Autonomy or automatons? (or 'autonomy anomaly'?)

Autonomy - The condition or quality of being autonomous; independence. Automaton - One that behaves or responds in a mechanical way.

A recent report in the Brisbane Times concerning the effectiveness of advance care directives (also known as advance health directives) focuses on a push from legal circles to make binding any patient's directives in respect to their treatment.

The article seems a little confused about precisely what kind of directives should or should not be considered to be binding; some comments in the article seem to suggest that the bind should be total; that all directives should be obeyed.

In South Australia recently, the parliament passed a bill that updated the existing provisions for people to make their wishes known in advance. This update was overdue; the statutes had not been effectively updated prior to this bill since the mid 1990s.

The Brisbane Times article opens by describing the plight of a Mr Peter Browning who, suffering from throat cancer some time ago, is dismayed (according to the article) to find that his directive that he not be resuscitated could have been effectively overridden by Queensland doctors if they felt that Browning's instructions 'conflict with good medical practice'. Interestingly, Browning recovered from his cancer; the article saying that he 'never knew the legal leeway existed'.

The Queensland Law Reform Commission wants this ability for the doctor to vary/ignore/override a written directive to be removed. QUT Health Law Research Centre's Professor Ben White agrees that the override clause on 'good medical practice' is a 'glaring exception' to the national approach. "There has to be a place in society for legally binding advance health directives," says White.

The 'national approach' mentioned by White would seem to refer to an agenda item raised by Australian Health Ministers that they look to a uniform, national scheme. South Australia seems to have gone out on their own with their reforms which, I believe should now be considered as the basis for such a uniform model. More on that a little later on.

White goes on to say, "I'm troubled by the notion that autonomy can only count when we're comfortable with the decision that's been reached." This statement goes to the very heart of the problem: can a person's right to make autonomous decisions bind and override another person's (the doctor's) rights to make their own autonomous decisions in respect to said directives and whether they will or will not carry them out?

Bear in mind also that the Queensland Act only protects a doctor's right to override an advance directive on the basis that he or she believes that directive to be "inconsistent with good medical practice."

We see this false argument for the inviolability of autonomy (read: the right to choose) played out frequently in pro-euthanasia legislation rhetoric. Ultimately, in terms of euthanasia, choice is an illusion precisely because the ultimate choice is the doctors - not the patient's. Patients can request what they like, but the doctor retains the choice to comply or refuse.

It should come as no surprise to note that the Australian Medical Association opposes any move to deny doctor discretion. To force a doctor to comply with any directive, against his or her better judgement is not only an offence against their autonomy (not to mention their training, expertise and experience) it will have the effect of reducing the medical fraternity to mere automatons: dispensing what patients want like a vending machine.

Recognise your right to refuse to carry out services which you consider to be professionally unethical, against your moral convictions, imposed on you for either administrative reasons or for financial gain or which you consider are not in the best interest of the patient. AMA Code of Ethics (revised 2006)