Bioethics: Living Wills, PAS, and Genetic Enhancement

Living Wills and the Limits of the 'Current Interests' Argument

Rebecca Dresser and John Robertson argue, in essence, that it is impossible for a competent individual to foresee his or her future interests as an incompetent patient. Living wills and advance directives appear to provide clarity to family members and give direction as to how to treat an incompetent patient, but in reality these documents merely confuse the debate further, as evidenced by end-of-life care court cases such as that of Terri Schiavo. Different people have different needs at different stages of their lives — just as a child has different interests than an adult — and they must be treated with this in mind by the law. No one can predict his or her future in its totality. Dresser and Robertson contend that the current interests of the incompetent patient should be evaluated by physicians, family members, and the courts, rather than by the individual's own projected assessment of his or her future interests. The authors also argue that living wills do not sufficiently take into consideration the emotional needs of families to have a say in how the ailing individual is treated, instead making treatment dependent merely upon a piece of paper.

The composed prose with which Dresser and Robertson advance their "current interests" argument obscures the fact that, given the emotionally charged circumstances when a patient is facing the end of life, it is very difficult for families to arrive at a competent assessment of the patient's interests. Family members, believing they have the patient's current interests at heart, may ignore medical advice that the patient him or herself was actually better positioned to evaluate while still competent. Family members will also inevitably conflict over what constitutes a quality life, given the morally and religiously contentious nature of this issue. If the patient, when competent, believed that a quality life was not one "hooked up to a machine," and the family holds religious objections to the termination of life, is it really in the incompetent patient's current interests to let the family prevail after he or she can no longer articulate these concerns? What if the family itself disagrees? The absence of a clear answer about when life begins or ends seems to argue in favor of leaving this decision to the patient. Dresser and Robertson's "current interests" argument is essentially end-of-life decision-making by committee, in which everyone except the incompetent patient gets to weigh in. This is precisely what transpired in the Terri Schiavo case: Schiavo, a young woman, had left no clear directives as to what she considered a quality life.

Autonomy, Family, and End-of-Life Decision-Making

In essence, all of us are constantly making decisions that will affect our future selves, and the dying, the terminally ill, or simply anyone who writes a living will should have the ability to make decisions in the same fashion. These decisions may not be perfect — no more than other life decisions we make about our future physical health, from the way we eat to our choices to smoke, drink, work, and love. However, the idea that at some point families have a right to intervene on the basis of their feelings — however well-intentioned — and circumvent an individual's decisions about how he or she dies seems to go profoundly against the individualistic orientation of our society. In the long run, such intervention is also more divisive to the relationships among the living members of a family, as was plainly evident in the Schiavo case.