I would like to thank Sullivan for his comments on this paper. However, I must respectfully disagree with many of the points he has raised in his letter.

It is quite clear, for instance, that many patients care very much about not just the outcome but the procedure itself and the effect of the said procedure on their bodies and their lives. To say that we know for certain that all such persons would want a feeding tube or any type of surgery is paternalistic in the extreme. I personally know of many patients who would refuse a feeding tube regardless of the eventual outcome, based solely on personal values and preferences. For example, many patients feel that this is one more threat to their already diminished autonomy, or one more simple pleasure in life of which they will be deprived. This is not based on supposition – I have seen this in clinical practice. To assume that one knows that a patient will want any procedure, as long as it results in a certain outcome, is to presume to know the mind and value system of that person. This is an unacceptable presumption in medicine. It is why we have living wills, so that we do not have to guess or presume.

I will, of course, defer to Sullivan, a lawyer, as to his opinion on the legality of these documents in his home province. However, in many jurisdictions in Canada and elsewhere, it is my understanding that they do in fact have status as legal documents.

A more careful read of the article indicates that using the patient's ‘best interest’ standard comes only after a consideration of their ‘specific wishes’ if these are known. This is analogous to Sullivan's ‘substituted judgment’. He also appears to have an unfortunate bias towards physicians, accusing them of ‘ignoring what the patients may have in fact wanted’.

I would also disagree with Sullivan's statement that it is ‘vital that legal advice in regard to these matters be obtained…’, and would instead refer back to the article's recommendation that ‘…it may be helpful to consult a lawyer with experience in this area’. Living wills are a personal matter between the patient, their family members and loved ones and their physician or other health-care provider. Patients are well-advised to obtain legal advice should they deem it to be necessary. To suggest that they must obtain it, however, seems to be unnecessarily directive and a waste of money in cases where it is not necessary.