Transcript arras

Marching Thru Arras
Mrs. Smith case
Severely demented
 In no pain
 Has some pleasure
 Pulls out NG tube
 Should we insert a G-tube?

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”
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

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

??
Mrs. Smith
??
One Case: PVS
Best way to decide is to assume patients
have no interests either for or against further
treatment
 WHY???

??
Mrs. Smith
Mrs. Jones
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

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

Another case: marginal
function
“Pleasantly demented”
 Incapable of making competent decision
 Still possesses multiple interests (“Person”)
 Should choose based on best interests
(burdens-benefits)

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

Mr. Black
Mrs. Smith
Mrs. Jones
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”

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

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”

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?
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)

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)
