Advance Directives in the United Kingdom: Ethical, Legal, and Practical Considerations

  • V. MetaxaEmail author
Part of the Annual Update in Intensive Care and Emergency Medicine book series (AUICEM)


Advance directives have been proposed as a way to promote self-determination in situations where the individual has lost decision-making capacity and cannot make important life and death decisions. They have significant theoretical advantages, as they allow patients to refuse future therapies and plan their future care, ensuring that the treatments they receive are consistent with their values and wishes. In the critical care setting, they have the potential to assist intensivists in their decision-making, especially as the majority of patients have impaired level of consciousness near the end of life. Despite the conceptual advantages, the number of valid advance directives in the UK remains very small, demonstrating an issue with their uptake. The most important moral concerns raised are around validity and applicability of advance directives in future scenarios, springing from uncertainties around understanding of the future disability, accuracy in forecasting one’s future preferences and potential changes in the values and wishes following the occurrence of that disability. Even though advance directives are legally binding in the UK, the courts have demonstrated reluctance to honor the wishes they express, especially when the outcome will be the patient’s death. The difficult balance between medicolegal paternalism and respect for the sanctity of life on one side and patient autonomy on the other prevents the universal adoption of advance directives, a fact that legalization itself did not change. A change of culture is required in order to accept the fact that patients have a right to refuse treatment, even it leads to their death.


Advance care planning Advance directives Paternalism Autonomy 


  1. 1.
    Department of Health. Mental Capacity Act, 2005. Accessed 10 Nov 2019.
  2. 2.
    Hughes PM, Bath PA, Ahmed N, et al. What progress has been made towards implementing national guidance on end of life care? A national survey of UK general practices. Palliat Med. 2009;24:68–78.CrossRefGoogle Scholar
  3. 3.
    Fagerlin A, Schneider CE. Enough: the failure of the living will. Hast Cent Rep. 2004;34:30–42.CrossRefGoogle Scholar
  4. 4.
    Teno JM, Licks S, Lynn J, et al. Do advance directives provide instructions that direct care? J Am Geriatr Soc. 1997;45:508–12.CrossRefGoogle Scholar
  5. 5.
    Horn R. “I don’t need my patients’ opinion to withdraw treatment”: patient preferences at the end-of-life and physician attitudes towards advance directives in England and France. Med Health Care Philos. 2014;17:425–35.CrossRefGoogle Scholar
  6. 6.
    Schiff R, Sacares P, Snook J, et al. Living wills and the mental capacity act: a postal questionnaire survey of UK geriatricians. Age Ageing. 2006;35:116–21.CrossRefGoogle Scholar
  7. 7.
    Bond CJ, Lowton K. Geriatricians’ views of advance decisions and their use in clinical care in England: qualitative study. Age Ageing. 2011;40:450–6.CrossRefGoogle Scholar
  8. 8.
    Beauchamp TL, Childress JF. Principles of biomedical ethics. Oxford: Oxford University Press; 2001.Google Scholar
  9. 9.
    Dworkin R. Life’s dominion. New York: Alfred A. Knopf; 1993.Google Scholar
  10. 10.
    Dresser R. Precommitment: a misguided strategy for securing death with dignity. Tex Law Rev. 2003;81:1823–47.PubMedGoogle Scholar
  11. 11.
    Ditto PH, Jacobson JA, Smucker WD, et al. Context changes choices: a prospective study of the effects of hospitalization on life-sustaining treatment preferences. Med Decis Mak. 2006;26:313–22.CrossRefGoogle Scholar
  12. 12.
    Michalowski S. Advance refusals of life-sustaining medical treatment: the relativity of an absolute right. Modern Law Rev. 2005;68:958–82.CrossRefGoogle Scholar
  13. 13.
    Wilson TDG, Daniel T. Affective forecasting. Adv Exp Soc Psychol. 2003;35:345–411.Google Scholar
  14. 14.
    Ditto PH, Smucker WDD, Joseph H, et al. Stability of older adults’ preferences for life-sustaining medical treatment. Health Psychol. 2003;22:605–15.CrossRefGoogle Scholar
  15. 15.
    Mallia P. Is there a Mediterranean bioethics? Med Health Care Philos. 2012;15:419–29.CrossRefGoogle Scholar
  16. 16.
    Wrigley A. Proxy consent: moral authority misconceived. J Med Ethics. 2007;33:527–31.CrossRefGoogle Scholar
  17. 17.
    Capron AM. Advance directives. In: Kuhse H, Singer P, editors. A companion to bioethics. Hoboken: Wiley; 2010. p. 299–311.Google Scholar
  18. 18.
    In Re F (Mental Patient: Sterilisation). 2 AC 1, 1990.Google Scholar
  19. 19.
    HE v A Hospital NHS Trust [2003] EWHC 1017 (Fam) at [46].Google Scholar
  20. 20.
    The NHS v T. [2004] EWHC 1279.Google Scholar
  21. 21.
    Re AK (Adult Patient) (Medical Treatment: Consent) 1 FLR 129, 2001.Google Scholar
  22. 22.
    Maclean AR. Advance directives and the rocky waters of anticipatory decision-making. Med Law Rev. 2008;16:1–22.CrossRefGoogle Scholar
  23. 23.
    A Local Health Authority v E. [2004] EWHC 1279.Google Scholar
  24. 24.
    Herring J. Medical law and ethics. 7th ed. Oxford: Oxford University Press; 2018.CrossRefGoogle Scholar
  25. 25.
    Voultsos P. The criminal problematic of euthanasia. Komotini: Sakkoulas AN; 2006.Google Scholar
  26. 26.
    British Medical Association. Decisions relating to cardiopulmonary resuscitation. A joint statement from the British Medical Association, the resuscitation council (UK) and the Royal College of nursing. BMA House: Tavistock; 2014.Google Scholar
  27. 27.
    R (Tracey) v Cambridge University Hospitals NHS Foundation Trust and another. EWCA Civ 822, 2014.Google Scholar
  28. 28.
    Winspear v City Hospital Sunderland NHS Foundation Trust. EWHC 3250 (QB), 2015.Google Scholar

Copyright information

© Springer Nature Switzerland AG 2020

Authors and Affiliations

  1. 1.Critical Care DepartmentKing’s College Hospital NHS Foundation TrustLondonUK

Personalised recommendations