saving treatment and the rights of the unborn child which must have some moral
force even if not normally recognised in English law). There must also be a
question mark, though perhaps no more than that, over the coherence of the
reasons given. These considerations ought to affect what happens when treatment
is refused, or indications given that it will be. For a refusal in the circumstances of
section 10.3.4 orRe Swill not be accepted at face value. Efforts will and should be
made to explain the consequences of the refusal and to persuade the patient to
reconsider. It would be desirable, in such a case, to ask for the patient's spiritual
adviser to offer counselling. If the patient is simply mistaken about what his/her
religious beliefs require, then the situation could be resolved at this stage without
resort to law.
Such a reaction to a refusal of treatment can only be properly understood in
terms of our moral disquiet about the decision taken and/or the reasons for it. But
though there are good moral reasons for wishing to oppose such a decision, it may
well be that there are equally good policy reasons for not giving that opposition
legal force. We may, in other words, disagree, perhaps profoundly, with the
decision without thinking that it would be right to enforce another course of action
on the patient. And, clearly, there are excellent reasons for thinking that a general
policy of enforcing caesarean sections on unwilling women would be an extremely
bad thing.
10.9 Advance directives
As mentioned above, it can happen that patients are no longer capable of con-
senting to treatment. This may be because of mental or physical deterioration or
both. In such cases treatment becomes a matter of what the health care team
consider to be in the patient's best interests see section 10.4.1). Ordinarily it
might be thought that such a situation would be eased if there exists what has
come to be called an advance directive'. This could take the form of anything from asimple statement If it comes to it, I don't want to be kept alive as a vegetable') to
the much more formal living will' which is becoming common in the USA. There, aliving will can be of two kinds. There is the simpler formal declaration of the circumstances in which you would no longer wish further treatment, for example. There is also a durable power of health care attorney which, effectively, nominates aproxy to take decisions on your behalf should you no longer be able to do so yourself [10]. The first of these is recognised under UK law, but the second is not. This is a shame, because in many ways the first is problematic. First of all, it is invariably hypothetical this is what I wantifthe following circumstances apply ...') and also
general rather than specific. This is inevitable since, in writing a living will, we are
trying to anticipate what might happen rather than dealing with an actual situa-
tion. What it means, however, is that it may still be difficult to determine how the
will was meant to apply since the circumstances will not necessarily be precisely
those envisaged. This is especially true if the will maker is not ± and most of us are
not ± medically qualified or knowledgeable. There is also a problem of timescale,
for two reasons. The first is perhaps the most obvious: that treatments may change
The Critically Ill Patient 217