The PSDA and the Depressed Elderly:
"Intermittent Competency" Revisited

Dianne N. Irving
and Adil E. Shamoo
February 1993
Reproduced with Permission


The contribution by Ganzini, Lee, Heintz and Bloom1 is a gentle yet lucid reminder from practioners in the field with hands-on experience, that the PSDA2 as prescribed and enacted poses certain challenges for those concerned with and responsible for patient care - as well as for the protection of their "autonomy". In the case of the depressed elderly presenting to hospital admissions, a "clean fit" with those for whom the Act was intended (competent adults) appears to be lacking. This "fact" should be seriously taken into consideration by those who will be involved in adapting the intent of the PSDA to their particular state regulation, health care institutions, or medical practices.3 It also points once again to the need of health care providers, lawyers, ethicists - and especially psychiatrists - to come to terms with a more realistic and agreed upon definition of "competency", "incompetency" - and, particularly, "intermittent competency". The need for psychiatry to make these distinctions was prominent in earlier controversial debates about the use of the mentally ill in both therapeutic and experimental research.4 Although progress has been made, there would seem to be a further need for clarification of these terms, as the article by Ganzini et al. illustrates. It is also a flag for philosophers, bioethicists and lawyers to continue to reconsider and refine their related definitions of "autonomy", "informed consent", and "civil competency" based on a more realistic and accurate understanding of those psychiatric terms.

The goals of the PSDA

The passage of the PSDA was, in large measure, a reaction to the Cruzan decision5, and the perceived injustices and inadequacies in the law to protect the rights of patients to make decisions about their own medical treatment - especially at such time when they would become "incompetent". It was also in part due to the desire of health care facilities and physicians to provide legal protection for themselves in these very difficult cases.6 The wise allocation of health resources and funds has also been a recent concern for society at large, and for providers in particular - especially in those situations in which society is paying the bill.

At present, health care rationing is a reality to millions of uninsured and under-insured patients. The PSDA brings the concept of health care rationing to the fore in a stark and clear way. We are now correctly facing this issue head-on. It is argued that public resources for any societal endeavor are finite, and therefore rationing is the logical step to take. This leads to the conclusion that utilitarian ethical standards should take precedence over the autonomous health care claims and special needs of these vulnerable patients. However, there is another reality operating here as well. Those individuals who are financially secure, who do not depend on resources from public funds or insurance, will not have to follow those utilitarian standards of health care rationing. What we should recognize is that there are really two different sets of ethical standards for rationing that are emerging.

The PSDA is now a fait accompli. Yet many are still in the process of attempting to sort out what it all means and how best to go forward with it. The goals of the Act are, of course, laudable7: to encourage competent adults to become aware of their rights (under state law) to accept or refuse medical or surgical treatment, and to formulate advanced directives to be used if they were to become incapacitated. Pursuant to these goals, the Act requires health care institutions to maintain written policies and procedures with respect to advanced directives (e.g., living wills and health care powers of attorney); to provide written information to patients at admission to these facilities about the patients' rights and the institutions' policies and their implementation; to document in the patients' medical records whether they have executed advance directives; and to provide education on advance directives for staff and the community.

The question still remains as to whether or not these goals are realistic8, or properly mandated or mediated by means of federal or state laws.9 Several of these issues are indicated by Ganzini et al. when they imply that the Act is really not appropriate for elderly persons hospitalized for depression. Their observations are thought-provoking for all concerned with both patient care and patient autonomy. Will the PSDA really provide the intended care and needed protection for these depressed elderly - or will they slip between the theoretical cracks of the too-abstract concepts of "competency" and "incompetency"? Are these patients really autonomous at admission to make authentic health care decisions; or is some limited degree of physician-directed paternalism appropriate under these circumstances? Where is the appropriate balance between patient autonomy and physician paternalism in this situation? Or is patient autonomy an absolute ethical and legal right?

Special Concerns About the Depressed Elderly

Some of the statements by Ganzini et al. are questionable. For example, that the intent of the PSDA concerns only life-sustaining therapies, or that the elderly are its only target is doubtful. Also, many states would allow psychiatrists to exercise their right of "therapeutic privilege" under these circumstances (depending on the state). However, their descriptions of the characteristics of the depressed elderly do "highlight the interplay between psychiatric illness and informed consent to medical treatment." Of particular interest, their discussion: describes certain characteristics of the depressed elderly which would preclude them from being simplistically categorized as either "competent" or "incompetent"; identifies a number of distinctions which should be made (but often are not) which are special to the depressed elderly; expresses the peculiar difficulties which psychiatric physicians face in establishing and maintaining a viable and workable physician-patient relationship; and gives voice to a rising concern about the use of advanced directives by the depressed elderly as a means of passive suicide.

In considerations of "competency" (and thus the ability to give "informed consent"), the depressed elderly do not seem to fit neatly into the current "competent" or "autonomy" mold. Rather, they constitute a part of that "grey area" of decision-making which is often not included seriously in "autonomy" or "informed consent" discussions and deliberations.10 Actually a diverse group, they are depressed for a variety of reasons. Sometimes they are considered competent to make important decisions, and sometimes not. Their special characteristics, as described by the authors, should give us pause, and force several distinctions which need to be made before embarking on policies and procedures directly affecting these patient populations - especially since they also include the mentally ill patient population as well, at one time or another.

According to Ganzini et al., these patients are not referred for admission to a hospital under frivolous circumstances, but only in crisis situations, when they are a danger to themselves or others, and when they cannot be treated in a less intensive setting. Major depression in the elderly is a very serious illness, and the cause is often associated with other psychotic features (e.g., schizophrenia, delusions, etc.) as well as a diverse number of physical or medical conditions (e.g., cancer or other serious diseases). These patients are often at the time already concerned that they are burdensome, have a very low quality of life, are unmotivated since they perceive that they are "doomed" to a bad outcome, often harbor distrust of their family and other care givers, and seriously express suicidal intents. On discharge, the majority of these patients will be in remission, accompanied by a significant reduction in such feelings of hopelessness and distrust. Thus the authors, with some justification, suggest that these patients during the admission process are vulnerable, need immediate care - and that this is an inappropriate time to present them with information about living wills and advance directives.

If this description of the characteristics of the depressed elderly is accurate, it would call into question the capacity of these patients to give informed consent or to execute living wills or health care powers of attorney at the time of admission.11 These patients are often seriously ill, and in urgent need of care. They are not (at that point in time) "autonomous" agents, but are temporarily "incompetent" to intellectually, emotionally and perhaps even physically process the legal and procedural information being given to them. Indeed their personal values and goals will likely be quite different after medical care has been provided for them.

Although the authors restrict their concern to patients who are depressed and elderly, the thrust of their article applies to all of those who suffer from mental illness (e.g., schizophrenia, dementia, etc.). The authors, to their credit, used the best example of what is clearly an issue of "intermittent competency" to illustrate their concern - i.e., major depression in the elderly. The authors also indicate correctly that at least one of the targets of the PSDA is the elderly patient. However, the PSDA affects the mentally ill in general, more than the general population, since the mentally ill develop the greatest number of physically debilitating illnesses due to neglect and abuse. This is especially true for homeless persons. The three key characteristics discussed by the authors for the depressed elderly patients also apply equally well to patients with other major chronic mental illnesses. For example, the mentally ill would also be affected by: (1) their capacity to give informed consent; (2) their capacity to make decisions regarding life-sustaining interventions, and (3) their therapeutic alliance with their physicians and other health care workers.

The continual reluctance of many writers to come to grips with the situation of the mentally ill population in the literature is chronic. For example, the authors quote from the report of Wolf et al.12 which raised concerns about the PSDA and how this legislation could apply to the depressed elderly patient. This report carries the signatures of sixteen distinguished scholars in the fields of medicine, science, ethics and the law. The most astonishing part of their report is what is missing. It raises concerns about various conditions and groups to whom the PSDA will be applied. It failed, however, to mention one of the most vulnerable groups affected by the PSDA - the mentally ill. This lack of reference and concern for the welfare of the mentally ill is consistent with what appears to be a moral blind spot of many others in the community of scholars who were recently addressing the issue of the use of the mentally ill in therapeutic and experimental research. In that situation the NIH rejected the National CommissionŐs standing recommendation that the mentally ill no longer be considered a vulnerable group in need of special considerations and protections.

There are significant disadvantages for even "competent" patients being presented this information at admissions in order to give informed consent. The authors did not emphasize sufficiently in their paper that competent patients must be able to understand and appreciate alternative treatments, options and outcomes. In the case of the depressed elderly it would seem logical and prudent to postpone this educational session until after these patients have been treated and stabilized.13 Even then, any living wills or advance directives should be periodically reviewed and updated.14 This situation does indicate the importance of the development of a workable physician-patient relationship well before the crisis event occurs, and would argue for physicians taking more of the initiative in integrating such education into their normal patient routine.15 This would also be the preferable setting in which to include family members and other possible future surrogates in the educational process.16 In fact, it could be argued that admission to a hospital during a crisis event is precisely one example of a time when the depressed elderly are in need of a reliable psychiatrist and a proxy who are familiar with their conditions, concerns and treatment preferences during more stable and lucid periods.

The Need for More Data

The first thing that is needed is more empirical data concerning these characteristics of the depressed elderly. Ganzini et al. courageously present data which - while interesting - would not pass a statistical t-test. More research is needed to ground our understanding of several important distinctions which their work begins to articulate.

For example, more empirical studies are needed: to distinguish mild from major depression; to distinguish major depression caused by psychotic illnesses from that caused by organic diseases; and to explain the effect of the interaction of these several conditions on an elderly person's ability to be autonomous and to give informed consent. These variables also seem to differ according to which type of institution or facility in which a study is being conducted - e.g., patients in general, geriatric, or psychiatric wards in a general hospital; in state mental institutions; or in nursing homes or other long-term care facilities. Very little work has been reported on the effect of major depression in elderly patients in terms of minority status.17

More empirical studies are also needed to determine the effects of the presentation of the PSDA educational material at admissions by hospital staff who are "unknowns" to the patients and who do not have significant information about the patient's medical history or value systems. More importantly, what is the effect of having a staff member, or a physician who is not a psychiatrist, make the complex clinical judgment that a particular depressed elderly patient is "competent" or "incompetent", and therefore able or not able to understand, process and act on the information which is being presented?

And finally, studies need to be conducted which examine the over-all effect that some legal distinctions between "civil competency" and "mental competency" really have on the depressed patient's care, and the physician-patient relationship in which they are involved. While it is unquestionably desirable that any person or patient is given as broad a latitude as possible in self-determination, it is possible that in an understandable zeal to protect patient autonomy, that zeal may back-fire on the patient by not acknowledging certain situations in which the person is genuinely compromised by attending circumstances. This is hardly a call to the return of physician paternalism, but rather to suggest that we should be confident about what constitutes "competency", "incompetency" and "intermittent competency" before choosing to forgo the "paternalistic" suggestions of the involved physician. Recent trends in philosophical "autonomy" and "civil capacity" could unwittingly damage the physician-patient relationship, which in turn could work against the proper care and best interests of the depressed elderly patient.

This concern is well articulated by these authors - as well as by others - especially with respect to the often expressed desire for suicide in the depressed elderly, and the possibility that these patients will use the refusal of treatment as a form of passive suicide.18 Arguments are posed by many concerned with patient autonomy that suicide is a "rational" choice,19 and should be accommodated if that is the patient's autonomous decision. But Ganzini et al. are trying to tell us that, at least in the depressed elderly, that choice is simply not an autonomous one, that the patient is probably at that time "intermittently incompetent". Given the psychological and physical complications attending major depression, and that these same patients usually change their minds about suicide after discharge, it would seem irresponsible to consider these suicidal requests as "rational" or "autonomous". It would seem particularly irresponsible for a psychiatrist who medically knows better and who is trying to develop and operate in a more meaningful physician-patient relationship, to defer to these patients' "rational choices" and withhold critical psychiatric and medical care. Yet some legal precedents concerning "civil competency" would seem to preclude the psychiatrist from overriding these patients' suicidal desires.20

What is "autonomous decision-making"?

Especially in light of cases such as the depressed elderly - where competency is really only intermittently possible - the question of "autonomous decision-making" deserves a more extensive treatment. It is at least arguable that the pure "autonomy" model often used in bioethics and the law21 is a too-abstract rationalistic myth, which somehow does not square with or explain the concrete situations such as those involving the depressed elderly. No one is ever truly and completely "autonomous" - it is, rather, a matter of degrees.

This consideration forces other related questions. Does patient autonomy ground an absolute right? A patient is not an island of rights unto himself, but also bears responsibility22 to those around him and who are also affected by his decisions and actions. But under what circumstances and to what extent would even a competent patient's autonomous decision have to yield to other valid considerations? And is there really such a thing as "rational suicide"? More often it is probably, instead, a flag to others to pay attention to or address perceived or very real problems affecting the patient. Is our acquiescence in "rational suicide" more a signal on the part of society that the depressed elderly are in fact a burden on us and such "rational suicide" is really an easy way out for us as well?23 Finally, is an autonomous decision necessarily, by definition, an ethical decision? The issue may not simply be one of the right of autonomous patients to make a decision, but whether that autonomous decision is ethical or not.

It would seem that our "autonomous" decisions rest more realistically in a fluid matrix of necessary and correct information, knowledge and appreciation of the circumstances and consequences surrounding our decisions, careful deliberation about this information in light of sound and valid goals, knowledge of the prudent means by which to reach those goals, the intention and the operative will to choose based on that information and deliberation, and the opportunity to actually, in fact, act on that choice. In the case of the depressed elderly, several of these components of autonomous decision-making are not present. In their summary, the authors leave the impression that the psychiatrist alone should be involved in making certain critical decisions. The question to be asked is - why the psychiatrist alone? Under the circumstances, it would seem more prudent for the patient's psychiatrist as well as another physician who is not a psychiatrist should be involved - as well as a family member or a proxy. Together they could cooperate to calm, treat and stabilize the patient so that the patient may regain as much of his "autonomy" and decision-making capacity as possible. It does not appear that the legislation of state or federal jurisprudence should preclude such care from the depressed elderly patient.


Insofar as the PSDA is considered only as an "impetus" to foster better patient autonomy and physician-patient communication, it has perhaps ultimately succeeded in the case of the depressed elderly. It has forced us to look once again at that "grey" area of intermittent competency, and to readjust our psychiatric, philosophical and legal concepts accordingly. Beyond that point we enter the arena of state and federal paternalism. Each state and facility should carefully model the intent of the PSDA around the kind of care required by the particular patients they are serving. To that extent the discussion by Ganzini, Lee, Heintz and Bloom has been quite helpful.


1 L. Ganzini, M.A. Lee, R.T. Heintz and J.D. Bloom, "Is the Patient Self-Determination Act Appropriate for Elderly Persons Hospitalized for Depression?", Journal of Clinical Ethics, infra. [Back]

2 Omnibus Reconciliation Act of 1990, Public Law No. 100-508, Sections 4206, 4751, 104 Stat. 1388 (Nov. 5, 1990). [Back]

3 C.P. Sabatino and V. Gottlich, "Seeking Self-Determination in the Patient Self-Determination Act", Clearinghouse Review (Oct. 1991):639-647; P.M. McCarrick, Living Wills and Durable Power of Attorney: Advance Directive Legislation and Issues, Scope Note 2 (National Reference Center for Bioethics Literature, Kennedy Institute of Ethics: Washington, D.C., 1992):6-8; K.N. Swisher, "Implementing the PSDA for Psychiatric Patients: A Common-Sense Approach", Journal of Clinical Ethics 2, no. 3 (1991):199-205; M.R. Gasner, "The PSDA: A Logical Next Step", Journal of Clinical Ethics 2, no. 3 (1991):173-177; S. Wolf, in F. Rouse, S. Johnson, D.W. Brock, L. Emanuel, S.M. Wolf, D. Mason, M. Mezey, R.B. Purtilo, E.L. McCloskey, "Practicing the PSDA", Hastings Center Report 21, no. 5:S1-S16; F.H. Cate and B.A. Gill, The Patient Self-Determination Act: Implementation Issues and Opportunities (Washington, D.C.: The Annenberg Washington Program in Communication Studies of North Western University, 1991); M. Dailey, "Euthanasia in Maryland: The Right to Die With Dignity?", Journal of Contemporary Health Law and Policy 5 (1989):297-317; G.H. Gordon and S.M Tolle, "Discussing Life-Sustaining Treatment: A Teaching Program for Residents", Archives of Internal Medicine 151, no. 3 (1991):567-570; A.J. Silver, "The Changing Role of Tube Feeding", Long-Term Care Forum 2, no. 2 (1992):1, 10-14. [Back]

4 G.J. Annas, L.H. Glantz and B.F. Katz, Informed Consent to Human Experimentation: The Subject's Dilemma (Cambridge, Mass.: Ballinger Publishing Co., 1977); N. Chayet, in U.S. National Commission for the Protection of Human Subjects, Report and Recommendations: Research Involving the Mentally Infirm (Washington, D.C.: Department of Health Education and Welfare, 1978), 99; A.S. Tannenbaum and R.A. Cook, "Report on the Mentally Infirm", in U.S. National Commission for the Protection of Human Subjects, Report and Recommendations: Research Involving the Mentally Infirm, Appendix (Washington, D.C.: Department of Health, Education and Welfare, 1978), 1-2; R.A. McCormick, S.J., "Proxy Consent in the Experimentation Situation,", Perspectives in Biology and Medicine 18 (1974):127; P. Ramsey, The Patient as Person (New Haven: Yale University Press, 1970), 14; W.E. May, "Experimenting on Human Subjects", Linacre Quarterly 41 (1974):238-252; I.N. Stone, Legal and Ethical Issues in Human Research and Treatment: Psychopharmacologic Considerations, eds. D.M. Gallant and R. Force (Jamaica, New York: Spectrum Publishers, 1978), 26-32. [Back]

5 Cruzan v Director Missouri Department of Health, 110 S.Ct. at 2841, (1990); M.R. Gosner (JCE 1991), op cit.; F. Rouse (HCR 1991), op cit.; also, "Advance Directives: Where are We Heading After Cruzan?", Law, Medicine and Health Care 18, no.4 (1990):353-359; L. Gostin, "Life and Death Choices After Cruzan", Law, Medicine and Health Care 19, no. 1-2 (1991):9-12; J. Areen, "Advance Directives Under State Law and Judicial Decisions", Law, Medicine and Health Care 19, no. 1-2 (1991):91-100; W.H.Colby, "Missouri Stands Alone", Hastings Center Report 20, no. 5 (1990):5-6. [Back]

6 M.R. Gasner (JCE, 1991), op cit.; R.B. Purtilo (HCR 1991), op cit.; P. Cotton, "Providers to Advise of 'Medical Miranda'", Journal of the American Medical Association 265, no. 3 (1991):306. [Back]

7 M.L. White and J.C. Fletcher, "The Patient Self-Determination Act: On Balance, More Help Than Hindrance", Journal of the American Medical Association 265, no. 3(1991):410-412; and, "Patient Self-Determination Act to Become Law: How Should Institutions Prepare?", Biolaw 2 (1991):S509-S514; E.L. McCloskey (HCR 1991), op cit. [Back]

8 A.M. Capron, "The Patient Self-Determination Act: Not Now", Hastings Center Report 20, no. 5 (1990):35-36; D. Brock (HCR 1991), op cit.; A. Sehgal, A. Galbraith, M. Chesney, et al., "How Strictly Do Dialysis Patients Want Their Advance Directives Followed?", Journal of the American Medical Association 267, no. 1 (1992):59-63; J.M. Roe, M.K. Goldstein, K. Massey, D. Pascal, "Durable Power of Attorney For Health Care: A Survey of Senior Center Participants", Archives of Internal Medicine 152, no. 2 (1992):292-296; S. M. Wolf, P. Boyle, D. Callahan, J.J. Fins, et al., "Sources of Concern About the Patient Self-Determination Act", New England Journal of Medicine 325, no. 23 (1991):1666-1671; N.M.P. King, "Dying Made Legal: New Challenge for Advance Directives", HEC Forum 3, no. 4 (1991):187-199; B.D. Colen, The Essential Guide to a Living Will (New York: Prentice-Hall, 1991); G.J. Annas, "The Health Care Proxy and the Living Will", New England Journal of Medicine 324, no. 17 (1991):210-213; R. Barry, "Advance Directives: No Guarantees of Patient Control", Medical Ethics for Physicians 3, no. 3 (1988):6-10; L.L. Heintz, "Legislative Hazard:Keeping Patients Living, Against Their Wills", Journal of Medical Ethics 14, no. 2 (1988):82-86; D.A. Peters, "Advance Medical Directives: The Case for the Durable Power of Attorney for Health Care", Journal of Legal Medicine 8, no. 3 (1987):437-464. [Back]

9 C.P. Sabatino and V. Gottlich (1991), op cit.; Gasner (JCE 1991), op cit.; A.M. Capron (HCR 1990), op cit.; S.M. Wolf (HCR 1991), op cit.. [Back]

10 S. Johnson (HCR 1991), op cit.; E.L. McCloskey (HCR 1991), op cit.. [Back]

11 K.N. Swisher (JCE 1991), op cit.; R.B. Purtilo (HCR 1991), op cit.; A Sehgal et al. (JAMA 1992), op cit.; C.P. Sabatino and V. Gottlich (1991), op cit.. [Back]

12 S.M. Wolf, P. Boyle, D. Callahan, et al., "Sources of Concern about the Patient Self-Determination Act", New England Journal of Medicine 325, no. 23 (1991):1666-1671. [Back]

13 E.D. Pellegrino and D.C. Thomasma, For the Patient's Good: The Restoration of Beneficence in Health Care (New York: Oxford University Press, 1988), 19, 84; L. Emanuel (HCR 1991), op cit.. [Back]

14 M.R. Gasner (JCE 1991), op cit.; A.M. Capron (1990), op. cit.; S. Johnson (HCR 1991), op cit.. [Back]

15 E.D. Pellegrino and D.C. Thomasma (1988), op cit.; L. Emanuel (HCR 1991), op cit.; and, "The Health Care Directive: Learning How to Draft Advance Care Documents", Journal of American Geriatrics Society 39, no. 12 (1991):1221-1228; A. Sehgal et al. (JAMA 1992), op cit.; C.C. Obade, "The Patient Self-Determination Act: Right Church, Wrong Pew", Journal of Clinical Ethics 1, no. 4 (1990):320-322; K.D. O'Rourke and D. Brodeur, "Advance Directives: Living Wills and Durable Power of Attorney Acts", in their Medical Ethics: Common Ground for Understanding, Vo. II (St. Louis: Catholic Hospital Association Press, 1989), 200-207; J. Cohen-Mansfield, "Care and Preferences Regarding the Utilization of Life-Sustaining Treatment in Nursing Home Residents", Archives of Internal Medicine 151, no. 2 (1991):289-294; K.W. Davidson and R. Moseley, "Advance Directives in Family Medicine", Journal of Family Practice 22, no. 5 (1986):439-442; E.R. Gamble, P.J. McDonald and P.R. Lichstein, "Knowledge, Attitudes and Behavior of Elderly Persons Regarding Living Wills", Archives of Internal Medicine 151, no. 2 (1991):277-280; A.E. Lazaroff and W.F. Orr, "Living Wills and Other Advance Directives: Ethical Issues in the Care of the Elderly", Clinics in Geriatric Medicine 2, no. 3 (1986):521-534; K.M. McIntyre, "Sherperding the Patient"s Right to Self-Determination: The Physician's Dawning Role", Archives of Internal Medicine 152, no. 2 (1992):259-261. [Back]

16 R.S. Olick, "Approximating Informed Consent and Fostering Communication: The Anatomy of An Advance Directive", Journal of Clinical Ethics 2, no. 3 (1991):181-189; L. Emanuel (HCR 1991), op cit.; D. Mason (HCR 1991), op cit. [Back]

17 N.J. Osgood, "Suicide in Long-Term Facilities", presented at the American Association of Suicidology, Washington, D.C. April, 1988; J. Miles, "Choosing an Advanced Directive", Health Progress 76, no. 6 (1991):24-26; M. Mezey (HCR 1991), op cit.; C. Sabatino and V. Gottlich (1991), op cit. [Back]

18 J.L McIntosh, "Older Adults: The Next Suicide Epidemic?", Suicide and Life-Threatening Behavior 22, no. 3 (1992):322-332; R.I Simon, "Silent Suicide in the Elderly", Bulletin of the American Academy of Psychiatry Law 17, no. 1 (1989):83-95; L.D. Wardle, "Suicide Among the Elderly: A Family Perspective", in An Aging World, Chapter 43 (Oxford: Clarendon Press, 1989); N.J. Osgood, "Suicide in Long-Term Facilities", (1988), op cit.; D.G. Cohen, "Suicide Among Seniors", Dayton Daily News, "Lifestyle", Jan. 21, 1990:1E. [Back]

19 Concern for Dying (now Choice in Dying), Advance Directives Protocols and the Patient Self-Determination Act: A Resource Manuel for the Development of Institutional Protocols (New York: Concern for Dying, 1991); Society for the Right to Die (now Choice in Dying), Refusal of Treatment Legislation: A State by State Compilation of Enacted and Model Statutes (New York: Society for the Right to Die, 1991); but see, M. P. Battin, "The Elderly's Right to Die is Manipulated Suicide" in Suicide: The Philosophical Issues, ed. M.P. Battin and D.J. Mayo (New York: St. Martin's Press, 1980), 201-205; K.N. Swisher (JCE 1991), op cit.; R.I. Simon (1989), op cit. [Back]

20 S.L. Godard, J.D. Bloom, M.H. Williams, L.R. Faulkner, "The Right to Refuse Treatment in Oregon: A Two-Year Statewide Experience", Behavioral Sciences and Law 4 (1986):293-304; C. Sabatino and V. Gottlich (1991), op cit.; M.R. Gasner (JCE 1991), op cit. [Back]

21 Robert A. Destro, "The Emerging 'Right' to a Good Life", Center for Religion and Society, This World 25 (Spring 89):73-90; also, "Target - The Elderly: A Nondiscrimination Perspective on Daniel Callahan's Setting Limits", Linacre Quarterly 59, no. 3 (1992):55-74; D.C. Thomasma, "Response to Erich Loewy: Commentary", Journal of Clinical Ethics 2, no. 2 (1991):90-91; L. Harmon, "Falling Off the Vine: Legal Fictions and the Doctrine of Substituted Judgment:, The Yale Law Journal 100, no. 1 (1990):1-71; D.C. Blake, "State Interests in Terminating Medical Treatment", Hastings Center Report 19, no. 3 (1989):5-13; D. Wertz and J.C. Fletcher, "Fatal Knowledge? Prenatal Diagnosis and Sex Selection", HCR 19, no. 3 (1989):21-27; J. F. Childress, "The Place of Autonomy in Bioethics", HCR 20, no. 1 (1990):12-17; S.E.Lammers, "Book Review" of G. Meilaender, The Limits of Love: Some Theological Explorations, in HCR 20, no. 1 (1990):51; J. Hardwig, "What About the Family?", HCR 20, no. 2 (1990):5-10; G. J. Agich, "Reassessing Autonomy in Long-Term Care", HCR 20, no. 6 (1990):12-17; M. Davis and L.R. Churchill, "Autonomy and the Common Weal", HCR 21, no. 1 (1990):25-31; N.S. Jecker and D.J. Self, "Medical Ethics in the 21st Century: Respect for Autonomy in Care of the Elderly Patient", Journal of Critical Care 6, no. 1 (1991):1-4; A.M. Capron, "Substituting Our Judgment", HCR 22, no. 2 (1992):58-59; D. J. Doukas, "Autonomy and Beneficence in the Family: Describing the Family Covenant", Journal of Clinical Ethics 2, no. 3 (1991):145-148; M.A. Glendon, Rights Talk: The Impoverishment of Political Discourse (New York: Pree Press, 1991); J.L. Nelson, "Taking Families Seriously", HCR 22, no. 4 (1992):6-12; E.W. Bernal, "The Nurse as Patient Advocate", HCR 22, no. 4 (1992):18-23; E.J. Emanuel and L.L. Emanuel, "Proxy Decision Making for Incompetent Patients: An Ethical and Empirical Analysis", Journal of the American Medical Association 267, no. 15 (1992):2067-2071; A. Weston, "Toward a Social Critique of Bioethics", Journal of Social Philosophy 22, no. 2 (1992):109-118. [Back]

22 Robert A. Destro, "Target - The Elderly: A Nondiscrimination Perspective on Daniel Callahan's Setting Limits", Linacre Quarterly 59, no. 3 (1992):55-74; C. Elliott, "Competency as Accountability", Journal of Clinical Ethics 2, no. 3 (1991); D. Brodeur, "Bishop's Response to Act on Rights of Terminally Ill", Health Progress 68, no. 1 (1987):22-25, 94; C. Cohen, "Book Review" of R.F. Weir, Abating Treatment With Critically Ill Patients (New York: Oxford University Press, 1989), in HCR 21, no. 1 (1991); G.J. Agich and S.J. Youngner, "For Experts Only? Access to Hospital Ethics Committees", HCR 21, no. 5 (1991):17-25. [Back]

23 National Legal Center for the Medically Dependent and Disabled, "Medical Treatment Rights of Older Persons and Persons With Disabilities", Clearinghouse Review 25, no. 9 (1992):1204-1217; M.P. Battin (1980), op cit.; R.I. Simon (1989), op cit.; K.G. Cohen (1990), op cit.. [Back]