1. Fall 2011 Philosophy 2440 Prof. Robert N. Johnson Monday, March 14, 2016 MEDICAL ETHICS

2. The Cruzan Case and Advanced Directives

3. Missouri Supreme Court, 1988 1) Treatment vs. Care Special Status of Nutrition and Hydration: Treatment is treatment Nutrition and hydration is care Treatment can be refused Nutrition can only rarely be refused, if at all What makes nutrition and hydration special?

4. Missouri Supreme Court, 1988 2)Benefits vs. Burdens No consideration of burdens on the family No consideration of burdens on the state No consideration of any burdens other than those on Nancy Cruzan herself Continued care presents Nancy Cruzan with no significant burden, therefore there is no good reason to remove it.

5. Missouri Supreme Court, 1988 3) Removal of care or treatment requires "clear and convincing evidence" of the patient's wishes Standards of Evidence: a)Preponderance of the evidence b)Clear and convincing evidence c)Proof beyond a reasonable doubt

6. Missouri Supreme Court, 1988 4)Competing state interests Interest in the protection of privacy: right to control what happens to one's body, right to refuse treatment vs. Interest in protecting life unqualified Life unqualified has greater weight

7. U.S. Supreme Court, 1990 1) Right to refuse treatment is protected by the liberty interest of the Constitution 2) "Treatment" includes nutrition and hydration 3) Each state may set its own rules and procedures for withdrawing or withholding treatment (parallel to Webster decision on abortion) Main Issue: What counts as "clear and convincing evidence”? Patient Self-Determination Act (1991)

8. Advance Directives Some forms: Verbal instructions (Cruzan) Living Will Durable Power of Attorney for Health Care Advance directives only become effective when the patient is incompetent or can't communicate

9. The Decision Hierarchy Competent Patient Incompetent Patient: With Instructions: Verbal instructions Living Will Durable Power of Attorney for health care Without Instructions: Substituted judgment Best interests