SAFEGUARD
FOR LIFE-ENDING DECISIONS
CERTIFICATION OF TERMINAL ILLNESS
OR INCURABLE CONDITION
The full account of the patient's condition will be
contained in the primary physician's
written
statement of condition and prognosis.
But there might be some validity in requiring a separate certification
of terminal illness.
If the patient is to be certified as terminally ill,
then this certificate should also include the independent assessment of
a second physician,
who has also examined the patient and done any independent tests needed
to confirm that the patient is in fact in the process of dying.
Generally, terminal illness is defined as having less than 6 month to
live.
The over-all purpose of this safeguard is
to make
sure that the patient is already
dying
before considering any life-ending decisions.
For patients who are being sustained by any
life-support methods,
the certification of terminal illness should make clear
whether the patient will die within the next 6 months
while still connected
to the life-support systems
or will die within 6 months without
the life-support systems.
In some cases, the patient will die immediately
after the life-support systems are unplugged.
If this is the meaning of "terminal illness",
then any patient kept alive on life-supports is terminal.
Some laws and proposed laws expand this safeguard to
include incurable disease.
If the patient has a condition, illness, or disease
that within reasonable medical judgment cannot be cured,
then this safeguard to prevent premature death has been met.
If it is clear that
the patient will never recover
and return to his or her normal life as it was before the illness,
then a life-ending decision might be appropriate.
When the patient is suffering as the result of an incurable disease,
then full evaluation of the medical situation would be wise.
What is the nature
and degree of the patient's suffering?
If the condition is getting worse, what would be the tipping point
at which a voluntary death or a merciful death
would be preferred over continued suffering?
However, "incurable disease"
is even more difficult to define than "terminal illness".
So it is always best to rely on the more complete statements of
condition and
prognosis
by all the physicians involved in the care of this patient.
The more complete medical analysis
does not require a simple-minded yes/no determination:
Yes or no, is this patient terminally ill?
Yes or no, is this disease incurable?
However, some laws do require an official
declaration of terminal illness.
One example of this might be admission
to a hospice program:
The physician must sign a statement saying
that the patient is likely to die within the next six months.
Likewise, some right-to-die laws require
an official certification of terminal illness
before a patient might be eligible for aid-in-dying.
However, it is probably much wiser to allow
terminal illness or incurable condition
to be one of the optional
situations
that would justify a voluntary death or a merciful death.
Keeping this safeguard optional protects the
right-to-die
for those patients who are not
going to die within the next 6 months.
Patients with slow, degenerative diseases
such as Alzheimer's would be
obvious examples.
The best time-to-die for such patients
who can no longer decide for
themselves
should be wisely decided by the duly authorized proxies,
following all the most appropriate safeguards to prevent premature
death.
And even when the patient is still capable of making
medical decisions,
the full medical diagnosis and prognosis
should inform any possible life-ending decisions
not just the official yes/no certification of terminal illness.
Patients who are not yet in the last 6 months of
their lives
should explain in their own
requests for death
(or their
proxies should explain for them)
why death at the planned time
is better than waiting for
natural death.
And these requests for death should be based on the full medical
situation,
as explained in the statements of the first and second
doctors,
not just on the certification of terminal illness.
HOW CERTIFICATION OF TERMINAL ILLNESS OR INCURABLE DISEASE
DISCOURAGES IRRATIONAL SUICIDE AND OTHER MISTAKES AND
ABUSES
Most people who are thinking of killing themselves
for foolish 'reasons'
do not believe that they are terminally ill.
And they will not seek any physician's statement
that certifies that
they are dying or that they have an incurable disease.
(And if any suicidal person seeks such a statement,
this will be an opportunity for the medical profession
to intervene to
prevent an irrational suicide.)
Thus a certificate of terminal illness will be an easy way
to separate voluntary deaths from irrational suicides.
However, there is a special case that needs to be
taken into account here:
Some patients become
suicidal when they receive a terminal diagnosis.
When they are told they have AIDS or cancer,
they immediately believe that they are dying.
And they might foolishly decide to shorten the dying process
before their meaningful lives are really absolutely finished.
In such situations, a declaration of terminal illness does not prevent irrational suicide.
Rather, the physician's declaration might precipitate an irrational
suicide.
Whether a certification or non-certification of
terminal illness
will prevent other forms of premature death is debatable.
But it will be a defense against the charge of causing a premature death
if the person(s) charged can show
that there was an official
declaration of terminal illness or incurable disease.
Some mistakes and abuses of the right-to-die have
occurred
when the medical status of the patient was not clear.
Thus an official declaration of terminal illness or incurable disease
might help all the other elements of the death-planning process.
But such a declaration should never be a substitute
for a full
presentation of the patient's condition and prognosis.
Created January
17, 2007; revised 3-8-2007; 3-14-2008; 3-20-2008