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Precommitment is a seductive concept in bioethics. Many see it as a way for people to answer all sorts of biomedical questions about the future, such as whether to participate in dementia research or whether to have children posthumously. Precommitment is most popular as a strategy to resolve questions about the future use of life-sustaining treatment. The living will was an early focus of the death with dignity movement and its successor, the advance treatment directive, is central to medical ethics and law.
Scholars and researchers have analyzed advance directives for more than three decades. Their work exhibits two contradictory themes. First, precommitment remains an alluring strategy for many people worried about end-of-life care. People in this group cling to the notion that advance decisionmaking will deliver them a dignified and merciful death. Many philosophers, clinicians, judges, and legislators belong to this group. At the same time, a second body of work questions the wisdom of the first position. This work describes a host of ethical and practical problems with relying on precommitment to resolve decisions about life-sustaining treatment.
I am part of the second group. In my view, reliance on advance treatment choice is misguided and morally troubling. Although a person's statements about future care can be relevant, they are just one element of a complex situation. In most instances, they offer little guidance to those making decisions at the bedside. And in some cases, such statements should be given less weight than other considerations affecting patient care.
In this Article, I explain why precommitment is an inferior strategy for making end-of-life decisions. Part I reviews the literature and legal rules promoting advance choice as the preferred approach to resolving treatment questions. Part II describes empirical findings that expose problems with the advance directive approach. Part III discusses ethical and policy objections to relying on precommitment to answer treatment questions. I conclude that precommitment is an impractical and inappropriate strategy for securing humane and dignified death.
I. The Pro-Precommitment Position in Ethics and Policy
The idea of advance treatment decisionmaking emerged as modern medicine became increasingly able to prolong the lives of seriously compromised patients. Attorney Luis Kutner published an early version of the living will in 1969.1 He said such a document was...