Advance directives

Like a will, everybody should have one

The moral duty to respect autonomy is now an established part of good clinical practice.1 Patients have the legal right to decide whether or not they will allow themselves to be touched for the purposes of medical treatment. Consequently, they also have the right to refuse proposed treatments, even when doctors believe that such treatments are in their best interests.2 The most dramatic example of such refusal is the rejection of life saving treatment.

Doctors often find it hard to accept that patients might prefer death to clinical care, especially when they are incompetent and cannot speak for themselves. If doubts exist about what a competent patient wants or needs, they can be discussed when they arise. Since incompetence precludes such debate, the duty of care must be guided by consideration of the patient's best interest.3 Where a clear consensus exists about the positive effects of treatment this provides an appropriate basis for clinical care. But when such agreement does not exist doctors may face intolerable moral and legal indeterminacy.

The …