Law Commission's report makes no provision for dissenting doctorsBMJ 1995; 310 doi: https://doi.org/10.1136/bmj.310.6994.1604d (Published 17 June 1995) Cite this as: BMJ 1995;310:1604
- A P Cole
EDITOR,—There is more to some advance directives than the extension of autonomy by a once competent patient. That of the Voluntary Euthanasia Society, for example, requires that insulin is withheld when required from a signatory who develops presenile dementia. If that advance directive were legally enforceable the doctor would have to give way to a patient's wish to have death brought forward by unreasonable measures.
Len Doyal1 does not mention a serious deficiency in the Law Commission's draft legislation—namely, the lack of any provision for a doctor to dissent for medical or moral reasons from implementing an advance directive. If the document cannot require doctors to act unlawfully, as the Law Commission claims, then it should not require them to act unethically either.
Practical problems can be foreseen: a patient who has taken an overdose may have signed an advance directive stating “do not resuscitate,” or a directive stating “I am not to be subjected to any medical treatment aimed at prolonging or sustaining life” may be found when a patient is on the operating table. Nor should it be accepted that analgesics can be used to treat thirst when simple help with nutrition will suffice.
When advance directives have been made legally enforceable, problems such as these have arisen. The doctor has been unable to treat a conscious patient who has lost the capacity to revoke the directive. As a result the patient has suffered, sometimes greatly.
The BMA's original stance on advance directives was that they should not be legally binding but should be a starting point for an improved dialogue with patients over choice of treatment. After certain judgments there has been an overhasty change. There is still, however, no mandate for the BMA's council to support the Law Commission's recommendations without widely consulting members.
There is no evidence in Britain that patients who become incompetent are being treated against their wishes or against their best interests. Nor is there any study of what the general public, as opposed to pressure groups that are seeking to advance their own agenda, really want. The original concept of a living will was introduced by Kutner in a commentary entitled “Due process of euthanasia: the living will a proposal.”2