A RESPONSE TO THE PAPERS BY MOLLOY AND COLLEAGUES (CANADA) AND CRANFORD (UNITED-STATES) ON ADVANCE DIRECTIVES

In this paper the author addresses issues raised in the papers by Molloy and colleagues and by Cranford on advance medical directives. The distinction is made between treatment directives and powers of attorney. Treatment directives are concerned with competent persons identifying specific choices in advance of possible states of incompetence. Durable or enduring powers of attorney for health care identify persons designated to make decisions on behalf of incompetent patients who may not have stated in advance what treatments they would accept or reject. The author discusses the standard of competence that individuals must meet to execute a directive and looks at the dysfunctions of setting high standards and creating complex legislated forms, tests and procedures. The issue of competence is related to an understanding of disclosures for informed consent. Also discussed are what awareness and cognitive ability a person must have regarding prospective medical procedures in order to give advance direction and the questions of who might discuss the preparation of directives with hospital patients and when such discussions might be appropriate. The wide attention given to court decisions is contrasted with the comparatively minor regard paid to the particular legislation such decisions often interpret.