Bioethics Final Word Analysis
TESTING THE LIMITS OF PROSPECTIVE AUTONOMY: FIVE SCENARIOS
Norman L. Cantor
Several examples will help crystallize the potential tension between an advance directive and the contemporaneous interests of an incompetent patient. In the following scenarios, assume that all patients were fifty years old at the time of making an advance directive and that the critical medical decisions are confronted five years later. Assume also that no evidence exists that the patient changed his or her mind or wavered in resolve between preparation of the advance directive and losing competence.
Scenario 1: Person A, a Jehovah’s Witness, prescribes in an advance directive that blood transfusions should not be administered regardless of the life-saving potential of such medical intervention. She is aware of the life and death implications of this religiously motivated instruction. Later, A becomes prematurely senile and incompetent. Still later, the senile patient develops bleeding ulcers which demand blood transfusions. With a blood transfusion, she will survive and continue to live as a “pleasantly senile” person for a number of years. The senile A no longer has recollection of, or interest in, religion; however, she remained an avid Jehovah’s Witness up until the time of incompetency. Should the attending physician administer a life-saving blood transfusion
Scenario 2: Person B believes both that life should be preserved to the maximum extent possible and that suffering is preordained and carries redemptive value in an afterlife. B prepares an advance directive in which all possible life-extending medical intervention is requested and all pain relief is rejected. At the time of the preparation of the directive, B has a conversation with a physician in which the physician explicitly warns B that many terminal illnesses entail excruciating pain. Despite that admonition, B directs that all means to preserve life be utilized and that analgesics be omitted. Subsequently, B suffers from cancer, which both affects his brain, rendering him incompetent, and causes him to suffer excruciating pain. Further medical treatment such as radiation or chemotherapy will extend B’s life, but will not itself relieve the pain or cause any remission in which competence would return. Should the attending physician sedate the patient, or cease the life-prolonging medical intervention, or both
Scenario 3: Person C is an individual with chronic heart problems. Physicians have informed C that at some stage he will need a heart transplant in order to survive. C prepares an advance directive stating that if he becomes incompetent and survival becomes dependent on a heart transplant, then such a transplant should be rejected because of its expense. C prefers to leave a substantial monetary legacy to his children. Later, C becomes prematurely senile and incompetent. Still later, C’s heart deteriorates and a heart transplant becomes necessary to preserve C’s life. With the transplant, C will very likely continue to live for three to five years. Without it, C will die within a few months. The transplant will cost $100,000 and is not covered by any insurance or government benefit program. C’s estate totals $100,000. Should a life-extending heart transplant be performed
Scenario 4: Person D is a health-care professional sensitive to society’s needs for organ and tissue donations. In her advance directive, D provides that if she should become incompetent but remain physically healthy, then she wishes to donate a kidney and bone marrow to needy recipients. Later, D is afflicted with Alzheimer’s disease and reaches a point of profound dementia. Needy recipients for kidney and bone marrow transplants have been located. The prospective transplant operations will pose only a slight risk to D and entail only mild pain. At the same time, the now incompetent D has no recollection of her prior instruction and no appreciation of
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the altruism involved in donating an organ or tissue. She will derive no contemporaneous gain from the contemplated operations. Should the transplants be performed in accord with D’s advance directive
Scenario 5: Person E is a sociology professor known for her intellectual sharpness. E takes enormous pride in that intellectual acuity. E drafts an advance directive prescribing that if she should become mentally impaired and incompetent to the point where she can no longer read and comprehend a sociology text, then all life-preserving medical intervention should be withheld. When reminded by her spouse about the potential for happiness in an incompetent state, E replies that she deems significant mental dysfunction to be degrading and personally distasteful. For her, such a debilitated existence is a fate worse than death. Later, E suffers a serious stroke which renders her permanently incompetent and incapable of reading or performing intellectual tasks. E is also unable to swallow and is therefore dependent on artificial nutrition. At the same time, E does not appear to be in any pain and seems to derive some pleasure from listening to music. Should the life-preserving nasogastric tube be continued
In each of the above situations, people have issued advance directives which effectuate their personal values and concepts of dignity. Yet implementation of those prior instructions conflict in some measure with the contemporaneous interests or well-being of the incompetent persona. Can the advance directive prevail Does prospective autonomy encompass the prerogative to impact negatively on the incompetent persona
From Advance Directives and the Pursuit of Death with Dignity by Norman L. Cantor, Indiana University Press, 1993. Reprinted with permission from the publisher.
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