The bioethical underpinnings of advance directives

Advance directives are instructions on health care. Executed by a mentally competent individual, an advance directive becomes active in the event that the person loses mental capacity to make health care decisions. Many social workers have embraced advance directives on the basis that they promote self-determination at the end of life. However, on closer inspection, undergirding the rationale for advance directives are complex philosophical theories and concepts that include: self-determination; the good death; congruity between the former mentally competent person and the current incapacitated self; and ethics of care. This paper discusses the philosophy, more specifically, bioethics—the discipline that deals with ethical questions that result from advances in medicine—as it relates to advance directives. In order to contextualize the discussion on a macro level, the United States will be used as a case study. Clinical examples will present ideological conflicts that have the potential to result in social work practice dilemmas. Addressed also are recommendations for social workers in both direct and indirect practice.