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Kerrie Wooltorton asked not to be treated after attempting suicide 

A young woman arrives by ambulance at A&E, having taken an overdose. It's a routine event, with what — in the past — amounted to a clinical routine for management. A suicide note would probably be filed, the contents mostly examined only for mention of relatives' contact details and what pills were taken. An experienced nurse would pump her stomach (they don't do it now) and a junior doctor would assess the need for any further specific treatment. 

I'm not sure we thought hard about "patient consent" in this specific situation — there's a certain illogicality in seeking informed consent to treat a self-harming patient. But now, with a renewed emphasis on patient autonomy, we have "Advance Directives" and, with these, the displacement of almost unthinking clinical routine by a potentially tragic combination of uncertainty and medical confusion. 

The Mental Capacity Act (2005) will not have been read word for word by more than a handful of doctors. But we are all now acutely aware that treating a non-consenting patient can be a criminal act and one of the clinical misdemeanours for which you could be struck off the Medical Register. Many doctors now believe, or vaguely assume, that patient autonomy always overrides clinical judgment.

So now such a patient can create medical uncertainty and panic. She has a note, clearly indicating she does not want active treatment for her suicide attempt. Relatives confirm it is her signature. She is not known to be psychiatrically ill and is certainly not drunk. Is this a valid advance directive? If not, doesn't it constitute something similar? If such a letter appeared in court, what more proof could be needed that you had treated the patient not just without her consent, but against her expressed wishes? All this in a crowded A&E department at 1am. 

The supremely simple unwritten rule of thumb "when in doubt, treat", which used to protect both patients and doctors, now no longer helps the latter. The worried, urgent and complex deliberations that replace it can lead to heartbreaking decisions. 

Last month saw the tragic case of 26-year-old Kerrie Wooltorton, who died in just such circumstances, receive much media attention, and other cases have undoubtedly occurred. There are some sound reasons behind the idea of advance directives. An individual with a serious cancer might reasonably wish to decline futile and burdensome treatments and there is wisdom in setting this out in advance. The Mental Capacity Act aimed, among other things, to provide a legal framework for such advance decisions (directives), and so could be said to be paved with perfectly good intentions. 

Many have argued though that the whole question of advance directives was always part of the pro-euthanasia lobby's agenda, smuggled through parliament inside the Trojan horse of the terminally ill patient's "right to refuse". Either way, those who frame and draft our laws should concentrate not merely on what the law aims to establish, but on what might happen if it were to be misinterpreted or misused — or, in this case, just misunderstood by muddled doctors. Never mind what should happen — what could happen?

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