Published online by Cambridge University Press: 29 July 2009
In the mid to late 1980s a debate arose over the moral and legal authority of advance medical directives. At the center of this debate were two point-counterpoint law journal articles by Rebecca Dresser and Nancy Rhoden. What appeared to have the makings of an ongoing critical dialogue ended with the untimely death of Nancy Rhoden. Rebecca Dresser, however, has continued her challenge of advance directives in numerous publications, most recently in a critique of Ronald Dworkin's Life's Dominion. Like Rhoden, Dworkin has been a staunch advocate of advance directives as an exercise of what has come to be referred to as prospective or precedent autonomy. In this paper I will consider a number of the issues that Dresser has repeatedly raised about the infirmities of advance directives, and suggest that it is from an understanding of and appreciation for the narrative dimension of the life of a person that advanced directives draw one of their most powerful justifications.
1. Dresser, R. Life, death, and incompetent patients: conceptual infirmities and hidden values in the law. Arizona Law Review 1986;28:373–405.Google ScholarPubMed
2. Rhoden, N. Litigating life and death. Harvard Law Review 1988;102:375–446.CrossRefGoogle ScholarPubMed
3. Dresser, R. Advance directives, self-determination, and personal identity. In Hackler, C, Moseley, R, Vawter, D, eds. Advance Directives in Medicine. New York: Praeger Publishers, 1989.Google Scholar
4. Dresser, R. Relitigating life and death. Ohio State Law Journal 1990;51:425–437.Google ScholarPubMed
5. Dresser, R. Missing persons: legal perceptions of incompetent patients. Rutgers Law Review 1994;46:609–719Google ScholarPubMed
6. Dresser, R. Dworkin on dementia: elegant theory, questionable policy. Hastings Center Report 1995;25(6):32–38.CrossRefGoogle ScholarPubMed
7. Firlik, AD. Margo's logo. JAMA 1991;265:201.CrossRefGoogle ScholarPubMed
8. Parfit, D. Reasons and Persons. New York: Oxford University Press, 1984.Google Scholar
9. Rich, BA. The values history: a new standard of care. Emory Law Journal 1991;40:1109–81.Google ScholarPubMed
10. In the eleven years between Dresser's first and most recent articles, both of which espouse or at least rely upon Parfit's theory of personal identity, the problematic policy implications that it entails have been identified by a number of authors, perhaps most notably Buchanan, Allen and Brock, Dan, Deciding for Others—The Ethics of Surrogate Decisionmaking. Cambridge: Cambridge University Press, 1989, pp. 177–78. Her failure or refusal to acknowledge and address these points suggests that she is avoiding the implications of the theory rather than merely overlooking them.Google Scholar
11. Hume, D. A Treatise of Human Nature. London: Penguin Books, 1969.Google Scholar
12. Locke, J. An Essay Concerning Human Understanding. ed., Nidditch, PH. Oxford: Oxford University Press, 1975,II.xxvii.9.Google Scholar
13. See note 12. Locke, 1975:II.xxvii.9.Google Scholar
14. Buchanan, A. Advance directives and the personal identity problem. Philosophy & Public Affairs, 1988;17:277–302.Google ScholarPubMed
15. Kuczewski, M. Whose will is it, anyway? A discussion of advance directives, personal identity, and consensus in medical ethics. Bioethics 1994;8:27–48.CrossRefGoogle ScholarPubMed
16. Samuel Sheffler expresses a similar sentiment when he states, with regard to Parfit's view of personal identity: “I don't have the faintest idea how I am to conceive of myself if I am not to conceive of myself in the usual way, as an agent existing over time,” Ethics, personal identity, and the ideals of the person. Canadian Journal of Philosophy 1982;12:229–46, p. 238.Google Scholar
17. Locke, J. Second Treatise of Government. Cambridge: Cambridge University Press, 1960, Ch. II., Sect. 4.Google Scholar
18. See note 2. Rhoden, 1988:418.Google Scholar
19. See note 7.
20. Buchanan, JH. Patient Encounters: The Experience of Disease. Charlottesville, Va.: University of Virginia Press, 1989, p. 40.Google Scholar
21. See note 20. Buchanan, 1989:45.Google Scholar
22. Nozick, R. Anarchy, State, and Utopia. New York: Basic Books, 1974, pp. 42–3.Google Scholar
23. Feinberg, J. Harm To Self. New York: Oxford University Press, 1986, pp. 361–2.Google Scholar
24. Buchanan and Brock offer three generally acknowledged conditions precedent for personhood: (1) consciousness of self as a being that exists over time, i.e., someone with a past and a future as well as a present; (2) the capacity to understand and appreciate reasons for and against acting and to control one's impulses or inclinations in conjunction with such reasons, and (3) the ability to engage in purposeful actions. Persons such as Margo, in the later stages of Alzheimer's demen tia, seem to have permanently lost these attributes out of which enduring persons are constructed from momentary person slices or stages. See note 10. Buchanan, and Brock, 1989:160.Google Scholar