The Rules of Insanity: Moral Responsibility and the Mentally Ill Offender (original) (raw)

The Curious Case Of the Advance Directive in Psychiatry

As discussions around the Mental Health Care Bill 2013 gain pace, one aspect of the bill, which is the Advance Directive, has perhaps not been discussed enough. The present essay is an attempt to explore different aspects of the advance directive in psychiatry, to understand the implications better. The article attempts to look at the conceptualization of the advance directive, questions regarding implementation, and possible unintended consequences. In doing so, it interrogates the larger question of ideology that drives the concept of the advance directive in psychiatry.

The Moral Bindingness of Advance Directives

Cambridge Quarterly of Healthcare Ethics, 2023

Professor Latham has written a thought-provoking commentary 1 on my paper about advance directives. 2 I am grateful for this opportunity to integrate the debate on the moral binding nature of these manifestations of will. As correctly inferred by Latham, under Italian law, not only are advance healthcare directives applied to refuse or request a given form of lifesaving or life-sustaining treatment (which is the case in the United States), but also to refuse or accept any form of treatment deemed useful and legally applicable, in accordance with medical ethics precepts, in cases where patients are temporarily unconscious. 3 Such a different scope of application of advance directives has a bearing on any judgment as to the binding or nonbinding nature of such expressions of patient will. It is, however, doubtful that the somewhat narrow scope of application of advance directives in the United States may justify their binding nature. As for the argument set forth by Latham, with reference to his 80-year-old mother, I doubt that it would be enough to merely inform her that the chance of survival in cases of cardiopulmonary resuscitation (CPR) following cardiac arrest is as low as 15%. Making a cogent decision does require much more thoroughly detailed information. As a matter of fact, the odds of success are closely linked to the timing of the medical intervention itself: "Defibrillation within 3-5 min of collapse can produce survival rates as high as 50%-70%." 4 Furthermore, the type of condition calling for CPR is a determining factor: in patients with heart conditions, being treated for cardiovascular diseases, resuscitation success rates are above average, at 70%. On the other hand, for patients with underlying conditions other than cardiovascular diseases, resuscitation procedures often prove useless: in such instances, in fact, cardiac arrest is only the climax, occurring as a result of major systemic failure. 5 That arguably entails that it is somewhat immaterial (in addition to uninformed) to express a refusal of a given treatment without specifying a real scenario and its related benefit-cost ratio. Undoubtedly, the obligation to provide information is more easily discharged if the patient needs immediate care. In fact, in such cases, doctors only have to make patients acquainted with the benefit-cost ratio inherent to the medical treatment, possible viable alternatives, and consequences of a refusal. Conversely, through advance directives, patients can refuse treatment options that may prove necessary because of various different conditions, with varying benefit-cost ratios for each disease. Moreover, the benefit-cost ratio for each treatment may vary based on (1) how old the patient will be when said treatment is necessary; (2) the presence of comorbidities; and (3) predictable case characteristics, for example, the time period between cardiac arrest and CPR. Such a higher degree of complexity, however, does not necessarily foreclose the use of advance directives. The main objective of figuring out what the patient's will would have been, in fact, may be achieved by construing and interpreting the directive's contents in a logical fashion, according to common sense. For instance, let us imagine that a patient refused a form of treatment through an advance directive outlining a hypothetical real-life scenario (i.e., type of disease, patient's age, timely medical intervention, etc.) presenting a favorable benefit-cost ratio. If, however, a different future

ADVANCE DIRECTIVES, AUTONOMY AND UNINTENDED DEATH

Bioethics, 1994

This Paper argues that Living wills are typically nebulous and confused documents that do not effectively enable you to determine your future treatment. Worse, signing a living will can end your life in ways you never intended, long before you are either incompetent or terminally ill. This danger is compounded by the fact that those who implement living wills are often themselves dangerously confused, so that, for example, they cannot be relied upon to distinguish living wills from DNR orders. In addition, the Paper argues that advance directives concerning resuscitation are often so confused that they end the lives of healthy, alert people who have not suffered cardiac or pulmonary arrest. Finally, the paper argues that advance directives establishing durable power of attorney for health care often preserve the chief dangers of living wills. Suggestions are offered as to how you can most effectively direct your future treatment without endangering your life.

Defining Features of Advance Directives in Law and Clinical Practice

Chest, 2012

A ll 50 states and the District of Columbia recognize the legal right of competent adults to write advance directives to provide direction for healthcare decisions near the end of life, when the ravages of illness, disease, or injury have taken the ability to decide for one's self. Advance directives may designate someone to make health-care decisions on the Editor's note: This essay is the fourth article in the Law and Medicine curriculum of the ongoing "Medical Ethics" series. To view all articles from the core curriculum, visit http://chestjournal.chestpubs. org/cgi/collection/medethics.-Constantine A. Manthous, MD, FCCP, Section Editor, Medical Ethics patient's behalf (a "proxy directive" or "durable power of attorney for health care"), state with some specifi city the person's wishes and instructions for care (a "living will" or "instruction directive"), or both (a "combined directive"). Most state statutes recognize both proxies and living wills and allow for combined directives; New York, Massachusetts, and Michigan recognize by statute only the health-care proxy. 1 This article reviews the defi ning features of advance directives and the governing law. I discuss some common In the. 30 years since the New Jersey Supreme Court's seminal opinion in the case of Karen Ann Quinlan, all 50 states and the District of Columbia have enacted legislation to recognize the legal right of competent adults to write advance directives. The purpose of advance directives is to provide direction for health-care decisions near the end of life, when the ravages of illness, disease, or injury have taken the ability to decide for one's self. This article reviews the defi ning features of advance directives and the governing law, discusses some common practical concerns regarding the use and effectiveness of advance directives, and identifi es several signifi cant ethical-legal challenges for honoring advance directives at the bedside. With a primary focus on the health-care proxy, the anatomy of advance directives is analyzed under four general rubrics: formal requirements, decisional capacity and when the directive takes effect, rights and responsibilities of proxies and health-care providers, and the scope and limitations of decisions to forego life-sustaining treatment. There is much common ground among state laws, but particular legal provisions may vary from state to state. Physicians, nurses, social workers, and other health-care professionals should be familiar with the law of their home state.

Autonomy and the Moral Authority of Advance Directives

Although advance directives are widely believed to be a key way to safeguard the autonomy of incompetent medical patients, significant questions exist about their moral authority. The main philosophical concern involves cases in which an incompetent patient no longer possesses the desires on which her advance directive was based (for example, in cases of severe dementia). The question is, does that entail that prior expressions of medical choices are no longer morally binding? I believe that the answer is ‘yes.’ I argue that a patient’s autonomy is not respected by honoring the desires she used to have but no longer does. I also consider and reject the view that honoring an advance directive that reflects the patient's previous values must be in that patient's best interests. If that is correct, then advance directives in the kind of case at issue are not morally binding.