Family physicians can play an important role in helping patients and their families to discuss life-sustaining treatments and to complete advance directives. This article reviews the legal status of, and empirical studies on, advance directives and addresses some important clinical questions about their use relevant to family practice.
Cites: CMAJ. 1992 Jun 1;146(11):1937-441596842
Cites: J Am Geriatr Soc. 1992 Mar;40(3):269-731538048
Cites: Am J Med. 1989 Jun;86(6):645-811659207
Cites: N Engl J Med. 1984 Apr 26;310(17):1115-66708993
Cites: N Engl J Med. 1986 Feb 13;314(7):457-603945276
Cites: J Gen Intern Med. 1986 Nov-Dec;1(6):373-93794836
Cites: Wis Med J. 1986 Oct;85(10):17-233798951
Cites: J Gen Intern Med. 1988 Jul-Aug;3(4):317-213404292
Cites: J Gen Intern Med. 1988 Jul-Aug;3(4):322-53042932
Cites: J Am Geriatr Soc. 1988 Sep;36(9):840-43411069
Cites: JAMA. 1989 Jun 9;261(22):3288-932636851
Cites: West J Med. 1989 Jun;150(6):705-72750162
Cites: JAMA. 1989 Nov 3;262(17):2415-92795827
Cites: N Engl J Med. 1991 Mar 28;324(13):889-952000111
Cites: N Engl J Med. 1991 Apr 25;324(17):1210-32011167
Cites: Adv Intern Med. 1991;36:57-792024588
Cites: J Am Geriatr Soc. 1993 Feb;41(2):112-68426030
Although the US Supreme Court recently reaffirmed a woman's right to end a pregnancy before viability, many women remain unable to exercise that right because their access to abortion is limited. 83% of the counties in the nation have no abortion providers, and many women must travel hundreds of miles to obtain an abortion. In its Planned Parenthood of Southeastern Pennsylvania vs. Casey decision, the Supreme Court upheld what it felt were the central tenets of Roe vs. Wade but appointed an "undue burden" standard instead of a "strict scrutiny" standard for the courts to use when determining whether or not a state restriction is to be allowed. This means that women must prove "undue" harm from a restriction. 2 other new concepts contained in Casey are that the state has an interest in fetal life throughout a pregnancy and that the government does not have to remain neutral in an abortion case even if it did not involve the issue of funding. This means that states can try to discourage a woman's choice to have an abortion. Since Casey, the Supreme Court has refused to review several abortion cases and federal courts have taken action allowing abortion restrictions to go into effect in Pennsylvania, Utah, South Dakota, North Dakota, and Mississippi. State courts in Ohio, Oklahoma, Tennessee, Alaska, New York, and West Virginia have also heard abortion restriction cases in the past year. These restrictions involved a waiting period, criminalization, a residency requirement, a community hospital's ban on abortions, and state funding for abortion. Following the Casey decision, efforts were made to codify Roe by reintroducing the Freedom of Choice Act in Congress. During the committee process, however, the bill was amended in such a way as to make pro-choice advocates doubt that the amended version will be able to accomplish the aims of the original Act. Because the High Court ruled in Bray vs. Alexandria Women's Health Clinic that the ability of abortion clinics to prevent antichoice blockades is limited since the blockades do not violate civil rights laws, Congress is advancing a measure called "The Freedom of Access to Clinic Entrances Act" to counteract the harassment which occurs outside of the clinics. State legislatures have taken action to impose mandatory delays and biased counseling on abortion-seekers, restrict the access of young women to abortion, prohibit Medicaid funding for abortion, require unnecessary reporting regulations on the part of abortion services, and institute protective measures for reproductive rights. Although the right acknowledged in the Roe vs. Wade decision continues to exist, the struggle for women's reproductive autonomy must go forward to assure constitutional protection for the right to choose and guaranteed access to that right for all women.
The author critically examines the majority judgment of the Supreme Court of Canada in Rodriguez v. Canada (A.G.) and concludes that the judges in the majority have adopted a legislative public policy mandate rather than carrying out a judicial function that accords with established canons of Charter interpretation and analysis. The author contends that the majority read section 7 of the Charter as enshrining the sanctity of life as an intrinsic, abstract societal value necessary to protect the ill and the vulnerable and not as an expression of the individual's entitlement to autonomy against the State. She also contends that the majority's section 1 analysis was unduly deferential not only to the Canadian Parliament but also to the legislatures of the majority of Western democracies. This came at the expense of considering the legislative pattern of abandoning laws against suicide, the common law respect for individual autonomy and quality of life regarding refusal of and withdrawal from medical treatment, and the widespread lax enforcement of laws critical of the majority's reliance on "slippery slope" reasoning, which subordinated Ms Rodriguez's Charter rights to apprehend wrongdoing by the medical profession and the presumed best interests of society as a whole. The author recommends that legislators who address the question of assisted suicide look to methods of regulating access to assisted suicide that reflect respect for individual dignity under the Charter at the end of life, and reject any reading of the majority judgment that suggests that legislators are free to regulate or to proscribe assisted suicide according to abstract notions of the sanctity of life, pragmatic views of the public good, or the false consciousness or perceived vulnerability of the terminally ill or disabled.