Skip to main content
SpringerLink
Log in

Advance Directives in English and French Law: Different Concepts, Different Values, Different Societies

  • Original Article
  • Published:
Health Care Analysis Aims and scope Submit manuscript

Abstract

In Western societies advance directives are widely recognised as important means to extend patient self-determination under circumstances of incapacity. Following other countries, England and France have adopted legislation aiming to clarify the legal status of advance directives. In this paper, I will explore similarities and differences in both sets of legislation, the arguments employed in the respective debates and the socio-political structures on which these differences are based. The comparison highlights how different legislations express different concepts emphasising different values accorded to the duty to respect autonomy and to protect life, and how these differences are informed by different socio-political contexts. Furthermore each country associates different ethical concerns with ADs which raise doubts about whether these directives are a theoretical idea which is hardly applicable in practice.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Similar content being viewed by others

Notes

  1. In this case a patient claimed for damages because she developed paraplegia as a result of a spinal operation without having been told that this can occur in very rare (1 %) cases [48].

  2. These criteria became the standard test for competence in England until the MCA which retains the functional approach, according to which the crucial element is the individual’s ability to understand the nature, purpose and benefits of a treatment (See test of capacity Mental Capacity Act Code of Practice, chapter 4).

  3. The Act specifies that “a person lacks capacity in relation to a matter if at the material time he is unable to make a decision for himself in relation to the matter because of an impairment of, or a disturbance in the functioning of, the mind or brain”.

  4. Two Information Reports, (Assemblée Nationale) one of 2004 which preceded the law of 2005, and one of 2008 which evaluates the law of 2005, are the most complex documents concentrating public and professional opinions, policies and studies regarding end-of-life issues in France today. 80 interviews were conducted in 2004 and 81 in 2008 with representatives of various public and professional milieus (politicians, physicians, natural scientists, human scientists, social scientists, pro-life/pro-euthanasia lobbyists, etc.). Counting how often the expression was employed during the interviews made for the Information Reports of 2004 and 2008, one discovers that the expression “advance directives” appears 99 times in 2008, but only three times in the report of 2004. On the contrary, the expression “living will” is used 180 times during the auditions for the report of 2004, but only 3 times in 2008.

  5. This conclusion abounds throughout the press and is also emphasised in a to date unpublished study on the view of the elderly on advance directives carried out by the Centre d’Ethique Clinique in Paris, paper presented at Etre vieux est-ce préparer sa mort? Les directives anticipées vues par les personnes âgées, MGEN, Paris, 11 October 2011.

  6. The new law of 2005 specifies that a terminally ill patient has the right to refuse “every” treatment, including artificial alimentation and hydration. Prior to this law, the law n° 2002-303 introduced in 2002 the right to refuse “a” treatment without specifying that this concerns life-sustaining treatments at the end of life.

  7. Dworkin defends the idea that past preferences should always be respected because of the individual’s “right to a life structured by his own values”; values that are to be placed over present “experiential” interests of the incapacitated person such as quality of life, contentment or lack of pain [16, pp. 201–202; 224].

  8. Referring to Parfit [39, p. 216], Dresser considers that personal identify, and thus values judgments, develop continually depending on various external and psychological factors [13, p. 379].

  9. A House of Lords Select Committee on Medical Ethics was created in [26] with the aim to consider, amongst others, the ethical, legal and clinical aspects of withdrawing life-sustaining treatment for persons who cannot consent to treatments on their behalf.

  10. This difference has been confirmed in interviews I undertook with French and English doctors. As yet, data analysis of the semi-structured 45 min lasting interviews with 14 English and 14 French physicians such as oncologists, nephrologists, neurologists is in its early stages and not ready to be published.

  11. Further papers discussing the empirical outcomes of my ongoing research will follow.

References

  1. Airedale NHS Trust v Bland [1993] AC 789.

  2. Assemblée Nationale. (2004). Mission d’information sur l’accompagnement de la fin de vie, n° 1708, vol. 1.

  3. Assemblée Nationale. (2004). Mission d’information sur l’accompagnement de la fin de vie, n° 1708, vol. 2.

  4. Assemblée Nationale. (2008). Mission d’évaluation de la loi n° 2005-370 du 22 avril 2005 relative aux droits des malades et à la fin de vie, n° 1287, vol. 2.

  5. Beauchamp, T. L., & Childress, J. F. (2008). Principles of biomedical ethics (6th ed.). New York: Oxford University Press.

    Google Scholar 

  6. Blank, R. H. (2011). End-of-life decision making across cultures. The Journal of Law, Medicine and Ethics, 39, 201–214.

    Article  PubMed  Google Scholar 

  7. BMA. (1995). Advanced statements about medical treatment. London: BMJ Publishing Group.

    Google Scholar 

  8. CCNE. (2000). Avis n°63 Fin de vie, arrêt de vie, euthanasie. Éthique et recherche biomédicale.

  9. Cohen, J., Marcoux, I., Bilsen, J., Deboosere, P., Van der Wal, G., & Deliens, L. (2006). European public acceptance of euthanasia: Socio-demographic and cultural factors associated with the acceptance of euthanasia in 33 European countries. Social Sciences and Medicine, 63, 743–756.

    Article  Google Scholar 

  10. Crane, D. (2009). The sanctity of social life: Physicians’ treatment of critically Ill patients. New Brunswick: Transaction Publishers (Original work published 1977).

  11. Dickenson, D. (1999). Cross-cultural issues in European bioethics. Bioethics, 913, 249–255.

    Article  Google Scholar 

  12. Ditto, P. H., et al. (2006). Context changes choices: A prospective study of the effects of hospitalization on life-sustaining treatment preferences. Medical Decision Making, 26, 313–322.

    Article  PubMed  Google Scholar 

  13. Dresser, R. (1986). Life, death, and incompetent patients: Conceptual infirmities and hidden values in the law. Arizona Law Review, 28, 373–405.

    PubMed  Google Scholar 

  14. Dunn, M., & Foster, C. (2010). Autonomy and welfare as amici curiae. Medical Law Review, 18, 86–95.

    Google Scholar 

  15. Durkheim, E. (2007). Le suicide. Paris: PUF (Original work published 1897).

  16. Dworkin, R. (1993). Life’s dominion: An argument about abortion, Euthanasia, and individual freedom. New York: Alfred A. Knopf.

    Google Scholar 

  17. Fagerlin, A., & Schneider, C. E. (2004). Enough: The failure of the living will. Hastings Center Report, 34, 30–42.

    Article  PubMed  Google Scholar 

  18. Feuillet, B. (2011). Les directives anticipées en France, un indice de consentement à effets limités. In S. Negri (Ed.), Self-determination, dignity and end-of-life care. Regulating advance directives in international and comparative perspective (pp. 195–207). Leiden, Boston: Martinus Nijhoff Publishers.

    Google Scholar 

  19. Foster, C. (2009). Choosing life, choosing death. The tyranny of autonomy in medical ethics and law. Oxford: Hart Publishing.

  20. Fovargue, S., & Miola, J. (2010). One step forward, two steps back? The GMC, the common law and ‘informed’ consent’. Journal of Medical Ethics, 36, 494–497.

    Article  PubMed  Google Scholar 

  21. GMC. (2008). Consent: Patients and doctors making decisions together. London: General Medical Council.

    Google Scholar 

  22. GMC. (2010). Treatment and care towards the end of life: Good practices in decision making. London: General Medical Council.

    Google Scholar 

  23. HE v A Hospital NHS Trust [2003] 2 FLR 408 (FD).

  24. Hope, T., Slowther, A., & Eccles, J. (2009). Best interests, dementia and the Mental Capacity Act (2005). Journal of Medical Ethics, 35, 733–738.

    Article  CAS  PubMed  Google Scholar 

  25. Horn, R. (2011, forthcoming). Euthanasia and end-of-life practices in France and Germany. A comparative study. Medicine, Health Care and Philosophy. doi:10.1007/s11019-011-9357-5.

  26. House of Lords. (1994). Report of the select committee on medical ethics. London: HMSO.

    Google Scholar 

  27. Locke, J (1993) The two treatises of government. Ed. by Goldie M. London: Everyman (Original work published 1690).

  28. Loi n°. (2002-303). du 4 mars 2002 relative aux droits des malades et à la qualité du système de santé. Journal Officiel 54, 4118.

  29. Loi n°. (2005-370). du 22 avril 2005 relative aux droits des malades et à la fin de vie. Journal Officiel 59, 7089.

  30. Maclean, A. R. (2008). Advance directives and the rocky waters of anticipatory decision-making. Medical Law Review, 16, 1–22.

    Article  PubMed  Google Scholar 

  31. Meñaca, A., Evans, N., Andrew, E., Toscani, F., Finetti, S., Gómez-Batiste, X. et al. (2011). End-of-life care across Southern Europe: A critical review of cultural similarities and differences between Italy, Spain and Portugal. Critical Review in Oncology Hematology. doi:10.1016/j.critrevonc.2011.06.002.

  32. Mendelson, D., & Stoltzfus Jost, T. (2003). A comparative study of the law of palliative care and end-of-life treatment. Journal of Law, Medicine and Ethics, 31, 134–135.

    Article  Google Scholar 

  33. Mental Capacity Act Code of Practice. (2007). Chapter 4 available at http://www.opsi.gov.uk/acts/acts2005/related/ukpgacop_20050009_en.pdf. Accessed 6 September 2011.

  34. Michalowski, S. (2005). Advance refusals of life-sustaining medical treatment: The relativity of an absolute right. The Modern Law Review, 68, 958–982.

    Article  Google Scholar 

  35. Mill, M. S. (2005). On liberty. New York: Cosimo classics (Original work published 1859).

  36. Mr Leslie Burke v GMC [2005] EWCA Civ 1003.

  37. Münch, R. (1986). Die Kultur der Moderne (2) Ihre Entwicklung in Frankreich und Deutschland. Frankfurt/Main: Suhrkamp.

    Google Scholar 

  38. Onwuteaka-Philipsen, B. D., Fisher, S., Cartwright, C., Deliens, L., Miccinesi, G., Norup, M., et al. (2006). End-of-life decision making in Europe and Australia. Archives for Internal Medicine, 166, 921–929.

    Article  Google Scholar 

  39. Parfit, D. (1984). Reasons and persons. Oxford: Clarendon Press.

    Google Scholar 

  40. Re AK (medical treatment: consent) [2001] 1 FLR 129.

  41. Re B (adult: refusal of medical treatment) [2002] 2 All ER 449.

  42. Re C (adult: refusal of treatment) [1994] 1 WLR 290.

  43. Re T (adult: refusal of treatment) [1992] 4 All ER 649.

  44. Ricot, J. (2008). Directives anticipées, révélateur de la nouvelle relation de soin. Bulletin de la Société des Sciences Médicales, 3, 399–413.

    Google Scholar 

  45. Rodríguez-Arias, D., et al. (2007). Advance directives and the family: French and American perspectives. Clinical Ethics, 2, 139–145.

    Article  PubMed Central  PubMed  Google Scholar 

  46. Rousseau, J.-J. (2006) Du contrat social. Paris: Flammarion (Originial work publised 1762).

  47. Schicktanz, S., Raz, A., & Shalev, C. (2010). The cultural context of end-of-life ethics: A comparison of Germany and Israel. Cambridge Quaterly of Health Care Ethics, 19, 381–394.

    Article  Google Scholar 

  48. Sidaway v Bethlem Royal Hospital Governors [1985] 1 All ER 643.

  49. Sidaway v Board of Governors of the Bethlem Royal Hospital [1985] AC 871.

  50. Smith v Tunbridge Wells Health Authority [1994] 5 Med. LR 334.

  51. Toscani, F., & Farsides, C. (2006). Deception, catholicism, and hope: Understanding problems in the communication of unfavorable prognoses in traditionally-catholic countries. The American Journal of Bioethics, 6, W6–W18.

    Article  PubMed  Google Scholar 

  52. W v M and S and A NHS Primary Care Trust [2011] EWHC 2443.

Download references

Acknowledgments

This paper forms part of wider research comparing policies, implementations and attitudes towards advance directives in England and France funded by an EU grant for the FP7 project, “Advance decision-making: Advance directives and proxy decision-making in France and in England” (ADVANCED - FP7-PEOPLE-2009-IEF-254825). An earlier version of the paper was presented at a workshop supported by the Institute for Advanced Studies and organised by the Centre for Ethics in Medicine, University of Bristol, “LEAP—Advance decision-making at the end-of-life”, in September 2011. I am grateful to the participants who contributed to discussion of the paper and to Kerry Gutridge for reviewing the text. I would particularly like to thank Richard Huxtable for his support and detailed comments on earlier drafts. Finally, I would like to thank the anonymous referees for critical comments and suggestions that led to improvements in the quality of this paper.

Author information

Authors and Affiliations

  1. Centre for Ethics in Medicine, University of Bristol, 39 Whatley Road, Bristol, BS8 2PS, UK

    Ruth Judith Horn

Authors
  1. Ruth Judith Horn
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Ruth Judith Horn.

Rights and permissions

Reprints and permissions

About this article

Cite this article

Horn, R.J. Advance Directives in English and French Law: Different Concepts, Different Values, Different Societies. Health Care Anal 22, 59–72 (2014). https://doi.org/10.1007/s10728-012-0210-7

Download citation

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s10728-012-0210-7

Keywords

Search

Navigation