Advance treatment directive: a tool for dialogue or self-protection in the physician-patient relation?

The authors intend to assess the efficacy of the advance treatment directive as a tool for involving patients into the decision-making process and the actual implementation of the physician-patient communication. It seems particularly appropriate to distinguish between "generic" advance directive, happening outside of the physician-patient relation, and documents drafted with the assistance of care providers, in the context of such an information and communication process. That is, in order to guarantee the awareness of patients and the pertinence of the disclosed indication to the current situation with reference to the subject-matter of advance treatment directive. In addition, considering the different ways for the will of a patient to be conveyed--written statements, unexpressed will reported by witnesses, expressed will in an intelligible way by patients with severe verbal communication deficit--it is deemed important to identify the formal requirements for the validity of the above expressions of will. From an ethical standpoint, if we transcend a merely contract-centred and defensive vision of the physician/patient relation, the positive meaning of autonomy lays in its effective enforcement in the decision-making and care processes, with regard to the defined circumstances and the specific objects it refers to. Physician/patient communication means, for the purposes of this discussion, a preferential tool to balance the substantially asymmetrical relation between a physician and a patient: the process is based on a path of mutual recognition where the formal protection of each other's scopes of competency and right to self-determination stand for an essential requisite, though only preliminarily, to the actual accomplishment of consent in its cognitive and practical features.