Advance care planning
Online posting: February 13, 1997
Published in print: Mar. 15, 1997 (CMAJ 1997;156:767)
Re: Bioethics for clinicians: 6. Advance care planning, by Peter A.
Singer, Gerald Robertson and David J. Roy, CMAJ
1996:155:1689-92 [full text / résumé]
The article by Singer, Robertson and Roy sounds as if they
were dealing with computers that can make yes/no, on/off digital
decisions and not with frail, foible, ambivalent humans. Surely
we know enough about humans to remember that decision-making is
an incredibly complex affair, especially in regard to future
health care. People are ambivalent about everything almost all of
the time, and especially about matters of life and death. People
are susceptible to pressures in and around them, including subtle
suggestions and innuendos that they not not even acknowledge to
themselves, let alone voice to anybody else. Dying is one of
life's most important occasions. Time is necessary to give
blessings, make reconciliation and say good-byes. Most people
have second thoughts about any decision they have made in the
past, especially when confronted with the reality of what is just
about to happen to them. Assessing mental capability is extremely
difficult. Capability varies from one day to another; people may
become lucid in episodes, after times when they are obviously
incapable. Few people can make a completely rational decision.
Those who have been abused expect to die young and survivors
often feel they deserve to die.
Because of these factors, ancient medicine included oaths that
provided immutable guidelines, so that they were not susceptible
to family squabbles, politically correct morality, economic
pressures or even the whims of patient choice. (Although the
ancients were without technology, they were wiser than we are).
Unless physicians, individually and collectively, adhere to an
oath that commits them always to treat, how can they ever be
trusted by anybody? It is not hard for patients to realize that
their physicians are human and can be pressured by demands for
beds, desires to inherit part of the patient's estate, selfish
guardians, lazy trustees, powerful people who need a donor organ
or the feeling that "this is taking too much time and effort when
I could be golfing."
Many modern ethicists would chortle at the idea that a
physician should always treat, but there is no safe option. If
the physician is determined to do his or her best with the
resources at hand, treating those who are most likely to benefit
when there are limited resources, then the population and the
patient will trust him or her. It is up to some other agency to
restrain him or her if that is necessary.
Philip G. Ney, MD, MA
International Institute for Pregnancy Loss and Child Abuse
Research and Recovery
Victoria, BC
iiplcarr@IslandNet.com
[One of the authors responds:]
As a practising internist, I care for dying patients every day. My patients and their families do
not always want all the treatment I could provide, and I respect their choices. I doubt many of
them would accept Dr. Ney's suggestion that a physician should always treat, based on the
"immutable guidelines" of "ancient medicine."
Peter A. Singer, MD, MPH
Sun Life Chair in Bioethics
Director
University of Toronto Joint Centre for Bioethics
peter.singer@utoronto.ca
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