Over the last month, Salford City Council in Greater Manchester has been promoting cards announcing 'Advance Decisions to Refuse Treatment'. Christened 'ADRTs' by the media, the small wallet-sized cards feature a prominent cartoon bubble saying 'Stop' and are attached to an explanatory leaflet. They are being promoted extensively in pubs, libraries and GP surgeries. Salford Council says that these cards simply reflect its statutory obligation to respond to the Mental Capacity Act, which came into force in October last year.

Advance Directives

Patients have a right to be involved as much as possible in decisions about their own treatment and care. Advance directives, previously known as 'living wills', are attempts to extend the decision-making capacity of autonomous patients into a period when they may have lost capacity to express their wishes. For example, a patient who suddenly has a stroke may no longer be able to communicate his or her long-held wish not to be resuscitated. As a safeguard against abuse, advance refusals of life-sustaining treatment must now be written, signed and witnessed. Only refusals can be made as no patient can insist in advance that they receive any particular treatment.

Back door to euthanasia?

However, individual autonomy must have limits, set in ethics and law, for the protection of others in the complex inter-related society we live in. One historic concern has been the promotion of ADRTs by various 'right-to-die' bodies around the world, with the campaign objective of securing suicidally-ideated advance directives: once patients who have refused, say, food and fluids, are seen to be suffering pointlessly for days or weeks before they die, then legalising a lethal injection earlier in that process is likely to be achieved.

For this reason and for the many practical reasons below, there are strong arguments against ADRTs being granted the force of statute law. Valid and applicable ADRTs do now have such force, under the Mental Capacity Act which does contain some protection against the 'back door route into euthanasia', namely:

  • ADRTs cannot be used to force a doctor to do anything that is otherwise unlawful (and Lord Joffe's Bill to legalise physician assisted suicide was soundly defeated in 2006);
  • refusals of life-sustaining treatments must be in writing, signed, and witnessed.

There is a real concern that ADRTs could become a back door route into euthanasia. We note the strong support of Dignity in Dying (formerly the Voluntary Euthanasia Society) for this Salford initiative and repeat our continuing opposition to intentionally ending the lives of our patients by commission or by omission.

Practical concerns

  • There are also other concerns that people considering making an ADRT should bear in mind.
  • Doctors are often much less certain about diagnosis than lay people might realise.
  • Doctors can never be certain about prognosis so when should an ADRT be activated?
  • The healthy do not make their choices in the same way as the sick.
  • How could I accurately foresee what I would want if 'x' or 'y' happened?
  • People do change their minds.
  • A North American study showed that 61% of patients with an ADRT thought doctors should sometimes over-ride them - they did not expect their ADRT to be absolute.
  • ADRTs may often achieve the opposite of what was intended - presumably those completing them had a not unreasonable fear of being over-treated inappropriately and hoped for a swift and peaceful demise when their time came. However, a blanket refusal of, for example, all antibiotics, could mean that certain untreated infections would not lead to death but to continued existence with even more distressing symptoms and still poorer quality of life.
  • An ADRT can misrepresent a patient's intentions. It's one thing to consider that 'if I had a major stroke and couldn't speak for myself or feed myself then I wouldn't want to be resuscitated'. It's quite another to decide that 'even though I'm perfectly well now, I wouldn't want resuscitating if I had a car crash!'
  • A card prominently saying 'Stop' might encourage negative or even nihilistic attitudes in A&E doctors faced with an unconscious patient, thus work against that patient's best interests.