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Lecture 23

PHL281H1 Lecture Notes - Lecture 23: Ronald Dworkin, Advance Healthcare Directive, Immanuel Kant

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Donald Ainslie

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PHL281 Lecture 23 – Alert but Formerly Competent
Advance Directives
- thinking about professional ethics – where the fundamental principle is the doctrine of informed consent
- in the case of a competent individual – doctor must disclose the information, secure comprehension, patient
must be acting voluntarily when consenting to treatment
- if the five criteria are met, then the doctors can violate you – would be considered assault in any other
- patient’s choices while competent should guide treatment while incompetent
usually an advanced directive guides the treatment of the formerly competent
securing that the patient’s values are held throughout care
usually it is the proxy who ensures that these values are maintained
- this should be the case whether unconscious or alert
- example of a surgery – unconscious but the doctors cannot violate the consent of the patient by doing
anything other than what the patient agreed to
- example
a competent person with AIDS declares that he is not to be put on a ventilator
he becomes in incoherent (dehydrated) and is hospitalized
pneumonia re-occurs and ventilation is medically indicated
- the problem with advanced directives is that the situation prepared for is never exactly the way it happens
- the way it works in reality is much more complicated
- person may not want to go to the hospital (because he wants to die at home) – but if the care at home is not
sufficient for any issues that come up, it may be difficult
- dying person (old age) wants not to be taken to hospital when deteriorating – but falls out of bed causes
fracture – broken leg causes severe pain and so he has to be taken to the hospital
- this is why a living will is best complimented by a proxy directive – someone who can advocate on your
behalf and who has insight to your values and can still determine your care in the unpredicted situations
Hard Cases
- Ronald Dworkin’s description of Margo
- case
Alzheimer’s patient – severe dementia
unique position of being a happy one
generally happy, despite not even being close to the way she once was
as presented in the case – she was previously a television executive (high powered career)
- what makes the case hard
she has an advanced directive
directive states that if she gets dementia, she is to be allowed to die
- if she gets pneumonia – no drugs to be administered
- if physician-assisted death is available, she is to be killed
likely to be alive for a relatively long time
incompetence is of a form that allows for positive experiences
seeming clash between interests of the incompetent patient and the interests of the patient when
- principle of beneficence – should be acting in the best interests of patient, particularly those with
incompetent patients (let her be happy)
- principle of autonomy – should be refusing treatment, hastening or causing her death – due to her advanced
- there is a serious conflict here – which do we follow
- clash between the interests of the patient while competent vs. incompetent
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Ronald Dworkin’s Analysis
- the clash between Margo’s present interests and her (prior) interests when competent is merely an apparent
- the competent person’s prior advance directive trumps the interests of the incompetent person
-kill Margo – or let die
Four Senses of “Autonomy”
- every time the word autonomy is seen in philosophy – need to determine the definition being used
- take care to see if the definition of the word changes even within the paper – as this often happens
- use the word autonomy and end up switching between meanings
- when it comes to philosophical thinking, clarity is very important
define terms
use the word consistently
be aware what you mean when you say something
- the term of autonomy is a particularly problematic term – over four meanings from this course alone
-Gerald Dworkin
autonomy as a capacity that allows us to structure our lives by our own values
almost all adults are autonomous
we are all autonomous – even when asleep, we still have that capacity
he wanted a term that would work for almost all humans
-Ronald Dworkin
autonomy is what results from the use of this capacity
a life which reflects the person’s considered values
how many of us are autonomous in this sense
not just someone with the capacity to direct their life by their own values, but someone who has
used that capacity and acted to direct their life by their own values
someone who has thought about what they really believe, and how to make his life live up to the
values he has selected
autonomous person has done this and is in fact living by their values
depending on how you view living your life by your values (and to what extent), it is a higher
threshold to meet
it is not easy
depending on how you spell it out, the autonomous individual could be very rare
- religious figure you really thought hard and investigated it
- the moral saint
- it may simply mean, the educated person who decided to go to university because it
enables the person to do what they want
if you lower the threshold of what “living by one’s values” is meant to mean, then more people can
be considered autonomous by this definition
-George Harris
the right of a person to do what she or he desires so long as the person does not thereby violate
others’ rights
this has much to do with the Lockian framework of rights
defined as an exploration of Fathers and Fetuses and what the male role in reproduction should be
“morally legitimate interest in self-determination” (596)
“primacy of importance of individual choice” (601)
idea that you are the one driving your life and other people should not be – and you have a right to
that ability to drive your life (against others)
you can do what you want with your body as long as you are not violating other people
- you can kill yourself
- you can masturbate
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