Osler suggested that early contact with patients was crucial, as was the "personal influence of the teacher upon the taught." Curiously, he also recommended that examinations be abolished, because they were "stumbling-blocks and rocks of offence in the pathway of the true student." Although he might now deny Jana MacLeod, MD it, McMaster's first dean of medMedical officer icine, Dr. John Evans (later presBagamoyo District ident of the University of ToronTanzania to), is remembered as saying that [Dr. MacLeod described the chal- the University of Toronto's medlenges of her work in Tanzania in ical school would one day be a the Apr. 1, 1992, issue of CMAJ satellite of McMaster's! (146: 1238-1239). - Ed.]
to need help in countries whose material and human resources are still in low supply. However, we must realize that the effect of this assistance will be limited until our Third World colleagues are given living conditions that facilitate 100% dedication to a difficult and demanding job.
The quest for quality begins in medical school D_ r. Alvin Newman's announcement of the new
Philip F. Hall, MD, FRCSC Professor and head Department of Obstetrics, Gynecology and Reproductive Sciences University of Manitoba Winnipeg, Man.
Reference 1. Osler W: Medical education [chap 12]. In Counsels and Ideals, HM, Boston, 1905
according to criteria shared in advance with the student. 5. Learning should be based on good interpersonal relationships. Is there a need for educational workshops for faculty members regarding their new roles? Ronald G. McAuley, MD, CCFP Professor and chair Department of Family Medicine McMaster University Hamilton, Ont.
Reference 1. Miller G, Abramson S, Cohen I et al: Teaching and Learning in Medical School, Harvard U Pr, Cambridge, Mass, 1962: 69-72
When to use advance treatment
directives
undergraduate curriculum at the University of Toronto's Faculty of Medicine (Can Med Assoc J 1992; 147: 391-392) states that these revolutionary developments "will feature a marked reduction of didactic teaching with a concomitant increase in independent study time and student-driven, patient-oriented, problem-based learning in small groups." Graduates of McMaster University's Faculty of Health Sciences, having studied only 60 or so kilometres west of Toronto, will recognize this as the philosophy of their alma mater, now in place for two decades. Sir William Osler,' who lived on the outskirts of Hamilton, would have excused the University of Toronto's tardiness in revising its approach: he understood education to be "a subtle, slowlyaffected change." Like Newman, he wrote of the "extraordinary difficulties in teaching the medical student" and said that "we expect too much of the student and try to teach him too much."
T n he debate on advance treatment directives discussed in articles such as I was intrigued by Dr. Newman's letter describing the curriculum "Ontario's proposed consent laws: changes being introduced this fall 1. Consent and capacity, substiat the University of Toronto's tute decisions, advance directives Faculty of Medicine "that will and emergency treatment," by Dr. allow us [faculty members] to give Peter A. Singer and Sujit Choudhand the students to receive feed- ry (Can Med Assoc J 1992; 146: back." In his response Dr. Bruce 829-832), has become increasingP. Squires (ibid: 392) wisely focus- ly perplexing. I believe that a phyes on the need for changes in the sician treating a patient with a chronic life-threatening illness attitudes of faculty members. It is worth while recalling the should be aware of the patient's five guiding principles for teach- wishes without the need for a ers enunciated so clearly 30 years piece of paper. Within a good ago in the classic text Teaching physician-patient relationship the and Learning in Medical School, physician is empowered to act as an advocate for the patient. by Miller and colleagues.I An advance directive might 1. Teaching is personal. Since learning involves a modification be useful when a person, previousof behaviour it can be accom- ly in perfect health, suffers a sudden life-threatening illness or acciplished only by the learner. 2. Learning must be meaning- dent. However, in this situation a proxy would almost always be inful. 3. Learning must be aimed at volved. I believe the question of further treatment is best left to realistic goals. 4. Learning should be accom- this stage, when the patient's conpanied by feedback. The ideal dition has stabilized. Discussion method is continual evaluation about the degree of acceptable
CAN MED ASSOC J 1992; 147 (10)
LE 15 NOVEMBRE 1992
1420
medical disability with a proxy is logical and should always be undertaken. If a clear-cut role for proxy involvement in these situations can be developed the practice of emergency medicine will be facilitated for all. It is cruel and inhumane to force patients to sign an advance directive on admission to hospital. The health care profession must resist such an institutionally driven requirement. An advance directive is designed to be in the best interest of the patient, not the institution. The debate on advance directives must be joined by physicians in the field. It is a good thing that philosophers, ethicists, lawyers and the public have entered the debate, but none of them are faced with treating patients in a life-threatening situation. Furthermore, the use of a directive in the emergency department may be quite different from its use in a chronic-disease setting. For example, in the acute case it is possible that a proxy would not be immediately available, whereas the resident of an institution providing long-term care or a palliative care unit has the time to arrange treatment directives with all concerned. I would love to see the philosophers, ethicists and lawyers who are discussing advance directives begin a debate on prevention. It would be interesting to read articles on how to make tobacco illegal, how to clean up the environment and how to ensure a job for all. I predict that more lives would be saved and there would be a greater reduction in health care costs than through 100% compliance with laws on advance directives.
A. Singer on advance directives
sarily prolonged. However, this can be a grey area, and so the designation of a proxy (with durable power of attorney) is a practical solution. As primary care physicians we should be aware of our patients' wishes and are ethically bound to consider them. I question the clinical usefulness of a document open to variable interpretation that essentially protects only patients' rights to refuse treatment but not their right to life. Once the patient is incompetent these documents dictate the cessation of therapy, possibly including basic care or nonburdensome, beneficial therapy. Instead of protection of patient autonomy the end result will be the loss of patients' right to treatment.
(ibid: 1937-1944) raises several questions. Why do most family physicians favour the use of advance directives when these documents originate from the Hemlock Society (in the United States) and are a first step in the promotion of euthanasia on request? They are actively promoted by organizations such as the Right to Die Society of Victoria. Are such documents really necessary when the Canadian legal system already enshrines in common law the patient's right to refuse treatment? At present, the incompetent patient's family acts on his or her behalf. This process functions much better than the use of a rigid document that can never cover all possible clinical situations in advance. The average living will is so vague as to be open to a wide variety of interpretations for example, "I direct that life-sustaining procedures should be withheld or withdrawn if I have an illness, disease or injury . . . such that there is no reasonable expectation of recovering a meaningful quality of life." What the patient means by this may be quite different from what a clinician may surmise. In a court of law it will be the legal interpretation that matters. Since "medical therapy" by legal definition usually includes artificially administered food and fluids, patients may be denied basic care. Hughes and Singer found that 18% of respondents felt that the wording of the instruction directive was "too vague" and that 49% were "unsure" about it. Why then did 86% favour the use of this type of document? In my practice, discussions Peter H.S. Geggie, MD, CM, FRCPC about living wills serve as a useful Department of Medical Oncology springboard in discerning paTom Baker Cancer Centre tients' desires about end-of-life isCalgary, Alta. sues. Generally, people want all The recently published study by the life to which they are entitled Drs. David L. Hughes and Peter without the dying being unneces-
Peter A. Singer, MD, MPH, FRCPC, FACP Associate director Centre for Bioethics University of Toronto 6 Queen's Park Cres. W Toronto, ON M5S 1A8
NOVEMBER 15, 1992
CAN MED ASSOC J 1992; 147 (10)
H. Robert C. Pankratz, MD Clearbrook, BC
[Dr. Singer responds.] Dr. Geggie emphasizes the need for clinical sensibility in the use of advance directives. I agree with this underlying theme and believe that it highlights the need for close collaboration between legislators and practising physicians regarding the development and implementation of advance directives legislation. Dr. Pankratz points out that many directive documents are unsatisfactory. The Centre for Bioethics at the University of Toronto has recently produced a living will that aims to remedy some of the problems that Pankratz notes. A copy is available for $3 plus GST from the centre at the address below or by telephoning (416) 978-2709. The proceeds will be used to support further research on living wills.
1421
to need help in countries whose material and human resources are still in low supply. However, we must realize that the effect of this assistance will be limited until our Third World colleagues are given living conditions that facilitate 100% dedication to a difficult and demanding job.
The quest for quality begins in medical school D_ r. Alvin Newman's announcement of the new
Philip F. Hall, MD, FRCSC Professor and head Department of Obstetrics, Gynecology and Reproductive Sciences University of Manitoba Winnipeg, Man.
Reference 1. Osler W: Medical education [chap 12]. In Counsels and Ideals, HM, Boston, 1905
according to criteria shared in advance with the student. 5. Learning should be based on good interpersonal relationships. Is there a need for educational workshops for faculty members regarding their new roles? Ronald G. McAuley, MD, CCFP Professor and chair Department of Family Medicine McMaster University Hamilton, Ont.
Reference 1. Miller G, Abramson S, Cohen I et al: Teaching and Learning in Medical School, Harvard U Pr, Cambridge, Mass, 1962: 69-72
When to use advance treatment
directives
undergraduate curriculum at the University of Toronto's Faculty of Medicine (Can Med Assoc J 1992; 147: 391-392) states that these revolutionary developments "will feature a marked reduction of didactic teaching with a concomitant increase in independent study time and student-driven, patient-oriented, problem-based learning in small groups." Graduates of McMaster University's Faculty of Health Sciences, having studied only 60 or so kilometres west of Toronto, will recognize this as the philosophy of their alma mater, now in place for two decades. Sir William Osler,' who lived on the outskirts of Hamilton, would have excused the University of Toronto's tardiness in revising its approach: he understood education to be "a subtle, slowlyaffected change." Like Newman, he wrote of the "extraordinary difficulties in teaching the medical student" and said that "we expect too much of the student and try to teach him too much."
T n he debate on advance treatment directives discussed in articles such as I was intrigued by Dr. Newman's letter describing the curriculum "Ontario's proposed consent laws: changes being introduced this fall 1. Consent and capacity, substiat the University of Toronto's tute decisions, advance directives Faculty of Medicine "that will and emergency treatment," by Dr. allow us [faculty members] to give Peter A. Singer and Sujit Choudhand the students to receive feed- ry (Can Med Assoc J 1992; 146: back." In his response Dr. Bruce 829-832), has become increasingP. Squires (ibid: 392) wisely focus- ly perplexing. I believe that a phyes on the need for changes in the sician treating a patient with a chronic life-threatening illness attitudes of faculty members. It is worth while recalling the should be aware of the patient's five guiding principles for teach- wishes without the need for a ers enunciated so clearly 30 years piece of paper. Within a good ago in the classic text Teaching physician-patient relationship the and Learning in Medical School, physician is empowered to act as an advocate for the patient. by Miller and colleagues.I An advance directive might 1. Teaching is personal. Since learning involves a modification be useful when a person, previousof behaviour it can be accom- ly in perfect health, suffers a sudden life-threatening illness or acciplished only by the learner. 2. Learning must be meaning- dent. However, in this situation a proxy would almost always be inful. 3. Learning must be aimed at volved. I believe the question of further treatment is best left to realistic goals. 4. Learning should be accom- this stage, when the patient's conpanied by feedback. The ideal dition has stabilized. Discussion method is continual evaluation about the degree of acceptable
CAN MED ASSOC J 1992; 147 (10)
LE 15 NOVEMBRE 1992
1420
medical disability with a proxy is logical and should always be undertaken. If a clear-cut role for proxy involvement in these situations can be developed the practice of emergency medicine will be facilitated for all. It is cruel and inhumane to force patients to sign an advance directive on admission to hospital. The health care profession must resist such an institutionally driven requirement. An advance directive is designed to be in the best interest of the patient, not the institution. The debate on advance directives must be joined by physicians in the field. It is a good thing that philosophers, ethicists, lawyers and the public have entered the debate, but none of them are faced with treating patients in a life-threatening situation. Furthermore, the use of a directive in the emergency department may be quite different from its use in a chronic-disease setting. For example, in the acute case it is possible that a proxy would not be immediately available, whereas the resident of an institution providing long-term care or a palliative care unit has the time to arrange treatment directives with all concerned. I would love to see the philosophers, ethicists and lawyers who are discussing advance directives begin a debate on prevention. It would be interesting to read articles on how to make tobacco illegal, how to clean up the environment and how to ensure a job for all. I predict that more lives would be saved and there would be a greater reduction in health care costs than through 100% compliance with laws on advance directives.
A. Singer on advance directives
sarily prolonged. However, this can be a grey area, and so the designation of a proxy (with durable power of attorney) is a practical solution. As primary care physicians we should be aware of our patients' wishes and are ethically bound to consider them. I question the clinical usefulness of a document open to variable interpretation that essentially protects only patients' rights to refuse treatment but not their right to life. Once the patient is incompetent these documents dictate the cessation of therapy, possibly including basic care or nonburdensome, beneficial therapy. Instead of protection of patient autonomy the end result will be the loss of patients' right to treatment.
(ibid: 1937-1944) raises several questions. Why do most family physicians favour the use of advance directives when these documents originate from the Hemlock Society (in the United States) and are a first step in the promotion of euthanasia on request? They are actively promoted by organizations such as the Right to Die Society of Victoria. Are such documents really necessary when the Canadian legal system already enshrines in common law the patient's right to refuse treatment? At present, the incompetent patient's family acts on his or her behalf. This process functions much better than the use of a rigid document that can never cover all possible clinical situations in advance. The average living will is so vague as to be open to a wide variety of interpretations for example, "I direct that life-sustaining procedures should be withheld or withdrawn if I have an illness, disease or injury . . . such that there is no reasonable expectation of recovering a meaningful quality of life." What the patient means by this may be quite different from what a clinician may surmise. In a court of law it will be the legal interpretation that matters. Since "medical therapy" by legal definition usually includes artificially administered food and fluids, patients may be denied basic care. Hughes and Singer found that 18% of respondents felt that the wording of the instruction directive was "too vague" and that 49% were "unsure" about it. Why then did 86% favour the use of this type of document? In my practice, discussions Peter H.S. Geggie, MD, CM, FRCPC about living wills serve as a useful Department of Medical Oncology springboard in discerning paTom Baker Cancer Centre tients' desires about end-of-life isCalgary, Alta. sues. Generally, people want all The recently published study by the life to which they are entitled Drs. David L. Hughes and Peter without the dying being unneces-
Peter A. Singer, MD, MPH, FRCPC, FACP Associate director Centre for Bioethics University of Toronto 6 Queen's Park Cres. W Toronto, ON M5S 1A8
NOVEMBER 15, 1992
CAN MED ASSOC J 1992; 147 (10)
H. Robert C. Pankratz, MD Clearbrook, BC
[Dr. Singer responds.] Dr. Geggie emphasizes the need for clinical sensibility in the use of advance directives. I agree with this underlying theme and believe that it highlights the need for close collaboration between legislators and practising physicians regarding the development and implementation of advance directives legislation. Dr. Pankratz points out that many directive documents are unsatisfactory. The Centre for Bioethics at the University of Toronto has recently produced a living will that aims to remedy some of the problems that Pankratz notes. A copy is available for $3 plus GST from the centre at the address below or by telephoning (416) 978-2709. The proceeds will be used to support further research on living wills.
1421
