Journal of Religion and Health Volume 28, No. 3, Fall 1989 Trust, Autonomy, and Advance Directives LARRY R. CHURCHILL ABSTRACT: Trust has been largely ignored in contemporary bioethical discussions and also by courts of law. The favored language of autonomy, privacy, and rights is useful but insufficient to speak to moral experience, especially the experience of persons who write advance directives, but also physicians who receive such directives. The Brophy case is analyzed for its salient features, and a more central place for the concept of trust is proposed. Let us begin with a case. Ethics is fundamentally a practical discipline, con- cerned with what we should do and how we should live. So beginning con- cretely may be wise. The case is that of Paul Brophy, and it is useful to ex- amine because it is well known and because its most salient features are frequently found in terminal care decisions. Paul Brophy was a Massachusetts fireman, aged 45, who in March of 1983 suffered a sub-arachnoid hemorrhage as a result of a ruptured aneurysm. Two weeks later, after the swelling had subsided, Brophy underwent a cra- niotomy. He never regained consciousness after the operation. For a year Brophy was fed through a gastrostomy tube. Mrs. Brophy then asked the physician caring for her husband to remove the feeding tube and allow him to die. She believed, as did the other members of the family, that Brophy would not have wanted to be sustained in a persistent vegetative state. When the physicians and hospital administrators refused to discontinue the artifi- cial feeding, Mrs. Brophy went to court. The lengthy court proceedings ended in October of 1985, when Judge David Kopelman ruled that a DNR order would be appropriate, and that a life-threatening condition (like pneumonia) need not be treated, but that removing the tube would be to kill the patient. The physicians and hospitals were permanently forbidden from removing or clamping the tube. 1 In September 1986, however, the Massachusetts State Supreme Court over- turned the lower court decision and ruled that Mr. Brophy could be trans- Larry R. Churchill, Ph.D., is Professor of Social Medicine at the University of North Carolina at Chapel Hill, North Carolina. This paper was presented at the Lehigh Valley Hospital Cen- ter Conference, "Making Medical Decisions with and for Patients in Difficult Medical Circum- stances," in 1988. The author has profited greatly in writing this paper from reading Nancy King's Making Sense of Advance Directives, to be published by D. Reidel, Dordrecht, The Nether- lands. 175 9 1989 Institutes of Religionand Health