Abstract

Over the past two decades a moral and policy consensus concerning decisions near the end of life for incompetent patients has emerged. The consensus accords the principle of respect for prospective autonomy regnant status in health care decisions, and holds that a patient's advance directive refusing life support takes priority over others' views of the patient's best interests. Nonetheless, the preeminence of autonomy remains contested terrain, and the nature and limits of prospective autonomy is clearly unsettled. The central themes and goals of this work are to develop a theory of the nature and limits of prospective autonomy and advance directives that reinvigorates and reaffirms the core tenets of the consensus; to defend the place of prospective autonomy against emerging conceptual challenges grounded in the claims that autonomy-based interests do not survive loss of competence, and that severely cognitively impaired patients have become new persons ; to clarify widespread confusion about the moral and legal weight of advance directives; and to point to practical policy initiatives designed to ensure that prospective autonomy and advance directives are taken seriously in the care of dying patients