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Is South Carolina Consistent with Biblical Principles and Considered Judgment? Article posted on 5/6/2008 Article has been viewed 1215 times. By G. Steven Suits, MD As Western societies entered the last quarter of the twentieth century patients increasingly experienced prolonged dying “hooked up to machines.” This resulted from many factors, including technological advances that made such mechanical support possible. Medical paternalism fed the use of advanced therapy and the prevailing fee-for-service system of professional compensation tended to lead to more rather than to less care. In response to these factors and well-organized campaigns by “right to die” groups, California first passed legislation recognizing “living wills” in 1976. By the mid-1990s most states had joined, passing legislation to recognize the living will, durable power of attorney for health care or both.[1] The living will is a declaration stating when the declarant wishes that life-sustaining procedures be withheld or withdrawn. In some states the declarant may appoint an agent to either ascertain that provisions of the declaration are enforced, or to revoke the declaration – whichever the declarant specifies.[2] A durable power of attorney for health care appoints a surrogate to make decisions on behalf of the principle when the principle becomes incompetent. Some states allow “mixed or combined advance directives.”[3] With such an instrument, the principle may specify what treatments must be given and which ones must be withheld and under what conditions. Such instructions obligate the agent (attorney in fact) to see to it that these wishes are carried out. Treatments unspecified remain the discretion of the surrogate, or agent. Since the passage of enabling legislation there has been extended efforts to make the use of these instruments more widespread. Targeted audiences include senior citizens organizations, Sunday School classes, nursing home residents and hospital patients. Illustrative of this, the South Carolina Governor’s Office Division on Aging has appointed an Advance Directive Coalition that has a Public Awareness Campaign Subcommittee. But ought these instruments be advocated? How informed and understanding are those who sign these documents? Do the living will and power of attorney for health care have clear language that gives unambiguous guidance to health care providers? How should we proceed? Before looking specifically at South Carolina law and the forms encoded therein, principles and purposes of advance directives as well as biblical principles and practical difficulties will be reviewed. The most common basis for promoting advance directives is the principle of autonomy. In concert with the legally recognized principle that a patient has the right to refuse medical treatment, these instruments are seen as a means of applying such decision making to times when the patient is no longer decisional. Long accepted as the priority legal and ethical maxim, it is claimed that autonomy can be extended to end-of-life decisions of incompetent patients if they have executed an advance directive. “Specifically, advance directives express the wishes of the individual to be applied at a time when he or she has become incapable of making decisions.”[4] In addition to the purported extension of autonomy to the time of incompetence, proponents of advance directives also acclaim their ability to allow “others to avoid the often difficult and uncertain task of making the choices”[5] needed at the end of life. This was the focus of a public service announcement produced by the South Carolina Governor’s Office Division on Aging Advance Directive Coalition Public Awareness Campaign Subcommittee. It concludes that, “By planning ahead, you can ease the burden on your loved ones.”[6] Advocates also say that physicians are relieved of difficult decision making when an advance directive has been executed. A biblical perspective ought to guide the thinking of Christians as they ponder the use of advance directives. God’s creation of humankind in His image is foundational to this topic. The concept of sanctity of human life derives from this imago Dei. “Then God said, ‘Let Us make man in Our image, according to Our likeness’ . . . God created man in His own image, in the image of God He created him; male and female He created them.”[7] Herein is the basis of human dignity – not the presence of some higher ability. This dignity is constitutive in all humans, part of each person’s being. It is not a mere characteristic of (some) human beings, nor merely functional. Biblical testimony clearly shows that mankind maintains this imago Dei-based dignity even after the Fall (Genesis 9.6; James 3.9). The Scripture also teaches the freedom of humans before God. Meilaender describes this as “the freedom by which we step forth as God’s representatives in the world.”[8] This freedom is not an arbitrary choosing, but ultimately, as Verhey argues, is a “freedom to have Christ as Lord, to choose and to act – to live – in the righteousness and grace of God, to be a servant of God and of the neighbor.”[9] He goes on to point out, “In Luther’s story freedom is not only part of God’s cause, it exists to serve God’s cause. And the cause of God determines . . . the appropriate uses of freedom. . . .”[10] This makes it clear that biblical freedom is not the autonomy of which proponents of advance directives speak. It is freedom within the boundaries of God’s sovereignty. It is freedom to choose (or not choose) God’s direction. In terms of end of life decisions, it is freedom to choose that which upholds the dignity of human life.[11] Flowing from a biblical understanding, such freedom mandates that in deciding for an incompetent patient we first ask, “Is the patient willing?”[12] The patient choosing against the biblical concept of imago Dei is similar to the choosing against Jesus Christ. The patient is wrong – with eternal consequences – but it is within his freedom to so choose. “Because God has given people such responsibility for their lives, we must ultimately accept people’s decisions to forgo treatment even if we do not agree with them. But for the believer there is more to decision-making than one’s personal wishes.”[13] It is important to seek and understand the biblical teaching on death also. Man, who is born of woman, Is short-lived and full of turmoil. Like a flower he comes forth and withers. He also flees like a shadow and does not remain. Since his days are determined, The number of his months is with You; And his limits You have set so that he cannot pass.[14] “And who of you by being worried can add a single hour to his life?”[15] Such verses establish the biblical consistency of the notion of futility. Dying is inevitable this side of the Parousia, and Christians should acknowledge this. This balances the sanctity of life principle, allowing the Christian to “affirm the divinely ordained value of human life in any form”[16] without running headlong into a vitalism that idolizes human life. Not that death should be regarded as desirable or as friend. It is enemy. But as Rae and Cox remind us, death is a conquered enemy.[17] “The last enemy that will be abolished is death . . . then will come about the saying that is written, ‘DEATH IS SWALLOWED UP in victory. O DEATH, WHERE IS YOUR VICTORY? O DEATH, WHERE IS YOUR STING?’ The sting of death is sin, and the power of sin is the law; but thanks be to God, who gives us the victory through our Lord Jesus Christ.”[18] While we recognize that death is the antithesis of life and that life is sacred, we do not fear death or clutch to life as if death is final. This, then, allows us to develop a biblical approach to end of life decisions. “Ethically the key question is not whether any action taken by the patient or another person is the medical cause of death . . . but whether anything is done or left undone with the intention of causing the patient’s death. Intention is the issue.”[19] Here, the crucial differentiation is between “‘accepting death’” and “‘intending death.’”[20] A patient may recognize the inevitability of his death and rightly choose to forgo treatment, not because he intends or desires death, but because further treatment merely adds to his suffering as he dies.[21] In such a case the burden of treatment outweighs any benefits that might come. But again, death must not be one’s aspiration, one’s intent. Having reviewed the purposes of advance directives and the biblical perspectives it is important to recognize some of the practical difficulties inherent in the use of these instruments. Some of these derive from uncertainty and others from experience with advance directives. There is a wide spectrum of “incompetence,” making it hard to be precise in discussing the incompetent patient. Everything from “total unconsciousness to one who is aware but without the capacity to process impressions”[22] would be included in this appraisal. Also, there is a multiplicity of factors that may be involved in end of life decisions. These include physical pain, appearance, incapacities, decreased mental function, dependence, religious factors, financial burdens, family well-being, and friendships.[23] Even to the lengthy list more could be added. But the point is clear: it is very difficult to consider all the factors that could be involved in an end of life decision, especially before one has existentially faced such circumstances. Further difficulty comes from principle conflicts that throw confusion into decision-making. These include religious factors such as “high-sanctity” positions that consider it a duty to seek life at all costs and deteriorate into idolatrous vitalism. The common concern about the children of Jehovah’s Witnesses who refuse blood transfusions is another example. On the other hand dignity-based arguments elevate autonomy to the ultimate value and consider loss of control the ultimate indignity. Just how stable are the decisions we make concerning ultimate things? There is reason to question that choices today are the same that one might make years (or even months) from now. Studies looking into this indicate that patients’ preferences for end of life therapies may be insufficiently firm to guide decision-making.[24] Though choices to forgo treatment seem more stable than choices for receiving therapy,[25] patients’ wishes show significant variability over time. Some of this is due to the multiplicity of factors involved in such decisions, the impact of principle conflicts and the changing situations of those making such decisions. Sugarman indicates that preferences are more stable if patients have experienced the condition for which therapies in question are indicated.[26] Thus, patient knowledge, which raises the issue of informed consent, likewise is a significant consideration. Nelson and Nelson rightly point out that there is a difference between preferences and considered judgments.[27] Is the instability of choices due to the lack of informed, considered judgment, emphasizing instead the mechanical filling out of a standard form on software downloaded into a computer and the blanks filled in? To call such a choice a preference, much more a considered judgment, is a “serious flaw.”[28] The push to increase the use of advance directives increases such uncritical standardization. As seen in the efforts of the South Carolina Governor’s Office Division on Aging, the focus is on increased utilization of living wills and health care power of attorneys. Little emphasis is place on the manner in which declarants make their decision. The Code of Laws of South Carolina, in establishing the health care power of attorney, mentions social workers and lawyers as sources of information without suggesting input from health professionals who alone have the knowledge of conditions that would activate these instruments.[29] Suggestions in the literature that “advance care planning interventions need to move out into the community”[30] ignore the danger to patient freedom from uninformed, non-considered judgment in preparing advance directives. Decisions to withhold treatments can easily be made without full understanding of the medical ramifications when circumstances exist in which the specific treatment might be indicated for vital therapeutic benefit.[31] Howsepian goes on to point out that the circumstances typical when these instruments are created remove a possible “informal safeguard” from the process. When a competent person makes a decision surrounded by, say, family members, initial opposition to a decision to forgo treatment might allow for further analysis of the ramifications of the decision.[32] This is beneficial to the process of informed, considered non-coerced judgment. There is much data indicating that many people do not care to discuss or carry out advance planning. Such studies also suggest that the older the person, the less they desire to be involved.[33] Though educating these of possible benefits with advance planning may alleviate their discomfort, to encourage such to “just do it” amounts to coercion and repudiation of patient freedom. Philosopher Jim Stone tells of attending church meetings “where well-intentioned doctors peddled truly frightening instruments, urging the audience to sign ‘before you go home.’”[34] Again, stress on actualization of advance directives is frequently seen in the literature[35] and needs to give way to emphasis on adequate informing prior to effecting advance directives. Further questioning the concept of stable, considered judgment with advance directives is the distance of the competent person from future events, which necessarily involve remote and abstract situations.[36] This remoteness and abstraction seriously question the opinion that advance directives improve the decision making process for incompetent patients.[37] Do advance directives “give individuals an opportunity to exercise a certain measure of control over care and treatment, especially life-sustaining treatments[?]”[38] Can they “express the wishes of the individual to be applied at a time when he or she has become incapable of making decisions[?]”[39] The interests of an incompetent person may differ radically and unpredictably from previous interests so as to render the question of what would be a satisfactory life unforeseeable.[40] Projected feelings and desires might not, in fact, occur at the time of activating an advance directive. Projected desires are hypothetical, not precise. Is the real decision not actually a conditioned one? That is, in signing an advance directive does a person not state “if I feel then like I do now, then . . .” Anyone familiar with adoption knows that mothers who have decided to give their child up for adoption often change their minds once birth occurs. Our laws actually protect their right to do so, giving a delay before finalizing the release. To opine that with advance directives the situation is different because the person has no mind to change is superficial and in many cases false. Being incompetent and having no mind are not the same. Being terminal and having no mind are not equivalent and neither necessarily are being permanently unconscious and having no mind as there is no certainty of the absence of thought in persistent vegetative states. In addition to this, the interests of an individual between the interval from effecting an advance directive and its activation may change substantially. Assuming that a directive will be revoked or modified in such life and death circumstances may not satisfy ethical decision making. What period of time is to be considered too remote to accept a declaration? It is commonly known and assumed that an operative permit must have been effectuated within a recent (specified) period to apply to a procedure and that permission for treatment is given with each admission to a health care facility. Are we to proceed on the analogy of disposition of property by means of a will or irrevocable trust and assume that once enacted an advance directive is permanently valid? To ask the question begs the obvious answer: the wishes of a healthy middle age adult are not the same as those of the same adult with a debilitating disease several years later. Having lived with a disability may change the attitude – one way or another – in important ways, so that a directive signed during a previous stage of life is totally inadequate. We ought to extend at a minimum the same care to these end of life “permits” as we do to operative consents and consents for treatment. A final area of uncertainty that frequently becomes part of discussions on advance directives is the ambiguity involved in their terminology. Just what does “life-threatening” illness intend? Does a patient with acute pancreatitis qualify? She certainly has a life-threatening condition. How about an elderly patient with multiple trauma; does he not have a life-threatening illness? Are these the types of situations in mind when people sign advance directives? Terms such as “heroic,” “extraordinary,” “terminal,” “imminent,” and “artificial nutrition” are sufficiently fluid as to disallow precise understanding. The meaning of each may change from situation to situation, disallowing even the usual statutory definitions to give enough constancy for considered judgments. Do people really understand that the “attending physician” may not (in current systems probably will not) be their “family doctor” or “primary care physician”? The attending physician can be totally unknown to the patient. It is quite unusual for the declarant to understand these ambiguities. Ambiguity is not limited to terminology. Many patients lack strong preferences in regards to decisions for end of life treatment.[41] Many persons who have completed quite specific advance directives nevertheless wanted their physicians or surrogates to have “complete leeway” to override the directive and a majority wanted them to have at least some leeway to do so.[42] Major ambiguity exists around the degree to which declarants want their directives to be binding.[43] Besides these practical difficulties deriving from uncertainty, experiential difficulties present as more people sign advance directives. Though current use of advance directives is greater than in the past studies suggest that they are still irrelevant to most. Literature abounds from philosophers, legal academics, health care workers and those involved in public policy, but this does not translate into an overwhelming interest in the general public.[44] Many still do not understand what an advance directive is, or the difference between a living will and a durable power of attorney for health care, and they have no felt need to complete a directive. Most certainly do not take the time or effort to do so. There continues to also be a wide discordance between those who have some knowledge of advance directives and those who make a declaration.[45] In two studies, only a minority of those with “adequate knowledge about advance directives” and who support their use actually effectuated a directive.[46] Other studies have documented that there is no difference in end of life care received by those with and those without advance directives,[47] again pointing out the relatively irrelevant nature of these documents. Looking at physicians instead of patients, surveys indicate that advance directives are not very helpful in medical decision making.[48] Overall, there is much evidence that advance directives are still irrelevant in existential practice. By definition unforeseen consequences cannot be anticipated. Included are medical advances such as just developed techniques of nerve cell repair that could lead to reversal, stabilization or even cure of multiple sclerosis, stroke and head trauma patients. Similarly, the Human Genome Project has amassed many benefits in genetic diseases and will impact diseases such as Alzheimer’s. A middle age person one decade ago, concerned about losing control from Alzheimer’s disease would have had no idea of such advances. While much is still in the future, there is a consensus that these types of advancement are no longer science fiction. A person may sign a declaration that calls for a sure diagnosis of permanent unconsciousness before activation of the advance directive. The instrument may stipulate that it is not to take effect until after the declarant is unconscious for one week. But it could well be impossible to make an accurate diagnosis of permanence after this (or any specific) length of time.[49] Unforeseen consequences remain a major hurdle to overcome in order ethically to create advance directives. Related to factors such as unstable preferences, distance of the subject from future events, informed consent and unforeseen consequences are the conflicts with a patient’s current best interests. Here the oft-discussed antagonism between autonomy and beneficence/non-maleficence enters. Given that patient preferences are fluid and that ample data suggest that many previous decisions no longer reflect current propensities, can supposed “autonomy” trump all other considerations? An advance directive may call for no life support, including antibiotics, if permanently incompetent and in a nursing home but the patient now enjoys life in the home when he develops pneumonia. How can one say that the previous feeling that such a life would be meaningless supersedes current evidence? Conflicts also occur between the directives and surrogate decision makers. Based on personal, intimate knowledge a surrogate may decide that the declarant did not intend to include the current situation in conditions that would activate the directive. Studies show that surrogates often disagree with declarants regarding medical care.[50] Here advance directives are in a Catch 22 situation. Living wills presume a patient’s autonomy is the highest good and that such disagreement from a surrogate necessitates the advance directive. A health care power of attorney depends on a surrogate and these studies challenge their ability to “act accurately under a substituted judgment principle.”[51] In his wonderful parody of the children’s classic Green Eggs and Ham, Forrow states that as a surrogate, “Although I am confident that in any future clinical situation I could effectively represent [my grandmother] and her preferences as a surrogate decisionmaker, I honestly have almost no idea about how she would most likely respond to many of the dichotomous choices posed in most of the research about proxy decisionmaking.”[52] Lest Forrow too hastily be accused of hubris in these remarks, there is evidence that elderly people frequently feel that a close family member could better decide at the time of health care interventions than they personally can in advance.[53] What should be made of expressions by incompetent but communicative patients? If they express a desire to live in a situation in which their advance directive calls for cessation of treatment should it continue? On the other hand, if the patient expresses a desire to withdraw or withhold treatment in opposition to the specifications of a directive, either verbally or through struggling to remove equipment, should these wishes automatically hold precedence? A final aspect of practical difficulties recognized from the use of advance directives concerns social factors. Specifications of a directive may conflict with the values of family, physicians or institutions. Family members may have religious objections or may disagree that the declarant really meant to include current circumstances in their directive. Physicians, as professionals, have a code of right and wrong that they profess. Clashing “autonomies” of the patient and physician lead to difficulties with implementing an advance directive. Language in statutes requiring that a physician with opposition to the directive “make a reasonable effort to locate a physician or health care facility that will follow the instruction”[54] adds to the conflict. Institutional opposition may follow from the religious nature of the institution or from a more callous (though probably more pervasive) concern for institution well-being. Conflicts with human dignity as derived from the imago Dei, a biblical concept of freedom as opposed to the Enlightenment idea of autonomy, and understanding death as a conquered enemy give a strong basis for a serious, considered approach to advance directives. Practical difficulties including issues of uncertainty such as ambiguity, instability of preferences, distance of decisions from future events, and truly informed consent increase the gravity in advance planning. Experiential difficulties – irrelevance, unforeseen circumstances, conflicts with patients’ current best interest, expressions by incompetent patients, and surrogate disagreement – reinforce these. South Carolina law recognizes two forms of advance directives, living will (“Declaration of a Desire for a Natural Death”) and a durable power of attorney for health care (“health care power of attorney”). Many of the difficulties discussed above are found within the enabling laws for these as well as in the standard forms included in these laws. A brief review of selected conflicts will serve to illustrate the real-world nature of the problems discussed. The “Death with Dignity Act”[55] displays the ambiguous language so frequent in these devices. In defining terminal illness it speaks of a condition that “could” cause death, not specifying that the condition, “within reasonable medical judgment” will cause death.[56] Many conditions could cause death that will not necessarily do so. This definition also speaks of a “reasonably short period of time” without further specification. Ten years is a reasonably short period of time when I contemplate my death. In the definition of “permanent unconsciousness” no observation period is required before making the diagnosis. After initially setting up a “ninety consecutive days” waiting period,[57] the law waives this requirement if there is a “high degree of medical certainty.”[58] In situations that are life-threatening (term not defined), “active treatment” is only required for six hours before the declaration takes effect. Under the “Instructions Concerning Artificial Nutrition and Hydration” the forced choices are for provision of or non-provision of “medically indicated means” of nutrition and hydration.[59] If a declarant wished to encourage spoon feeding but decline a surgically implanted tube, which choice is appropriate? Another area of concern with the Declaration of a Desire for a Natural Death is in its revocation. Here the burden is on the declarant. The standard form states in all-uppercase letters, “A REVOCATION IS NOT EFFECTIVE UNTIL IT IS COMMUNICATED TO THE ATTENDING PHYSICIAN.” Several means are listed for revoking the declaration including destruction of the original document(s) in expression of intent to revoke by the declarant, a written, signed and dated revocation, an oral expression by the patient or other person if certain conditions are met – including communication to the attending physician, revocation by a designee or by execution of a new declaration.[60] Subsequent details, however, do not protect against those who rely on copies of revoked declarations but act “in good faith.”[61] Again, the burden is on the declarant. How is he to control the distribution of copies of a declaration and ascertain destruction of them all should he desire to revoke his declaration? Indeed, revocation may be impossible. A final, and perhaps the greatest, problem with the Declaration of a Desire for a Natural Death is its presumption for death. The title of the declaration as well as the title of the law (Death with Dignity Act) imply that the State of South Carolina puts a higher value on non-intervention and intending death. Biblically we saw that death – natural or otherwise – is not to be desired. Death is an enemy. Throughout the declaration, the emphasis is obviously on withholding or withdrawing, and food and water are treated the same as any other life-sustaining intervention. South Carolina law does not adequately safeguard freedom based on informed choices. The health care power of attorney statute does not fare much better. It contains similar inherent weaknesses and an additional one: even if it is signed subsequent to a living will, the living will takes precedence. If a person sets up a “safer” power of attorney thinking that in doing so the living will has been revoked, he is mistaken. The declaration is still valid. Given these inherent problems with advance directives how should we then proceed? Can a Christian implement a directive on sound biblical grounds and within acceptable ethical principles? Finally, is there a “safe” form of advance planning? I aver that a Christian’s advance directive ought not to be founded on intent to die.[62] The person making the advance directive must be fully informed, not only of the intricacies of the directive but also of the fluidity of preferences and the uncertainty inherent in such documents. Declarants of living wills and principals of health care powers of attorney should discuss at length their desires and the basis for them with family and health care providers. If others are involved (e.g., as surrogates, principals or agents), these, too, need to be fully informed. Finally, care must be taken that the counselor chosen to construct the directive does not uncritically fill out a standardized, fill-in-the-blank computer program. One friend of mine who went to have a health care power of attorney crafted in which he was naming me as his agent returned with a living will instead. When I pointed this out to him he showed me that I was named in it. What he had signed was to have me enforce his decision to withhold treatment, not act as his surrogate. Given the nature of the directive I cannot advise that anyone sign a living will. The dangers inherent are too great. With the above safeguards in mind, a person desiring an advance directive might be safely craft a health care power of attorney that is consistent with Christian principles. Even then, the standard form in South Carolina law should not be uncritically filled out. Rather, the person should create a power of attorney that clearly reveals an intention for life but recognizes the reality of futility and burdensome treatment. Biblical principles and considered judgment demand such an approach. Bibliography 1 Corinthians 15.26, 54-57 (NASB, 1997). Blondeau D, Valois P, Keyserlinkh EW, et al. Comparison of patients’ and health care professionals’ attitudes towards advance directives. Journal of Medical Ethics 1998; 24: 328-335. Brock DW. Good decisionmaking for incompetent patients. Hastings Center Report 1994; 24 (6, Special Supplement): S8-S11. Cantor N. Advance Directives and the Pursuit of Death with Dignity. Bloomington and Indianapolis, IN: Indiana University Press, 1993. Code of Laws of South Carolina, 1976, as amended, Title 44 Code of Laws of South Carolina, 1976, as amended, Title 62 Danis M. Following advance directives. Hastings Center Report 1994; 24 (6, Special Supplement): S21-S23. Dresser R. Advance directives: implications for policy. Hastings Center Report 1994; 24 (6, Special Supplement): S2-S5. Emanuel LL. What makes a directive valid? Hastings Center Report 1994; 24 (6, Special Supplement): S27-S29. Forrow L. The Green Eggs and Ham phenomena. Hastings Center Report 1994; 24 (6, Special Supplement):S29-S32. Genesis 1.26a, 27 (NASB, 1997). High DM. Families roles in advance directives. Hastings Center Report 1994; 24 (6, Special Supplement): S16-S18. Howsepian AA. Are advance directives an advance? Ethics & Medicine 1998; 14(2): 34-41. Jaggard PL. Advance directives: the case for greater dialogue. In Kilner JF, Cameron NMdeS, Schiedermayer DL. Bioethics and the Future of Medicine: A Christian Appraisal. Grand Rapids, MI: William B. Eerdmans Publishing Company, 1995: 250-262. Job 14.1, 2, 5 (NASB, 1997). Kilner JF. Forgoing treatment. In Kilner JF, Miller AB, Pellegrino ED. Dignity and Dying: A Christian Appraisal. Grand Rapids, MI: William B. Eerdmans Publishing Company, 1996: 69-83. Kilner JF. Life on the Line: Ethics, Aging, Ending Patients’ Lives, and Allocating Vital Resources. Grand Rapids, MI: William B. Eerdmans Publishing Company, 1992. Kuczewski MG. Whose will is it, anyway? A discussion of advance directives, personal identity, and consensus in medical ethics. Bioethics 8(1): 27-48. Lynn J, Teno JM. After the patient self-determination act: the need for empirical research on formal advance directives. Hastings Center Report 1993; 23 (1): 20-24. Matthew 6.27 (NASB, 1997). Meilaender, Gilbert. Bioethics: A Primer for Christians. Grand Rapids, MI: William B. Eerdmans Publishing Company, 1996. Minutes of the South Carolina Governor’s Office Division on Aging Advance Directive Coalition Public Awareness Campaign Subcommittee, February 6, 1996. Nelson HL, Nelson JL. Preferences and other moral sources. Hastings Center Report 1994; 24 (6, Special Supplement): S19-S21. Pearlman RA. Are we asking the right questions? Hastings Center Report 1994; 24 (6, Special Supplement): S24-S27. Rae SB, Cox PM. Bioethics: A Christian Approach in a Pluralistic Age. Grand Rapids, MI: William B. Eerdmans Publishing Company, 1999. Sachs GA. Increasing the prevalence of advance care planning. Hastings Center Report 1994; 24 (6, Special Supplement): S13-S16. Stone J. Advance directives, autonomy and unintended death. Bioethics 1994; 8(3): 223-246. Sugarman J. Recognizing good decisionmaking for incapacitated patients. Hastings Center Report 1994; 24 (6, Special Supplement): S11-S13. Teno JM, Hill TP, O’Connor MA. Advance Care Planning: Priorities for ethical and empirical research. Hastings Center Report 1994; 24 (6, Special Supplement): S1. Teno JM, Nelson HL, Lynn J. Advance care planning: priorities for ethical and empirical research. Hastings Center Report 1994; 24 (6, Special Supplement): S32-S36. Verhey AD. Luther’s ‘Freedom of a Christian’ and a patient’s autonomy. In Kilner JF, Cameron NMdeS, Schiedermayer DL. Bioethics and the Future of Medicine: A Christian Appraisal. Grand Rapids, MI: William B. Eerdmans Publishing Company, 1995: 81-92. Wetle T. Individual preferences and advance directives. Hastings Center Report 1994; 24 (6, Special Supplement): S5-S8. Appendix A. Death with Dignity Act (Living Will) (Code of Laws of South Carolina, Title 44, Chapter 77) B. Healthcare Power of Attorney (Code of Laws of South Carolina, Title 62, Chapter 5, sections 504 -505) Endnotes [1] Teno JM, Hill TP, O’Connor MA. Advance Care Planning: Priorities for ethical and empirical research. Hastings Center Report 1994; 24 (6, Special Supplement): S1. [2] See, for example, Code of Laws of South Carolina, 1976, as amended, Title 44, Chapter 77, Section 85 (44-77-85). [3] Meilaender, Gilbert. Bioethics: A Primer for Christians. Grand Rapids, MI: William B. Eerdmans Publishing Company, 1996, 85. [4] Blondeau D, Valois P, Keyserlinkh EW, et al. Comparison of patients’ and health care professionals’ attitudes towards advance directives. Journal of Medical Ethics 1998; 24: 328. [5] Lynn J, Teno JM. After the patient self-determination act: the need for empirical research on formal advance directives. Hastings Center Report 1993; 23 (1): 20. [6] Quoted in the minutes of the South Carolina Governor’s Office Division on Aging Advance Directive Coalition Public Awareness Campaign Subcommittee, February 6, 1996. [7] Genesis 1.26a, 27 (NASB, 1997) [8] Meilaender, 5. [9] Verhey AD. Luther’s ‘Freedom of a Christian’ and a patient’s autonomy. In Kilner JF, Cameron NMdeS, Schiedermayer DL. Bioethics and the Future of Medicine: A Christian Appraisal. Grand Rapids, MI: William B. Eerdmans Publishing Company, 1995, 84-85. [10] Ibid., 87 [11] The idea of “death with dignity” has so permeated the jargon of those who advocate for advance directives, physician assisted killing and euthanasia that it is almost pointless today to speak of dignity. An example is the South Carolina law that established the legality of living wills. It is called the “Death with Dignity Act.” [12] Kilner JF. Forgoing treatment. In Kilner JF, Miller AB, Pellegrino ED. Dignity and Dying: A Christian Appraisal. Grand Rapids, MI: William B. Eerdmans Publishing Company, 1996,75. [13] Ibid., 77. [14] Job 14.1, 2, 5 (NASB, 1997) [15] Matthew 6.27 (NASB, 1997) [16] Jaggard PL. Advance directives: the case for greater dialogue. In Kilner JF, Cameron NMdeS, Schiedermayer DL. Bioethics and the Future of Medicine: A Christian Appraisal. Grand Rapids, MI: William B. Eerdmans Publishing Company, 1995, 256. [17] Rae SB, Cox PM. Bioethics: A Christian Approach in a Pluralistic Age. Grand Rapids, MI: William B. Eerdmans Publishing Company, 1999, 217. [18] 1 Corinthians 15.26, 54-57. [19] Kilner JF. Life on the Line: Ethics, Aging, Ending Patients’ Lives, and Allocating Vital Resources. Grand Rapids, MI: William B. Eerdmans Publishing Company, 1992, 118 (emphasis in the original). [20] Kilner JF. Forgoing treatment. In Kilner JF, Miller AB, Pellegrino ED. Dignity and Dying: A Christian Appraisal. Grand Rapids, MI: William B. Eerdmans Publishing Company, 1996,78. [21] Ibid., 80. [22] Cantor N. Advance Directives and the Pursuit of Death with Dignity. Bloomington and Indianapolis, IN: Indiana University Press, 1993, 25. [23] Ibid. [24] Sugarman J. Recognizing good decisionmaking for incapacitated patients. Hastings Center Report 1994; 24 (6, Special Supplement): S12. [25] Danis M. Following advance directives. Hastings Center Report 1994; 24 (6, Special Supplement): S21. [26] Sugarman, S12. [27] Nelson HL, Nelson JL. Preferences and other moral sources. Hastings Center Report 1994; 24 (6, Special Supplement): S19. [28] Forrow L. The Green Eggs and Ham phenomena. Hastings Center Report 1994; 24 (6, Special Supplement): S29. [29] Code of Laws of South Carolina, 1976, as amended, [62-5-504(D)5]. [30] Sachs GA. Increasing the prevalence of advance care planning. Hastings Center Report 1994; 24 (6, Special Supplement): S15. Even the title of this article illustrates the overemphasis on numbers at the expense of critical thinking and decision making. [31] Howsepian AA. Are advance directives an advance? Ethics & Medicine 1998; 14(2): 37. [32] Ibid. [33] Wetle T. Individual preferences and advance directives. Hastings Center Report 1994; 24 (6, Special Supplement): S5. [34] Stone J. Advance directives, autonomy and unintended death. Bioethics 1994; 8(3): 224. [35] Sachs. (Title: Increasing the prevelance of advance care planing) [36] Cantor, 26. [37] Sachs, S13. [38] Blondeau, 328. [39] Ibid. [40] Howsepian. [41] Wetle, S6. [42] Dresser, S4. [43] Wetle, S7. [44] Dresser R. Advance directives: implications for policy. Hastings Center Report 1994; 24 (6, Special Supplement): S3. [45] Ibid. [46] Blondeau, 334. [47] Dresser. [48] Lynn and Teno, 22. [49] Howsepian. [50] Sugarman. [51] Ibid. [52] Forrow, S30. [53] High DM. Families roles in advance directives. Hastings Center Report 1994; 24 (6, Special Supplement): S18. [54] Code of Laws of South Carolina, 1976, as amended, [62-5-504(R)]. [55] Code of Laws of South Carolina, 1976, as amended, Title 44, Chapter 77. [56] Code of Laws of South Carolina, 1976, as amended, [44-77-20 (4)]. [57] Code of Laws of South Carolina, 1976, as amended, (44-77-30). [58] Ibid. [59] Code of Laws of South Carolina, 1976, as amended, (44-77-50). [60] Code of Laws of South Carolina, 1976, as amended, (44-77-80). [61] Code of Laws of South Carolina, 1976, as amended, Title 44, Section 44-77-90. [62] Howsepian, 40. [ return to main selection screen ]
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