The International Encyclopedia of Ethics. Edited by Hugh LaFollette, print pages 80–86. © 2013 Blackwell Publishing Ltd. Published 2013 by Blackwell Publishing Ltd. DOI: 10.1002/ 9781444367072.wbiee356 1 Advance Directives David John Doukas Advance directives are statements by a competent patient indicating who should act as surrogate or what treatment the patient would accept or refuse in the event of a future incapacity, particularly one in which terminal illness or irreversible loss of consciousness could occur. Such a directive is expressible in almost any medium, so long as it is witnessed (and if possible, recorded). There are two common types of advance directives: the living will and the durable power of attorney for healthcare (DPAHC). In the United States, all states recognize by statute at least a living will or DPAHC (48 recognize both). Worldwide, advance directives are legal in many countries (Austria, Australia, Canada, Finland, Hungary, the Netherlands, Singapore, Spain, South Africa, and the UK), with multiple EU countries acknowledging their validity in patient care. Just as a testamentary will expresses personal decisions about disposition of one’s body and property upon death, the living will is a written expression of personal decisions regarding demarcations of treatment for oneself upon incapacity. The durable (i.e., surviving incapacity) power of attorney for healthcare transfers decision-making powers to another person in circumstances of future incapacity. The DPAHC names a surrogate (and a possible alternate if the first is unable or unwilling to serve) to assist in making relevant decisions consistent with the patient’s values and preferences. The DPAHC allows for flexibility in following the values and preferences of the incapacitated patient in the face of unforeseen health conditions or available treatments. Ethical Issues in the Use of Advance Directives The ethical basis for the use of advance directives is predicated on the principle of autonomy (see autonomy). This notion of respecting the autonomy of each person is intrinsic to common-law interpretations of respecting an individual’s values and his desire to carry them out as actions that are part of his life plan, as well as limiting the state’s intrusiveness upon the individual’s values and actions, as articulated in a century of US informed consent case law (Hanson 2009; see informed consent). Advance directives enhance autonomy, as they allow a patient to preserve their personal decision-making into incapacity by considering future states of health and future treatment options in advance. Accepting or refusing future treatment allows the patient to make decisions about future care based on their own interpretation of benefit, consistent with their values, moral purpose, and personal commitments. Further, advance directives can articulate for family (see family), friends, and health