In 1994 the House of Lords Select Committee on Medical Ethics called for a Code of Practice on Advance Directives for health professionals. The BMA took up the challenge and coordinated a multi-professional group that this month published the Code as an impressive booklet.
It comes as a 40-page paperback containing the principle points of the Code expanded with explanatory notes throughout. The main points are repeated in a concise 16-page insert contained in a back pocket.
The Code takes immediate pains to point out that there are a wide variety of advance statements (living wills) under consideration, including directives, statements of wishes, beliefs and values, triggering statements, oral statements, notes of a discussion, or the nominating of a representative. It includes sections on the current legal position, the drafting of such statements and directives, assessing capacity, and implementation. Two handy flowcharts are provided - one on the types of statement (reproduced opposite) and one on the decision-making process the health care team should follow when confronted by such a document. The health care team must ask if the statement is a clear and applicable refusal of treatment, and address such questions as, is it is valid? is it an emergency? is the patient pregnant? and so on. A clear framework is given showing when the advance statement should or shouldn't be followed, and how to act in each particular set of circumstances. The differences between Scotland, England and Wales are considered, the liability of health professionals, and the - situation with regards to conscientious objection. Finally a very responsible nine-point minimum requirements list is appended.
All in all the booklet seems set to have a profound effect on the attitude of health professionals towards the implementation of living wills. The BMA clearly have done their homework very well; aware of some of the pitfalls that the USA has fallen into with its legislation on living wills dating from 1990, the drafters of the new Code have gone back to basics to stress the underlying values of the patient that must be respected, and the place of advance statements in this process. It will hopefully prove a salutary lesson to the drafters of living wills that produce overly medicalized or quasi-legal documents, which research indicates are so ineffective in practice. It will provide an unambiguous and easily digestible guide to health professionals that have struggled with the quagmire of confusion and questions over what comprises ethical conduct and good medical practice if a living will is presented. Perhaps most importantly, by emphasising the underlying values about which there is in fact little argument, the Code is an inestimably important step in reconciling the differences between the "pro" and "anti" lobbies on this important question.
© 1996 Chris Docker.
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