Advance Directives: Implications for Policy

One mark of a maturing discipline is its members' willingness to expose the field's accepted wisdom to scrutiny and challenge. In any applied field, such scrutiny must include consideration of whether accepted theoretical principles are well-suited to real life conditions. We in bioethics are fortunate to have many colleagues eager to explore the practical dimensions of various theoretical viewpoints. One of their most popular subjects has been the advance treatment directive, and the empirical findings to date have important implications for health care policy. The empirical data on advance directives provide guidance at two policy levels. At the broadest level, the empirical data challenge the existing consensus that directives are the ideal mechanism for resolving decisions on life-sustaining treatment for incompetent patients. The data speak to the question of how much financial and other support the government, health care institutions, and other funding sources should devote to educating and otherwise encouraging members of the public to complete a directive. At the second level, the data suggest some targets for "tinkering." That is, if we agree that directives are valuable to at least some segment of the population, what can we do to remove existing unnecessary and unjustified impediments to their use? Other contributors to this supplement offer helpful suggestions on removing these impediments. I will instead focus on the broader implications of some of the empirical findings. The assumption underlying most of the bioethics and legal commentary, as well as the relevant empirical research, has been that advance directives, and the exercise of "precedent autonomy"[1] they represent, constitute the preferred approach to determining how aggressively to treat seriously ill incompetent patients. Implicit in most of the literature is die notion that it would be good if more people completed advance directives. This judgment can be contested, however. Why are directives preferable to other possible approaches to end-of-life decisionmaking for incompetent patients? Why are they preferable to, for example, an approach that permits close relatives or friends to decide how aggressively to treat such patients, after consultation with caregivers and within a range of choices deemed acceptable by courts, legislators, and other institutions involved in establishing normative standards in our society Philosophers and others favoring the advance directive approach have contended that since autonomy is @and ought to be assigned a high priority by most members of this society, it should carry the most weight in resolving decisions on medical treatment. When it comes to patients who cannot tell us how they would exercise their autonomy when a question concerning life-sustaining treatment arises, we should look to their past expressions of autonomy to resolve the question. Any possible alternative approach is second-best, to be used only when patients fail to leave us an indication of how they would decide. In recent years, a few writers have questioned the moral justification for assigning directives this high priority.[2] But the empirical data suggest another kind of weakness in the advance directive approach: irrelevance. The arguments favoring advance directives assume that autonomy over one's future as an incompetent patient is a precious freedom that law and policy should go to great lengths to protect. But how important is precedent autonomy to people in this country Precedent autonomy clearly is important to many of the philosophers, legal academics, and policy makers writing on this subject. Empirical findings, however, indicate that many study subjects do not understand what an advance directive is and that fewer still have undertaken to complete a formal directive. These data suggest that the exercise of precedent autonomy might not be very important to most of the public. At least, not so important that they are willing to take the time and trouble to learn about directives and to complete a written directive. …