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Advance decisions to refuse treatment - Ethical and practical concerns

summer 2008

From triple helix - summer 2008 - Advance decisions to refuse treatment - Ethical and practical concerns [p5]

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Salford City Council has begun promoting cards announcing 'Advance Decisions to Refuse Treatment'.[1] Christened ADRTs by the media, these wallet-sized cards display a prominent cartoon bubble saying 'Stop' and carry NHS and Council logos. They are attached to an explanatory leaflet and are being promoted extensively in GP surgeries, pubs and libraries. Salford claim[2] this promotion simply reflects their statutory obligation to respond to the Mental Capacity Act, which came into force in October 2007. They have 'trained' 2,500 staff in the principle of advance refusals, and other local authorities and bodies overseas have shown interest.

Advance directives[3] are attempts to extend the decision-making capacity of autonomous patients into a period when they have lost mental capacity. They can be verbal or written, though as a safeguard against abuse, advance refusals of lifesustaining treatment must 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 and CMF therefore has both ethical and practical concerns about ADRTs. They could be a back door into euthanasia. Historically they have been promoted by the euthanasia movement 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 long periods before they die, then it is more likely society will legalise a lethal injection earlier in that process.

Further, there are many practical concerns about application. There are often uncertainties about diagnosis and always about prognosis; the healthy do not make their choices in the same way as the sick; a North American study [4] showed that 61% of patients carrying an ADRT thought doctors should sometimes over-ride them; clinically, ADRTs may often achieve the opposite of what was intended; cards prominently saying 'Stop' might encourage negative or even nihilistic attitudes; doctors might wrongly under-treat patients to avoid prosecution; and an ADRT may make patients vulnerable to exploitation by people or institutions with a financial or emotional interest in their deaths.

ADRTs have the force of statutory law and if valid and applicable it is a criminal offence not to abide by them. However, they may force health professionals to practise with one hand tied behind their back, and appointing proxies may be safer. CMF is currently working with other groups to produce alternative ADRTs which balance preserving autonomy with safeguards.


  2. Head of Social Work interviewed on BBC Radio Five Live on 21 May
  3. Paul J. Advance Directives. CMF File 2002;19
  4. Sehgal A et al. How strictly do dialysis patients want their advance directives followed? JAMA 1992;267:59-63

Article written by Andrew Fergusson

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