Kindle Notes & Highlights
Perhaps the doctors were obligated
why wake her up just for the purpose of letting her choose between horrible options?
should her children be consulted?
difficult to get the information
autonomy and beneficence may conflict.
How should bioethicists and healthcare professionals address racism?
the US healthcare system has played an important role in maintaining health disparities,
racism can be such a fundamental failure to respect patients as persons,
Structural “racism
personal racism,
can also determine how healthy people are and how long they live.
In the United States, racial and ethnic minorities have higher rates of chronic disease and premature death than do White people.
women who are already overloaded with stress hormones as a result of their day-to-day existence, are more likely to give birth prematurely.”
Metrics of racism: Premature birth
maternal mortality rates,
Metrics of racism: Maternal mortality
high blood pressure.
Metrics of racism: Hypertension
inflammation, increasing the risk of cancer and kidney and heart disease. Racism can also affect mental health, causing depression, anxiety, and often leading to substance abuse and other unhealthy behaviors.
Metrics of racism: cancer & mental health
less pain medication
two and a half times as likely to be described as noncompliant or noncooperative
failure of non-Black doctors to listen to their patients.
increase the number of Black physicians.
African Americans often lack trust in the White medical establishment that has historically inflicted many abuses on them,
Concluding thoughts
What is an advance directive for medical care?
Advance directives (ADs) are written or recorded by people to preserve their moral right to make their own decisions about treatment and healthcare for later times when they have lost decision-making capacity.
What constitutes a relevant change of mind?
Margot Bentley.
84-year-old former nurse,
she would still accept food, had Mrs. Bentley changed her mind?
legally valid revocation requires sufficient cognitive capacity to revoke. The person would have to understand the directive, the act of revoking it, and what may replace it, if anything.
she does not understand that what she is doing in her current context when she eats is what she said in her directive should not be done.
What is the “then-self/now-self” problem?
Rebecca Dresser and John Robertson make this criticism of what they call “the orthodox approach” to ADs prevalent in American law courts and dominant in the outlook of many others.5 In the orthodox approach, “respect for incompetent patients requires according such patients the same right to refuse treatment accorded competent patients.” Refusal is based on the patient’s own wishes, either stated in an AD or discerned by the patient’s proxy in “substituted judgment” about those wishes. Allegedly this respects the autonomy of the person in avoiding treatment the patient does not want.
The now incompetent person is not an autonomous chooser. The autonomous chooser who made the AD no longer exists.
the current person may have quite different interests
that the current patient must be treated according to the patient’s current best interests—the so-called best interest standard, not according to previous wishes expressed in a directive.
If the patient’s current interests align with his AD, then the directive is superfluous, and, if the two conflict, the directive must give way. Either ADs are superfluous or they are irrelevant—bad news indeed for ADs.
Ms. A.
Ms. Snyder.
How have defenders of advance directives responded to this problem?
the later incompetent individual is the same person,
People write ADs knowing perfectly well that they may not later have the same interests, but they will still be the same person. Ms. A is still Ms. A, the Jehovah’s Witness, and Ms. Snyder still nephew Larry’s Aunt Ellen.
something is wrong . . . when we treat formerly competent patients as if they were never competent. Someone who makes a prior directive sees herself as the unified subject of a human life. She sees her concern for her body, her goals, or her family as transcending her incapacity. . . . One . . . component of treating persons with respect [is] that we view them as they view themselves. . . . To do this, we must not ignore their prior choices and values.
The Dresser-Robertson position effectively erases the life of the person being treated.
mistakes like thinking Ms. Snyder’s AD is irrelevant because she is no longer aware of it or because she will never know that we have not followed it. What she cared about in writing her AD was her life and how it would end, for even when she loses capacity, it will still be her life.10 Since it is hers, doesn’t she have a right to control it?
Can advance directives accommodate the then-self/now-self problem?
ADs, however, have the same moral force. Their strength varies with a number of factors. It is greater (1) when they are based on realistic assessment of the facts. People who write an AD wishing to avoid living years into severe dementia, for example, must inform themselves about the various stages of dementia and what life may then be like. They need to know that they might turn out to be relatively contented, though they could also be terribly frightened, anxious, and confused. Directives’ force is also greater (2) when they reflect the person’s enduring values, and those values are
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The main complicating factor, already discussed, is that the writer of the directive, when he gets to the stage where he said life-saving care should be withheld, may still enjoy his life and have an interest in living. The stronger that interest is, the harder it is to justify following the instructions of even a knowledgeably written, clear, and recently reiterated AD.
Margot Bentley was probably not suffering, but by then the value of her life to her was vanishingly low. What is the value to a person of her own survival in a condition where she cannot anticipate tomorrow, and, when she gets to tomorrow, she cannot remember yesterday? It is not nothing, but it is very little. When we value our survival, we are not just valuing the moment.
viewing decisions on following an AD in the face of a then-self/now-self problem as a “sliding scale” in which both the person’s autonomous choice represented in the AD and his capacity for current enjoyment and appreciation of life are taken into account.
“not yet” decisions—
