Advanced Directives: Results of a Patient Survey and Commentary from the Ethical Perspective

Medical and health care should first of all serve the well-being of the patient (salus aegroti suprema lex). These efforts, in accordance with the Ethics of Care, are in the midst of a crisis. The basic causes of this crisis are on the one hand the increase in power medicine has over life, which raises the question as to whether everything that medicine does really serves the well-being of the patient, and the increasing individualization of points of view and values in western industrial societies on the other [1, 2]. This means that the pursuit of autonomous self-realization in accordance with each person’s point of view will become the central ethical principle. On the plane of philosophical and legal reflection, this makes the autonomy of one’s own life the central content of human dignity. Religious and ‘metaphysical’ understanding of humans and their dignity, where the persons is not the autonomous master of his/her own life, but rather is primarily viewed in his/her permanent dependency on the natural circumstances of life, his/her reliance on the will of God and fellowman is increasingly viewed as a contradiction of the central demand for autonomous self-determination and categorically rejected [3]. Under these conditions, medical treatment which is not based on, or at least approved by, the autonomous decision of the patient is suspected of being ‘paternalistic control’, of a degrading treatment as an object of more or less well-intended care. The consequences of the change in attitudes and the emphasis of the patient’s autonomy are not only a crisis in the traditional ethics of care of the health care professions, but a destabilization of the ethos of the doctor-patient relationship which is increasingly subjected to legalities. The initial basis is the asssumption of an autonomy of mankind over his/her life and the type of treatment. This makes the patient’s will the first commandment (voluntas aegroti suprema lex). The patient should, even must, decide about his/her treatment. Legal precedence has followed this development, continually placing more and more emphasis on the patient’s discretionary powers. This can also be seen in the legal requirements to inform which asume that the patient’s decision is based on a properly informed patients (informed consent) [4]. It is not primarily the physician, but rather only the patient who can know and, therefore, decide which treatment best corresponds with his/her way of living. What physicians no longer may, can, or want to decide must now be decided ‘autonomously’ by the patient. The duty of the physician is basically limited to the dissemination of purely medical information. The question is whether such a medical assessment and candidly presented information allows the patients to make such a difficult decision about their life alone, whether such a type of explanation is the definitive support so as to be able to make an ‘autonomous’ decision about their treatment, and whether patients do not expect something completely different from their attending physicians, even if they can or want to decide autonomously as the legal requirements presuppose and demand. In these considerations, an increasing autonomy of the patient is assumed. The decisive questions are, however, whether seriously ill persons are primarily concerned with the autonomous self-determination of their lives and the autonomous decision about their treatment, whether in the actual state of illness they expect more from their physicians than plain medical information as the prerequisite for a more or less autonomous decision, whether and under what circumstances they are even capable of mak-