In this chapter, we provide an explication of advance directives (ADs) in a broad, international context, laying out the origins of the concept and how this is developing over time, as well as some of the conceptual and practical challenges that arise when ADs are implemented. We then put forward the two key rationales for our focus on the Asian context of advance directives and conclude with an introduction of the typology of jurisdictions that is employed in this volume.

Values and goals at the end of life

Death is an unavoidable fact of life. However, the manner in which we each will die is a matter of great concern and conjecture, not least given the considerable advances presented to us by modern medicine. It is nowadays possible for us to delay death and, in many cases, to enable those who would previously have died prematurely to recover and to live full and healthy lives. Such techniques also allow us to exert a greater degree of control over the processes of dying, even when full recovery is not possible. This means that there are people who can now be kept alive by medical interventions but who will never recover sufficiently to live an independent, or in some cases even a conscious, life as a result. There are also patients for whom medical interventions make no (or no appreciable) difference to their suffering – and, sometimes, these patients insist that they would rather die than endure their current existence.

The occurrence of such requests, along with the opportunities and challenges that modern medical techniques simultaneously present, raise a host of important ethical questions. In this chapter we will explore various dilemmas that arise in end-of-life care.

Why call this book a ‘workbook’? Isn't it more than that? In length and coverage alone, this is a full-fledged textbook, not what might seem a mere auxiliary teaching item. We are all experienced teachers of medical ethics and law, and this book embodies the pedagogic methods and strategies in which we believe. And while we are committed above all else to helping readers make up their own minds, we also have our own positions on the issues we raise, along with our own ‘take’ on the theoretical underpinnings of medical ethics. It is fair to say that we are much less utilitarian in our approach than the dominant trend in British bioethics, for example. So aren't we selling ourselves and the book short by trivializing it with the title of ‘workbook’?

What might seem a pedantic issue of nomenclature has preoccupied the authors since we began planning for a second edition of the Cambridge Medical Ethics Workbook as long ago as 2004. At least one reviewer of the first edition made the point we set out above, which provoked us into some very profitable discussions about our overall purpose, going well beyond the title issue. In the end we chose to retain the original name, on the principle that the book has enjoyed a very favourable reception under that title; but here at the start of the second edition, we want to point out that our ambitions and the book's ‘mission’ are considerably broader than the title ‘workbook’ may imply to some readers.

In this appendix we have mapped The Cambridge Medical Ethics Workbook against the most commonly used keywords scheme in medical ethics: the Kennedy Institute of Bioethics classification (otherwise known as the National Reference Center for Bioethics Literature Library Classification Scheme).

For some chapters in this book, such as Chapters 1 (Death and dying: decisions at the end of life) and 2 (Reproduction: decisions at the start of life), there are copious and obvious Kennedy keywords, whereas other chapters appear at first to be less well matched to the scheme. Chapters 6 (Long-term care: autonomy, ageing and dependence) and 7 (Children and young people: conflicting responsibilities) are both major topics to us, whereas neither occupies more than a sub-sub-heading in the Kennedy Institute classification. This difference in emphasis should not, of course, be taken to imply that Chapters 1 and 2 are richer or more ‘heavyweight’ than Chapters 6 and 7. As it turns out, the list of keywords for Chapter 6 is no shorter than that for Chapters 1 or 2, because in the course of dealing with everyday ethical issues that arise in the care of the elderly, we cover major topics such as truth-telling, disclosure and conflicting ethical principles. Chapter 7 actually garnered the longest list of cross-references of any topic, including confidentiality, right to refuse treatment, and availability of genetic testing, abortion counselling or HIV testing to minors. In the end, then, the classification system did prove productive and appropriate for these chapters, despite initial appearances.

The Cambridge Medical Ethics Workbook is a practical, case-based introduction to medical ethics for anyone who is interested in finding out more about and reflecting on the ethical issues raised by modern medicine. It is designed to be flexible; suitable both to be read in its own right and also for use as a set text in group teaching or in open learning. It is aimed at the interested general reader, at practising healthcare professionals and at medical and nursing students studying ethics for the first time.

The workbook is able to be flexible in this way because it is based around the reading of and reflection upon real cases. It uses a variety of structured activities to introduce and to explore the major ethical issues facing medicine today. These activities are clustered around: (a) cases (which were provided by healthcare professionals from many countries); (b) commentaries on those cases by healthcare professionals, ethicists, lawyers and so on; and (c) short papers by experts in the area concerned. This is very much a workbook, designed to help readers think about, reflect upon and to work their own way through ethical problems, by deliberating on the issues raised by them either alone or together with others. In this way, the reader is guided through the core themes in medical ethics in a way which is appropriate for them and which is relevant to their own experience.