FOUR LEGAL MEANS
TO CHOOSE A
VOLUNTARY DEATH
OR A MERCIFUL
DEATH
{alternate title: Legal Ways of End Our Lives}
1. Increasing Pain Medication.
2. Terminal Sedation.
3. Withdrawal of
Life-Support Systems.
4. Voluntary Death by
Dehydration.
Voluntary death and merciful death
as used here are technical terms,
which must be distinguished from the more common opposites
—irrational suicide and mercy killing.
These pairs can be separated by asking four questions:
1. Was the death helpful or harmful?
2. Was the death rational or irrational?
3. Was the death well-planned or capricious?
4. Was the death admirable and commendable or regrettable and tragic?
Two other cyber-sermons work out these distinctions in full detail:
Four
Differences between Irrational Suicide and Voluntary Death
http://www.tc.umn.edu/~parkx032/CY-IS-VD.html
Four
Differences between Mercy Killing and Merciful Death
.
http://www.tc.umn.edu/~parkx032/CY-MK-MD.html
When carefully separated from their opposites,
voluntary death and merciful death are choices we can
make
which are fully moral and will eventually be fully legal
in all states of the USA and all other countries.
Society does not want to condone irrational suicide or mercy killing.
But we do want to allow wise medical choices at the end of life.
What is the difference between voluntary death and merciful death?
Voluntary death occurs when the patient does the choosing himself or
herself.
Merciful death occurs when proxies for the patient
must make the life-ending decisions.
We shall now turn to the specific actions that might
be taken
that will bring about a timely and more peaceful death.
These four kinds of action are all completely legal
within all of the states of the United States
and also in most advanced countries of the world.
In addition, most moral authorities also support these means
of choosing a wise end to a human life.
1. Increasing Pain Medication.
If we are under the care of doctors toward the end
of our lives
and if we are already receiving some kind of medication for our
terminal pain,
it is entirely within the law and good medical practice everywhere
for our doctors to increase our pain medication
even if this higher dose will shorten the process of dying.
When considering the amount of medication to
administer,
the patient, proxies, & doctor should be clear about
the purposes for which the medication is being increased.
If there is still some realistic hope of recovery,
then caution is appropriate when deciding the dose of pain-reliever.
Too much of any medication could be harmful.
And if we—the patients—are hoping to return to ordinary life,
or just hoping to have a few more days of meaningful life,
then we do not want the additional problems related to
bodies or brains damaged by too much of any drug.
However, if we are not expected to recover and
return to ordinary life,
and/or if the burden of the pain is greater than the benefit of the additional time,
then the possible side-effects of the pain-medication need not concern
anyone.
One side-effect of pain-relievers is dependence
on the drug,
which could also be called 'addiction'.
But why worry about drug-dependence if we will never recover?
When we have entered the last phase of our lives
—namely the downward pathway towards death—
then the only relevant considerations
are the effects of the drugs on our bodies and minds
between now and the hour of our death.
In other words, decisions that are part of terminal
care
differ sharply from decisions that are aimed at recovery.
We could even say that some of the decisions
taken as part of terminal care are life-ending decisions.
And if we are actually making decisions that will bring our lives to an
end,
then we should be explicit about this new purpose for medical care.
This is the sense in which we might consider
the consequence of shorting the process of dying.
Medications that can control pain
often also repress several bodily functions,
including the abilities of our brain-stems to control our heart-beat
and breathing.
When large doses of morphine (for instance) are prescribed,
the doctor knows that one of the side-effects of this drug
is that our lives will be shortened by a few days.
We might say that increasing pain-medication
is a life-shortening decision
rather than a life-ending
decision
because the higher dose of pain-relivers will not immediately end our
lives.
Rather, one predictable result will be fewer days of terminal
suffering.
And the pain-medication itself will reduce the severity of that
suffering.
We might spend much of our last few days sleeping.
This decision to increase pain-killing drugs
does not involve any new decision-makers.
The same people who first authorized, ordered, & administered the
drugs
will simply increase the dose to some reasonable level
that will achieve the wished-for result of less suffering
while the natural processes of dying are taking place.
Increased pain-medication can assure a more peaceful
and painless death,
even if that death comes a few days sooner than it would have
if we had made no decision to increase the pain-killers.
And the doctors can probably predict
how many days we will survive with the increased dose of
pain-medication.
One traditional way of examining the details
of the decision to increase pain-medication
was called the principle of double-effect:
There is one action—a reasonable increase in pain-medication.
But there are two effects—less pain and a shorter process of dying.
Traditional ethics and law approve the action if it is taken primarily to achieve a good result,
—here the reduction of terminal pain—
even if the second effect—here the shortening of life—is an easily-foreseen result.
Modern thinking has moved away from the principle of double-effect
because it is so problematic to discover real intentions.
How can we know if the doctor was intending or not intending death?
But a reasonable increase in pain-relievers
—within the parameters of standard medical care—
should not create any legal problems for anyone involved.
2. Terminal Sedation.
Another way to use sedative drugs is to
administer enough medication
to make sure that the patient will
never have another moment of consciousness.
This method would be appropriate when the burdens of the dying process
exceed the benefits of being awake.
In the most extreme situations, every moment of conscious life
might be meaningless suffering and torment.
If there is no hope of recovery from the
medical condition
that will ultimately cause our deaths,
and if every conscious moment between now and death will only be agony,
then the truly compassionate practice would be
to keep us in an unconscious state
until the natural processes of dying are finished.
And as noted in the first option—increased
pain-medication—
the drugs themselves will probably shorten the process of dying.
Terminal sedation is clearly a decision
that acknowledges that death is coming within a few days at most.
And the proxies for the dying person have decided
that it is better to keep the patient unconscious
than for the patient to have even a few more moments of suffering.
Also, a timely death might mean earlier
rather than later under these circumstances.
Once terminal sedation has been chosen as the
best pathway towards death,
then other medical decisions also follow logically:
Unconscious people can no longer eat or drink.
And there is no point in continuing to give food and fluids by means of
tubes
because that would only prolong the process of dying.
Also, if any other life-support systems are being used,
they can be discontinued when terminal sedation begins.
Or the terminal sedation might begin some time after the life-supports are disconnected,
especially if there will be suffering and distress
as a result of removing the life-supports.
The family and friends can even begin their
process of grieving,
since it is known with absolute certainty that death is coming.
They can even begin the orderly process
of arranging the funeral or memorial service
since the approximate day of death will be known in advance.
Terminal sedation might seem an unnecessary
step in some cases.
Occasionally the family will ask why the process must take so long,
since everyone knows that death is coming in a week or less.
And if and when new laws allows merciful death
—defined as purposefully ending the life of another
when proper safeguards have been fulfilled—
then a lethal injection could bring death immediately
instead of starting terminal sedation and waiting for the natural end.
But it might be some years before such means of merciful death are
permitted.
Each legal jurisdiction on the Earth
must make such forms of merciful death a permitted and legal option.
3. Withdrawal of Life-Support Systems.
Modern science has created an ever-increasing
array
of technical means to support life:
heart-lung machines, mechanical respirators,
drugs to control every natural process of the body,
means of providing fluids and nutrition to the body,
ways of clearing toxins from the blood, etc.
And there is no end in sight for further advances in medical technology.
In fact, if we end our days in a hospital,
it is very likely that we will have some form of life-support.
And in the Western world, most deaths now take place in hospitals.
Thus, one easy (and legal) way to end our lives
is simply to turn off the machines and disconnect the tubes.
Such a life-ending decision should not be
taken easily or lightly.
Very careful consideration of all possible means of cure
should be explored before we give up hope of a cure
and decide to disconnect the life-supports.
Since being connected to life-support systems
usually means that we are in a hospital,
there are already good safeguards in place
to make sure that disconnection does not take place accidentally or
casually.
A series of medical cures will already have been attempted.
And new possibilities can always be proposed.
But will they really save us from death?
Eventually in almost every case,
there comes a time to consider turning off the machines
because the life-supports are doing no good.
Doctors will be the main technical advisors
for this decision.
But according to law as practiced in the Western world,
the decision to terminate life-supports must be taken by the patient.
And if the patient is no longer able to make medical decisions,
then the duly-authorized proxies for the patient
must make the decision to withdraw the life-supports.
When one of the life-supports was a respirator,
death will follow almost immediately
when the breathing machine is disconnected.
The same is true if machines were performing the functions of the heart.
Without blood circulating, death will come immediately.
When the main form of life-support was
tube-feeding,
then it might take a few days for the body to shut down.
And if there is any possibility of suffering due to disconnecting any
machines,
such suffering can be prevented by appropriate drugs.
If necessary, the patient can be kept completely unconscious
during what remains of the dying process.
This might be called "terminal sedation"
if it is going to take any significant time for death to occur.
Disconnecting life-support systems used to be
controversial
because it was thought to be too active a means of allowing death to
occur.
But modern thinking about life-support systems
now allow the decision to discontinue (or never start) all
life-supports.
Another worry that has mostly passed from
medical practice
regards the question of beginning life-supports:
Once a patient has been attached to life-supports,
is it morally wrong to disconnect the machines?
The universal answer in medical ethics now is that
beginning to use any system of life-supports
does not require that they remain in place until natural death occurs
with the tubes and machines still attached and operating.
Thus if we are asked to approve some form of
life-support,
we should not worry that we will be prevented
from disconnect the tubes and machines later if they do no good.
In many cases, it is wise to use life-support systems
as a temporary measure while some methods of cure are attempted.
But when all means of saving us from death have been tried,
then the most appropriate course of action
might be to disconnect the life-support systems
and "to let nature take its course".
Life-support systems were originally invented
to sustain life
while the body of an accident victim, for instance,
was given medical care so that he or she could return to normal life.
Also life-support systems maintain vital functions during modern
surgery.
But increasingly life-support systems have become
the standard equipment of dying.
Dying patients are routinely put into the Intensive Care Unit (ICU),
where they are connected to several different machines at once.
But when it becomes clear that recovery is not going to happen,
and/or if the patient finds the burdens of life-support intolerable,
then the machines are turned off and death takes place.
In fact, disconnecting life-support systems
has become so routine
that this action is seldom mentioned on death-certificates.
The death is recorded as having been caused by the underlying disease
or condition
that put the patient in the hospital in the first place.
Disconnecting the life-supports was simply the last step in the medical
care.
4. Voluntary Death by Dehydration.
The first three legal means of ending our lives
—increasing pain-medication, terminal sedation, & withdrawing
life-supports—
all include actions by physicians, usually in hospitals.
But giving up eating and drinking is a legal means of death
anyone can use anywhere.
If and when we have carefully determined that
death is the best option,
we can achieve a peaceful death simply by giving up fluids and food.
Depending on the condition of our body, death will come in a week or
two.
Good palliative care can limit the various kinds of distress
associated with dying by dehydration.
The advantages of this pathway towards death are
explored in
Voluntary
Death by Dehydration
:
http://www.tc.umn.edu/%7Eparkx032/CY-VD-H2.html
CONCLUSION
These four legal means of drawing our lives to
a close
could be expanded to include other permitted means
of choosing a voluntary death or a merciful death.
But these are four means that we can recommend
because they are not as likely to be misused to bring death too soon.
When considering the various ways we might end our lives,
we need to consider the possible misuse of any such means
to commit irrational suicide or to commit a mercy killing.
Assisting an irrational suicide or committing a mercy killing
should both remain criminal acts
because they definitely harm the victims.
Here is a proposed law that would permit a wise choice of death
while at the time time prohibiting causing premature death.
Increasing pain-medication, beginning terminal
sedation,
withdrawing all life-supports, & choosing terminal dehydration
are all reasonable and wise ways
to draw a human life to a peaceful and painless close.
Medical ethics already recognizes the validity of these methods.
Legal authorities know that each of these actions
—when taken with careful safeguards—
is a fully permitted choice at the end of life.
The reason these four legal and moral means
of choosing a voluntary death or a merciful death were selected
—while thousands of other means of committing suicide were omitted—
is that each of these includes implicit safeguards
that will go a long way toward preventing abuses and mistakes.
The first three methods—increasing pain-medication,
terminal sedation, & withdrawing life-supports—
all take place within medical institutions
where good record-keeping and professional standards of care
will prevent abuses of these methods of choosing death.
The fourth method—voluntary death by dehydration—
contains within the very process of continually deciding not to eat or drink
the safeguards that will discourage irrational suicide
and other forms of premature death.
When other methods of choosing death are discussed,
safeguards to prevent abuses and mistakes need to be included.
Here is a catalog of a dozen possible dangers, perils, & worries,
each of which is addressed by a specific set of safeguards:
http://www.tc.umn.edu/~parkx032/SG-ABUSE.html
LAWS THAT EXPLICITLY RECOGNIZE THESE MEANS OF CHOOSING DEATH
Sometimes these long-acknowledged principles of medical care
are expicitly embodied in the laws of the various states of the USA
and in the national laws of other countries.
When any such laws are identified, they can be linked from here.
The modifications of some laws might help other jurisdictions to make wise revisions,
which will acknowledge that these four means of choosing death
are completely legal and moral.
In Minnesota, the changes were embodied in the revised law against assisted suicide:
http://www.tc.umn.edu/~parkx032/MN-SUIC.html
Please send links for other laws (from anywhere in the world)
which explicitly endorse these methods of choosing a wise and compassionate death.
Send information to: James Park, e-mail: PARKx032@TC.UMN.EDU.
drafted
10-13-2005; revised 10-24-2005; 11-25-2005; 8-10-2006; 2-19-2008; 3-3-2008; 3-4-2008
AUTHOR:
James Park is an independent existential philosopher
with deep interest in end-of-life issues.
Much more information about him will be found on his website
—An Existential Philosopher's Museum:
http://www.tc.umn.edu/~parkx032/
Here are a few related cyber-sermons by James Park:
Pulling the Plug:
A Paradigm for Life-Ending Decisions .
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 .
Voluntary Death
by Dehydration
.
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
.