Marching Thru Arras

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Marching Thru Arras
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Mrs. Smith case

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

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Two Sources for Subjectivity

• Mrs. Smiths 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

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Two Approaches to Incompetent Patient

• Subjective-- Patients own wishes and values
• Objective-- Patients best interests,
  benefits and burdens of continued treatment
• Neither gives us an especially clear route to
  follow in this case

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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

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One Case PVS

• Best way to decide is to assume patients have no
  interests either for or against further treatment
• WHY???

Mrs. Jones
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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

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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

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Another case marginal function

• Pleasantly demented
• Incapable of making competent decision
• Still possesses multiple interests (Person)
• Should choose based on best interests
  (burdens-benefits)

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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

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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

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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

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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

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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?
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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
  Arrass)

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Possible Replies (cont.)

• I disagree with Arras patient does not have any
  interests at all (I.e., Mrs. Smiths state is
  functionally no different from PVS)
• (so need to explain why my account of interests
  differs from Arrass)