Precommitment in bioethics: some theoretical issues.

I. Introduction Precommitment is a strategy thought to be widely used in medicine and health care. In this Essay, I consider several examples of such use to raise some theoretical questions about precommitment. The following apparent uses of precommitment in bioethics are discussed throughout the Essay. Standard Advance Directive.-A patient executes a living will or durable power of attorney for health care giving instructions about specific care he does or does not want in specified future circumstances should he become unable to make a competent decision about care at that time. The patient is now in those circumstances, and his physicians must decide what care to provide. Dementia Case.-A former college professor, whose life has revolved around intellectual work, has specified in an advance directive, while competent, that she does not want any life-extending care should she become so sufficiently demented that she can no longer recognize any of her friends or family, or continue with her work. The patient has now become demented and cannot work or recognize any friends or family. She also cannot remember her advance directive, but she appears to enjoy her existence, which consists mainly of watching television. She does not appear to suffer any significant psychological distress from her dementia. She has now developed pneumonia, which should be relatively easy to treat with antibiotics, and doing so would continue her apparently pleasant life. Should her advance directive be followed by withholding the antibiotics that are likely needed to prevent her death? Mental Health Directive.-A patient has a long history of bipolar disease (manic depression) that has been stabilized in the past with medications. However, like many patients with the disease, after a period of stabilization he has often stopped taking them. Invariably, he becomes increasingly manic, with disastrous consequences for his personal and professional life. While stabilized on medications, he executed an advance directive authorizing his treating psychiatrist to administer medications to him against his will should he refuse to take them and relapse, or be in imminent danger of relapsing, to a manic state. Two weeks ago he stopped taking his medications and shows signs of increasing manic behavior. He refuses to take his medications, stating that he does not need them. Surrogacy Case.-A woman, who has had a partial hysterectomy in the past, wishes to have children. She and her husband find another woman willing to carry their embryo to term and then relinquish the child to them. The embryo will be created by retrieving one of the eggs of the woman without a uterus, fertilizing the egg with her husband's sperm, and implanting it in the surrogate. The surrogate, who has children of her own, agrees to sign a binding agreement with the couple to turn over the baby once it is born, recognizing that she may become attached to it over the course of the pregnancy and then not wish to fulfill her agreement. Quadriplegic Case.-A 20-year-old patient has suffered a catastrophic accident leaving him paralyzed from the neck down and respirator dependent. He insists that his respirator support be withdrawn so that he may be allowed to die. In response to efforts to convince him that other patients with similar conditions adjust to their circumstances and come to value their lives, he acknowledges that he too would likely do so. However, he insists that he does not want to become the kind of person who would find such a compromised life acceptable and worth living. The Dying Atheist.-A person is dying after a long life in which, as a young man, he firmly rejected the religion in which he was raised. He had become a confirmed atheist, antagonistic to, and wanting no association of any sort with, organized religion. Now, knowing he is on his deathbed, he asks that a priest be called. Consider two versions of the case. …