PHLB09H3 Chap.4 Advance Directives and Dementia
Advance Directives and Dementia
The question the week poses
Week five covers advance directives and substitute decision-making through Rebecca Dresser's article on Ronald Dworkin and dementia.
The oral exam question frames the topic as a dispute about scope: Dworkin and Dresser agree that directives exist, but disagree about how far a directive written while competent should govern care after dementia sets in.
The clinical framework
The CMA Code sets an order of standards for patients who lack capacity.
Physicians respect previously expressed wishes and values, whether recorded in advance care planning or conveyed by a substitute decision-maker. If those are unknown, they act on the values that can be discerned; if none can be discerned, they act in the patient's best interests.
The Code also asks physicians to support cognitively impaired patients' participation in decisions.
Why dementia is the hard case
A person with advanced dementia may seem content with a life the earlier self said they would not want. Dworkin, as quoted in another reading, treats momentous decisions about death as belonging to the individual.
Dresser's title calls his position elegant theory but questionable policy, so the debate turns on whether the earlier choice should bind the later patient.
What this chapter covers
- 01
Advance Care Planning
- 02
Substitute Decision-Maker
- 03
Discernible Values
- 04
Best Interests Standard
- 05
Earlier Self and Later Self
- 06
Scope of a Directive
Worked example · free
Choose the standard for an incapacitated patient
- 2Identify the applicable rung of the Code's standards.
- 2Explain the son's argument in terms of present interests.
- 2State what would be needed to depart from the directive.
Key terms
- Discernible Values
- Discernible values are the values that can be inferred from a patient's life and commitments when no explicit instruction exists.
- Best Interests Standard
- The best interests standard is the fallback basis for decisions when neither a patient's prior wishes nor discernible values are available.
Advance Directives and Dementia FAQ
What does the CMA Code say about patients who cannot decide for themselves?
It asks physicians to respect the values and intentions a patient expressed while capable, through advance care planning or a substitute decision-maker. Where those intentions are unknown, physicians act on the patient's discernible values, and failing those, on the patient's best interests. It also asks physicians to support cognitively impaired patients' participation in their own care where possible.
What is the Dworkin and Dresser dispute about?
The oral exam question frames it as a disagreement over how much authority advance directives should have when the writer later develops dementia. The issue is how far a directive written by a competent person should govern decisions after dementia changes that person, especially when the later patient seems content with a life the directive rejected.
How should I prepare this oral topic?
Reread the assigned Dresser article and reduce Dworkin's argument to numbered premises. Then list the reasons Dresser gives against the premises she targets, and any case she uses. Practise a one-minute opening that states the dispute, then rehearse follow-ups, such as whether you find each argument persuasive, without needing to defend a view of your own.
Why is predicting one's own future so important in this debate?
An advance directive is a forecast: the writer predicts what a life with dementia would be like and decides in advance how it should be treated. The consent reading reports that healthy people predicted life on dialysis would be miserable, while patients rated their happiness close to healthy controls. Similar errors in forecasting could affect directives, which is one reason to ask how far they should bind.
Exam move
Draw the Code's three standards as a ladder from memory and attach one invented case to each rung. Write the conflict between earlier choice and present interests in two sentences, one for each side. Reread the Dresser article with a pen and number Dworkin's premises in the margin, marking each place Dresser objects.
Rehearse a one-minute opening aloud and a two-minute answer to the question of whether an earlier self may bind a later one.
