Consultation Paper on Bioethics - Law Reform Commission

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leave the matter to be decided by the medical profession in accordance with the medical practice prevailing at the time when a person‟s advance directive is to be executed. It suggested that the following wording should be used in the model advance directive form: "Save for basic and palliative care, I do not consent to receive any life-sustaining treatment. Non-artificial nutrition and hydration shall, for the purposes of this form, form part of basic care.” 89 1.52 The Commission provisionally recommends that an advance care directive cannot refuse actions concerning basic care. (b) Enforced treatment 1.53 Under the English Mental Capacity Act 2005, an advance decision will not operate to prevent treatment where consent is not necessary, 90 for example, where enforced treatment is provided to civilly confined patients under Part IV of the Mental Health Act 1983 as amended by section 12 of the Mental Health Act 2007. (c) Refusing life-sustaining treatment during pregnancy 1.54 A question arises where a woman refuses life-sustaining treatment during the course of a pregnancy. The Scottish Law Commission has argued that a terminally ill woman ought to be kept alive for “longer than strictly necessary” if there is a reasonable chance of thereby saving her unborn child. 91 The Law Commission for England and Wales considered the issue in its 1995 Report on Mental Incapacity and recommended a statutory presumption that advance refusals of treatment would not apply if the viability of a foetus were at risk. 92 The English Mental Capacity Act 2005 chose not to incorporate a presumption to this effect. However, the Code of Practice made under the 2005 Act does advise healthcare professionals to consider whether there have been changes in the patient‟s personal life which were not anticipated when they made the advance decision that might affect the validity of the advance decision. It specifically cites pregnancy as an example of such a change. 93 89 Law Reform Commission of Hong Kong Report on Substitute Decision-Making and Advance Directives in Relation to Medical Treatment (2006) at 169. 90 Section 28 of the Mental Capacity Act 2005. 91 Scottish Law Commission Discussion <strong>Paper</strong> on Mentally Disabled Adults – Legal Arrangements for Managing their Welfare and Finances (No 94 1991) at paragraph 5.111. 92 The Law Commission for England and Wales Report on Mental Incapacity (No 231 1995) at paragraph 5.26 93 Mental Capacity Act 2005 - Code of Practice at paragraph 9.43. 28
However the refusal of life-sustaining treatment during pregnancy is outside the scope of this paper. This matter would be affected by Article 40.3.3° of the Constitution of Ireland. F Healthcare Proxy (1) Instructional directives 1.55 An instructional directive is a document by which a person specifies his or her wishes concerning future treatment. There are a significant number of drawbacks to this form of advance care directive. First, an instructional directive is often a “standard, fill-in-the-blanks form” and therefore lacks flexibility. 94 Secondly, the information provided may not be clinically relevant. For example, some directives use vague statements such as “take no heroic measures” or “continue treatment only if the benefits outweigh the burdens.” 95 Conversely, instructional directives that outline specific interventions may fail to instruct a physician because “not all treatment situations fit neatly into one of the specific scenarios. 96 Third, people frequently change their minds. As Clough has noted, “when placed in the midst of an illness, what once was unthinkable may become acceptable.” 97 Fourth, medical science may advance considerably in the period between the making of the advance care directive and the medical situation provided for arising in practice. 98 (2) Appointing a person to carry out advance care directives 1.56 Patients may wish to designate a person (commonly known as a proxy) who can represent them in a situation of future incompetence and who has the authority to give or to withhold consent to medical interventions on their behalf. The central advantage is that the proxy can “step into the shoes of the patient and make decisions in the light of the current medical situation and the advice of the attending physician” whereas an instructional directive “may not 94 Dunlap “Mental Health Advance Directives: Having One‟s Say?” (2000-2001) 89 Kentucky Law Journal 327 at 347. 95 In a study by Teno et al, only 22 of 688 advance care directives written by terminally ill patients contained instructions explicit enough to guide medical care: Teno et al “Do Advance Directives Provide Instructions that Direct Care?” (1997) 45 Journal of the American Geriatric Society 508. 96 Clough “A Critique of Advance Directives and Advance Directives Legislation” (2006) 11 Appeal: Review of Current Law and Law Reform 16 at 29. 97 Ibid at 30. 98 Law Reform Commission <strong>Consultation</strong> <strong>Paper</strong> on Vulnerable Adults and the Law: Capacity (LRC CP 37-2005) at paragraph 7.64. 29
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 24 and 25: whether current criminal law on hom
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 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
Page 75 and 76: nutrition and hydration would only
Page 77 and 78: e reflected in the rules or framewo
Page 79 and 80: example, refuse a blood transfusion
Page 81 and 82: 2.54 In North Western Health Board
Page 83 and 84: to the religious convictions of par
Page 85 and 86: As one of Jehovah‟s Witnesses wit
Page 87 and 88: 3 CHAPTER 3 INFORMED DECISION MAKIN
Page 89 and 90: the context allows the patient to v
Page 91 and 92: treatment was not legally binding o
Page 93 and 94: to consult with a healthcare profes
Page 95 and 96: (3) Assessing capacity (a) England
Page 97 and 98: that a person will not be regarded
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She held that Ms K‟s clinicians h
Page 101 and 102:
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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