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Publication Date

2001

Abstract

Advance directives have been identified as the "quick fix" of bioethics. The logic goes something like this: If we could only get patients to tell us, in advance of disability, the specifics of the health care they would want to receive in the future, we could put our ethical and legal qualms aside and march ahead with care that we know is patient appropriate and legally protected. If we could only get the patient to commit, we could proceed with moral certainty and risk assurance. If we could only be given explicit instructions, we could act accordingly and be comfortable and secure in the rightness of our actions. Such was the thinking that underlay the development of the first wave of advance directives. The living will was the first attempted solution to the problem of the patient who could not make contemporaneous, ethically compelling, and legally protective decisions. It was designed to query the patient when she was capable of making health-care choices in order to implement her decisions when she was no longer able to consider the benefits, risks, and alternatives of medical options for intervention. It seemed, at the time, like a good idea. The origin of the concept lay in the experience of patients and their families with care at the end of life. As technology became more and more sophisticated, and as machines were increasingly able to substitute for organ function even when integrated cognitive function was absent, families and loved ones became more and more convinced that this was not the sort of exit from life that the patient would have desired. This notion that there was patient preference for the sort of death that should occur was the underlying impetus for the development of living wills.

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