Abstract

While patient autonomy is an important component of end-of-life decision-making, existing analyses and interpretations of it in the clinical setting, especially as regards incompetent or barely competent persons, are inadequate. In my dissertation I describe and defend a robust conception of autonomy that better understands the work that a conception of autonomy must do in the clinical setting. In addition, I support a unified-agent approach which provides the basis for explaining the sense in which even incompetent patients, who are no longer able to make decisions for themselves, can be autonomous. Their prior wishes, expressed through advance directives, can and should be respected. Advance directives raise both practical and deep philosophical issues. Included in the philosophical problems that I take up is the then-self/now-self problem. That is, the very process that renders an individual incompetent and brings the advance directive into play can---and indeed often does---change the person so much that he or she seems to be a "different person". To be sure, regardless of what view of personal identity one adopts, it may be the case that the values incorporated in an advance directive, such as dignity, independence, and bodily integrity, may have no meaning for the incompetent patient as he or she is now. What justifies imposing these values and interests on someone who, even if she is not a different person, has no awareness of such interests, or even an understanding of the concepts involved in such interests. ;The solution to this dilemma is an amalgamation of a unified-agent approach, in addition to the distinction, originally drawn by Ronald Dworkin, between critical and experiential interests. Specifically, the competent person and his or her critical interests are given primacy over the incompetent person and his or her experiential interests, based on the competent persons' status as a moral agent, the future-oriented nature inherent in moral agency, and the nature of critical and experiential interests. Implications for the clinical setting and ways in which the use of advance directives can be encouraged are also examined