Inapplicability of advance directives in a paternalistic setting: the case of a post-communist health system

Abstract

BackgroundThe Albanian medical system and Albanian health legislation have adopted a paternalistic position with regard to individual decision making. This reflects the practices of a not-so-remote past when state-run facilities and a totalitarian philosophy of medical care were politically imposed. Because of this history, advance directives concerning treatment refusal and do-not-resuscitate decisions are still extremely uncommon in Albania. Medical teams cannot abstain from intervening even when the patient explicitly and repeatedly solicits therapeutic abstinence. The Albanian law on health care has no provisions regarding limits or withdrawal of treatment. This restricts the individual's healthcare choices.DiscussionThe question of 'medically futile' interventions and pointless life-prolonging treatment has been discussed by several authors. Dutch physicians call such interventions 'medisch zinloos' (senseless), and the Netherlands, as one of the first states to legislate on end-of-life situations, actually regulates such issues through appropriate laws. In contrast, leaving an 'advance directive' is not a viable option for Albanian ailing individuals of advanced age. Verbal requests are provided during periods of mental competence, but unfortunately such instructions are rarely taken seriously, and none of them has ever been upheld in a legal or other official forum.SummaryEnd-of-life decisions, treatment refusal and do-not-resuscitate policies are hazardous options in Albania, from the legal point of view. Complying with them involves significant risk on the part of the physician. Culturally, the application of such instructions is influenced from a mixture of religious beliefs, death coping-behaviors and an immense confusion concerning the role of proxies as decision-makers. Nevertheless, Albanian tradition is familiar with the notion of 'amanet', a sort of living will that mainly deals the property and inheritance issues. Such living wills, verbally transmitted, may in certain cases include advance directives regarding end-of-life decisions of the patient including refusal or termination of futile medical treatments. Since these living wills are never formally and legally validated, their application is impossible and treatment refusal remains still non practicable. Tricks to avoid institutional treatment under desperate conditions are used, aiming to provide legal coverage for medical teams and relatives that in extreme situations comply with the advice of withholding senseless treatment.

Self-assessment questionnaire for family doctors’ assessment of quality improvement competencies: a cross-cultural adaptation in Slovenia

“…In our study, the lowest Spearman's rho scores were found in the methods and tools domain and the highest in the equity and ethical practice domain. Probably, there are organisational and cultural differences between both countries, which could explain the differences in our results (29,30). The instrument proved to be a reliable one also in a sample of patients assessing the desired level of given competencies of their FPs (23).…”

Paternalism and autonomy: views of patients and providers in a transitional (post-communist) country

“…The results of our study confirmed that ethical dilemmas regarding patient autonomy – so thickly described in medical literature [ 23 – 25 ] -- appear frequently in medical practice in Croatia and that there, as in other countries, physicians often find themselves unprepared to tackle them [ 26 – 28 ]. As described in literature too, a range of approaches could be found in dealing with these issues: from the strictly paternalistic [ 29 ] where the physician is the one who decides what is best for patients to those more libertarian in orientation which emphasize patient self-determination as the ultimate principle [ 30 – 32 ]. However, it is worth emphasizing that physicians in Croatia should not generally be considered paternalistic since their approaches largely varied according to their individual attitudes as well as patient characteristics (age, cognitive status, and expectations) and the broader socio-cultural context.…”

“…Even though there is empirical evidence of a paternalistic mentality persisting in some post-communist countries [ 29 ], little research has been done in this field. We believe our study has added to the slender knowledge regarding the changing attitudes in transitional countries about patient autonomy issues.…”

“…In Croatia as well as in other countries worldwide, patients often welcome paternalism, even authoritarianism, in medical issues. In other words, they voluntarily relinquish their autonomy in the name of ‘doctor-knows-best’ [ 9 , 29 , 31 , 32 ]. Some of the explanations found in literature for this attitude are that patients lack confidence, are not sure which option they prefer, have conflicting priorities, or anticipate blaming themselves if outcomes are poor [ 7 ].…”

Causal Attribution and Coping Maxims Differences between Immigrants and Non-Immigrants Suffering from Back Pain in Switzerland

“…Part of the explanation might lie in the fact that most of the participants with an immigration background in this study came from countries that until fairly recently still had a very paternalistic vision on healthcare, thus ascribing the physician a very important role in treating illnesses [49, 50]. The study further identified that Albanian-speakers were more likely to attribute their back pain to “Burden and Fatigue” and “Climate”.…”