Advance directive

Medical science today can draw on an ever increasing panoply of possibilities in the treatment of disease and the saving and prolongation of life. In most cases their use is regarded as helpful by the patients concerned, their families and their doctors alike. Yet there are also circumstances in which patients themselves no longer wish to avail themselves of the full range of potential treatments. Possible reasons are fear of the strain or risks of the specific treatments, rejection of the associated need for hospitalization, or simply the wish not to have their lives prolonged. In such cases, which arise mainly at the end of life, the relationship of trust between doctor and patient assumes particular importance. After all, in accordance with both current law and generally accepted ethical principles, patients should be able to exercise their right of self-determination in this situation as in others, but for this purpose they as a rule need information and support from a doctor.

Decisions on treatment are particularly difficult when the patients concerned are no longer able to express themselves. An increasing number of people wish to make provision for such cases by placing on record their decision as to the measures to be adopted in these circumstances (in an advance directive[1]), by empowering a trusted individual to make such decisions (through an enduring power of attorney) or by nominating a person to be appointed by the court as their representative (in a directive as to representation). Both experts and the public at large disagree on the scope of such an instance of “advance self-determination” and on the conditions on which it should be respected.

The conditions to which the exercise of the right of self-determination by means of an advance directive should be subject are discussed in the Opinion "The advance directive: an instrument of self-determination" (June 2005), as a contribution to the establishment of legal certainty for patients on the one hand and for doctors, family members and nursing staff on the other.

These considerations form part of a comprehensive Opinion drawn up by the National Ethics Council on the ethical, legal and social context of end-of-life care and on its reality.

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