Customer Reviews

Advance Directives and Surrogate Decision Making in Health Care: United States, Germany, and Japan

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I am a student of health sciences in USA, and I picked this book for a comparison on US and Japan and germany health care system and policy. I was interested in the book, it was well written, but it provided me with no detail insight into the real mechanismas of health care policy abroad. I would only recommend this to people who do not have to analyse the topic for course work.

Hans-Martin Sass, Robert M. Veatch, & Rohito Kimura, editors
Advance Directives and Surrogate Decision making in Health Care:
United States, Germany, and Japan

(Baltimore, MD: Johns Hopkins University Press: [...], 1998) 311 pages
(ISBN: 0-8018-5831-3; hardcover)
(Library of Congress call number: R726.2.A38 1998)
(Medical call number: W85.5A245 1998)

This book examines many aspects of advance decision-making
for people who might later become incapable of making medical decisions.
It takes a cross-cultural look at actual practices
as well as the laws in the USA, Germany, & Japan.
Each contributor writes about the situation in his own country.

The most important chapter is by Alan Meisel, JD:
Chapter 2: "Legal Issues in Decision Making for Incompetent Patients:
Advance Directives and Surrogate Decision Making".
When state laws have attempted to limit the scope of Advance Directives,
the courts have usually allowed the written AD to prevail.
Legal incompetence (losing all adult rights) is usually not required
for an Advance Directive to be effective.
Normally the doctor merely turns to the next of kin
when the patient seems no longer able to make wise medical decisions.
Some states have attempted to set a higher standard of proof
for the decision to withhold or withdraw food and water,
but courts have usually ruled that these are forms of medical treatment,
which can therefore be decided in the same ways as any other treatments.
We always have the right to refuse medical treatment.
And we always have the right to give up food and water.
The fact that nutrition and hydration are provided by tubes makes no difference.

Meisel notes that 'check-list' Advance Directives
do not easily take into account specific situations where decisions must be made.
For example, many people check the box stating
that they never want to be put on a ventilator.
But all reasonable people would accept temporary breathing assistance
is it will restore them to their normal, healthy lives.
'Check-list' ADs might seem attractive to doctors and patients
because they look like standard medical forms.
But more personal statements and discussions
are more helpful for actual medical decision-making.
Most ADs are expressed in brief and general language,
which does not easily translate into medical decisions at the bedside.
Therefore, it is very important to appoint appropriate proxies.
When there are no surrogates named,
the law says that doctor should ask the 'next of kin'.
But the law cannot tell the difference between
kin who are close and kin who are estranged.
Therefore, we should name the person or persons
we find most appropriate to make our medical decisions
when we can no longer make wise choices.
Because proxies are usually involved in our lives,
they almost always have something to lose or gain by our deaths.
Such conflicts of interest cannot be entirely avoided.
But we can be aware of them and seek to minimize their effect.

The status of Advance Directives in Germany
is a few decades behind their status in the United States.
Few doctors have been asked to deal with them.
They are not yet legal documents.
And most of the suggested forms are about refusing treatment.

The situation in Japan is similar:
Paternalism from the medical profession prevails.
And sometimes the patient is not even told that he or she is dying.
This is intended to spare the patient the additional suffering of facing death.
It is just too distressing to the patient and family to talk about dying.
When no one is willing to acknowledge the dying process,
Advance Directives for Medical Care are irrelevant.
Everything is going to be decided by the doctor in any case.
Also, writing down one's wishes
might be taken as a sign of distrust of one's relatives.
It is more polite to communicate verbally and interpersonally.
The only medical discussions are about treatments,
seldom about preparing for death.
In Japan ADs are only for people already dying:
"If you get a terminal disease, do you want to write an advance directive?"
And, as in Germany, ADs do not yet have the force of law.
And even fewer Japanese create ADs than Americans.

Because of the Japanese denial of death,
there is also very little organ transplantation
because there is no way to decide in advance to donate.
Brain-death has only recently been accepted as a definition of death.

This book concludes with about 50 pages
devoted to several kinds of Advance Directives,
from the USA, Germany, & Japan.
These range from short generic statements,
to check-lists of treatments and values,
to narrative forms that ask what we would want
if we were in the given circumstances.

This book is probably the first to discuss
Advance Directives across different cultures.
The English-speaking world has led the way.
And we can see how far we have already come in the USA
when we look at the situations in other countries.

If you would like to see my reviews of several other books on Advance Directives,
search the Internet for the following phrase:
"Books on Advance Directives for Medical Care".

James Leonard Park, medical ethicist