at 132.
80. Supra, n.47, Kuhse at 359-360.
81. This is arguably the case for patients in a persistent vegetative state.
82. M. Quante, 'Precedent Autonomy and Personal Identity' (1999) 9 Kennedy Institute of Ethics Journal 365 at 372.
83. Ibid. at 373-374.
84. Ibid. at 374.
85. Supra, n.40, Rich at 145.
86. Ibid. at 146.
87. For example, see supra, n.62, Kuczewski at 38.
88. Ibid. at 42.
89. Ibid. at 44-45.
90. Ibid. at 45.
91. Supra, n.7.
92. I use objective here to refer to a view based on at least a degree of consensus and not just an individual's subjective opinion. I am not claiming that the judgment is a matter of fact.
93. Supra, n.49.
94. Ibid. at 103.
95. Ibid. at 113-114.
96. Ibid. at 123.
97. J.C. Hughes, 'Views of the Person with Dementia' (2001) 27 Journal of Medical Ethics 86 at 87.
98. Ibid. at 86.
99. Supra, n.38 at 294ff.
100. Ibid. at 295-296.
101. Ibid. at 298.
102. Ibid. Terminologically, it is arguable that Buchanan is wrong: The two entities are the same individual but different selves.
103. See, e.g. McMahan who acknowledges that the competent and demented parts of the person's life lack unity but nevertheless he argues that the competent person's life is retroactively harmed by not following an advance directive. Since that part of the individual's life as a whole is the 'dominant' part, the demented self should be 'sacrificed for the greater good of her earlier self': J. McMahan, The Ethics of Killing (Oxford University Press 2002) at 502-503. This solution suffers from giving too much weight to what is necessarily the indirect harm of not following the advance directive: How can the person be harmed directly if that person no longer exists?
104. Supra, n.40, Rich at 142.
105. McMahan calls this 'egoistical concern about the future' the 'prudential unity relations': Supra, n.85 at 42.
106. O. O'Neill, 'Children's Rights and Children's Lives' (1988) 98 Ethics 445 at 448.
107. In Gillick v. W. Norfolk and Wisbech AHA [1986] A.C. 112 at 184,
108. Lord Scarman stated: 'The principle of the law... is that parental rights are derived from parental duty and exist only so long as they are needed for the protection of the person and property of the child'.
109. Gillick v. W. Norfolk and Wisbech AHA [1986] A.C. 112, HL.
110. S v. McC; W v. W [1972] A.C. 24, HL.
111. As Lord Fraser stated: 'parental rights to control a child do not exist for the benefit of the parent. They exist for the benefit of the child and they are justified only in so far as they enable the parent to perform his duties towards the child, and towards other children in the family': Gillick v. W. Norfolk and Wisbech AHA [1986] A.C. 112 at 170.
112. Glass v. UK (2004) 39 E.H.R.R. 15 at 341-365. I make this claim only in the context of medical treatment decision-making.
113. I thank the anonymous reviewer for making this point.
114. On this point, it might be noted that a competent person may have carers but their role as carers do not justify them having decisional authority, which remains with the competent person.
115. Supra, n.28 at 302.
116. Ibid. at 264.
117. See: F v. Wirral Metropolitan Council [1991] 2 W.L.R. 1132, CA.
118. M. Maclean and J. Eekelaar, The Parental Obligation: A Study of Parenthood Across Households (Hart Publishing 1997) at 35.
119. P.M. Sailors, 'Autonomy, Benevolence and Alzheimer's Disease' (2001) 10 Cambridge Quarterly of Healthcare Ethics 184 at 191.
120. Ibid. at 192.
121. Ibid. at 192-193.
122. Over the course of a single life there may be more than one former-self, but once the continuity of the selves is broken, then the former-self that existed just prior to the break cannot be replaced. In this sense, that former-self is unique.
123. If it did, then arguably the authority should not be open to challenge, and should be as authoritative as personal autonomy. Also, note Dworkin's arguments regarding the justification for respecting an autonomous individual's self-regarding decisions, at n.13-n.15.