PULLING THE PLUG:
A
PARADIGM FOR LIFE-ENDING DECISIONS
SYNOPSIS:
When a patient is being maintained by some system of
life-supports,
we are often faced with the decision about how long to maintain such
supports.
And it is now becoming more common to 'pull the plug'
before the patient dies despite the 'tubes and machines'.
We do have informal and behinds-the-scenes methods
of making such withdrawal decisions.
If we were to regularize and formalize these life-ending decisions,
perhaps some of the same safeguards
could be applied to other decisions about when best to draw life to a
close,
even for patients who are not dependent on life-support machinery.
OUTLINE:
1.
ENDING LIFE-SUPPORTS IS A WELL-ESTABLISHED MEDICAL PROCEDURE.
2.
SOME FORMS OF 'PULLING THE PLUG' ARE MORE CONTROVERSIAL.
3. SAFEGUARDS TO PREVENT PREMATURE WITHDRAWAL OF LIFE-SUPPORTS.
4.
SINCE WE CAN BE REASONABLE
ABOUT 'PULLING THE PLUG',
PERHAPS THE SAME DECISION-MAKING PROCESS
CAN BE APPLIED TO OTHER LIFE-ENDING DECISIONS.
PULLING
THE PLUG:
A
PARADIGM FOR LIFE-ENDING DECISIONS
by
James Park
As the 21st century advances,
more of us will be supported by machinery and drugs
in the last few days or weeks of our lives.
If we die from some disease or condition
that normally takes months or years to bring death,
then our dependence on life-support systems could be even longer.
If we are in fact being kept alive by some form of
medical technology,
then any decisions we make about the best time to die
and about the best means to
bring about our deaths
will have to include questions about what to do
with the life-support systems in place—keeping us alive.
1. ENDING LIFE-SUPPORTS IS A
WELL-ESTABLISHED MEDICAL PROCEDURE.
The medical ethics of the 21st century has no
problem with ending life-support.
And by extension, there are many life-ending decisions
that take the form of never
starting life-supports
when it is clear in advance that putting us on a ventilator, for
example,
will only delay our
inevitable deaths.
If there are no particular reasons to keep us alive for a few more days,
then everyone involved in this end-of-life decision
will probably agree that there is no point in extending the dying
process.
And even when there is no clear decline into death
because further deterioration is being prevented by the
life-supports,
reasonable people can agree that if there will be no recovery,
there is no point in keeping us in a coma on life-supports indefinitely.
On the other hand, when we are drawing our lives to
a close,
we might have some very meaningful things we want to achieve
before the end of our lives.
And usually these will be quite independent
of any medical facts found in our medical charts.
For example, we might have some religious practices
or good-byes
that we want to complete before we decide 'to allow nature to take its
course'.
We might want to have our sins forgiven before we 'meet our maker'.
We might want to make amends with family members who have been
estranged.
We might want to see a grandchild or great-grandchild before we die.
Every death leaves some loose ends that could have been tied up
before the final scene of our lives.
If we see our lives as a play or movie,
we know what scenes we would like to have
before the end of the show.
And if we are realistic about the amount of time left,
we will know which projects we can complete within that time-span
and what new projects would be completely out of the question.
2. SOME FORMS OF 'PULLING THE
PLUG' ARE MORE CONTROVERSIAL.
'Pulling the plug' on our life-support systems
does not carry any stigma,
as might be the case with taking a lethal chemical to bring death.
Perhaps this is because we can see clearly (and sometimes dramatically)
that 'life' in the intensive care unit
has almost no similarities to the life we lived
in all the years leading up to this final scene.
When we are being supported by a heart-lung machine
that is keeping our blood circulating and oxygenated,
we know that this situation cannot continue indefinitely.
Our feelings about 'pulling the plug' are somewhat
different
when the means of life-support seems more like daily living.
For example, our lives might be sustained
by medication to control our blood-pressure
that is keeping our own hearts operating within tolerable limits.
If we go off that medication, we know that we could easily die
from the heart-condition that is being controlled by the drugs.
As a matter of fact, if we live long enough,
most of us will be dependent on some kinds of medication at the end of
our lives.
And there might be so many
different prescription drugs
in our bodies that we do not remember them all.
And we might have experienced continual adjustments of our drugs
because of the subtle interactions among them:
One drug causes a particular side-effect,
which needs to be controlled by another drug, etc.
In such situations, when we are ready for our lives
to end,
we can simply refuse to take any
of the drugs that are keeping us alive.
And depending on the nature of our disease or physical condition,
the doctors can tell us how long we can expect to live
without the medications that have been assisting our vital functions.
A somewhat more controversial situation arises
when the life-support is a feeding-tube
or other means of supplying food and water.
At the end of our lives, if we cannot eat normally,
then we might be attached (either temporarily or permanently)
to a feeding-tube that puts special foods directly into our stomachs.
Or we might have fluid and nutrition put directly into our veins,
by-passing our digestive systems completely.
But even discontinuing artificial feeding
has now become a part of standard medical practice.
It is not a decision that should ever be taken lightly
and without considering all the implications for everyone involved,
but from the perspective of medical practice
discontinuing artificial nutrition and hydration
is a common means by which human life comes to an end.
When we think of our own lives coming to an end
by means of withdrawing or withholding a feeding-tube,
we know that the utmost caution is needed
in the decision-making process that might lead to this conclusion.
Each of us should consider just how such a life-ending decision
should be reached with respect to our own lives.
And we should answer this question in our advance directives for
medical care.
If we clarify our own medical ethics well in advance of any situation
in which withdrawing a feeding-tube becomes a real option,
then we have faced this means of choosing death on the philosophical
level
probably years before it becomes a real-life choice.
3. SAFEGUARDS TO PREVENT
PREMATURE WITHDRAWAL OF LIFE-SUPPORTS.
It probably does not happen very often in medical
institutions,
but sometimes harmful
decisions are made
with inadequate consideration of all the options.
So we as the patients do
need protection from mistakes and abuses
of any system that allows withdrawal of life-support systems.
Medical facts and opinions need to be gathered from
doctors.
And because one doctor might miss something important,
other doctors, perhaps specialists in our disease or condition,
might be called upon to examine us and to explore our medical options.
Our
own
views on life and death should be primary
in any life-ending decision.
Each
of us has strong beliefs and values
that we have been using to shape our lives thru-out adulthood.
We have some life-principles that form the basis of our medical ethics.
And here also, it might be useful to ask for input from others.
There might be people we trust
who will help us to formulate our own conclusions about life and death.
And even beyond helping us to clarify our own values,
the views of others who have been close to us
might have to be called into action
if and when we can no longer make our own medical decisions.
This is the role of medical proxies,
whom we should appoint in our advance directives for medical care.
When we are beyond making our own choices,
our proxies are empowered to make all of the medical decisions
that were automatically given to us
while we were still functioning as full persons.
If it happens that we find ourselves in very
difficult dilemmas
at the end of our lives,
we might have occasion to call upon a group of ethical consultants.
There might be an institutional ethics committee
in the hospital or nursing home were we are receiving our terminal care.
Because these people have faced several similar situations,
they might be able to offer wise advice to the legal deciders,
who might be facing life-ending decisions for the very first time.
Another layer of protection would be the legal
system.
We have laws and the means of enforcing them
so that people who cannot always protect themselves
will be saved from others
who might not be operating in their best interests.
The same safeguards that we apply to withdrawing
life-supports
could also be applied to other forms of life-ending decisions.
Even if we are not dependent on any forms
of modern medical technology at the end of our lives,
we still do have the right to choose
the best time and the
best means for our
lives to end.
We should think it thru ourselves,
possibly getting feedback from the people closest to us.
We should appoint proxies who will carry forward our settled values
if and when we can no longer decide for ourselves
or can no longer express our wishes.
And we might consider presenting the pros and cons
of our proposed life-ending decision
to an ethics consultant or an ethics committee.
Whoever is called upon to offer an opinion or make a
decision
should be sure that all of the available alternatives
have been seriously considered.
And it might even be wise to put these deliberations into writing,
in case these decisions might need to be reviewed later
by others who were not present at the time the choices had to be
made.
Some relatives might be quite distant
and be included in the decision-process only when the end of near.
So, instead of starting the process all over from scratch,
these late-comers can be permitted to read the death-planning record,
which will detail all of the deliberations to that point.
If our practice of withdrawing life-supports
does indeed become the paradigm for all life-ending decisions,
then we will discover some 'safeguards' that are really not appropriate.
If any proposed safeguards have never been applied
to any situations of giving up life-support systems,
then they should not be applied to other circumstances.
Here is an extreme example:
Some opponents of the right-to-die hold
that doctors should never cooperate in any death-planning process.
This sometimes takes the form of ethics affirmed by a medical society:
"Doctors must not kill."
But it would be very difficult to apply such a 'hands-off' policy
to life-ending decisions that include withdrawing life-supports.
If doctors can give their professional opinions concerning
life-supports,
they should also be permitted to give the medical facts and opinions
that would be relevant to any other kind of life-ending decision.
Perhaps we need laws that regularize and safeguard
the withdrawal of life-supports.
And any such provisions could be included in new laws against causing
premature death.
Here is a model for such laws:
http://www.tc.umn.edu/~parkx032/PREM-DTH.html.
This draft legislation contains 26 safeguards for life-ending
decisions.
4. SINCE WE CAN BE REASONABLE
ABOUT 'PULLING THE PLUG',
PERHAPS THE SAME
DECISION-MAKING PROCESS
CAN BE APPLIED TO OTHER
LIFE-ENDING DECISIONS.
As more of us experience the process of withdrawing
life-support systems,
we will become more familiar with the safeguards that should be used
to make sure that any harm to the patient is less than
the harm already being inflicted by the life-support systems themselves.
Of all deaths that now occur in hospitals,
about 80% involve some important elements of choice.
If no choices are made, the patients will continue to be maintained
on life-support systems until they die despite the 'tubes and
machines'.
As a culture we have not given much attention to
life-ending decisions.
But if over half of deaths in American now include some choices,
then we are already making over a million life-ending decisions each
year.
Implicit safeguards are already being used for these medical decisions.
And as we become more aware of such medical decisions that bring death,
we can make the safeguards more explicit
—perhaps
with an eye on other life-ending decisions
that are not so completely within the control of doctors.
As we learn to make wise decisions about terminating
life-supports,
we are also learning how to articulate the safeguards
that should be applied to all life-ending decisions.
The right-to-die means being able to make wise decisions
so that we can die at the best
time and by the best
means.
Created
February 2,
2007; revised 9-2-2007; 10-9-2007; 2-2-2008
Safeguards Website:
If you would like to explore safeguards for life-ending
decisions,
here is an organized catalog of of over 30 such proposed safeguards:
http://www.tc.umn.edu/~parkx032/SG-CAT.html
AUTHOR:
James Park is an independent existential philosopher
with deep interest in medical ethics,
especially the many issues that arise at 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:
A New
Way to
Secure the Right to Die:
Laws against Causing Premature Death .
When Is
A
Person?
Pre-Persons & Former Persons
.
Advance
Directives for Medical Care:
24 Important Questions to Answer
.
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 .
Voluntary
Death
by Dehydration
.
The
Living
Cadaver:
Medical Uses
of Permanently Unconscious Bodies .
Depressed?
Don't Kill
Yourself! .
Further Reading:
Books on Advance
Directives for Medical Care
<>
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.
Go to the Book
Review Index
to discover 400 other reviews
organized into more than 40 bibliographies.
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
.