Let’s assume, for the sake of argument, the unavailability of Plan A, in your sleep surrounded by your 36 adoring great grandchildren. Let’s assume, for the sake of argument, that Plan Z, at the wrong end of a needle cocktail, isn’t mandated. And let’s assume, for the sake of argument, that a choice has to be made. That’s why we have advance directives, right?
It’s become an article of faith that determination of how we choose to go is best made when we have a clear and viable mind, aren’t under extremis, We all either have one, or are remiss for our failure. We know better. Whether it’s a matter of ending our life with dignity, or relieving the burden on our loved ones, everyone knows that Living Will is the way to go, right?
Over at Co-Op, Kathleen Boozang has shaken my confidence with this provocative challenge.
It’s become an article of faith that determination of how we choose to go is best made when we have a clear and viable mind, aren’t under extremis, We all either have one, or are remiss for our failure. We know better. Whether it’s a matter of ending our life with dignity, or relieving the burden on our loved ones, everyone knows that Living Will is the way to go, right?
Over at Co-Op, Kathleen Boozang has shaken my confidence with this provocative challenge.
Rebecca Dresser of Washington University in St. Louis employs personal identity theory to oppose exclusive reliance on advance directives, arguing that the competent, functioning person who decides what health care she should receive, say, fifteen years hence is not the same person to whom these directives will apply. That is, that the person now in a nursing home with Alzheimer’s Disease who no longer recognizes his wife or children but seems basically content , is not the same “person” who executed the Advance Directive a decade or two ago with a dread of incompetence.
Speaking to the situation of her student, about to ship off to war, Boozang writes:
It’s been such a long time since my Living Will was prepared that I can’t recall precisely what’s in there, though I’m sure that it reflects my more youthful cavalier disregard for life under conditions that were less than optimal. While not quite ready to pull the plug for losing my Adonis-like physique, an opportunity since squandered, I was clearly of the view that I did not want to live if my brain was significantly compromised. Is that still my view? And where, along the spectrum of intellectual deficit, am I ready to give it up?
While I’m not quite convinced that advance directives aren’t a better alternative than letting some doctor in Florida make my decisions for me, Boozang has given me good reason to rethink my views, and more importantly, to inject some additional concerns and advice to young people who seek a Living Will, whether they are in uniform or post-partum and feeling the need to nest. Do young people really have an adequate grasp of life, death and disability to make decisions about how much, or little, they are willing to suffer before choosing to die?
Much to think about, and important to think about. After all, it’s not like you can change your mind after Plan B goes into effect.
I have become disenchanted with power we accord autonomy. Sometimes other principles should prevail, and sometimes a decision is patently wrong or irrational or transient. I can’t bring myself to aid an 18 year old who should be on a date at the movies prospectively decide whether he’s willing to live a life without legs, or imagine whether she can tolerate living with the consequences of brain injury.We assume that we know how we will feel when the time comes to make a decision. For the most part, people use advance directives to avoid heroic life-preserving care, assuming one believes life to refer to the functioning of some bodily organs without others, like the brain. We sign off on pulling the plug, and we’re confident with our decision.
It’s been such a long time since my Living Will was prepared that I can’t recall precisely what’s in there, though I’m sure that it reflects my more youthful cavalier disregard for life under conditions that were less than optimal. While not quite ready to pull the plug for losing my Adonis-like physique, an opportunity since squandered, I was clearly of the view that I did not want to live if my brain was significantly compromised. Is that still my view? And where, along the spectrum of intellectual deficit, am I ready to give it up?
While I’m not quite convinced that advance directives aren’t a better alternative than letting some doctor in Florida make my decisions for me, Boozang has given me good reason to rethink my views, and more importantly, to inject some additional concerns and advice to young people who seek a Living Will, whether they are in uniform or post-partum and feeling the need to nest. Do young people really have an adequate grasp of life, death and disability to make decisions about how much, or little, they are willing to suffer before choosing to die?
Much to think about, and important to think about. After all, it’s not like you can change your mind after Plan B goes into effect.
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This post caught my eye yesterday too. It actually is not that heretical or uncommon among estate planning attorneys to express skepticism towards living wills in favor of health care representative appointments. I generally tell clients that while everyone should appoint a health care representative to make health care decisions for them in the event they can’t communicate their own decisions, living wills are completely optional. The problem I identify for them is that it is very difficult to anticipate in advance all the varied circumstances that might obtain at the time the advance directive would go into effect. Boozang identifies a different but related problem — that what they think they would want in that situation now might not be what they would in fact want in that situation could they express themselves. If you have appointed a health care representative (with whom you have hopefully discussed your values and whom you trust to act in your best interests as he/she understands them), you really don’t need a living will. About the only advantages of living wills, I tell them, is that some clients feel it takes some of the burden of the decision off the health care representative, and that if no health care representative or successor health care representative is available when needed there will nevertheless be a record of the client’s wishes. My living wills also have a place where client’s can say whether the living will takes precedence over the authority of the health care representative or serves merely as a guideline. Those clients who elect to sign a living will almost always choose the latter option, and after this talk the majority of clients elect not to sign a living will at all.
I didn’t really see, though, why Boozang’s reasonable skepticism towards living wills necessarily entails less of a commitment to what we rightly accord the principle of self-determination. Rather, the skepticism towards living wills is based on the simple recognition that it represents very imperfect evidence of what the patient really wants at the time the decision whether to pull the plug must be made. The health care representative on the other hand, who is generally a close family member or someone who knows the patient well, has the benefit of being able to make the decision on behalf of the patient while much closer to the actual situation than the patient presumably was at the time he/she signed the living will.
First, welcome back. Second, I’ve found the representative route problematic as well. As much as we might hope that our rep respects our wishes and reflects our sensibilities, when push comes to shove it remains the representative’s decision rather than our own. Some people are fortunate enough to have a rep in whom they repose complete trust and confidence. Most do not, and most don’t even realize that the appointed rep sees things somewhat differently than they do. To make matters worse, add the situational issues and pressures on the health care representative and wonder what will they decide when the time comes.
It’s like shooting in the dark, and you only get one shot.
There is no really good answer to this problem. I have personal experience of several people “rethinking” their own past personal directives. I also know of multiple instances where trusted relatives, who were given durable power of attorney for health care, turned out to be untrustworthy (i.e. putting their own interests first).
However, I think it is still an even worse alternative to put your trust in health-care providers. At that point, you might just as well leave a directive for people to flip a coin.