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The Illusion of Patient Choice in End-of-Life Decisions

Received June 27, 2000; revised October 19, 2000; accepted February 13, 2001. From the University of Washington Dept. of Psychiatry and Behavioral Sciences, Medical History, and Ethics. Address correspondence to Mark D. Sullivan, M.D., Ph.D., Associate Professor, Psychiatry and Behavioral Sciences, Box 356560, University of Washington, Seattle, WA 98195. e-mail: sullimar{at}u.washington.edu

After passage of the Patient Self-Determination Act and the Cruzan decision by the Supreme Court, honoring individual patient choice has become the primary means by which we have sought to improve the quality of life of the dying patient. However, the decision-making capacity of the dying patient is usually compromised, and advance directives have not consistently improved the dying process. We respect patient autonomy in order to respect the patient as a person; patient autonomy should be respected to the degree that it is intact. When autonomy is significantly diminished, as it usually is in dying patients, respecting autonomy reconstructed from documents or proxies may not be the best way to respect the dying person. We rather need to seek social consensus about when patients are dying, the nature of a "good death," and when it is preferable to a longer life.

Key Words: End-of-Life Issues • Suicide • Depression

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