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Submission from CMF to the BMA Working Party on Advance Directives

Published: 1st January 1994

Introduction

Christian Medical Fellowship is interdenominational and has as members well over 4,000 British doctors who are Christians and who desire their professional and personal lives to be governed by the Christian faith as revealed in the Bible. We have members in all branches of the profession and through the International Christian Medical and Dental Association are linked with like-minded colleagues in more than 60 other countries.

We regularly make submissions on ethical matters to governmental and other bodies and indeed made a detailed Submission in 1993 to the Select Committee of the House of Lords on Medical Ethics, opposing euthanasia. This commented on their specific question about Advance Directives, and for brevity we are here summarising those views together with some updating comments.

CMF position on Advance Directives

We want to give our patients the maximum possible involvement in their healthcare, and therefore accept that Advance Directives can be of some help in indicating patients' wishes. However, we continue to agree with the BMA's 1993 view [1] that they should not be legally binding, for reasons set out below.

We acknowledge that case law so far confirms that 'when an individual signs an advance directive at common law it is legally binding'[2] and understand therefore why the BMA Council in 1994 decided [2] 'that it was impractical to continue to oppose specific legislation'. However, we are concerned that dropping this formal opposition should not lead to an uncritical acceptance of Advance Directives and we urge the greatest caution in the construction of a code of practice.

Our concerns about Advance Directives may be summarised in two areas:

Concerns that Advance Directives will hinder and not help

1. Issues of timing - when should they be implemented? There would have to be a clearly identifiable 'trigger event'- either the onset of incompetence or the occurrence of another event in the already incompetent. Could all those responsible agree on this? Would incompetence have to be permanent, or temporary? How would 'permanent' be defined?
2. Issues of informed consent - how could people precisely foresee future situations? No-one could foresee all future possibilities, nor how new medical treatments might affect those situations in years to come. People would be unlikely to update their documents regularly.
3. Changed minds - the healthy do not choose in the same way as the sick. When we become unwell our attitudes to what we want change, but an earlier Advance Directive might still be in force...
4. Difficulties of diagnosis and prognosis - could all concerned ever be sufficiently sure medically that implementation was appropriate?
5. Advance Directives may hinder communication rather than help it. Where there is some possibility of communication with a patient, but it is difficult, doctors may be tempted to rely on the Directive rather than make the effort to communicate with the patient.
6. Advance Directives indicate a lack of trust in the doctor and this 'vote of no confidence' does not encourage either party in the doctor-patient relationship to communicate.
7. We are concerned that the language of Advance Directives reinforces negative images of disability and disease and feeds patients' fears.

Concerns that Advance Directives will allow Euthanasia by the back door

Like the BMA, we oppose euthanasia. Lord Allen's Bill [3] to legalise Advance Directives, no longer before Parliament, was sponsored by the Voluntary Euthanasia Society whose own Advance Directive [4] states 'that any distressing symptoms (including any caused by lack of food or fluid) are to be fully controlled by appropriate analgesic or other treatment, even though that treatment may shorten my life'.

Legal powers were being sought to starve and dehydrate people to death. If these powers were ever obtained. it would not be long before it was argued that this was not 'compassionate' and that a lethal injection should rather be given as soon as the decision was taken.

In our Submission to the House of Lords Select Committee we questioned the real motive of Lord Allen's Bill, and we continue to question the real motive of the Voluntary Euthanasia Society where Advance Directives are concerned.

Conclusions

Nothing has happened since 1993 to make us change our minds about the wisdom of legally binding Advance Directives. In fact, more evidence is accumulating that they are unsatisfactory in principle and in practice. Helga Kuhse and Peter Singer, editors of the respected journal Bioethics, comment philosophically [5] on a paper by Savulescu [6] that 'past preferences are not necessarily a true expression of a person's autonomy', and Stone [7] argues from cases in the USA that 'signing a living will can end your life in ways that you never intended, long before you are either incompetent or terminally ill'.

We urge the Working Party to ensure that any code of practice for Advance Directives specifically excludes 'starve and dehydrate me to death' clauses, and is worded most carefully to avoid the pitfalls mentioned. We are not convinced this can be done.

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.