A position paper on advance medical directives : ethical safeguards

Abstract

This position paper has been prepared by an interdisciplinary group of academics from the University of Malta, bringing together expertise in medicine, ethics, theology, philosophy, law, and jurisprudence, in collaboration with senior clinical staff at Mater Dei Hospital, in response to the proposed Advanced Medical Directives Act (2026). The proposed legislation aims to establish a legal framework governing the drafting, registration, recognition, and implementation of advance medical directives. The authors welcome this initiative as both timely and necessary, particularly in safeguarding patient dignity at the end of life, supporting families faced with difficult decisions, and providing guidance and legal protection to healthcare professionals. Nevertheless, the paper identifies several ethical considerations that must be addressed to ensure that the legislation achieves its intended purpose while protecting vulnerable individuals and maintaining sound clinical judgement.

A central concern of the position paper is the need for a prudent interpretation of advance medical directives. While legal clarity is essential, decisions at the end of life cannot be reduced to a purely legalistic application of written instructions. Rather, advance directives must be interpreted within a broader ethical framework that includes prudence, proportionality of treatment, and respect for human dignity. The paper distinguishes between two commonly recognised forms of advance medical directives: the living will and the durable power of attorney for healthcare. It notes that the Bill provides for living wills but omits provisions for healthcare proxies, which are often considered more flexible and effective in ensuring that patient wishes are respected in complex clinical situations.

Particular attention is given to artificial nutrition and hydration (ANH), which the Bill treats as life-sustaining interventions. The paper identifies three broad clinical scenarios. First, temporary ANH in reversible conditions generally falls outside the scope of advance refusals. Second, long-term ANH in chronic illness may shift over time from supportive care to life-prolonging treatment, requiring prudent reassessment in light of evolving circumstances. Third, in the final stages of dying, ANH may become burdensome and ethically permissible to be withdrawn, particularly where its continuation increases discomfort or prolongs suffering. In these cases, the focus of care shifts from sustaining physiological functions to providing comfort, alleviating suffering, and supporting families.

Throughout the paper, emphasis is placed on maintaining the distinction between proportionate and disproportionate treatment, and between allowing natural death and euthanasia. Advance medical directives should guide clinical decision-making, preferably, in the context of advanced care planning. Additionally, the paper stresses the need to safeguard vulnerable individuals, particularly elderly persons, from coercion or subtle pressure when drafting advance directives.

This paper also acknowledges that, despite the presence of a clear advance directive, the patient’s actual circumstances may not fully align with those anticipated in the directive. For this reason, it proposes the inclusion of a durable power of attorney alongside the advance medical directive.

The paper concludes with several recommendations, including: promoting advance care planning rather than relying solely on written directives; introducing a durable power of attorney for healthcare; establishing clinical ethics consultation services; strengthening palliative care; introducing a conscience clause; reviewing DNR practices; clarifying mental capacity assessment procedures; ensuring safeguards against coercion; providing clinical guidance on ANH; and allowing individuals to express ethical or religious values to guide interpretation of directives.

Ultimately, the paper affirms that advance medical directives can serve as valuable instruments for compassionate and ethically responsible end-of-life care, provided they are embedded within a robust ethical framework that prioritises dignity, prudence, and solidarity.