By Dr Ray Campbell
I AM frequently asked questions about “end of life care”.
Some people want to know if it is alright to refuse medical treatments towards the end of life.
Others are concerned that they might be deprived of treatment which would sustain his or her life.
It is because of questions like these that some people are strongly promoting what is known as “advance health care planning”.
Just recently Karen Brooks published an article in The Courier-Mail encouraging people to complete an Advance Health Directive – one of the options for advance health care planning.
Advance health care planning refers to making provisions for your wishes for your health care to be respected at a time when you are no longer competent to make those wishes known.
The idea of a legally binding advance health directive is a relatively new phenomenon.
There are many different factors behind the promotion of such an instrument.
I cannot begin to enumerate them here, but I would like to reflect upon one matter as an introduction to answering the questions posed above.
One of the factors behind advance health directives can be a desire to control. Brooks herself mentions maintaining some form of control, not only of our life, but of our death as well.
Control over death. This seems to be the issue for some. But is control the answer?
Death in a sense confronts us with our powerlessness.
We are powerless in the face of death.
Generally we do not like to feel powerless. We tend to rage against it. We look for ways to regain control, to dominate.
And so it can be with death.
We look for ways to control it, to dominate.
This can lead to euthanasia or assisted suicide. Rather than admit our powerlessness in the face of death we seek to control it by bringing it upon ourselves.
But it is exactly in our powerlessness that we confront the paradox of our Christian faith.
As St Paul said to the Corinthians, “when I am weak, then I am strong”, because it is then that the power of Christ is made manifest.
So too in our powerlessness in the face of death – our powerlessness is an occasion for us to trust in the power of God, not to restore us to health, but to help us face death with peacefulness and trust in God’s goodness.
So to return to the questions of our duties when confronted with various treatment options towards the end of life.
Generally speaking if we are ill we should seek help to maximize our chances of recovery and to minimise the effects of chronic disability or handicap.
If illness is life-threatening we should seek to avert the threat. That simply follows from our respect for the gift of life.
The positive duty to protect our life, like all positive duties, has limits. A failure to respect those limits can lead to “overtreatment”.
Overtreatment can be defined as the continual use or commencement of procedures aimed at cure where that is no longer possible, or the use of burdensome and intrusive procedures which are of little benefit.
So it is quite appropriate to consider the benefit and the burden of the treatment proposed, given the condition of the patient.
We do not try and judge a person’s “quality of life”, which often becomes a judgment of the supposed value of a person’s life.
The judgment is of the value of the treatment.
So we might consider how much pain and discomfort the treatment will bring, and what will be the benefit? How will the person handle the treatment?
We might even have to consider how much the treatment will cost?
It is very difficult to say in advance what treatments will be too burdensome in different circumstances.
This is one of the reasons why an Advance Health Directive, such as the Queensland model, is a blunt instrument.
The way it is set out it can imply that being a person in a certain condition makes one’s life no longer worthwhile.
The alternative to an Advance Health Directive is to appoint an enduring power of attorney for health matters.
By this mechanism you can appoint someone who will speak on your behalf regarding your health care when you are no longer competent.
The power of attorney for health matters only has authority when you are no longer able to ‘speak for yourself.’
By appointing someone you trust to this role you have the security of knowing that someone who cares for you will be in a position to make choices about your care based upon your wishes.
One of the advantages of appointing a power of attorney for health matters is that they are in a position to be able to make judgments in unpredictable future situations.
You can tell your power of attorney in advance what kind of treatments you might consider too burdensome in various situations, and you can even put that in writing for them, and then trust them to make the decisions when and if the circumstances arise.
As a general rule of thumb I counsel appointing an enduring power of attorney.
If one does want to complete a legally binding advance health care directive, then one should have a good talk with a doctor you trust to make sure you fully understand the implications of the wishes you express.
A consultation draft for A National Framework for Advance Care Directives from the Australian governments indicates that the combined approach is gaining favour: “It … became apparent that written instructions alone are of limited effectiveness, and recent international legislative activity has favoured a combination of substitute decision-making (by power of attorney) and written directions”.
A document which gives some explanation of advance health care planning, including the refusal of treatment, and gives an example of an advance health care directive, is available from the Catholic Health Australia website: http://cha.org.au/site.php?id=223
The document recommends the appointment of a power of attorney to whom you might also give your written wishes.
At this time we remember the last words of Jesus: “Into your hands O Lord, I commend my spirit.”
Dr Ray Campbell is the director of the Queensland Bioethics Centre.
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