Q8- What do other advanced countries regulate in PSDA?

World Medical Association has repeatedly stated “Refusing medical treatment is the patient’s basic right and conforms to medical ethics”. Patient autonomy is not just an international trend, but also a universe value recognized by the international society. Here we will see the examples of the United States and Germany:

In the Cruzan case in 1990, the United States Supreme Court ruled in favor for the refusal of medical treatment, including feeding tubes that prolong life. In the same year, the Patient Self-Determination Act was passed by the United States Congress. This Act ensures the patient’s right to refuse medical treatment, provides Advance Directive as a legal status, assigns a medical surrogate agent for those who are not able to express themselves clearly.

In 1990, the Federal Court of Justice of Germany (BGH) ruled that as long as there is a written will (der mutmassliche Wille), the patient—even those who are incompetent—can still have the right to refuse artificial sustaining treatments such as feeding tubes. In 2003, BGH announced the legal enforcement of Patientenverfügung; and in 2009 amended Article 1901 in the German Civil Code (Bürgerliches Gesetzbuch) stating:

  1. A person of full age can give his/her consent in written form to determine whether he/she would consent or refuse to any specific tests, treatments or medical interventions not yet directly immanent at the time of determination in advance (§ 1901a.1 BGB).
  2. The patient’s living will is effective regardless of the nature and stage of any illness of the person under custodianship (§ 1901a.3 BGB).
  3. The patient can refuse any kind of medical treatment, including those physicians deem valuable.
  4. The first priority of the appointed medical surrogate agent or court assigned custodian is to protect and fulfill the patient’s will.
  5. The patient’s expressed will and the medical surrogate agent’s decision should both be made under the premise that a proper and comprehensive medical professional advice is given (which makes ACP consultation important).
  6. The will expressed by the patient will be the most crucial and effective; the second most effective is the paper in Advance Directive-like form; and the third most effective is the presumed will on the basis of previous given oral or written statements, ethical or religious convictions and other personal values. Finally, the patient’s close relatives and other significant persons can make the decision based on the patient’s best interest. (§ 1901a.2 BGB) (§ 1901b.2 BGB)