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Title: Planning for the future : a comparative study of advance directives in Scotland, England and the Netherlands
Author: Anderson, Susan J.
Awarding Body: University of Edinburgh
Current Institution: University of Edinburgh
Date of Award: 2006
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This thesis comprises three comparative case studies of advance directives under existing legislative arrangements in the Netherlands, Scotland and England. In the Netherlands, an Act of Parliament gives statutory backing to advance directives; in Scotland, an Act of Parliament specifies that they should be taken into account; whereas in England, there is no relevant Act of Parliament and medical decision making is governed by the common law. The research seeks to elucidate attitudes to advance directives within the medical and legal professions in each country and to determine how much impact (if any) they have on treatment decision-making for incapacitated persons. It focuses on the process of medical decision-making for patients with and without capacity, and the ways in which medical and legal professions assess the adequacy of existing arrangements. The primary goals of the thesis are to understand whether, and if so how, advance directives contribute to patient autonomy, the extent to which legal regulation controls medical decision-making, and the effects of Advance Directives on the balance of power between doctors and patients. Two models of decision-making (‘substituted judgement’ and ‘best interests’) and how doctors use them to make decisions for persons without capacity are considered. The study uses a socio-legal approach based on fieldwork in the Netherlands, Scotland and England. Qualitative interviews were conducted with 10 lawyers and 10 doctors in each country and interview data were analysed using NVIVO. The data were used to assess the influence of Advance Directives on medical decision-making, and to ascertain their effects on individual and professional autonomy and the balance of power between doctor and patient. The main findings are that, in all three countries, Advance Directives can be significant in protecting patient autonomy and can be used to strengthen the patient’s substituted judgement. Statutory regulation of Advance Directives (in the Netherlands) does not appear to protect patients’ autonomy any more than the Common Law (in Scotland and England); in fact the Common Law seems to be marginally better at ensuring incapacitated patients’ rights to their own choices. Differences in legal regulation of Advance Directives in each country have made little difference to the inequality of power between doctor and patient but legislation is being used to initiate a reduction of that inequality in the Netherlands, where statutory regulation can strengthen the patient’s substituted judgement and emphasise or enhance decisions made by a patient’s representative. Power in both England and in Scotland is still heavily weighted on the side of the physician but, in England, Advance Directives can help relationships between doctor and patient where the act of writing an Advance Directive encourages patients to open a dialogue with their doctors and promote discussions of future treatment preferences.
Supervisor: Not available Sponsor: Not available
Qualification Name: Thesis (Ph.D.) Qualification Level: Doctoral
EThOS ID:  DOI: Not available