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De Jure Law Journal

On-line version ISSN 2225-7160
Print version ISSN 1466-3597

De Jure (Pretoria) vol.44 n.2 Pretoria  2011




The legal validity of an advance refusal of medical treatment in South African law (Part 2)


Die regsgeldigheid van 'n gebeurlikheidsweiering van mediese behandeling in die Suid-Afrikaanse reg (Deel 2)



Louise Jordaan

BProc LLB LLD Professor, Department of Criminal Law, University of South Africa




Mediese gebeurlikheidsaanwysings stel persone in staat om mediese behandeling in die toekoms, wanneer hulle nie meer in staat is om wilsbesluite te neem nie, te weier. 'n Mediese gebeurlikheidsaanwysing is 'n lewende testament waarin die outeur weier om mediese behandeling in bepaalde omstandighede in die toekoms te ondergaan. Dit kan ook bestaan uit 'n volmag waarin die outeur 'n ander persoon aanstel om namens hom of haar in die toekoms mediese behandeling te weier. In Suid-Afrika is die regsgeldigheid en afdwingbaarheid van sodanige gebeurlikheidsaanwysing onseker. In die eerste gedeelte van hierdie bydrae wat in 2011 De Jure 32 verskyn het, is die regsposisie soos dit tans in Suid-Afrika daar uitsien, bespreek. Die etiese norme wat in die mediese beroep geld is oorweeg en met die huidige regsposisie vergelyk. Voorts is die relevante grondwetlike waardes wat in ons samelewing geld, kontekstueel ontleed en teen bepaalde belange van die gemeenskap opgeweeg. Hierdie ontleding en belange-afweging het tot die gevolgtrekking gelei dat mediese gebeurlikheidsaanwysings in beginsel as regtens afdwingbare wilsbesluite erken behoort te word.
In die tweede gedeelte van hierdie bydrae word aandag geskenk aan die etiese oorwegings wat 'n rol behoort te speel by beantwoording van die vraag of 'n mediese gebeurlikheidsaanwysing in bepaalde omstandighede as regtens afdwingbaar beskou behoort te word. Die ontwikkelinge in buitelandse regstelsels word dan oorweeg en empiriese navorsing wat aldaar onderneem is om die doeltreffendheid van gebeurlikheidsaanwysings in die praktyk te evalueer, word krities ontleed. Die slotsom wat bereik word, is dat die Suid-Afrikaanse parlement oorweging moet skenk aan die destydse voorstelle van die Suid-Afrikaanse Regskommissie in hierdie verband en dat statutêre erkenning aan die regsgeldigheid van mediese gebeurlikheidsaanwysings verleen moet word. Die ondervinding in buitelandse regstelsels dui egter daarop dat blote statutêre erkenning van die regsgeldigheid van gebeurlikheidsaanwysings nie enige noemenswaardige verandering in die praktyk teweeg bring nie. 'n Verandering in opvattings word slegs teweeggebring deur behoorlike opvoeding en die instelling van opleidingsprogramme en ondersteuningstelsels in gesondheid-sorginstellings soos klinieke en hospitale. Daar dus word aan die hand gedoen dat 'n holistiese benadering gevolg moet word, wat beteken dat die staat self betrokke moet raak by die implementering van doeltreffende strategieë om sodoende groter bewuswording van die reg op selfbeskikking van pasiënte by gesondheidsorg-werkers sowel as die breë publiek te bewerkstellig.



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69 Rich "Advance directives: The Next Generation" 1998 Journal of Legal Medicine 63 67 observes: "When .         [ Links ].. a healthy person states preferences for treatment or non-treatment of a hypothetical condition that might arise during some possible future period of decisional incapacity, the level of potential uncertainty is greatly increased. The question then arises whether the uncertainty is so great that, as a matter of ethics, law and public policy, it is reasonable to honour such declarations." Buchanan & Brock "Deciding for Others" in Battin, Francis & Landesman (eds) Death, Dying and the Ending of Life (2007) 205 248-249 question the ability of a competent person to predict a future situation and express concern about proper procedural safeguards for future decision-making.         [ Links ]
70 Dresser "Dworkin on dementia: 'Elegant Theory, Questionable Policy'" in Bioethics - An Anthology (eds Kuhse & Singer)(1999) 312 ff.         [ Links ]
71 Dresser 315.
72 Ibid.
73 Parfit Reasons and Persons (1984) 204-206
74 Dworkin Life's Dominium - An Argument about Abortion and Euthanasia (1993) 190-213.         [ Links ] Dworkin explains (201-202) that critical interests are "[c]onvictions about what makes life good as a whole ... [t]hey represent critical judgments rather than just experiential preferences". He argues (199) that "how we think and talk about dying - the emphasis we put on dying with 'dignity' - shows how important it is that life ends appropriately, that death keeps faith with the way we wanted to have lived".
75 Dworkin 231.
76 Bernat "The Living Will: Does an Advance Refusal of Treatment made with Capacity Always Survive any Supervening Incapacity"? 1999 Medical Law International 5-15.
77 MacLean "Advance directives, future selves and decision-making" 2006 Medical LR 291 315-320.
78 MacLean 2006 Medical LR320.
79 See the views of Kusman "Swing low, Sweet Chariot: Abandoning the Disinterested Witness Requirement for Advance Directives" 2006 American Journal of Law and Medicine 112: "Without the input of a doctor, however, the substance of the directive may be fatally defective. Many living wills contain ambiguous or contradictory instructions, reflecting a lack of comprehension of the medical issues and treatment possibilities involved." See also Hickey "The Disutility of Advance Directives: We know the Problems, but are there Solutions?" 2003 American Health Law Association Journal of Health Law 455 ff for a discussion of physician-imposed and patient-imposed barriers to completion of advance directives in the USA.
80 Cf the views of Dunlap "Mental Health Advance Directives: Having one's Say" 2000 Kentucky LJ327 348.
81 In re Quinlan355 A2d 647 (NJ) 429 US 922 (1976).
82 Cruzan v Director Missouri Dept of Health 497 US 261 (1990).
83 265-269.
84 278-279.
85 280.
86 After the decision in Cruzan most states introduced legislation to codify their evidentiary requirements with respect to the treatment preferences of incompetent patients. These so-called "Living Will Statutes" or "Natural Death Acts" set out the requirements for advance directives but they vary widely from state to state. See Kusman 2006 American Journal of Law and Medicine 96.
87 The first "living will" legislation was introduced in South Australia (the Natural Death Act 1983(SA)) and similar legislation followed in 1988 in the Northern Territory (the Natural Death Act 1988 (NT)). At present five of the eight states and territories have advance-directive legislation whereas four states have legislation allowing the appointment of a proxy for health care decision-making. In Canada each province has advance-directive legislation. See Brown "The law and Practice associated with Advance Directives in Canada and Australia: Similarities, Differences and debates" 2003 Journal of Law and Medicine 59 59-60.
88 For instance, the Missouri statute excludes specifically from the phrase "death prolonging procedure" artificial nutrition and hydration or the administration of any medication. In the state of Colorado, the living will statute requires declarants to state specifically that they do not wish to receive artificial nutrition and hydration when they lack mental capacity in future. See Rich 1998 Journal of Legal Medicine75.
89 Kusmin 2006 American Journal of Law and Medicine 113-116.
90 See Webster "Enforcement Problems arising from Conflicting Views of Living Wills in the Legal, Medical and Patient Communities" 2001 University of Pittsburg LR793 799-801 for the position in the United States of America. In the United Kingdom, is has been reported that the General Medical Council is to announce that doctors who fail to respect the advance directives of terminally ill patients refusing treatment once they become incompetent may be struck off the roll. See accessed on 2010-05-20.
91 Webster 2001 University of Pittsburg LR 799-801. In a minority of jurisdictions in the United States of America minor criminal penalties may be imposed for an intentional and bad-faith failure to comply with a living will. Perry "Legal Implications for Failure to comply with Advance Directives: An Examination of the Incompetent Individual's Right to Refuse Life-Sustaining Medical Treatment" 2002 Behavioural Sciences and the Law253 266-268 discusses in more detail the relevant civil causes of action which may be instituted for a refusal to honour an advance non-treatment directive. These include an action in the tort of battery; an action for pain, suffering and mental anguish for the patient and the family if life-sustaining treatments are administered contrary to the wishes of the patient or his or her surrogate. He points out that an action based on wrongful life or wrongful prolongation of life has also surfaced in American courts but that such claims have not been successful.
92 Webster 2001 University of Pittsburg LR 799. See also Wilmot, White & continued on next page Howard "Refusing Advance Refusals: Advance Directives and Life-Sustaining Medical Treatment" 2006 Melbourne University LR 211 220-236 for a detailed discussion of the circumstances in which a health professional or a court is permitted to disregard an advance directive in Australian law. These circumstances include: where there has been a change in circumstances for example if the patient is pregnant; if there is evidence of an intention to revoke the advance directive; where there is uncertainty as to the meaning of a directive eg, where the language is vague and imprecise or if it is based on incorrect information or an incorrect assumption.
93 The relevant part of s 8 of the European Convention of Human Rights provides: 1. "Everyone has the right to respect for his private and family life ..." 2. "There shall be no interference by a public authority with the exercise of this right except such as is in accordance with the law and is necessary in a democratic society in the interests of national security, public safety or the economic well-being of the country, for the prevention of disorder or crime, for the protection of health or morals, or for the protection of the rights and freedoms of others."
94 35 EHRR 1.
95 Par 63.
96 Mental Capacity Act 2005. See Jones & Jones "Advance Directives and Implications for Emergency Departments" 2007 British Journal of Nursing 220 and Bell "The Legal Framework for End of Life Care: A United Kingdom Perspective" 2007 Intensive Care Medicine 158 for a discussion of the provisions of the act and its possible application in practice.
97 Ss 24(1); 25(5) and 25(6) of the Mental Capacity Act 2005 at (accessed 2011-02-02).
98 S 9.28 of the Mental Capacity Act Code of Practice 2007 at (accessed 201102-02).
99 S 25(4)(c) of the Mental Capacity Act 2005.
100 Ss 9-14.
101 See (accessed 2011-02-02)
102 In a civil case decided in 2003, The Bundesgerichithiof described an advance directive as an expression of the patient's continuous right to self-determination in terms of the Grundgesetz. See 2003 Neue Juristische Wochienschirift 1588 1591.
103 Ss 109a and 109b Bürgerlichies Gesetzbuch! (BGB) as amended on 2009-0901 (BGB1 2009 2286). See Clemens (ed) Handbuch des Arztrechts 6 ed (2010) 1512-1516 for a discussion of these provisions.
104 Ss 1901a and 109b BGB discussed in Clemens et al 1512-1516.
105 Ibid.
106 See Andorno, Biller-Andorno & Brauer "Advance Health Care Directives: Towards a Coordinated European Policy?" 2009 European Journal of Health Law 207 212-223.
107 See Andorno et al2009 European Journal of Health Law 213-218 for a discussion of the Spanish law.
108 Andorno et al2009 European Journal of Health Law215.
109 See Servillo & Striano "End of life: Still an Italian Dilemma" 2008 Intensive Care Medicine1333 1335. These writers encourage the implementation of effective strategies to address the problems encountered in Italy with the enforcement of advance directives.
110 In France advance directives only have advisory force and are not binding upon physicians. See Griffiths, Weyers & Adams Euthanasia and Law in Europe (2008) 383-385.
111 Griffiths et al58.
112 S 450 (3) Wet op de Geneeskundige Behandelingsovereenkomst (Wet 1994-11-17 Stb. 1994 837, tot wijziging van het Burgerlijk Wetboek) at accessed on 2011-02-10.
113 See the views of Griffiths et al58 n 27.
114 S 450(3) Wet op de Geneeskundige Behandelingsovereenkomst.
115 See Griffiths et al 59.
116 Griffiths et al 163, relying on a survey conducted by Kleijer "Het wordt geregeld ..." Een onderzoek naar (zelf)-regulering bij het staken van de behandeling op Intensive Cares(Dissertation 2005 University of Groningen); Vezzoni Advance Treatment Directives and Autonomy for Incompetent Patients in Law and Practice (2008) 201-209.
117 See Griffiths et al162-163 n 45, relying on the research conducted by Kleijer.
118 See Griffiths et al163 relying on the research conducted by Vezzoni.
119 Ibid.
120 Ibid.
121 See Van Oorschot & Simon "Importance of the Advance Directive and the Beginning of the Dying Process from the Point of view of German Doctors and Judges dealing with Guardianship Matters: Results of an Empirical Survey" 2006 Journal of Medical Ethics 623.
122 Van Oorschot & Simon 2006 Journal of Medical Ethics 625-626.
123 See Kusmin 2006 American Journal of Law and Medicine 97, who relies on a survey by the website He notes that the use of advance directives is known to be highly correlated with income, race and education.
124 Patient Self-Determination Act codified at 42 USCA par 1395 (West 1992). The act came into effect on 1991-12-01.
125 See Olick 25.
126 Ibid.
127 See Rich 1998 Journal of Legal Medicine 79-80.
128 Perkins "Controlling Death: The False Promise of Advance Directives" 2007 Annals of Internal Medicine 51 54 observes: "Most people surely want 'dignified' care that is tailored to their wishes. However, the necessary detailed prior planning is emotionally draining, and most people lack the courage for it."
129 Barnes Nothing to be Frightened Of (2009) 26.
130 Ibid.
131 Ibid.
132 See Rich 1998 Journal of Legal Medicine 2006 78-97 and Brown 2003 Journal of Law and Medicine 65-68 for initiatives taken in Canada and the United States of America.
133 Andorno 2009 European Journal of Health Law224 discusses the findings of an exploratory workshop on advance directives with participants from 19 European countries and the United States of America held at the University of Zurich in 2008. The conclusion of the group was that "the important thing, would be to disseminate information among patients about the possibility of making advance directives, and to motivate practitioners to respect patients' autonomous decisions".

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