"D" Is for Discussions, Decisions, and Directives

By Margaret R. McLean

If there is one thing we all know about ethics, it is that ethics is about making decisions. There are perhaps no more important, or troubling, or painful, decisions that we as individuals and as a society have to make than those concerning death.

It was not so very long ago that death happened without decisions, without discussions. Now, in many instances, death no longer steals upon us, but is confronted and managed by us. As long as we live, we face questions about life's end.

The moral bedrock of our decision-making about death is autonomy, our ability to decide for ourselves and to have people honor our choices. But, what happens if autonomy disappears--perhaps through a stroke, an accident, or a coma? Then, we must rely on others to decide for us. We can help the people who may one day have to make medical decisions for us by having an advance directive, a document such as a Durable Power of Attorney for Health Care, which tells family and friends what we want and/or who should decide for us.

An advance directive can be an immense help to my family and friends. But before I fill-out the form, there are two main questions I need to think about and discuss with loved ones: First, what makes life valuable to me? I need to figure out just what it is that I value about life so that I can begin to make decisions about its end. I might consider things like what, if anything, would make my life so unbearable that I might not want to be kept alive. Second, who should be the one to decide for me if I am physically unable to decide? This should be someone I trust--after all, I am potentially placing my life in his or her hands. I must talk to this person, discuss what it is that I value, what I want them to do if I am ill or dying and no longer able to make my decisions myself.

Discussions and decisions about death are hard, but like death itself, they are not optional. Perhaps the best way to think about these discussions, decisions, and directives, is as gifts-gifts we give to those whom we love, and to ourselves as well.

Margaret R. McLean is director of health care and biotechnology ethics at the Markkula Center for Applied Ethics.

Return to The ABC's of Medical Ethics.

Posted August 2006