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Advance Healthcare Directives: Binding or Informational Value?



Advance directives entail a refusal expressed by a still-healthy patient. Three consequences stem from that fact: (a) advance refusal is unspecific, since it is impossible to predict what the patient’s conditions and the risk-benefit ratio may be in the foreseeable future; (b) those decisions cannot be as well informed as those formulated while the disease is in progress; (c) while both current consent and refusal can be revoked as the disease unfolds, until the treatment starts out, advance directives become effective when the patient becomes incapable or unconscious; such decisions can therefore not be revoked at any stage of the disease. Therefore, advance directives are binding for doctors only at the stage of advance treatment planning, i.e., only if they refer to an illness already in progress.



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12. Such cases have been at the heart of legal decisions of utmost significance for the evolution of the regulatory framework of advance directives, as in the widely debated Eluana Englaro case. Patti S. L’autonomia decisionale della persona alla fine della vita, in VV.AA. Testamento Biologico: Riflessione di dieci giuristi. Milano: Fondazione Umberto Veronesi; 2006, at 1–13.

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15. Pizzetti, FG. Alle frontiere della vita: Il testamento biologico tra valori costituzionali e promozione della persona. Milano: Giuffré; 2008.

16. In the European background, the right to consent to any treatment is deemed to be enshrined within Convention for the Protection of Human Rights and Fundamental Freedoms, better known as the European Convention on Human Rights, which was opened for signature in Rome on 4 November 1950 by the then newly formed Council of Europe, and came into force in 1953, although such a right is explicitly mentioned within the Charter of Fundamental Rights of the European Union (Article. 1-Human Dignity and 3-Right to Personal Integrity) as well as in the 1997 Convention for the Protection of Human Rights and Dignity of the Human Being with regard to the Application of Biology and Medicine, also known as the Oviedo Convention, wherein Articles 5 and 9 respectively state that an intervention in the health field may only be carried out after the person concerned has given free and informed consent to it (which consent may be withdrawn at any time) and, just as importantly, the previously expressed wishes relating to a medical intervention by a patient who is not, at the time of the intervention, in a state to express his or her wishes shall be taken into account.

17. Ivone, I. Exploring self-determination and informed consent in advance directives in light of the Italian legal system, in Negri, S, ed. Self-Determination, Dignity and End-of-Life Care. Boston: Martinus Nijhoff Publishers; 2011, at 381410.

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21. The Italian Bioethics Committee, in its 2003 release titled “Dichiarazioni anticipate di trattamento” argues in favor of “the law binding doctors to take into account advance directives, openly ruling out their binding nature, but compelling doctors to elaborate on the motives for which they ultimately decided to disregard them, in writing, within the patient records.”

22. Council of Europe, Resolution 25 January 2012, Number 1859; available at (last accessed 23 Dec 2018): “Close in time to the decision-making situation, more precisely at the time when he or she is dying, and in an appropriate situation without exertion of pressure or mental disability.”

23. Council of Europe, Guide on the decision-making process regarding medical treatment in end-of-life situations, 2014; available at (last accessed 23 Dec 2018).

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26. Ackermann, RJ. Care of patients at the end of life: Advance care planning. FP Essentials 2016;447:2531.

27. Winter, L. Patient values and preferences for end-of-life treatments: Are values better predictors than a living will? Journal of Palliative Medicine 2013;16(4):362–8.

28. Burlá, C, Rego, G, Nunes, R. Alzheimer, dementia and the living will: A proposal. Medicine, Health Care and Philosophy 2014;17(3):389–95.

29. See note 28, Burlá et al. 2014.

30. D’Avack, L. Scelte di fine vita, in VV.AA. Testamento biologico: Riflessione di dieci giuristi . Milano: Fondazione Umberto Veronesi; 2006, at 4787.

31. See note 15, Pizzetti 2008, at 250 ss.

32. Barrio-Cantalejo, I.M, Molina-Rui, A, Simón-Lorda, P, Cámara-Medina, C, Toral López, I, Del Mar Rodríguez Del Aguila M, et al. Advance directives and proxies’ predictions about patients’ treatment preferences. Nursing Ethics 2009;16(1):93109; Wodos, S. Respect for persons, autonomy and palliative care, in Medicine. Health, Care and Philosophy 2005;8(2):243–53.


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