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Lecture 21

PHL281H1 Lecture Notes - Lecture 21: Advance Healthcare Directive, Cochlear Implant, Fetus

Course Code
Donald Ainslie

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PHL281 Lecture 21 – Not Yet Competent
Option 1: Written Evidence
- it lets health professionals know how patients want to be treated when incompetent
- information directive – “living will”
often involves checking off preferred treatments in various scenarios
- living will gives a chance to identify a proxy (the one health professionals with contact if you are unable to
- instruction directive – offers a table where one can consider various scenarios you might find yourself in,
and what treatments available that you would want
- also asks for further instructions about health care and personal care
- need witness to make it binding
Problems with Living Wills
1. change of mind
incumbent on patient to change living will when attitudes change
important to update as you change certain values
perhaps incorporate revision into updating that occurs with other major documents (will,
mortgage, driver’s licence)
2. unexpected medical advances
regular updating as partial solution
things change – there are new diseases that come up
accompany a chart or list of diseases with statement of general values
will need help from health care professionals (info lines, websites, etc.)
3. comprehensiveness
might not address relevant issues
a general statement of values could accompany preferences for particular scenarios
articulate what you thing when confronting these diseases
4. hard to know what one thinks of the scenarios when they are merely hypothetical
values affected by confrontation with disease
updating should occur with onset of serious condition
something that may really change one’s values is confrontation with the prospect of death –
one may realize that what is really important is something else entirely
this may be that you were never able to properly articulate your true values until that point, or
because your values change
a good way to combat this is to refine and alter the living will every time you are confronted
with illness or a disease
5. hard to enforce
need some sort of advocate
oversight of advocate
conflicts with family
6. what of those without an instruction directive
Option 2: Proxies
- appeal to surrogate decision maker
- example of next of kin
- it is when the next of kin is unclear, or there are differences in value with the next of kin, that a proxy should
be named
- the point is not for the proxy to use his own values, but to know the person’s values and to respect them
enough to be able to enforce it
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- this is also helpful in cases where the living will is not completely clear – the proxy will know the person well
enough to be able to explain of clarify
- assumption that surrogate has insight into an unconscious patient’s vales that can guide medical care
- solves problems of enforcement and interpretation in living wills
Problems with Proxies
1. sometimes the next of kin does not have insight into patient’s values (if estranged)
in cases such as when the adult child holds different religious values – either known or
unknown to parents
if there is disconnect between the values you and your next of kin holds – and if you worry that
your next of kin does not quite understand your values – important to designate a proxy who
does understand your values
can designate a surrogate decision maker in another form of advanced directive, a proxy
medical durable power of attorney
an autonomous designation of a surrogate decision maker to handle health care decisions
while incompetent
2. possible tyranny of the surrogate
can be intentional
- example- parents who want an adult child to die in a manner that befits a religion that
the child rejects
- need some kind of oversight – but need someone to trigger this and get the boards
- perhaps from hospital ethics board of professional tribunal
- ultimately Official Guardians Office and the courts
can be unintentional
- ignorance
- instruction directive (ID) can supplement proxy directive (PD)
- this is a good idea no matter what, because it is an important decision – sometimes
the proxy (no matter how well intentioned) may have difficulty decide what you would
want under a specific set of circumstances
3. some people have no next of kin
no next of kin and no proxy can be problematic
have to make do with an instruction directive – if one can be found
or “best interests standard”
principle of beneficence
but how can meaningfulness interests be known if there is no instruction directive
- focus on experiential interests (suffering or pain – different treatments can be
decided, or even withdrawal)
- restoration of autonomy, if possible
The Not Yet Competent
- doctrine of informed consent is the core doctrine when deciding medical treatment
- the doctrine of informed consent presupposes the competence of the patient
there may be those who have lost their competence
there are those who have never been competent
- the not yet competent – children
- the never competent – cognitively impaired
- those who have lost competence – there are many who are conscious and seemingly quite happy as well
those with Alzheimer’s for example – disease has many different kinds of manifestations
some are able to enjoy themselves – what do you do in the cases of advanced directive
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