Marching Thru Arras

1. Marching Thru Arras

2. Mrs. Smith case • Severely demented • In no pain • Has some pleasure • Pulls out NG tube • Should we insert a G-tube?

3. Two Sources for “Subjectivity” • Mrs. Smith’s prior values • Lead to plausible but hardly certain conclusion that Mrs. S. would forgo G-tube • Deserve much less respect than a prior decision • Aversive behavior • May be pure reflex • Of little weight in deciding what patient “would want”

4. Two Approaches to Incompetent Patient • “Subjective”-- Patient’s own wishes and values • “Objective”-- Patient’s “best interests,” benefits and burdens of continued treatment • Neither gives us an especially clear route to follow in this case

5. ?? Mrs. Smith ?? An Ethical Approach • Find cases “on either side” of Mrs. Smith for which we have “fairly firm moral intuitions” • See if we can then reason from those cases back to the less clear case

6. ?? Mrs. Smith One Case: PVS • Best way to decide is to assume patients have no interests either for or against further treatment • WHY??? Mrs. Jones

7. Interests and Persons • PVS: Cease to “be a ‘person’ in any meaningful moral sense” • Person (in meaningful moral sense) = potential bearer of rights and interests • To have an interest in something, it must make a difference to you whether that is done to you or not

8. Interests and Persons (cont.) • If you have no sense of self or world, no ability to feel pleasure or pain, no memory of past experience, it can make no difference to you what is done (including whether you get medical treatment or not, including whether you live or die) • Therefore PVS patient has no meaningful interests either way (in present state) • Free to decide based on others’ interests

9. Mr. Black Mrs. Smith Mrs. Jones Another case: marginal function • “Pleasantly demented” • Incapable of making competent decision • Still possesses multiple interests (“Person”) • Should choose based on best interests (burdens-benefits)

10. Mr. Black Mrs. Smith Mrs. Jones Applying Lessons: Mrs. Smith • Like Mrs. Jones, seems to lack “personhood” or “self” (biological but not biographical life) • Like Mr. Black, has consciousness and so some rudimentary interests

11. Apply Conroy Standard? • Benefits of continued life are minimal but not zero • Burdens of continued life are minor • On balance, cannot show Mrs. Smith is “better off dead”

12. An Impasse? • Tried to apply a substituted judgment (“subjective”) test, but that was inconclusive • Tried to apply a best-interests (“objective”) test, but that led to an unsatisfactory conclusion that there exists a strong duty to keep Mrs. Smith alive contrary to wishes of close family

13. A Way Out? • We are asking wrong questions in face of uncertainty • Either “subjective” or “objective” standard ends up demanding unrealistic level of evidence • Best solution is procedural-- Family discretion within the “gray area”

14. Sept. 21: Arras bases a good deal of his argument on the "best interests" of an elderly patient with dementia, and how hard it may be to determine what those interests are. Can you explain what Arras means by "interests" and what sorts of things count as interests in these sorts of cases? Do you agree or disagree with his account of what is in the "interests" of such a patient?

15. Possible Replies • I agree with Arras; patient has some rudimentary interests but not an interest in life-prolonging medical care • I disagree with Arras; patient does have an interest in prolonging life (so need to explain why my account of “interests” differs from Arras’s)

16. Possible Replies (cont.) • I disagree with Arras; patient does not have any interests at all (I.e., Mrs. Smith’s state is functionally no different from PVS) • (so need to explain why my account of “interests” differs from Arras’s)