Advance directives in sonora: barriers to the exercise of a human right from a bioethical and personal autonomy perspective

Abstract

Advance directives constitute a legal, bioethical, and public health instrument designed to safeguard personal autonomy, human dignity, and informed consent in end-of-life decision-making. Their development has been driven by scientific and technological advances that have enabled the prolongation of life through increasingly sophisticated life-sustaining treatments, giving rise to ethical and legal challenges associated with medically futile or disproportionate interventions that may result in therapeutic obstinacy. Although many countries have incorporated advance care planning mechanisms into their legal frameworks, international evidence indicates that only 20% to 40% of eligible individuals complete an advance directive. In Mexico, despite the progressive legal recognition of this right and the registration of more than 10,000 advance directives in the states where such legislation exists, their utilization remains limited and significant barriers continue to hinder their effective implementation.

This article aims to analyze the barriers that limit the exercise of the right to advance directives in the state of Sonora from the perspectives of human rights, bioethics, and public health. A qualitative, legal-doctrinal study was conducted through documentary analysis of the Political Constitution of the United Mexican States, the General Health Law, the Advance Directives Law of the State of Sonora, international human rights instruments, specialized bioethics literature, and institutional documents addressing end-of-life care.

The findings reveal that, despite the existence of a legal framework recognizing this right, multiple legal, institutional, educational, cultural, and bioethical barriers continue to restrict its effective implementation. These barriers include limited public awareness, insufficient training of healthcare professionals, inadequate institutional dissemination, the absence of standardized clinical protocols, and the persistence of paternalistic models of healthcare delivery. Furthermore, the lack of publicly available statistical data on the implementation of advance directives in Sonora hinders the evaluation of the law's effectiveness and the development of evidence-based public policies.

The study concludes that the effectiveness of advance directives depends not only on their legal recognition but also on the existence of institutional, educational, and cultural conditions that enable their practical implementation. It highlights the need to strengthen public policies, bioethics education, healthcare professional training, and institutional mechanisms to ensure effective respect for patient autonomy and human dignity at the end of life.