Under the auspices of/Sous l'égide de - International Academy of ...

213.2. Advance Directives, Future Selves and Decision MakingAlasdair Maclean, University of Glasgow (A.Maclean@law.gla.ac.uk)An advance directive (AD) is a device that allows a competent individual to issue directions that prohibitpossible future interventions that may be carried out when the individual is no longer competent to make acontemporaneous decision. The justification for respecting such a direction is grounded in the competentindividual’s right to autonomy. This justification is open to challenge from those who, like Parfit, believethat individual personal identity is unimportant. These non-reductionists argue that what matters is thepsychological connectedness and continuity between the present and future selves. Where that relationshiphas been disrupted by, for example, the onset of dementia, the previous competent self’s autonomy carriesno particular weight, and decisions for the present incompetent self should not be bound by the AD. Thisargument approaches the issue from the perspective of the individual’s right to autonomy. If, instead, thequestion is explored from the alternative perspective, of the most appropriate way to make decisions forincompetent individuals, then it may be arguable that the non-reductionist view still supports, albeit in alimited form, reliance on an AD. It is this approach that I will examine in this paper.3.3. Advance Directives – Relevance to Civil CommitmentRichard O’Reilly, University of Western Ontario (roreilly@uwo.ca)John E. Gray, University of Western OntarioAdvance directives were initially championed to assist individuals plan the health care they are to receive atthe end of life. Over time, advance directives increasingly came to be used to plan the management ofchronic illnesses including psychiatric disorders. A particularly difficult scenario occurs when a patientwho is involuntarily committed to a psychiatric hospital has previously made an advance directive statingthat psychotropic medications, needed to affect recovery and release from hospital, must not be given. Suchan individual will remain incarcerated in hospital until he or she has a spontaneous remission or dies.Society cannot be sure that this person, if capable, would not have had a change of mind and chosentreatment over a lifetime of incarceration. Many observers believe that this situation is unacceptable - butwhat mechanisms can be developed to prevent it occurring? We describe three approaches. First, societycan place the onus on the individual to prove that any advance directive, calling for the rejection ofstandard medical care, was made when the individual was capable and that the directive was intended toapply in altered circumstances (such as after committal). The second approach, taken by some jurisdictions,is not to follow advance directives that reject psychiatric treatment for committed patients. The final modelpermits an override of an individual’s advance directive where following the directive would endanger thephysical or mental health of the person or of another person. The advantages and disadvantages of thesethree models will be discussed.