Executive summary of a response to the Irish Law Reform Commission’s report Bioethics: Advance Care Directives.

Summary of criticisms of the report and draft bill

·       Advance care directives are an ethically flawed and potentially dangerous response to the problem of patient fears regarding end of life treatment and care.

·       Advance care directives rely on an exaggerated view of patient autonomy, encouraging patients to make life and death decisions outside of a healthcare setting.

·       This means that patients are encouraged to make decisions:

o       without the benefit of medical advice,

o       without assessment of their capacity to make such decisions,

o       without protection from the influence or coercion of third parties,

o       and without subjective experience of pain and other symptoms that future medical treatment might address.

·       Advance care directives are therefore in contravention of the principle of informed consent.

·       Advance care directives facilitate euthanasia by omission.

·       Advance care directives imply that incapacitated patients do not deserve the same standard of care and medical decision-making.

·       Advance care directives undermine the role and ethos of the medical profession, by replacing objective medical decision-making with a service delivery model directed by patients’ uninformed wishes.

·       The report establishes an arbitrary and convoluted distinction between medical treatment and basic care, concluding that artificial nutrition and hydration can be withdrawn if a patient is unlikely to recover.

Summary of recommendations

·    The principles and practice of good medical decision-making in the best interests of the patient are the best response to advance care directives, and to the original problem of patient fears about end-of-life treatment.

·    The draft bill should be opposed.

·    If it cannot be defeated, the draft bill should be amended to:

o    Limit the activation of advance care directives to the terminal phase of a terminal illness.

·   doctors to ignore advance care directives that contravene the best interests of the patient.

·   Disallow suicidal refusals of treatment and basic care such as artificial nutrition and hydration.

·   Require doctors to ignore advance care directives, where treatment will restore the decision-making capacity of the patient.