ethics in cardiopulmonary medicine Pulling the Plug on Living Wills* A Critical Analysis of Advance Directives

TPhe recent emphasis placed on patient autonomy¦* ¦ within medical ethics has had a profound influ¬ ence not only on the practice of medicine, but on the concept of autonomy itself. As medical practice has For editorial comment see page 589 evolved from an ideal of the beneficent physician, practicing with little guidance from the patient, toward the acceptance of a nearly absolute right of patients to control the means and manner of their health care, the very boundaries of personal autonomy have been met and forced back. Autonomy is currently seen as so in¬ tegral to medical decision making that it is advocated as a guiding principle even in individuals who are no longer autonomous. The assertion that the right of self-determination is not lost in incompetent, and therefore nonautonomous, patients has required the creation of means by which such a right can be exer¬ cised. These tools for extending personal autonomy in medical decision making are generally referred to as advance directives. The instructive directive {ie, living will) aims to direct future medical care by outlining preferred courses of action, including the refusal of specific therapies, in the event that an individual is no longer able to participate directly in decision making. The proxy directive {ie, durable power of attorney for health care) designates a surrogate, chosen by the pa¬ tient, to make medical decisions in the event of future patient incompetence. Combinations of these two types of directives are available.1 Surveys ofboth patients2 and physicians3 have found widespread support for these instruments. The federal government has voiced its approval by enacting the Patient Self-Determination Act, implemented in De¬ cember 1991.4 The Act explicitly requires all Medi