Advance Directives: Compelling But Problematic

Paul T. Menzel

Advance directives are widely embraced as a morally and legally legitimate means through which people can exercise self-determination and personal autonomy in medical care.  Nonetheless, they face an inherent and fundamental challenge, the “then-self vs. now-self” problem:  why should the earlier self who wrote the directive have authority over the current incompetent self who does not care about the directive and no longer values autonomy? The seminar will clarify the challenge itself and critically probe several defenses that have been offered:  self-ownership, the reality of an enduring narrative self, and the moral need to treat previously competent patients differently from never-competent patients.  More yet may be needed to make these intuitively compelling defenses work – a richer understanding of patients’ current interests, refinement of the subjective value of survival, or clarification of what constitutes a “change of mind.” Individual cases will be used to illustrate the problem and its potential resolution.  Some will involve severe dementia, and some will involve directives to forego oral feeding.  

Paul T. Menzel, PhD, is Professor of Philosophy emeritus at Pacific Lutheran University. He has published widely on moral questions in health economics and health policy, including Strong Medicine: The Ethical Rationing of Health Care and (as co-editor) Prevention vs. Treatment: What’s the Right Balance?  Most recently he has written on end of life issues, including advance directives for dementia and voluntarily stopping eating and drinking.  He has been a visiting scholar at Kennedy Institute of Ethics, Rockefeller Center-Bellagio, Brocher Foundation, and Chinese University of Hong Kong.