WHICH
CAN BE APPLIED SELECTIVELY
FOR ANY LIFE-ENDING DECISION
Even in situations where no safeguards are required
or suggested by law,
individuals faced with end-of-life choices
might want to apply any of the following recommended safeguards
as a way to make sure that the decision to end this life
is a wise and compassionate
choice
rather than some form of mistake or abuse
that will result in a premature
death.
For example, if you are required to make
life-or-death decisions for your retarded daughter,
you will clarify the options by applying the safeguards listed below.
When you call upon others for their personal and professional opinions,
you are more likely to make
the right choice.
The same will happen when you are considering your
own death.
Your own thinking might be distorted by the disease process itself.
Therefore, you might want to use some of the safeguards below
to make sure that you are wisely choosing a voluntary death
rather than foolishly considering irrational suicide.
Each of the following 26 proposed safeguards for
life-ending decisions
is linked to a much more extensive explanation of how to use that
safeguard.
If you wish to apply a specific safeguard to your current situation,
you will probably want to read the more detailed presentation.
A written statement setting forth the patient's
philosophy of life and death
is probably the most basic document for making life-ending decisions.
Life belongs to each individual patient.
His or her settled values should shape all medical decisions.
Once the patient has created an Advance Directive
for Medical Care,
he or she will share the AD with significant others, especially those
chosen as proxies.
And they should create brief statements expressing their agreement with
the Advance Directive
and (if they are proxies) their commitment to carry forward the settled
values of the patient.
The patient owns his or her own death.
While the patient is still capable of making medical decisions,
any and all serious requests for death should be recorded,
stating the date, time, and circumstances.
The patient should also explain why he or she thinks death at the chosen time
would be better than death
at some later time.
Such requests for death might lead to creative discussions
among all people concerned with this patient's life and death.
If the patient is no longer capable of making
medical decisions,
the duly-authorized proxies then have the power and responsibility
to make any reasonable requests for death on behalf of the patient.
If there is any doubt about the patient's capacity
to make medical decisions —including any
decisions that will terminate his or her life—
then this capacity should be clarified by the testimony of laypersons
who have known the patient for some period of years
as well as by the professional opinions of licensed psychologists or
psychiatrists.
The most important document created by a medical
professional
will be the primary physician's summary of the patient's condition and
prognosis.
In order to avoid any confusion, ambiguity, or misunderstanding,
this statement should be put
into writing
as well as explained to the satisfaction of those who must decide.
Whenever making life-or-death decisions,
it is always wise to seek a second, independent, professional opinion.
This second opinion might be sought from a specialist in the disease or
condition
from which the patient is possibly dying.
If there are differences in these professional opinions,
they should be resolved by further investigation
before any plans for a voluntary death
or merciful
death
proceed.
Even tho the patient need not be in a terminal
condition to request death,
if the disease or condition is
terminal,
the same physicians who have written the full statements of the
patient's condition and prognosis
might also create separate documents to certify terminal illness
if the patient is likely to die within the next 6 months.
Or such certification could be included in the doctors' statements.
These statement should specify whether the projections include
life-supports or not.
An important question for any life-ending decision
is whether the patient is suffering in some way that cannot be relieved
and which the patient finds intolerable.
Such physical suffering can be explained and documented
by the doctors who are called upon to treat the suffering.
The patient might also be suffering emotionally.
Only the patient can ultimately decide whether such suffering is
intolerable.
But professional efforts to alleviate it should also be documented.
Both lay and professional opinion can attempt to evaluate this
suffering.
And if the psychological suffering is so great
as to make the patient incapable of making wise medical decisions,
then the power to decide passes to the duly-authorized proxies.
The proxies will make any life-ending decisions
if death now seems
wiser than death later.
The actual application of comfort care
by medical professionals well trained in the care of the dying
will help to decided which is the wisest course of action.
Sometimes physical and psychological suffering can be so reduced
that the patient and/or proxies no longer believe death is the best
choice at this time.
However, in some obvious cases, palliative care
would be useless.
But at least the patient and/or proxies should be fully informed
about the benefits of palliative care
and even consult with a palliative-care specialist.
The patient must have full information
about his or her condition
and all the relevant medical options that still remain
open.
Only when the patient has received and understood
the medical statements from the doctors concerning
condition and prognosis
is the patient able to make wise end-of-life decisions.
If the patient can no longer make
meaningful medical decisions,
then the decision-making power shifts to the proxies,
who have been carefully chosen by the patient
when the patient was still fully able to make all such
decisions.
The proxies shall carefully consider all of
the facts and opinions
expressed by the others who are considering what would be
best for the patient.
Then the proxies can
decide to make requests for death
in exactly the same ways as such requests were possible
for the patient.
If the patient is
being treated in a hospital
or receiving terminal care in a hospice program,
any such medical institution will keep careful records
of all
discussions and decisions regarding the care of the patient,
including all discussions and decisions related to
end-of-life choices.
Beyond the official medical records kept by
the hospital or hospice,
nurses, doctors, & volunteers who have had
meaningful connections with the patient
can also create statements
about their discussions with the patient about life-ending decisions.
Other persons who
have known the patient
for meaningful
periods of time agree with the life-ending decision.
Even tho these significant other persons might not be directly involved
in the process of making any life-ending decisions
and they will not be responsible for carrying out any terminal choices, they know of
the
plans for death well in advance
and in their considered opinions,
voluntary death or merciful death for this patient at this time is a
wise
choice.
A member of the
clergy of any religious organization
or the professional leader of an ethical
organization
known by the patient approves of the life-ending
decision.
If the patient is not part of any such
organization,
another similar responsible member of the
community
might fill this role of neutral
ethical
observer.
If chosen by the patient, some authority on
the doctrine
of the religious organization with which the patient is
affiliated
reviews how those moral principles apply to the
end-of-life
decisions
being considered by the patient and/or the proxies for
the patient.
If that
interpretation of the religious doctrine supports a life-ending
decision,
then a written statement to that effect could be included in the
death-planning record.
If the patient and/or the proxies so choose,
some non-religious moral principles
could be brought to bear on this life-ending decision.
An ethics
committee of the institution
where the patient is being cared for
reviews all of the documents created for the
death-planning process
and approves the life-ending decision.
If the patient has any worries that he or
she might be discriminated against
because he or she is a member of any group sometimes
disfavored by society,
he or she can select an advocate from his or her
identity group
who will review the death-planning documents
to make sure that no discrimination has taken place
because of the group-identity of the patient.
Adding any such statements to the death-planning record
will assure others who are not as close to the patient
that the life-ending
decision was as free as possible from discrimination
and that the patient received terminal care independent
of group identity.
If those who are planning the
voluntary death or merciful death
have any doubts about the legality
of their
proposed course of action,
they can opt to send a report of
the death-planning process
to the local
prosecuting authority for review.
They might explain which of the
following they are planning:
(a) withdrawal or withholding life-support
systems,
(b) assisting in a voluntary death, or
(c) granting a merciful death.
And the several documents of the death-planning
process already created
might be shared or summarized for the prosecutor
to show that the proposed course of action
violates no laws.
The prosecutor should be
allowed one week to respond.
The prosecutor might reply that the planned death will not harm the
patient
and that all who participate or cooperate in the
planned death
will not be subject to prosecution for any crime.
Or the prosecutor can ask for additional
information
to make sure that this death will not be
premature.
If the prosecutor always automatically says "no"
to any proposed life-ending decision,
that prosecutor should be replaced.
Civil and
criminal penalties will remain in place.
Anyone tempted to encourage or cause a premature death
will know that there are criminal and civil penalties
that will be applied if someone does any harm to another
under the guise of the right-to-die.
An appropriate
waiting period is allowed to elapse
between the time when the life-ending decision is
taken
and when the life-ending act is performed:
(a) one week for the
withdrawal of life-support systems,
(b) one year for a voluntary
death, or
(c) six months for a merciful
death.
These waiting periods may be adjusted
when adequately explained by
the special circumstances of this life-ending
decision.
Spreading the life-ending decision over significant
periods of time
allows all concerned to re-think their previous
decisions.
If the patient has already
begun the death-planning process,
ample
opportunities shall be provided for the patient to change his or her
mind.
The people offering these opportunities shall
document
that the patient was giving several chances to
reverse
the death-planning process.
Does the patient decline each opportunity to
change course
and reaffirm his or her determination to choose
a voluntary death?
Once most of the other statements have
been written,
the physicians most responsible for the patient's
terminal care
will read and
respond to each statement
and
make a final recommendation.
The death-planning process
should be completely open and above-board.
The written
statements of all persons involved
should be
shared freely among everyone who has a
legitimate right
to take part in (or to know about) this
life-ending decision.
The fact of such open sharing and discussion —with signed and
recorded opinions from many
participants—
should go a long way toward making sure that this is a
well-considered decision,
not a hidden or secret conspiracy to cause a premature
death.
While this is not a requirement to prove
that the life-ending decision is wise,
the facts that the patient
remains conscious until the last moment of life
and possibly takes some
life-ending action by his or her own hand
will be strong reasons to believe
that his or her death is not being chosen
prematurely.
If the process of planning the patient's
death
employs a death-planning
coordinator
or if someone volunteers to organize the death-planning
records,
this level of organization for the death-planning process
will be impressive evidence that the chosen death is a
wise decision.
And the complete collection of death-planning documents
can be permanently stored in case there is ever any
future reason
to review this life-ending decision.
This list of 26 recommended safeguards
is organized in a different way in a cyber-sermon named:
"A New Way to Secure the Right-to-Die:
Laws Against Causing Premature Death": http://www.tc.umn.edu/~parkx032/CY-RTD-N.html
In this cyber-sermon, the 26 recommended safeguards
are organized according to who
is primarily responsible
for fulfilling each specific safeguard:
SAFEGUARDS TO BE
FULFILLED BY
PHYSICIANS
AND OTHER PROFESSIONAL CONSULTANTS
SAFEGUARDS TO BE FULFILLED BY THE
PATIENT
SAFEGUARDS TO BE FULFILLED BY
PROXIES FOR THE
PATIENT
AND/OR FAMILY MEMBERS
SAFEGUARDS TO BE FULFILLED BY
MEMBERS OF THE CLERGY
SAFEGUARDS TO BE FULFILLED BY THE
PROSECUTING
AUTHORITY
SAFEGUARDS TO BE FULFILLED BY THE
DEATH-PLANNING
COORDINATOR
To join week-by-week discussion of these safeguards —one
safeguard each week—
see information about the Safeguards Group
on the opening page of this Safeguards Website: http://www.tc.umn.edu/~parkx032/SG.html
Comments and suggestions for revising these 26 proposed safeguards
should be sent to the webmaster:
James Park: e-mail: PARKx032@TC.UMN.EDU