Ethics of Advance Directives in End-of-Life Care
This paper examines the ethical dimensions of advance directives — including living wills, durable power of attorney, and Do-Not-Resuscitate orders — in end-of-life medical care. It argues that a patient's advance directive, when legally executed, should be honored regardless of family or medical personnel objections. The paper explores the Patient Self-Determination Act, the tension between precedent autonomy and contemporaneous autonomy in dementia cases, intervention-based versus value-based approaches to end-of-life planning, and the practical challenges hospitals and families face when directives conflict with emotional responses or new medical knowledge. Recommendations from ethics committees and patient advocacy groups are also discussed.
- Introduction: The Right to Direct One's Own End-of-Life Care: Overview of advance directives and paper's thesis
- Legal Framework and Types of Advance Directives: Living wills, PSDA, DNR, and legal requirements
- Ethical Conflicts When Families Override Directives: When and why families challenge valid directives
- Dementia and the Problem of Personal Identity: Autonomy conflicts in dementia patients' directives
- Value-Based Approaches and Patient Autonomy: Shift from intervention-based to values-based planning
- Hospital Ethics Committees and Compliance Challenges: Ethics committees, compliance failures, and physician pressures
- Conclusion: Honoring Patient Wishes: Reaffirmation that legally made directives must be honored
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What makes this paper effective
- The paper consistently returns to a clear normative thesis — that legally executed advance directives must be honored — and tests it against multiple complicating scenarios rather than stating it once and moving on.
- It draws on a range of evidence types: legislation (the PSDA), clinical studies (Goodman, 1998; Weiler, 1996), philosophical frameworks (Dworkin on precedent autonomy), and patient testimony (Dax Cowart), giving the argument both empirical and ethical grounding.
- The paper acknowledges genuine counterarguments — such as decisions made during fever or pain — and engages with them honestly before reasserting the primary position, which demonstrates intellectual fairness.
Key academic technique demonstrated
The paper models the use of extended quotation and paraphrase from a secondary philosophical source (Buccafumi, 2004) to introduce a two-sided conceptual debate — precedent autonomy vs. contemporaneous autonomy — and then applies that framework directly to a concrete clinical scenario involving dementia patients. This technique of importing theoretical vocabulary to sharpen a practical ethical question is characteristic of applied-ethics writing at the undergraduate level.
Structure breakdown
The paper opens with a thesis statement and a practical checklist of end-of-life questions, then moves through legal definitions (living will, PSDA, DNR), ethical complications (family override, dementia identity problems), approaches to directive design (intervention-based vs. value-based), empirical evidence from hospital studies, and finally institutional mechanisms (ethics committees) before closing with a reaffirmation of the thesis. The structure is broadly linear and cumulative, building complexity with each section.
Introduction: The Right to Direct One's Own End-of-Life Care
Adults have both the right and the responsibility to make decisions concerning their final days in advance. Whether to decline life support if death is imminent, or if a coma becomes permanent, is typically an ethical position that a person has already formed. An adult who wishes to record such a decision can do so by creating a living will, a durable power of attorney for health care, or a directive appointing a health care representative. A physician may ask a patient to prepare such a document in advance and keep it on file. It is the central argument of this paper that a person's advance directive should be followed, no matter how difficult that may be for the family or for medical personnel.
Many health facilities recommend that individuals preparing advance directives ask themselves the following questions:
Who would you like to make treatment decisions for you if you become unable to do so? How do you feel about ventilators, surgery, resuscitation (CPR), drugs, or tube feeding if you were to become terminally ill — if you were unconscious and not likely to wake up, or if you were suffering from dementia? What kind of medical treatment would you want if you had a severe stroke or other condition that made you dependent on others for all your care? What mental, physical, or social abilities are important for you to enjoy living? Do you want to receive every treatment your caregivers recommend? (University of Michigan Health Systems, p. 1)
If a patient reaches a point where they can no longer make such decisions, an advance directive — if one exists — is called upon. The appointment of a person who holds durable power of attorney or serves as a health care representative reflects the patient's choice of someone they trust, who ideally shares their values regarding end-of-life care, to stand in their place when they can no longer direct their own care. This person is also directed to consult with the attending physician or physicians when circumstances are complex. In such cases, many physicians feel that if a patient has a reasonable chance of recovering and retaining quality of life, life support should be sustained. However, if quality of life would be significantly impaired, experienced physicians may counsel the health care representative to withdraw life support and allow natural death. Because relatives do not always share the patient's views on end-of-life matters, the appointment of a health care representative may extend to close friends or even a member of the clergy.
References
Buccafumi, D. (2004). Advance directives and the problem of personal identity. Global Virtue Ethics Review. 1 Apr 2004.
Caring Connections. (2008). End-of-life decisions: advance directives. Compassionate Care Helpline, National Alliance for Hispanic Health. Retrieved March 8, 2008 at
Edwards, B. S. (1994). When a living will is ignored. American Journal of Nursing, 94(7), 64–65.
Goodman, M. D. (1998). Effect of advance directives on the management of elderly critically ill patients: Clinical investigations. Critical Care Medicine, 26(4), 701–704.
McGee, G. (1997). Dear Dax... Penn Bioethics, 2(4), Summer 1997.
Rubin, S. (2001). Medical ethics and the humanities in end-of-life care. San Diego Hospice. Ethics Videos on the Web. Retrieved March 8, 2008 at
University of Michigan Health System. (2008). Advance directives/living wills. University of Michigan Health System. Retrieved March 8, 2008 at
Weiler, K., Eland, J., & Buckwalter, K. C. (1996). Iowa nurses' knowledge of living wills and perceptions of patient autonomy. Journal of Professional Nursing, 12(4), 245–252.
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