Ethical Issues of Advance Directives
Advance directives are written documents that spell out your medical care preferences. These documents usually take effect when you no longer can make informed health care choices for yourself. While these documents are helpful to loved ones and caregivers, there are a number of ethical considerations that can make the development and execution of advance directives difficult.
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Types
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Advance directives typically take two forms. The first is a Living Will, which is a document that delineates your preferences in a variety of medical circumstances. A Do Not Resuscitate Order is a specific form of living will that applies only to a medical situation where you require intervention to restart breathing or heart functionality. The second is a medical durable power of attorney, also known as a durable power of attorney for health care. A durable power of attorney formally designates another individual to make medical decisions on your behalf.
Considerations
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The first challenge associated with advance directives is determining the content. Do you want a basic proclamation of your wishes? Statements like "I want to pursue all forms of treatment," are general in nature. Statements such as "I want life-sustaining procedures to be continued for no more than 30 days when my medical condition has shown no signs of improvement," are much more specific.
General statements cause ethical concerns because they quickly give rise to debate about the individual's intention. In the above example, does "treatment" mean procedures that will improve the underlying medical impairment, or does it include life-sustaining measures? Specific statements also can be problematic, especially if the actual situation does not directly parallel the situation covered in the directive.
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Effects
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Additional ethical issues can be raised when the instructions in advance medical directives conflict with the spiritual beliefs of the patient, the doctor or the facility. Some instructions might be considered a form of assisted suicide, for example. Likewise, directives included in a patient's documents can result in an ethical dilemma between following the patient's wishes and the oath taken by medical professionals.
Warning
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A medical power of attorney resolves certain ethical issues raised by living wills. For example, appointing someone to make informed decisions on your behalf removes the problems caused when instructions are unclear or not completely related to the current medical situation. The designated person's instructions are always relevant because they are made at the time with all the information at hand. However, even more daunting ethical issues can arise. The appointed proxy is supposed to make decisions based upon previously communicated wishes. However, that person can face the question of whether to go with what "feels right" or "seems correct" in a given situation if it technically goes against something the patient had previously relayed.
Misconceptions
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All too often, people use the terms "living will", "medical power of attorney" and "do not resuscitate order" interchangeably. However, they provide very different powers and instructions. For example, with a DNR, you could be placed on a ventilator for years, as long as your condition never actually required resuscitation. While both a living will and a medical power of attorney are more comprehensive than a DNR, one provides a list of written instructions to medical providers, while the other directs doctors to take instructions from another person.
Likewise, there is a misconception that one type of advanced directive is "more powerful" than the others. When an ethical conflict arises, or a gray area is encountered, none of the documents is more powerful than the others.
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References
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