Fall 2011Philosophy 2440Prof. Robert N. Johnson

Wednesday, April 19, 2023

Medical Ethics

The Cruzan CaseandAdvanced Directives

Missouri Supreme Court, 1988

1) Treatment vs. Care

Special Status of Nutrition and Hydration:

Treatment is treatment

Nutrition and hydration is care

Treatment can be refused

Nutrition can only rarely be refused, if at all

What makes nutrition and hydration special?

Missouri Supreme Court, 19882) Benefits vs. Burdens

No consideration of burdens on the family

No consideration of burdens on the state

No consideration of any burdens other than those on Nancy Cruzan herself

Continued care presents Nancy Cruzan with no significant

burden, therefore there is no good reason to remove it.

Missouri Supreme Court, 19883) Removal of care or treatment requires "clear and convincing evidence" of the patient's wishes

Standards of Evidence:

a) Preponderance of the evidence

b) Clear and convincing evidence

c) Proof beyond a reasonable doubt

Missouri Supreme Court, 19884) Competing state interests

Interest in the protection of privacy: right to control what happens to one's body, right

to refuse treatment

vs.

Interest in protecting life unqualified

Life unqualified has greater weight

U.S. Supreme Court, 19901) Right to refuse treatment is protected by the liberty interest of the Constitution

2) "Treatment" includes nutrition and hydration

3) Each state may set its own rules and procedures for withdrawing or withholding treatment (parallel to Webster decision on abortion)

Main Issue: What counts as "clear and convincing evidence”?

Patient Self-Determination Act (1991)

Advance DirectivesSome forms:

•Verbal instructions (Cruzan)

•Living Will

•Durable Power of Attorney for Health Care

•Advance directives only become effective when the patient is incompetent or can't communicate

The Decision Hierarchy•Competent Patient

• Incompetent Patient:

•With Instructions:

•Verbal instructions

•Living Will

•Durable Power of Attorney for health care

•Without Instructions:

•Substituted judgment

•Best interests