| Preface |
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xi | |
| Introduction |
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1 | (1) |
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1 | (1) |
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The history of the problem |
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2 | (2) |
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4 | (1) |
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Ethics and public policy analysis |
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5 | (2) |
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7 | (2) |
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9 | (6) |
| Part one Theory |
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15 | (198) |
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Competence and incompetence |
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17 | (70) |
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The concept of competence |
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18 | (5) |
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Competence as decision-relative |
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18 | (2) |
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Global conceptions of competence |
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20 | (3) |
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Capacities needed for competence |
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23 | (3) |
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Competence as a threshold concept, not a comparative one |
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26 | (3) |
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Standads of competence: Underlying values |
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29 | (12) |
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Promotion of individual well-being |
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29 | (7) |
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Respect for individual self-determination |
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36 | (4) |
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Conflict between the values of self-determination and well-being |
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40 | (1) |
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Contrast with a single value foundation - individual self-determination as sovereign |
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41 | (6) |
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Deciding on standards of competence |
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47 | (1) |
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Different standards of competence |
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48 | (3) |
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A minimal standards of competence |
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49 | (1) |
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An outcome standard of competence |
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49 | (1) |
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A process standard of decision-making competence |
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50 | (1) |
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Relation of the process standard of competence to expected harms and benefits |
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51 | (6) |
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Table 1.1: Decision-making competence and patient well-being |
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53 | (4) |
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Relation of refusal of treatment to determination of incompetence |
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57 | (2) |
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Contrast with a fixed minimum threshold conception of competence |
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59 | (6) |
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A two-step model of patient decision-making authority - the competence of the decision-maker and the rationality of his or her choice |
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65 | (5) |
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Operational measures in the medical setting |
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70 | (5) |
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Use of formal tests to determine competence |
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71 | (2) |
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Importance of informal evaluations of competence |
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73 | (2) |
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Competence determination in nonmedical settings |
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75 | (2) |
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Varying standards of competence |
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77 | (3) |
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Difficulties raised by determinations regarding the incompetent's finances |
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78 | (2) |
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The need for institutional policies for the determination of competence |
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80 | (4) |
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Summary of conclusions concerning competence |
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84 | (3) |
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The primary ethical framework: patient-centered principles |
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87 | (65) |
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The need for an ethical framework |
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87 | (2) |
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Underlying ethical values |
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89 | (4) |
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The scope of the competent patient's right to refuse treatment |
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90 | (2) |
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Limitations on the competent person's right to refuse care or treatment |
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92 | (1) |
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93 | (3) |
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Conflicts among guidance principles |
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96 | (2) |
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The advance directive principles |
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98 | (14) |
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The case against always giving priority to advance dirctives |
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101 | (1) |
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101 | (2) |
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103 | (7) |
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Conclusions: The scope and limits of the moral authority of advance directives |
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110 | (2) |
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The substituted judgment standard |
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112 | (5) |
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Scope and limits of the moral authority of substituted judgment |
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117 | (5) |
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The best interest principle |
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122 | (12) |
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Beyond the scope of the best interest principle: Permanently unconscious patients |
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126 | (6) |
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The individual's interest in the good of others |
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132 | (1) |
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The dependence of the patient's well-being on institutional options and others' interest in the patient |
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133 | (1) |
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Authority principles: Who should decide? |
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134 | (8) |
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The family as decision-maker |
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136 | (2) |
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Disagreements within the family |
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138 | (1) |
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Physicians and judges as decision-makers |
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139 | (3) |
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Intervention principles: Attempts to specify conditions that rebut the presumptive authority of the family |
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142 | (10) |
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Challenges to the family as decision-maker |
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147 | (1) |
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The institutional ethics committee |
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148 | (4) |
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Advance directives, personhood, and personal identity |
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152 | (38) |
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The value of advance directives |
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152 | (1) |
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The moral authority of advance directives |
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152 | (2) |
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Loss of personal identity |
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154 | (5) |
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How much psychological continuity is enough? |
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159 | (3) |
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162 | (3) |
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The distinction between the surviving interests of a self that no longer exists and the surviving interests in the persisting self |
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165 | (4) |
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Attempts to raise the threshold for psychological continuity |
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169 | (9) |
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178 | (6) |
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Conclusions concerning personal identity |
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184 | (6) |
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Distributive justice and the incompetent |
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190 | (23) |
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The need to qualify the patient-centered approach |
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190 | (1) |
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The relevance of guidance principles to questions of distributive justice |
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191 | (9) |
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Incompetence, moral status, and rights of distributive justice |
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193 | (1) |
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The permanently unconscious: Minimal interests |
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194 | (2) |
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The severely and permanetly demanted: Truncated interests |
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196 | (4) |
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Rationing health care: The role of physicians and surrogates deciding for incompetents |
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200 | (7) |
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The moral responsibility of families toward elderly incomptent individuals |
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207 | (6) |
| Part two Application |
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213 | (153) |
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215 | (52) |
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216 | (30) |
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The current legal presumption of incompetence |
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216 | (1) |
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The concept of competence |
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217 | (1) |
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The developmental evidence about children's decision-making capacities |
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218 | (6) |
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Determining a standard of competence |
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224 | (1) |
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The values at state in the competence determination |
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225 | (1) |
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226 | (3) |
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The child's self-determination |
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229 | (3) |
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The parents' interest in making decisions concerning their children |
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232 | (2) |
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Children's competence and children's decisional authority |
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234 | (1) |
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The legitimate interests of parents and the best interest principle |
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235 | (2) |
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The variable standard of competence |
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237 | (3) |
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Implications for medical practice and legal policy regarding children's competence |
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240 | (6) |
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246 | (21) |
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The correct guidance principle: Best interest, not substituted judgment |
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246 | (1) |
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The nature of the infant's interests |
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247 | (12) |
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259 | (1) |
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The fundamental moral status of infants: A radical challenge to the decision-making framework |
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260 | (7) |
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267 | (44) |
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The magnitude of the problem |
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267 | (4) |
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Table 6.1: Share of U.S. population over 64 years of age, 1900, 1940, 1960, 1975, and 2000 |
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269 | (1) |
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Table 6.2: Distribution of U.S. elderly population by age-group, 1950, 1975 and 2000 |
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269 | (2) |
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How incompetence is determined, formally and informally, and by whom, in varioius settings |
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271 | (18) |
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Determinaing competence to make medical decisions |
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272 | (8) |
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Formal determinations of incompetence for decisions concerning finances and places of residence |
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280 | (9) |
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How surrogates actually decide for those elderly individuals who are considered to be incompetent |
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289 | (1) |
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Some important trends in recent case law |
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290 | (5) |
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Advance directives and other planning approaches: Who uses them and how effective are they? |
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295 | (11) |
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296 | (1) |
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Durable powers of attorney |
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297 | (1) |
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General durable power of attorney |
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297 | (1) |
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Durable power of attorney for health care |
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298 | (8) |
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306 | (5) |
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311 | (55) |
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Decisions about involuntary hospitalization or commitment |
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312 | (20) |
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The historical context of involuntary commitment |
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312 | (5) |
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Patient-centered commitment - danger to self versus need for care and treatment |
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317 | (8) |
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Society-centered commitment - dangerousness to others |
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325 | (7) |
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Decisions to refuse treatment by involuntary committed patients |
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332 | (15) |
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The historical context of treatment refusal by involvuntarily committed patients |
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332 | (4) |
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An ethical framework for treatment refusal by involuntarily committed mental patients |
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336 | (1) |
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Persons dangerous to others |
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336 | (6) |
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Persons dangerous to themselves or in need of care and treatment |
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342 | (5) |
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Some residual issues in decisions for the mentally ill |
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347 | (19) |
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The least restrictive alternative condition |
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347 | (3) |
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Advance directives by the mentally ill |
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350 | (8) |
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Involuntary outpatient commitment |
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358 | (3) |
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Special limits on surrogate consent for ``inhumane'' treatments |
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361 | (5) |
| Looking forward |
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366 | (4) |
| Appendix one: Living trust and nomination of conservatorship |
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370 | (4) |
| Appendix two: Durable power of attoreny for health care |
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374 | (13) |
| Notes |
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387 | (26) |
| Index |
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413 | |
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