What makes a directive valid

Advance directives apply to those individuals who are incapable of having a wish. It is necessarily the case that the purpose of advance directives cannot be to express the wishes of a wishless individual. In contrast to some previous interpretations, advance directives, therefore, should not be understood to be about what a wishless person would have wanted if they could have a wish. Rather, advance directives are about what a person did want in advance, and the directives that we honor concern the surviving interests of the patient.[1] The same form of justification applies to estate wills. The theoretical basis for advance directives is that the end of life and the process of death are critical matters that the individual has more right to manage than any other person.[2] The person who leads it, more than any other person, has a rightful interest in molding the narrative whole that is her or his life. The argument that the patient with an advance directive made a mistake rarely holds, because the possibility of misjudgment is hard - if not impossible - to establish, and because the right to manage surviving interests includes the right to judge differently from others.[3] From the above reasoning it follows that substituted judgments for wishless individuals should be used to judge as they would have when they were competent if they had considered the situation that ultimately arose. Best interests judgments for wishless individuals then should be reserved for situations in which surviving interests cannot be ascertained or in which the patient stated in advance that best interests judgments may be used. There are limits to the situations in which advance directives carry moral validity. In particular, patients who are capable of having a wish but are decisionally incapacitated fall into a conceptually distinct category. When a person is radically changed and the narrative theme of this person's life - the theme that motivated the advance directive - has changed, the advance directive may no longer be valid. Although it is in practice extremely difficult, first, to define clearly which people belong in this liminal category and second, to know their wishes, it may occasionally be reasonable to disregard their advance directives. People have a surviving interest in managing their moments of incapacity, but people also have an interest in being protected from unreasonable bondage to an action they would have changed if they could.[4] , Note, however, that this limit applies to situations in which advance directives are morally valid. It does not alter the fundamental justifying argument: whenever advance directives are morally valid it is by reason of surviving interests. Practical Criteria of Moral Validity: Seeking Empirical Standards If it is clear that advance directives are justified by surviving interests, the standards by which to judge directives' validity are also clear. First, directives must meet standard criteria for real-time informed consent for medical decisionmaking.[5] The person must have adequate and fairly framed information about the procedure in question, the risks, benefits, and alternatives. Next, the person must be competent to consent or make the decision(s); the decision(s) must be uncoerced. And finally, the decisions should ideally be made with due attention to the process and context, so that there is an established therapeutic relationship with an advising physician, consultants are involved where relevant, and family members and others are involved as appropriate. Moreover, directives must meet standards that are specifically relevant to advance decisionmaking. First, the documentation of preferences should be made in ways that accurately present wishes. For this to occur, predrafted documents and worksheets should be validated. Second, the preferences should be reasonably stable. While genuine changes in preference based on new experience or education are acceptable and even desirable, fleeting changes in preferences should be excluded ahead of time if possible. …