Consultation Paper on Bioethics - Law Reform Commission

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whether current criminal law on homicide or suicide should be changed. This <strong>Consultation</strong> <strong>Paper</strong> is not, therefore, concerned with euthanasia. The Commission is of the clear view that any steps taken to hasten death in a manner that would, under current law, amount to murder or to assisting suicide will not in any way be affected by the proposals being considered in this <strong>Consultation</strong> <strong>Paper</strong>. 11. Nor does this <strong>Consultation</strong> <strong>Paper</strong> include psychiatric advance care directives. Psychiatric advance care directives offer individuals suffering from a mental illness a practical means to express their treatment preferences in writing. “By engaging the person in the process of deliberating on their illness history and the factors, including medication, that had been effective during previous psychiatric episodes, it is believed advance directives could improve the therapeutic alliance between clinicians and patient and may improve the person‟s treatment adherence with its consequent benefits in terms of quality of life and reduced need for hospitalisation.” 13 The most controversial form of psychiatric advance directive is what is commonly referred to as the Ulysses directive. It enables individuals to bind themselves to psychiatric treatment and override, in advance, their refusals during acute episodes of their illness. The name references the Odyssey, in which Ulysses directed his crew to tie him to the ship‟s mast and leave him bound as the ship approached the Sirens, regardless of his subsequent pleas to cut him loose. 14 12. The English Mental Capacity Act 2005 and the Scottish Mental Health (Care and Treatment) (Scotland) Act 2003 contains no provision for a person to use advance decisions to express a positive preference for particular forms of treatment. It has been argued that this represents a missed opportunity to allow patients and healthcare professionals to “engage in a more constructive approach to treatment planning.” 15 The Mental Health (Care and Treatment) and the (Scotland) Act 2003 gives some recognition to the concept of advance directives in psychiatry by requiring tribunals and mental health professionals to “have regard” to their terms. The Scottish executive was not prepared to accept that the compulsory powers in mental health legislation could be overruled by a 13 Exworthy “Psychiatric Advance Decisions – An Opportunity Missed” (2004) Journal of Mental Health Law 129. See also Sheetz “The Choice to Limit Choice: Using Psychiatric Advance Directives to Manage the Effects of Mental Illness and Support Self-Responsibility” (2006) 40 U Mich J L Reform 401; Gevers “Advance Directives in Psychiatry” (2002) 9 European Journal of Health Law 19; Dunlap “Mental Health Advance Directives: Having One‟s Say?” (2001) Kentucky Law Journal 327. 14 Homer The Odyssey Book XII, lines 177-83. 15 Ibid at 134. 4
psychiatric advance directive made by a competent person. It was felt that the time was not right for such a radical approach. 16 Given the complexities involved, the Commission has concluded that it should confine its analysis to advance care directives that do not involve mental health. The Commission may return to this area at a future date. E Outline of this <strong>Consultation</strong> <strong>Paper</strong> 13. In Chapter 1, the Commission discusses the origins and nature of advance care directives. The Commission also reiterates that this <strong>Consultation</strong> <strong>Paper</strong> does not address euthanasia or assisted suicide. The Commission discusses the terminology, such as „living wills‟, associated with advance care directives. This Chapter also notes the different forms of directives, both in terms of the difference between negative advance care directives and positive advance care directives and also that some can be written but can also be given verbally, especially in a hospital admissions setting. The Commission discusses the use of Enduring Powers of Attorney (EPAs) and, more widely, a healthcare proxy in connection with advance care directives. 14. In Chapter 2, the Commission explores in some detail the legal basis for recognising advance care directives, notably how the constitutional right to refuse treatment in Irish law provides a framework for advance care directives. The Commission also discusses the various types of legal frameworks that have emerged in a number of States; this includes a consideration of whether fundamental principles and policies concerning advance care directives should be embodied in legislation or in non-statutory ethical guides. The Commission‟s analysis includes a consideration of advance care directives that refuse treatment on religious grounds, an issue that was addressed recently in a High Court case. 15. In Chapter 3, the Commission discusses informed decision-making and the capacity to make advance care directives. The Commission assesses the importance of ensuring that any medical treatment decision, whether contemporaneous or anticipatory, is sufficiently informed and whether it should be a mandatory requirement to receive advice while drafting an advance care directive. The Commission addresses capacity in general terms and also in the specific context of the age at which a person should be considered competent to refuse treatment in an advance care directive setting. 16. In Chapter 4, the Commission considers a number of specific formalities concerning advance care directives. The Commission begins by 16 Patrick “Scottish Parliament acts on Mental Health Law Reform” (2003) Journal of Mental Health Law 71, at 74. 5
Page 1: BIOETHICS: ADVANCE CARE DIRECTIVES
Page 4 and 5: LAW REFORM COMMISSION‟S ROLE The
Page 6 and 7: LAW REFORM RESEARCH STAFF Director
Page 8 and 9: CONTACT DETAILS Further information
Page 11 and 12: TABLE OF CONTENTS INTRODUCTION 1 A
Page 13 and 14: CHAPTER 4 FORMALITIES FOR ADVANCE C
Page 15 and 16: TABLE OF LEGISLATION Advance Medica
Page 17 and 18: TABLE OF CASES Airedale NHS Trust v
Page 19: Re B (adult: refusal of medical tre
Page 22 and 23: The Commission therefore confined i
Page 26 and 27: discussing whether an advance care
Page 28 and 29: “(a) at a later time and in such
Page 30 and 31: holiness I will pass my life and pr
Page 32 and 33: 1.14 In other words, the Law Commis
Page 34 and 35: two Houses of Parliament. Many of t
Page 36 and 37: Example 4: “I do not wish to rece
Page 38 and 39: common law and under Articles 2, 3
Page 40 and 41: patient. 53 It acknowledged that pa
Page 42 and 43: Therefore, a person can state that
Page 44 and 45: the doctrine of informed consent be
Page 46 and 47: Where there is no benefit in restar
Page 48 and 49: leave the matter to be decided by t
Page 50 and 51: address the situation or may be so
Page 52 and 53: is at least in theory no routine as
Page 55 and 56: 2 CHAPTER 2 LEGAL BASIS FOR THE REC
Page 57 and 58: the principle that „the doctor kn
Page 59 and 60: treatment, such as the withdrawal o
Page 61 and 62: “the law on consent to medical tr
Page 63 and 64: C United States of America (1) Re Q
Page 65 and 66: expressed wishes” regarding medic
Page 67 and 68: D The English legal position (1) Th
Page 69 and 70: compliance. Second, legislation cou
Page 71 and 72: ecommendations of the Law Commissio
Page 73 and 74: F Hong Kong 2.37 The Law Reform Com
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nutrition and hydration would only
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e reflected in the rules or framewo
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example, refuse a blood transfusion
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2.54 In North Western Health Board
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to the religious convictions of par
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As one of Jehovah‟s Witnesses wit
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3 CHAPTER 3 INFORMED DECISION MAKIN
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the context allows the patient to v
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treatment was not legally binding o
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to consult with a healthcare profes
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(3) Assessing capacity (a) England
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that a person will not be regarded
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She held that Ms K‟s clinicians h
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Capacity to Make Healthcare Decisio
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effective as it would be if he were
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competent child can consent to trea
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Manitoba, a person must be over 16.
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4.03 The decision in W Healthcare N
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a clear note of the decision, the t
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signed by the maker of the advance
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including babies, the elderly and p
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“…a health care or long-term ca
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E Prescribed form 4.34 In certain j
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4.41 The scope of section 25(2)(c)
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These provisions are also considera
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she had been sufficiently informed
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4.53 Australian statutes have dealt
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settings. The health care provider
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4.64 In early living will statutes
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condition in an advance directive p
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(3) Intention to revoke 4.76 A numb
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unjustifiable gravy train for lawye
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4.87 There are some registries for
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“If an act resulting in death is
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(a) directly or indirectly applies
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not covered under this act. 22 The
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the enormous difficulty plaintiffs
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“[a] physician who treats a patie
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law review article in 1986. Althoug
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ubella, her child was born with a d
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cause of action in light of the ave
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that right. 92 In Educational Compa
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purposes as tort law, may still ser
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the 1987 Act contains a presumption
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The Code of Practice cites a number
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the change in circumstances is such
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(b) the recognised ethical standard
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6 CHAPTER 6 SUMMARY OF PROVISIONAL
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6.19 The Commission provisionally r
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