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Statement by the Christian Medical Fellowship on the Advance Decision to Refuse Treatment card being promoted by Salford City Council

Introduction

Salford City Council (in the Greater Manchester area) has begun promoting cards announcing 'Advance Decisions to Refuse Treatment' (already christened ADRTs by the media). The small wallet-sized cards with a prominent cartoon bubble saying 'Stop', attached to an explanatory leaflet, are being promoted extensively in pubs, libraries, and GP surgeries. They carry the logos of the NHS and the council.

According to their Head of Social Work, interviewed on BBC Radio Five Live on 21 May, this promotion simply reflects the council's statutory obligation to respond to the Mental Capacity Act (MCA), which came into force in October 2007. The council has 'trained' 2,500 staff in the principle of the card, saying they are simply being proactive and responsible. Other local authorities and bodies in other countries are reported to have shown interest.

Advance Directives

Advance directives, previously known as 'living wills', are attempts to extend the decision-making capacity of autonomous patients into a period when they may have lost mental capacity. They can (in theory) be verbal or written, though as a safeguard against abuse, advance refusals of life-sustaining treatment must now, according to the MCA, be written, signed and witnessed. Only refusals can be made; no patient can insist in advance that they receive any particular treatment.

CMF supports patient autonomy and members wish to involve their patients as much as possible in decisions about their own treatment and care. However, individual autonomy must have limits, set in ethics and law, for the protection of others in the complex inter-related society we live in. Further, there are many practical concerns that what may look good in principle may not work well in real life.

Back door to euthanasia

One historic concern has been the promotion of ADRTs by various 'right-to-die' bodies around the world, with the campaign objective of securing suicidally ideated ADs: once patients who have refused, say, food and fluids, are seen to be suffering for days or weeks before they die, then legalising a lethal injection earlier in that process is more likely to be achieved.

For this reason and for the many practical reasons below, CMF has always argued that advance directives should not have the force of statute law. Valid and applicable ADRTs* do now have such force, under the Mental Capacity Act. There is still however some protection against this 'back door route into euthanasia', namely:

• ADRTs cannot be used to force a doctor to do anything which is otherwise unlawful (and Lord Joffe's Bill to legalise physician assisted suicide was soundly defeated in 2006)
• refusals of life-sustaining treatments must be in writing, signed, and witnessed

Practical concerns

There are many concerns which people considering whether to complete an ADRT card should bear in mind:

• Doctors are often much less certain about diagnosis than lay people might realise – so would I be satisfied that my advance wishes should now come into play?
• Similarly, doctors can never be certain about prognosis – again, should my ADRT be activated now?
• The healthy do not make their choices in the same way as the sick – how could I accurately foresee what I would want if 'x' or 'y' happened?
• Much illness is reversible – how do I know that I might not later recover my mental capacity, but perhaps be unable to express it then?
• A North American study showed that 61% of patients carrying an ADRT thought doctors should sometimes over-ride them – they did not expect them to be absolute – is my ADRT forcing my doctor to act against my best interests?
• ADRTs may often achieve the opposite of what was intended – presumably those completing them had a not unreasonable fear of being over-treated inappropriately and hoped for a swift and peaceful demise when their time came, but a blanket refusal of all antibiotics, for example, could mean that certain untreated infections would not lead to death but to continued existence with even more distressing symptoms and poorer still quality of life
• A card prominently saying 'Stop' might encourage negative or even nihilistic attitudes in health professionals faced with an unconscious patient, and thus work against that patient's best interests. Alternatively it might lead doctors to under treat a patient in order to avoid being prosecuted for giving a treatment the patient did not want.
• An ADRT may make people susceptible to being exploited by some person or institution with a financial or emotional interest in their deaths.

Conclusion

ADRTs have the force of statutory law and if valid and applicable* not abiding by them is a criminal offence. However, they may place health professionals in the position of having to practise with one hand tied behind their back, and for this reason CMF prefers the idea of appointing proxies – having two or three close individuals informed and regularly updated about wishes in the event of incapacity. CMF is currently working with other groups to produce alternative ADRTs which balance preserving autonomy with providing safeguards for patients.

Finally, we must all be vigilant that ADRTs do not become a back door route into euthanasia. We note the strong support of Dignity in Dying (formerly the Voluntary Euthanasia Society) for this Salford initiative and repeat our continuing opposition to intentionally ending the lives of our patients by commission or by omission.

* 'An advance refusal of treatment made when an adult patient was competent, on the basis of adequate information about the implications of his/her choice, is legally binding and must be respected where it is clearly applicable to the patient's present circumstances and where there is no reason to believe that the patient had changed his/her mind.' (From the Glossary to the 2002 General Medical Council guidance Withholding and withdrawing life- prolonging treatments – good practice in decision-making, and reflected in the later Act.)

For further information:

Steven Fouch (CMF Head of Communications) 020 7234 9668

Media Enquiries:

Alistair Thompson on 07970 162 225

About CMF:

Christian Medical Fellowship (CMF) was founded in 1949 and is an interdenominational organisation with over 5,000 doctors, 900medical and nursing students and 300 nurses and midwives as members in all branches of medicine, nursing and midwifery. A registered charity, it is linked to over 100 similar bodies in other countries throughout the world.

CMF exists to unite Christian healthcare professionals to pursue the highest ethical standards in Christian and professional life and to increase faith in Christ and acceptance of his ethical teaching.