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

Cue the recent South Australian legislation: The Advance Care Directives Bill does have a binding provision clause with respect solely to directives that concern refusal of care. (Note: all other directives are non-binding). But, even here, there are some notable and justifiable exceptions:

Subject to this Act, an advance care directive cannot make provisions of the following kinds:

(a) a provision-

(i) that is unlawful; or

(ii) that would require an unlawful act to be performed; or

Example-An example of such a provision would be a request for euthanasia.

(iii) that would, if given effect, cause a health practitioner or other person to contravene a professional standard or code of conduct (however described) applying to the health practitioner or person;

The doctor also retains the right to refuse to act as a matter of his or her own conscience.

The doctor also has discretion in terms of whether a particular medical event is the event foreseen by the person making the advance directive as being the trigger for a particular directive. This is vitally important. What if a person with a terminal diagnosis had written a directive to the effect that he or she refuses all forms of medical intervention should they become incompetent and then, whilst otherwise not dying, they suffer a diabetic coma, for example? Should a 'do not resuscitate' directive apply to this circumstance?

Moreover, what if the original diagnosis were proven to be wrong? This is not an unknown occurrence.

During the debate on the SA bill, I raised concerns that the wording of the bill, as it then stood, created a risk (albeit, small) that a directive could be written so as to give effect to a person's wishes to die by starvation and dehydration. In effect, an advance request for euthanasia. Not withstanding the prohibition cited above, this was a possibility as we saw it that, thankfully, was dealt with via government amendments.

Some euthanasia & assisted suicide advocacy groups overseas actually do advise people to consciously refuse to eat and drink so as to effect a premature death. It concerned me that, were the original wording in the SA Advance Care Directives Bill to remain, that domestic advocacy groups may well have begun to advise supporters of a particular form of words for their own advance directives that would have bound doctors to comply with similar intentions.

These type of concerns do need to be balanced with evidence that suggests that patients are receiving 'acute care in hospital that they never wanted'. It is sometimes said that some doctors do see death as a failure of their craft. Over treatment - especially burdensome and futile treatment - can be a cruel and unnecessary imposition. But binding advance care provisions without the tempering effect of the doctor's recourse to his or her own experience (and that of their colleagues and ethics units) and their autonomy is not the answer.

Patient's choices must be respected, but so must doctor's choices.