Living Wills and End-of-Life Decisions: The Italian Case

Advance directives are an exercise in self-determination which record a patient’s wishes regarding future health-care choices. In order for self-determination not to result in arbitrariness, it must be exercised, not only in a lawful manner, that is, not contrary to mandatory rules, public order, good morals, but also in a worthy manner, that is designed to exemplify positive values. The taking of one’s own life, albeit lawful—the law prohibits consensual homicide, not suicide—is contrary to human dignity; nonetheless, suicide is not perceived as warrantingthe sanction of the law. Euthanasia is not allowed, but any patient can refuse futile care, thereby exercising, not a right to death, but a different right—not to have her life artificially prolonged by disproportionate treatments. Hence, advance directives have a preceptive function for health personnel, in that they establish a framework for the continuance of the therapeutic relationship. They do not transfer the settlor’s rights to a beneficiary, but they convey the peculiar meaning of «subjective disposability», that is, they afford to third parties a decisionmaking power that they would not, otherwise, have. If advance directives are not a contract, but a non-economic act, then they should not be binding upon the doctor. Wishes expressed in advance must always be contextualized according to an assessment which must take into account the interval between the time the living will was signed and the moment it requires to be implemented. Full respect for advance directives implies that they cannot be implemented whenever the doctor finds a discrepancy between what was supposed by the patient and what will transpire if the directives are enforced, or whenever medicine has made such progress that, had it been foreseen or expected by the patient, it would have led to a different decision.