"The bias against treatment in some advance directives is so strong as to limit the autonomy of the health care team and informal carers. For instance, some suggested directives dictate that in the event of Alzheimer's disease all life- sustaining treatment should cease this would forbid the giving of insulin to a diabetic patient with Alzheimer's disease if the directive were legally binding. Withdrawal of insulin in these circumstances might well be morally objectionable to the whole health care team, and it is hard to see how the autonomy of health care professionals could be safeguarded if such directives were legally binding. Another example would be a legal document specifying no surgery, which could prevent the pinning of a fractured hip. [HL. . . , Vol. II, 13.7.93:208]

 

CHN FACT-SHEET SERIES:

ADVANCE DIRECTIVES/LIVING WILLS

E-MAIL: chn@intergate.ca

 

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LIVING WILLS

How could you be sure that every medical option had been fully explained and understood, and that the diagnosis was correct? People often change their minds about treatment when close to death. Advance directives only tell us what people felt in the past.

Involving Parliament, laws, police, magistrates, judges, jury and prisons would be an utterly disastrous way to care for the dying. New legislation is unnecessary, undesirable, inappropriate and will probably be unhelpful.

The British Medical Association agrees that Living Wills need no force of law and recently voted against euthanasia by three to one. The pro-euthanasia lobby sees legalised Living Wills as a vital next step to acceptance of euthanasia.

The real answer lies not in laws but proper medical training, good communication, compassionate common sense and expert appropriate treatment taking into account the expressed wishes of each individual.

[Dr. Patrick Dixon, Euthanasia, No cure for medical madness, from faxed correspondence to C. Eckstein, President CHN, dated 18.3.94, used with permission. Dr. Dixon is a specialist in the care of those dying of cancer and AIDS. He is the Medical director of AIDS CARE EDUCATION AND TRAINING (ACET), in London England.]

ADVANCED DIRECTIVES AND PROXY DECISION-MAKERS



"No-one could foresee all future possibilities, nor how new medical treatments might change them in years to come. No-one could possibly document their views on all such eventualities. It is probably unlikely that people would update any documents sufficiently regularly. [. . .] The healthy do not make their choices in the same way as the sick. An important review of a recent paper from Canada states:

"The authors conclude that: an advance Directive prepared by a healthy person is not a valid indicator of the preferences of a similar person when sick;" This is not necessarily an argument against advance Directives, but it is an argument against them having the force of law. Our experience is that people change their minds when they become unwell, but an earlier advance Directive might still be in force.

[House of Lords (HL) Select Committee on Medical Ethics, Vol. II, Oral Evidence, 18.6.:93, (110). See also: Comment in Bulletin of medical Ethics review, March 1993, p.17, on: Tierney, M C et al. How reliable are advance Directives for Health care? A study of attitudes of the healthy and unwell to treatment of the terminally ill. Annals of the Royal College of Physicians and Surgeons of Canada, 1992, 25, 267-70. ]

Memorandum by the Association for Palliative Medicine (Ethics Group)

"A comprehensive review on the subject of advance directives is given in the statement of November 1992 by the British Medical Association (BMA). The BMA is not in favour of legal enforcement of such documents, a view with which we entirely agree. From our working practice we would highlight particularly the following points against advance directives being enforceable by law.

 

  1. Ambiguity and the Scope for Misinterpretation

    Whatever care is put into the wordings of advance directives the precise meaning of terms such as terminal illness, active treatment and competence will always be open to doubt.

     

  2. Pressure on Vulnerable Groups

    The likelihood of particularly the elderly and chronic sick who feel themselves to be a burden being pressurised into signing advance directives will increase if such documents become legally binding.

     

  3. Bias

    Bias against active treatment inherent in some published advance directives may limit rather than enhance an individuals autonomy.

     

  4. Implications for Euthanasia

    We deplore moves to make advance directives legally binding as part of a gradualist policy to legalise euthanasia.

    We believe that the interests of patients will be best served by resisting attempts to make advance directives enforceable by law." [House of Lords (HL) Select Committee on Medical Ethics,, Vol. II, 13.6.93: 183]

     

Memorandum by the National Council for Hospice and Specialist Palliative Care

"By the time the directive comes into force, medical treatment may have advanced to the point that the illness mentioned is either curable or remediable or a treatment may no longer be distressing to the extent the patient did not anticipate when the directive was written or the proxy instructed, ie medical circumstances may have changed. In this instance a legally binding directive or proxy instruction would prevent potentially curative or very beneficial treatment being given."[ . . . ]

"The bias against treatment in some advance directives is so strong as to limit the autonomy of the health care team and informal carers. For instance, some suggested directives dictate that in the event of Alzheimer's disease all life- sustaining treatment should cease this would forbid the giving of insulin to a diabetic patient with Alzheimer's disease if the directive were legally binding. Withdrawal of insulin in these circumstances might well be morally objectionable to the whole health care team, and it is hard to see how the autonomy of health care professionals could be safeguarded if such directives were legally binding. Another example would be a legal document specifying no surgery, which could prevent the pinning of a fractured hip. [HL. . . , Vol. II, 13.7.93:208]

DEFINITIONS

"One has to define carefully things like "a terminal condition", "ordinary Treatment" and "extraordinary treatment" and so on or people can drive a truck through the loopholes."

[Lord Ralinson of Ewell, House of Lords, Select Committee on Medical Ethics, Vol. II. 2.11.93:261]


SUMMER 1995 VOL. 2 No. I

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