A Review of the Ethical Considerations in Advance Directives (With Particular Reference to Their Status in Iranian Law)
akhlāq-i pizishkī i.e., Medical Ethics,
Vol. 20 (1405),
13 July 2026
,
Page 1-15
https://doi.org/10.22037/mej.v20i.51313
Abstract
Background and Aim: The global expansion of individualistic ideologies has influenced the field of medicine and has led to the development of the concept titled "autonomy of patients" in contrast to the traditional "paternalism" dominating medical practice. The development of the "Advance Directive" is one of the prominent outcomes and manifestations of these ideologies. "Advance Directive" allows patients to reflect their current treatment preferences in predetermined forms, so that they can be utilized by physicians in the future and in situations in which they lose their decision-making capacity. This study aims to explain the concept of advance directives, analyze principal ethical considerations, and examine its status within the legal framework of Iran.
Methods: This study was a narrative review. Persian and English articles were searched in databases, including SID, Noormags, ScienceDirect, and the Google Scholar search engine. Keywords included "Advance Directives," "Advance Care Planning," and their Persian equivalents. The articles published from 2015 to 2025 were included in this study.
Ethical Considerations: Throughout all study stages, the fundamental principles of research ethics, including originality, honesty, and trustworthiness, have been observed.
Results: According to the research findings, although the "Advance Directive" was developed to promote patients’ autonomy and respect for their preferences. However, its implementation faces fundamental challenges and considerations. At the theoretical level, these challenges include self-paternalism, the prioritization of autonomy over principles of beneficence and non-maleficence, violation of human dignity, and neglect of relational autonomy. At the practical level, these challenges include uncertainty in predicting patients’ future preferences, ambiguity in interpretation, disregard for the influence of cultural and social factors, physicians’ failure for its implementation due to deeply established medical practices, and lack of access in emergency situations.
Conclusion: Studies indicate that although the "advance directive" has been introduced to respect patients’ autonomy in the course of medical treatment and has attempted to overcome certain challenges associated with medical paternalism, it faces fundamental challenges at both theoretical and practical levels. Therefore, it cannot necessarily be considered a definitive and effective solution for end-of-life care. Within the Iranian legal system, particularly under the Patient Rights Charter, the advance directive has been recognized as a therapeutic instrument; however, it lacks legally binding force.
- Advance Directive
- Medical Ethics
- Patient Autonomy
- Medical Law
- Patient Dignity
- Patient Rights Charter
How to Cite
References
1. Kittay EF. The liberal autonomous subject and the question of health inequalities. In: Buchbinder M, Rivkin-Fish M, Walker RL, editors. Understanding Health Inequalities and Justice: New Conversations Across the Disciplines. Chapel Hill (NC): University of North Carolina Press; 2016. p.112-34.
2. Taylor HJ. What are ‘best interests’? A critical evaluation of ‘best interests’decision-making in clinical practice. Medical Law Review. 2016;24(2):176-205.
3. Peicius E, Blazeviciene A, Kaminskas R. Are advance directives helpful for good end of life decision making: A cross sectional survey of health professionals. BMC Medical Ethics. 2017;18(1):40.
4. Thompson AE. Advance directives. JAMA. 2015;313(8):868.
5. Sedini C, Biotto M, Crespi Bel’skij LM, Moroni Grandini RE, Cesari M. Advance care planning and advance directives: An overview of the main critical issues. Aging Clinical and Experimental Research. 2022;34(2):325-30.
6. Banja J, Sumler M. Overriding advance directives: A 20‐year legal and ethical overview. Journal of Healthcare Risk Management. 2019;39(2):11-18.
7. Vogelstein E. Autonomy and the moral authority of advance directives. Journal of Medicine and Philosophy. 2016;41(5):500-20.
8. House SA, Schoo C, Ogilvie WA. Advance directives [Internet]. Treasure Island (FL): StatPearls Publishing; 2017 [cited 2026 May 1]. Available from: https://www.ncbi.nlm.nih.gov/books/NBK459133.
9. Carter M. Advance directives: The principle of determining authenticity. Hastings Center Report. 2022;52(1):32-41.
10. Arruda LM, Abreu KP, Santana LB, Sales MV. Variables that influence the medical decision regarding Advance Directives and their impact on end-of-life care. Einstein (São Paulo). 2019;18:eRW4852.
11. Scholten G, Bourguignon S, Delanote A, Vermeulen B, Van Boxem G, Schoenmakers B. Advance directive: Does the GP know and address what the patient wants? Advance directive in primary care. BMC Medical Ethics. 2018;19(1):58.
12. Asagumo A. Relational autonomy, the right to reject treatment and advance directives in Japan. Asian Bioethics Review. 2022;14(1):57-69.
13. Tsinorema S. The principle of autonomy and the ethics of advance directives. Synthesis Philosophica. 2015;59(1):73-88.
14. Dixon J, Matosevic T, Knapp M. The economic evidence for advance care planning: Systematic review of evidence. Palliative Medicine. 2015;29(10):869-84.
15. Arman A, Mobasher M, Aminizadeh M. Is it Possible to apply an Advance Directive in Iran’s Health System?. Iranian Journal of Medical Ethics and History of Medicine. 2024;17(1):154-64. [Persian]
16. Um S. Vices in autonomous paternalism: The case of advance directives and persons living with dementia 1. Bioethics. 2022;36(5):511-8.
17. Luck G, Eggenberger TL, Bautista A, Peters D, Mellman RT, Keller KB, et al. Fearing pain at the end of life: A review of advance directives. American Journal of Hospice and Palliative Medicine. 2024;41(7):824-30.
18. Stock E, Nickel CH, Elger BS, Martani A. The instrumental value of advance directives: Lesson learned from the COVID-19 pandemic for policymaking. Research in Health Services & Regions. 2025;4:1-9
19. Rodríguez‐Prat A, Balaguer A, Crespo I, Monforte‐Royo C. Feeling like a burden to others and the wish to hasten death in patients with advanced illness: A systematic review. Bioethics. 2019;33(4):411-20.
20. Lima JS, Lima JG, Lima SI, Alves HK, Rodrigues WF. Advance directives: Patient autonomy and professional safety. Revista Bioética. 2022;30(4):769-79.
21. Vitale A. Advanced healthcare directives: An analysis of the ethical and legal related issues and a current comparison among EU Members States. Bioethica. 2019;5(2):51-66.
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