Precedent vs. Contemporaneous Autonomy in Regard to Advance Directives - Essay Example

Melissa Greenblatt Biomedical ethics – HSOC 101 Precedent vs. Contemporaneous Autonomy in Regard to Advance Directives An advance directive is a set of written instructions a person gives. It specifies the kind of actions to be taken for his or her health if he/she is no longer able to make decisions due to illness or incapacity. An ethical argument exists around advanced directives in cases where a patient’s current desires conflict with the desires he or she had expressed in his or her advance directive (Marshall, 65). Suppose a patient is incompetent in the general, overall sense, but years ago, when competent, he executed a living will contradicting what he expresses now. Ronald Dworkin argues that if we can declare this patient incompetent, he does not have the capacity that autonomy represents. This means that respect should be upheld to the patients’ prior wishes made when competent. This is because a competent person’s decisions are autonomous ones. This view is referred to as the integrity view, which states that the value of autonomy derives from the capacity it protects: the capacity to express one’s own character traits, values, commitments, convictions and critical as well as experiential interest in a life one leads (Marshall, 71). However, it is arguable that, in most cases the present desires expressed by a patient need to be respected. Dworkin constructs a hypothetical case, where there exists a woman named Margo, who has dementia, but still seems to find pleasure in seemingly meaningless activities, such as reading, eating snacks among others. He even explains that Margo may be one of the happiest people he “knows.” However, years back, Margo had signed an advance directive expressing her desire to be left to die if she were to need life saving medical treatment once afflicted with dementia. Dworkin claims that even though Margo may “appear” to be enjoying her life, she is really only enjoying her experiential interests, which Dworkin defines as her desires to have enjoyable experiences (Marshall, 65). Whereas, it is one’s critical interests that Dworkin finds to hold value; these critical interests according to Dworkin refer to ones meaningful life goals and projects and can only be expressed when one is competent and consequently capable of autonomy. Dworkin believes we must respect Margo’s advance directive, as Margo living with dementia is her living against her critical interests that she held while competent. Experiential interests, in my opinion, hold a great deal of value, enough that experiential interests alone make one valuable and thus their life worth continuing. As Dworkin points out, pleasures that experiential interests provide are essential for a good life. A good life has value in it of itself, and while “genuine meaning and coherence” may enhance this value, no requirement for value to be obtained (Marshall, 123). I deduce that the reason we have critical interests are so we can enhance individual experiential ones. For instance, Dworkin claims establishing close friendships are an example of a critical interest. The reason we wish to establish such relationships is so when “watching football, or seeing Casablanca for the twelfth time or walking in the woods in October” (Marshall, 51) we are that much happier and life is more enjoyable. However, if one performs these experiential interests without having formed close relationships, they do not suddenly lack value; they are just perhaps slightly less enjoyable. However, if one were still to argue on critical interests that hold true value, we can see in many instances where experiential interests remain valuable on their own. The existence of a person who is solely able to attain experiential interests may allow someone else to enhance his or her critical interests. For example, in the case of Margo, there existed a medical student, Firlik, who took a specific interest in her case (Marshall, 144). By being able to visit Margo daily, Firlik was able to answer his questions and gain knowledge about an illness, enabling him to achieve further competence in his work thus fostering his own critical interest. Dworkin claims that when one is unable to have critical interests, he is no longer autonomous. Thus in order to respect one’s autonomy, we must listen to the advanced directive he/she signed when able to have such interests. However, there exist a number of flaws in Dworkin’s logic (Marshall, 312). I argue that in many cases, when signing an advanced directive, it is done without autonomy. Julian Savulescu gives an elaborate definition of what autonomy requires and claims that a fully competent patient’s desire may fail to be an autonomous desire. According to Savulescu autonomy requires one to be informed of relevant information, there must be no relevant correctable errors of logic in evaluating that information, and lastly, it must involve a vivid imagination by the person of what each state of affairs would be like for that person (Marshall, 321). When signing advance directives, people are often denied knowledge of treatments and other relevant information that may be developed between their signing and the time it goes into effect, or the opportunity to clarify any confusions they may have over the agreement. Conversely, there is immense variation among each case of such complex diseases, it is almost impossible to imagine oneself in his/her future state. Thus to say precedent autonomy holds more value than contemporaneous autonomy seems arbitrary, and in some cases by Savulescu’s definition, we hold more autonomy when we are actually able to experience the state. Dworkin concedes to this point himself by saying, “people are not the finest adjudicators of what their own best wellbeing would be under situation they have never meet and in which their predilection and needs may considerably change” (Marshall, 341). In the case of Margo, when signing her advanced directive, she was most likely not signing it autonomously. Margo may have been uninformed of the fact that it was possible to have such positive experiential interests with dementia or unable to imagine herself experiencing the happiness she has felt thus far. Lastly, whether it is due to a disease or a natural progression, human beings change over time; chosen personal experiences or uncontrollable, unpredictable events shape and alter the narrative. When signing advance directive one is assuming his or her life follows a predictable trajectory. This directive needs to be signed with care and without chances of logical error. Moreover, we clearly understand this natural progression as a competent individual is allowed to change his or her advance directive until deemed incompetent. However, as Rebecca Dresser states, “a policy of complete adherence to progress directives means that we refute people like Margo the autonomy we enjoy as capable people to modify decisions that clash with our succeeding experiential interests” (Marshall, 369). Margo’s contemporaneous desire to disregard her advance directive is a personal development whether or not it is independent of her disease. Margo is a changed person and to respect her precedent “autonomy,” is to respect something that is no longer relevant and consequently valid. In my opinion, such uncertainty and ambiguity can be resolved by respecting one’s contemporaneous desires. Work cited Cohen, Marshall. Ronald Dworkin and Contemporary Jurisprudence. Totowa, N.J: Rowman & Allanheld, 1984. Print. Read More