The Forecast For Advance Directives: Indispensable or Superfluous?

Abstract

Advance directives are popular these days. Patient advocacy groups, medical ethics “think tanks”, attorneys, and many health care institutions are promoting them to patients and providers as useful and even indispensable documents. Advocacy groups send subscribers wallet-size laminated “living will” cards containing toll-free numbers for a central registry that can supply callers with the full text of the patient’s directive in emergencies. “Medic Alert” bracelets, ordinarily used to alert emergency personnel to a patient’s health problems, have been designed to alert caregivers to the patient’s refusal of hospitalization and treatment (see In re Finsterbach, 1990). Federal legislation has been passed requiring health care facilities to promote advance directives in order to receive Medicare and Medicaid dollars (Patient Self-Determination Act, 1990). At the same time, however, institutions, caregivers, and sometimes patients’ families fight hard to continue care for decisionally incapable patients and to promote policies that preserve life and discourage the cessation of treatment before death. This stark opposition could be a sign of healthy diversity of values in a pluralistic culture; it could represent the adversary viewpoints necessary, as in a court of law, for distilling the proper perspective; or it could demonstrate collective ambivalence and confusion over what advance directives are all about.

Because death is so profoundly personal, public reflection on it is unusual.…[H]owever, such reflection must become more common if we are to deal responsibly with the modern circumstances of death (Cruzan v. Director, 1990, p. 4936 [(J. Stevens, dissenting)]).