FIFTEEN SAFEGUARDS FOR LIFE-ENDING DECISIONS

SYNOPSIS:

    We can claim the right-to-die in any of three forms:

(1) withdrawing or withholding medical treatments and life-supports,
(2) voluntary death—chosen rationally by the patient, or
(3) merciful death—chosen rationally by proxies for the patient.

    However, each of these life-ending decisions is open to abuse:

(1) premature withdrawal of life-supports,
(2) irrational suicide and manipulated or coerced death, or
(3) mercy killing.

    This cyber-sermon will propose practical safeguards
to prevent abuses of the right-to-die
while permitting appropriate and reasonable decisions for death.
Basically the safeguards gather the considered opinions of the patient,
the doctors, the family, & any ethical consultants who might be involved,
including (possibly) members of the clergy.
Also there should be appropriate waiting periods, full reporting,
and the possibility of prosecution for those who violate the safeguards.

OUTLINE:

1.  Living Will and/or other Requests for Death from the Patient  

2.  Informed Consent from the Patient and Unbearable Suffering

3.  Psychological Consultant Certifies that the Patient is Able to Decide      

4.  Doctor's Summary of Condition and Prognosis                          

5.  Independent Doctor Confirms the Condition and Prognosis   

6.  Hospital or Hospice Care        
 
7.  Significant Others Agree with the Life-Ending Decision

8.  Requests for Death from the Proxies           

9.  Member of the Clergy Approves the Life-Ending Decision             

10.  Statements from Advocates for Disadvantaged Groups

11.  Ethics Committee Reviews the Life-Ending Decision       

12.  Report to the Prosecutor before the Death Takes Place
      
13.  Criminal and Civil Penalties for Causing Premature Death          

14.  Waiting Periods Before Death is Permitted                          

15.  Complete Reporting of all Material Facts   

    (Note on length: Because the number
of possible safeguards continues to increase,
this cyber-sermon has ballooned to twice its original length.
Instead of dividing it into two cyber-sermons,
it remains here as a double-length cyber-sermon.

    Note on links: Each of the safeguards introduced in this cyber-sermon
has a more extensive explanation on the Internet,
which is linked from each brief description here.
If you have deep interest in this subject,
you might go directly to the catalog of possible safeguards.
This catalog includes some additional safeguards
that are not mentioned here.)



Fifteen Safeguards for Life-Ending Decisions

by James Park

       In the 21st century, the style of our dying will change.
Death has been a fact of life ever since life began.
And until recently, we human beings could do little to extend our lives. 
When our bodies wore out or we caught fatal diseases, we died
—just like all the other animals with whom we share the Earth. 

     But in the last 350 years—since the dawn of modern science—
we have gained ever more control over the ways we live and die.  
And now most deaths that take place in modern hospitals 
have some element of choice involved with them. 

     So we must think more deeply about life-ending decisions. 
Otherwise we will 'decide' by default,
which means allowing the standard operating procedures
of modern medicine to make our end-of-life decisions for us, 
based on generic medical principles we might not share.  

1.  Living Will and/or other Requests for Death from the Patient

    Each of us must eventually face our own death.  
If we have planned ahead for this eventuality, 
we will have created advance directives for medical care. 
And as we approach the last days of our lives,
we will know the likely causes of our deaths.   
And we can revise our 'living wills' accordingly.  

    We might even include an explicit request for death
when our condition deteriorates to a certain point.  
Any such requests for death should be in writing,
so that all of the others who will be involved with our dying
will know our wishes and the reasons behind our choices.  

2.  Informed Consent from the Patient and Unbearable Suffering

    Related to our requests for death
is the basis for these requests in our actual medical condition.
These safeguards will be more meaningful
if we have fully understood our doctors' summaries of our condition and prognosis.
We have examined all of the available options for further treatment
and we have probably tried the most likely possible cures.
Only then can be give wise and informed consent for the option of death.

    It will help others to understand our life-ending decision
if we explain in our own words the kinds of suffering we are now experiencing.
If we have physical suffering beyond what we can bear,
then this would be a valid reason for choosing a voluntary death.

    Likewise, the nature of our suffering might be psychological or mental.
When we explain our unbearable psychological suffering,
others who read our explanations will also agree with us
that choosing a voluntary death now
might be better than more psychological suffering,
which will only end in a natural death after more unbearable suffering.

3.  Psychological Consultant Certifies that the Patient is Able to Decide 

    If there is any doubt about our mental capacity to make life-ending decisions,
then a psychological professional can be asked for an opinion.
This consultant will make sure
(1) that we have considered all the reasonable alternatives to death,
(2) that we are making a fully-informed choice to end our lives,
(3) that we are not being coerced in any way to end our lives,
(4) that we are not depressed by some bio-chemical imbalance.
This professional opinion should also be put into writing. 

4.  Doctor's Summary of Condition and Prognosis

    Most of us will be under some kind of medical care at the end of our lives.
The doctor in charge of our care should write a summary
of our physical condition and the likely developments
under various options of treatment or non-treatment.

    The other people who will take part in our end-of-life choices
should refer to this doctor's opinion when writing their own statements.


5.  Independent Doctor Confirms the Condition and Prognosis

    Because doctors are not infallible, a second opinion should be sought.
And this second doctor must examine us in person,
not merely review the medical record and affirm the first doctor's opinion.
If this second professional medical opinion differs from the first,
further examination of the facts might be in order.  

6.  Hospital or Hospice Care

    When we are seriously considering how to end our lives,
we are probably receiving some form of hospital or hospice care.
The records of our medical treatments will be maintained by the institutions caring for us,
including any reports from our doctors of treatments already tried
and new possibilities being considered.

    If we are receiving hospice care,
this shows that we have been evaluated to make sure such care is appropriate,
usually because we are dying and will be dead within the next 6 months.
Palliative care is important because without it,
we might have some forms of suffering that really can be treated effectively.
And if we still decide to shorten the process of our dying,
we can show to all that we really have tried palliative care,
not just talked with someone about the possible benefits of palliative care.

    And if we have been cared for in some medical institution
for a meaningful period of time,
there will be staff members who can write their own statements
supporting our conclusions that death now would be better than death later.

7.  Significant Others Agree with the Life-Ending Decision

    The people who have known us for the longest time,
our closest relatives and friends, should be called upon to review
the written statements from us and all our professional consultants.
These persons will know our values and understand our choices
better than professionals who were called in at the end of our lives.

    The people who have been closest to us during our lives
will not have any veto power over our life-ending choices.
But all of their perspectives should be taken into account.  

    And if we have established a Medical Care Decisions Committee,
these persons especially should be asked for their written opinions.
These discussions among our proxies will become especially important
if we are no longer capable of making life-ending decisions ourselves.

8.  Requests for Death from the Proxies

    If our disease, illness, or condition makes it impossible
for us to make our own requests for death,
then our duly-authorized proxies have all the same powers
to make medical decisions that we had during most of our lives.
Or if we requested death before we lost our decision-making power,
then our proxies can reaffirm our original decision
—now with even more reasons behind that decision
because we have deteriorated further in our process of dying.

9.  Member of the Clergy Approves the Life-Ending Decision

    If we have some meaningful connections with organized religion,
we might call upon our religious advisors to join in these discussions.
Once again, the point of involving the clergy is not to give them a veto.
But if they have been personally involved in our lives,
they should be able to give another valuable perspective
on our choice to end our lives now
rather than merely letting the standard operating procedures
of the hospital determine how our lives will end.

    If no formal religious leader knows us at the end of our lives,
we might think of some other respected member of the community
who is not too overwhelmed by the prospect of death
and who can give an unbiased opinion about the choice of death.

    If our proposed death poses some difficult moral questions,
we and/or our proxies might ask for
moral analysis from religious or other moral thinkers.
Any relevant general writings could be added to our death-planning record.
And if some moral thinkers specifically address our case,
such statements of moral principle might also be included.


10.  Statements from Advocates for Disadvantaged Groups

    If there is any reason to suspect
that we might not be receiving the best care
because we are disabled, belong to a minority group, or are female, etc.,
then we might ask for our case to be reviewed by some individual or group
that knows our situation and the possible discrimination
that might be leading to a premature decision for death.
We name such advocates in our advance directives for medical care
and specify what powers they shall have to review our care.

    Of course, any such advocate we choose must be open to all options.
If the advocate believes that black people or disabled people
should never be considered for voluntary death or merciful death,
then, there is no point in asking for such a consultation.
If we do not believe in any form of the right-to-die,
we can simply put into our advance directives for medical care
that we will never approve of voluntary death or merciful death for ourselves.

    This safeguard is completely optional.
Advocates for disadvantaged groups will only become involved
if we and/or our proxies explicitly ask for them to give an opinion.

11.  Ethics Committee Reviews the Life-Ending Decision

    If at the end of our lives, we are being cared for in some medical facility,
there might be an medical ethics committee
that has experience with life-ending decisions.  
These people will also be new to us and our situation,
but they should nevertheless review all the written statements
created in fulfilling the safeguards.
And at least one representative of the ethics committee
should meet with us and those who are closest to us
to see if the life-ending decision seems wise from their perspective.  
Once again, the ethics committee does not have veto power.
But their statement of agreement will assure everyone
that this life-ending decision was taken very carefully.


12.  Report to the Prosecutor before the Death Takes Place

    If there is any reason to think that some criminal behavior
might be involved in our life-ending decision,
then we can have everything collected for our death-planning records
copied and sent to the prosecuting authority
that would be responsible for bringing criminal charges
if our death might later be declared premature.

    It is important to do this before the planned death takes place,
so that the prosecuting authority can halt the process
if there is good reason to believe that a harm will be committed against us.

    On the other hand, if everything is in order,
then the prosecuting authority can issue a statement
assuring everyone involved that no criminal changes
will be brought if the planning process is carried forward
as explained in the death-planning documents.

13.  Criminal and Civil Penalties for Causing Premature Death

    As an additional layer of safety, new laws might be needed
concerning the mistakes and abuses that could arise
in making life-ending decisions.
Immunity from prosecution should be given to everyone acting in good faith.
But anyone who participates in bringing our lives to an end prematurely
should know that there are laws in place,
which could be used to punish any person
who has distorted the process of making a life-ending decision.


14.  Waiting Periods Before Death is Permitted

    When we are making the irreversible decision to end our lives,
we want to be as certain as possible that this is the right choice.
Therefore, meaningful waiting periods should be included
in any death-planning process.

    In order to make any 'waiting periods' meaningful,
we will not merely be putting in the time.
Rather we will be using all waiting periods
for the active fulfilling of all the most relevant safeguards.

    If we are planning our own deaths,
while we are still fully capable of making life-ending decisions,
12 months does not seem like an unreasonable time.
One year will give us all the time we need to wind up
all of our business and personal relationships.
And we will be able to gather the written statements
of everyone else involved
—possibly including revisions that respond to each other
and to our changing medical condition.  

    If we have already lost the capacity to decide for ourselves,
then our proxies will take over our medical decisions.
And if they are considering a life-ending process,
then they might need to take up to 6 months to make this decision.
In their written statements, they will clarify how much time
would be needed to fulfill the safeguards they find most relevant
before everyone involved will be convinced
that a merciful death is the best course of action.

    When the means of death will be withdrawal of life-supports,
the waiting period can be the shortest,
since careful medical procedures are already being followed.
The time required to gather all of the written statements
should itself be a long enough waiting period.
In general, this will be about one week.  

    In all cases, most of the deciders should agree
that an appropriate waiting period has been allowed
so that no mistakes or abuses of the right-to-die will occur.


15. Complete Reporting of all Material Facts

    The written requests and supporting documents
should all be gathered in one place,
where they can be reviewed by everyone involved.
Perhaps one of the professional consultants
could serve this function of making sure
that all of the material facts are gathered into
a comprehensive death-planning record.  

    When our deaths take place in medical institutions,
these death-planning statements can be made a part of the medical record.
And the prosecuting authorities can have access to these records
in case there is any question that a crime might have been committed
under the color of a rational process of making a life-ending decision.

    When our death is going to occur at home,
then it might be wise to submit the death-planning documents
to the prosecuting authority in that location
before our death is achieved by the means we have chosen.  
This will require some changes of procedure
in the office that normally prosecutes crimes.
But after a few years of reviewing life-ending decisions,
they should develop some expertise
in spotting crimes about to be committed
and separating them from rational decisions to draw our lives to a close.

    The first brave individuals and families who use these safeguards
will set a pattern that can be followed by others.  

Conclusion

    These safeguards do not call for the establishment of any government official
who will approve or disapprove any proposed life-ending decision.
As far as possible, strangers should be kept out of the decision-loop.

    When substantially all of these safeguards have been fulfilled
(with an explanation of why some were not relevant),
then the death should be recorded as having been caused
by the underlying disease or physical condition
that lead to the life-ending decision.
And the additional note could be added
that the patient chose a shorter process of dying,
that life-supports were removed,
and/or that proxies were involved in the decision to end this life at this time
rather than waiting for the complete failure of all bodily systems
even while life-support systems were still operating.  

    If it seems that too much time and energy is needed to fulfill these safeguards,
consider how much more would be required by a court case
that attempts to reach the same conclusion.  
Then lawyers and judges who never knew the candidate
are required to apply abstract principles
that might have nothing to do with how best to draw our lives to a close.

    These safeguards make the life-ending choice
a collective decision to whatever degree that seems wise.
Personal autonomy is preserved to the end of life.
And mistakes and abuses of this right-to-die are prevented.  

    When such careful safeguards are used,
even some people who were initially opposed to any right-to-die
will see the wisdom of allowing careful life-ending decisions.


UPDATE, January 2008:

    If you are serious about safeguards for life-ending decisions,
here is an even more extensive list of such safeguards:
26 Recommended Safeguards (A-Z):
http://www.tc.umn.edu/~parkx032/SG-A-Z.html
cyber-sermon drafted 12-9-2003; revised 7-27-2005; 2-25-2007; 1-24-2008; 4-6-2008

AUTHOR:

    James Park is an independent existential philosopher
with deep interest in medical ethics,
especially the many issues surrounding the end of life.  
Medical Ethics and Death are two of the seven doors
to his website called "An Existential Philosopher's Museum":
http://www.tc.umn.edu/~parkx032/

    Here are a few related cyber-sermons also by James Park:

When Is A Person?
Pre-Persons & Former Persons .

Advance Directives for Medical Care:
24 Important Questions to Ask .

Fifteen Safeguards for Life-Ending Decisions .

Four Differences between Irrational Suicide and Voluntary Death .

Four Differences between Mercy Killing and Merciful Death .

Four Legal Means to Choose a Voluntary Death or a Merciful Death .

Pulling the Plug:
A Paradigm for Life-Ending Decisions .

Voluntary Death by Dehydration .

The Living Cadaver:
Medical Uses of Permanently Unconscious Bodies .

Depressed?
Don't Kill Yourself! .
    Further Reading:

Best Books on Voluntary Death


Best Books on Preparing for Death


Books on Terminal Care


Books on Helping People to Die


Best Books on the Right-to-Die
Books Opposing the Right-to-Die


Go to the Right-to-Die Portal.

Return to the DEATH page.

Go to the Medical Ethics index page.

Go to other cyber-sermons by James Park,
organized into 9 subject-areas.

Return to the beginning of this website:
An Existential Philosopher's Museum .




The views and opinions expressed in this page are strictly those of the page author.
The contents of this page have not been reviewed or approved by the University of Minnesota.