Recommended Ways in which Others May Use my 'Living Will'       2

PART I Scope of this Declaration
& Appointment of Proxy Decision-Makers       3

Answer 1 Identifying the Declarant—James Leonard Park;
the Scope and Function of this Declaration—MY Medical Ethics       3

Answer 2 Appointing My Proxy Decision-Makers       4

Answer 3 Self-Activation of My Medical Care Decisions Committee       5

PART II Quality-of-Life Issues       9

Answer 4 The Level of Personhood
I Wish to Preserve thru Medical Care       9

Answer 5 I Request All Treatments that Will
Prolong and Preserve my Life as a Person       11

Answer 6 If I Get Alzheimer's Disease
or a Similar Condition that Limits My Mental Capacities       12

PART III Pain Control, Nursing Home,
Financial Limits, & Medical Information      17

Answer 7 Pain Control      17

Answer 8 Nursing-Home Placement       18

Answer 9 I Prefer to Die at Home by Anesthesia       22

Answer 10 Financial Limits on My Terminal Care       23

Answer 11 I Want the Whole Truth about My Medical Condition       24

PART IV Life-Ending Decisions       26

Answer 12 Ending Curative Treatments       26

Answer 13 Writing Do-Not-Resuscitate Orders      27

Answer 14 Maintaining Me on Life-Support Systems      28

Answer 15 Withdrawing and Withholding Food and Water       29

Answer 16 More Active Means of Ending My Life:
Voluntary Death and Merciful Death       30

Answer 17 The Conditions under which I Request Death       33

Answer 18 The One-Month-Less Club      35

Answer 19 Permanent Unconsciousness
is My Preferred Definition of Death       36

PART V Disposition of My Remains       38

Answer 20 I Wish to Donate My Organs So that Others May Live      38

Answer 21 I Wish to Donate My Whole Body as a Living Cadaver       39

Answer 22 Final Disposition of My Remains       41

PART VI Philosophical-Spiritual Perspectives & Readiness for Death      42

Answer 23 Respect for My Life as a Person;
My Death with Dignity and Meaning       42

Answer 24 My Readiness for Death; Living Well to the End       44

PART VII State Form and Legal Status       45

Answer 25 The Minnesota Health Care Directive      45

Answer 26 Legal Status of this Advance Directive for Medical Care       46

Signature and Witnesses Page       48

Recommended Ways in which Others May Use My 'Living Will'

    I have published my own Advance Directive for Medical Care
in the next section of this book in case my thinking might benefit others.

    Each Answer corresponds to the Question of the same number
in the main part of this book.
Each Question for 'Living Wills' or Advance Directive
is repeated before the beginning of each Answer.

    Each of us should independently think thru these end-of-life issues.
And we should discuss them with the people who are closest to us,
especially the ones who will be our proxies
or the members of our Medical Care Decisions Committees.
A few other people who should be involved in this process include:
other family members, important friends, our doctors, clergy people,
lawyers, ethical consultants, psychologists, therapists, etc.

    If you agree with the medical ethics exemplified in my 'living will',
you are welcome to adapt my words and phrases.
But you will probably have to re-write every page
because of the frequent personal references included in my Advance Directive.
And expressing your views in your own words
will show that you thought carefully about what you were saying.

    Most readers will want a shorter 'living will',
so you will omit some of the details I have included.
(And you will put in other special provisions I do not have.)

    I have not attempted to create an Advance Directive in general terms,
so that other could adapt it wholesale.

    However, I have written the appended essay:
"Death of the Self: Becoming a Former Person"
so that it could be attached to other people's Advance Directives.
You merely have to note on your copy of that essay that you agree
with the definition of personhood and the questions included.
If you decide to use only parts of my essay on personhood
and/or only some of the Questions for Proxies,
please give the original source
so that others who read your Advance Directive
will be able to find the full text if they so desire.

    Here is the full text on the Internet:
http://www.tc.umn.edu/~parkx032/PERSON.html
On the Internet, it is called
"When is a Person? Pre-Persons and Former Persons".

PART I Scope of this Declaration
& Appointment of Proxy Decision-Makers

Question 1. Should your Advance Directive for Medical Care
be limited to a period of 'terminal illness'
or should it apply to all situations in which you are not capable
of making medical decisions or are unable to express your wishes?

Answer 1 Identifying the Declarant—James Leonard Park;
the Scope and Function of this Declaration—MY Medical Ethics

    I, James Leonard Park, currently living at 1829 Third Avenue South,
Apartment 218, Minneapolis, Minnesota 55404; phone: (612) 871-PARK,
being an adult of sound mind, willingly and voluntarily
make this statement as a directive to be followed if and when
I am unable to participate in decisions regarding my health care.
I explicitly do not limit the application of this directive
to a period of 'terminal illness' or 'terminal condition'.
Rather, it shall apply to all situations
in which I am unable to make medical decisions for myself
and/or I am unable to express my wishes.
The beginnings and endings of these situations
shall be decided by my Medical Care Decisions Committee,
as described in Answer 3 of this declaration.
I understand that my health-care providers
are legally bound to follow my wishes, within the limits
of reasonable medical practice and applicable law.
I also understand that I retain the right to make
medical and health decisions for myself as long as I am able.
In addition, I retain the right to change my mind
about any element of this declaration
as long as I am able to make medical decisions for myself. 

    This Advance Directive for Medical Care or 'Living Will'
is an expression of my personal medical ethics.
It is not an attempt to create a universal system of medical ethics
that should apply to all people in similar circumstances.
I recognize that other people will choose other options
when confronted with similar medical problems.

    In general, this 'living will' is my statement
of the ways I wish to be treated beyond generic medical ethics,
beyond the principles of standard medical care,
which are necessarily conservative and average
because generic medical ethics strive to make one pattern fit all.
Basically, I agree with the most advanced and liberal medical ethics,
but there is much leeway within the common law,
within the precedents that govern medical practice,
within generic medical ethics as taught in medical schools,
and within the personal medical ethics of each doctor or nurse.
Most medical professionals recognize the right of others
to make different medical decisions than they would for themselves.
This Advance Directive states what options should be selected for me
even if my choices go beyond the edge of contemporary medical ethics.

Question 2. What person or persons should make medical decisions for you
if you become incapable of making your own decisions
or unable to express your wishes?

Chapter 2 Appointing My Proxy Decision-Makers

    I hereby create a Medical Care Decisions Committee (MCDC)
to make my medical decisions for me
during any period of time (either temporary or permanent)
when I am not able to make my own decisions
or during any period of time when I am not able to express my wishes.

    {At this place in the paper version of this Advance Directive,
the names, addresses, phone numbers, and relationships
of each of the five members of my MCDC are included.
The chairperson and vice-chairperson are identified.}

    The chairperson of my MCDC shall sign medical-consent forms for me.
Emergency and routine consent shall be given by the chairperson alone.
I authorize the chairperson of my MCDC to make all necessary arrangements
to carry out all the plans and decisions contained in this Advance Directive.
The chairperson shall decide when to consult the other members.
Normally, the full committee will make all life-ending decisions.
If not all members of my MCDC agree on any particular decision,
or if some are not available when a decision is required,
a majority of the available members shall have the power to decide.
Each member of my MCDC (including the chairperson) has one vote.
In case of a tie vote, the chairperson's view shall prevail.

    In case the designated chairperson is not available,
Warren Park shall become temporary chairperson.
If he also is not available, the remaining members of my MCDC
shall select a chairperson from among their members.
And if additional members are needed for my MCDC,
the existing members have the power to appoint additional members.
As long as I remain capable, I retain the power to change
the composition of my MCDC simply by informing the current members.

    Other relatives are hereby noted but are not included in my MCDC:
Both of my parents are dead. 
I have no children.
I have two other living siblings: Betty Ponder & Douglas Park.
These two shall be informed of my condition when appropriate,
but they shall have no power concerning my health-care decisions.
And they shall have no power to sue on my behalf.

    None of the above mentioned persons
bears any financial responsibility for the costs of my medical care.
I have no children or other dependents.
And I am not dependent on anyone else.
Direct expenses such as telephone calls, travel, & legal expenses
associated with the operation of my MCDC will be paid by my estate.

    This Advance Directive for Medical Care contains
a health care power of attorney.
I hereby appoint the chairperson as defined above
to be my health care agent under Minnesota Statute 145C.
The other members of my MCDC shall be consulted
at least for all decisions that might end my life.
And the contents of this Advance Directive for Medical Care
become my explicit instructions to my health care agent.

Question 3. When and how should your proxies
be empowered to make medical decisions?

Chapter 3 Self-Activation of My Medical Care Decisions Committee

    I realize it is often difficult to declare someone incapable
of making his or her own medical decisions.
Especially if we had deep respect for that person (or former person),
we will exercise great care in taking over their medical decisions.
But I believe it is better to transfer this power in an official way
rather than leave the deciding authority ambiguous.

    Thus I have decided to give my MCDC the power to activate itself.
The members of my MCDC have known me for many years.
They are in the best position to notice the waning of my mental powers.
And they have my best interests at heart.
Thus it would be better for them to decide my capabilities
than for my case to be heard by a judge who never knew me,
based on the testimony of a psychiatrist who talked with me briefly.
Of course, if my proxies wonder about my level of mental ability,
they may seek professional opinions if that seems appropriate.
I have offered about 100 questions for examining capabilities
in the autonomy section of my essay on personhood:
"When Is a Person? Pre-Persons and Former Persons" .

    If my mental powers begin to slip,
this would first become evident to the chairperson of my MCDC,
who has almost daily contact with me.
She should call on the other members of my MCDC
to consider carefully my condition and prognosis,
to ask for some professional advice if that seems appropriate,
and to take a vote about activating my MCDC.

    When my MCDC votes to take over my medical decisions,
they shall define the duration of this authority, for instance,
(1) until I regain my mental abilities to decide for myself
(which may be determined by a vote of my MCDC if necessary),
(2) until other members of my MCDC can be consulted, or
(3) until my death if my disability is likely to be indefinite.

    The beginning of this authority shall be communicated officially
to my health-care providers,
giving the date and time my MCDC activated itself.
And the duration of these powers shall also be stated.

    I can think of four obvious situations in which my MCDC
should officially take over my medical decisions:
(1) I am unconscious and incapable of being awakened,
(2) I am in a persistent vegetative state,
(3) I am not capable of communicating my wishes in any way,
even tho I might have views concerning my medical care,
(4) my mind is no longer capable (perhaps because of pain or drugs)
of receiving and weighing information
and making wise and rational choices based on my settled values.

    Here are some situations in which
I will retain my power to make medical decisions:
(1) When I am a fully rational, functioning, & autonomous person.
(2) When I am still handling my other affairs without problems.

    And here are some borderline situations:
(1) When I am awake and aware only sporadically,
so that I cannot be depended upon to make decisions as needed.
(2) When the doctors in charge of my care
find it easier to consult first with my proxies.
(3) When the chairperson of my MCDC
finds herself consulting me less and making decisions herself more.
(4) When I am in too much pain to think clearly
and to weigh the alternatives rationally.
Or when medications make it difficult for me
to understand completely what is going on around me.
The medical personnel may know in advance that certain treatments
(such as drugs) are going to make it difficult
for me to continue making my own medical decisions,
so they can recommend the best time for my MCDC to activate itself.

    In practice, this Advance Directive for Medical Care
will come into operation as soon as
I am no longer able to sign my own informed-consent authorizations
—as soon as it seems wise for others to sign for me.
This turn-over of responsibility will occur when I can no longer
make intelligent and informed decisions about my health care,
perhaps because the issues involved are too complex
or because they require more analytical power than I have at the time.
And even while I can still give informed consent,
this prior statement of my personal medical ethics should be consulted.
What I thought beforehand may be a more valid expression of my settled values
than what I feel when I am in pain, under the influence of drugs,
or subject to the pressure of medical personnel and institutions.

    I may also decide voluntarily to turn over my medical decisions
to my MCDC for a defined period of time
—if I know I will not be able to make decisions during that period
or if I do not want the responsibility.
The power to make my own medical decisions shall be returned to me
if and when I become sufficiently able to analyze my situation
and to process the information necessary to make wise decisions.
If and when my decision-making power is returned to me,
the date and time shall be officially noted in my medical record.

    And what if I am semi-capable?
When I am not operating at my mental best,
the official power to make my medical decisions will rest with my MCDC,
but they will ask me to participate in their decisions as much as I can.
I may not be able to weigh all the relevant factors
as well as the members of my MCDC, who are functioning
without the limitations of my disease or condition.
So they may ask me to decide questions I can easily decide.
But the major decisions will have to be made by them.
Their collective decisions may be better than mine.
Thus my MCDC protects me from my possible loss of mental capacity.
When I am no longer functioning as the person I was,
this should be evident to the persons closest to me.
And they will compassionately make my medical decisions for me.

    My MCDC shall always strive to follow this Advance Directive.
But I realize that many possibilities could not be included.
So my MCDC will have to extrapolate from what I have said
to determine what I would have chosen in the unforeseen circumstances.

    I believe the power to make my medical decisions should rest with
the 5 individuals I have chosen to make up my MCDC.
None of them is a doctor,
but all of them have considerable knowledge about medical matters.
They will seek medical advice as needed, of course,
but these people have known me during the best years of my life
and are therefore in the best position to enforce
the choices I have made about my death,
even if the medical professionals may be reluctant
at first to comply with my wishes.

    I give these powers to my MCDC in order to counter-balance
the decision-making power of the medical professionals
who will be involved in my care.
These medical personnel might have known me only for a short time
and they are more likely to attempt to make decisions using
some general principles—some generic medical ethics—
which might not be appropriate for me,
because I have unusual values and beliefs about life and death.

    Thus, I empower my MCDC to reject the recommendations of the doctors
if the preferences of the doctors are not in accord with the principles
articulated in this Advance Directive (including appendices).
If the conflict is serious, they may have to change my doctors.
My MCDC shall have the same powers to make medical decisions
that I have while I am still fully capable.

    My MCDC may be needed to counter-balance doctors
who are accustomed to making all medical decisions
—getting automatic approval from their patients.
Sometimes doctors deal with uncooperative patients
by ordering a 'psychiatric consultation',
which allows the psychiatrist to declare the patient incompetent,
so that the wishes of the doctor can be carried out.
Such psychiatric opinions are almost never sought
when the patient agrees to follow the doctor's suggestions.
Only 'contrary' patients have their views invalidated by psychiatry.
My MCDC shall not approve a psychiatric consultation
unless they see valid reasons for obtaining such a professional opinion.

    As said before, the members of my MCDC
are better able to evaluate my level of mental functioning
than professionals who have known me only a short time.
The members of my MCDC are familiar with my ways of thinking
and my ways of expressing myself.
So they will be the first to notice any disordered thinking.
When I am in the middle of such an episode,
I may not recognize how disordered my thought-processes have become.

    If being senile is something like being in a dream,
there might still be some moments of clarity during the day
when I am able to look back on my senile behavior and thinking
and recognize that it was not fully me.
If I slip in and out of such a state without notice,
then I should voluntarily give my medical decisions to my MCDC.
When I have moments of clarity, they should still consult me,
allowing me to participate as fully as possible in the decisions.
But if I am not consistently in my fully-functioning mode,
I cannot be depended upon to make decisions in a timely manner.

    So perhaps I should be an ex officio member of my MCDC,
participating as much as possible at any given time
but without a vote or other decision-making power.
My MCDC will decide just how to take my current 'views' into account.
They will also have to weigh the professional input
from the doctors and nurses in making medical decisions for me.

    And my MCDC shall return my decision-making power to me
when they determine that I have regained the ability
to make my medical decisions, when, for instance,
I have recovered at least some of my former power of thinking.
If this does not happen,
the powers will continue to rest with my MCDC indefinitely.

PART II Quality-of-Life Issues

Question 4. What level of personhood do you wish to preserve thru medical care?
When—according to your own criteria—would you become a former person?

Chapter 4 The Level of Personhood I Wish to Preserve thru Medical Care

    In all cases, health-care decisions for me should be made by asking
whether the proposed treatments will enhance my life as a person.

    I offer a full definition and description of personhood
in the appendix entitled "Death of the Self: Becoming a Former Person".
If time permits, the decision to end my life should be made
only after a thoro discussion by the members of my MCDC
of all the issues raised in that essay,
especially as they apply to my specific condition at that time.

    There is no doubt that I have been a full person most of my life.
But I will have passed over into being a former person
if I have lost most of the following marks of personhood
(and there is little chance of these lost functions returning):
1. consciousness—the ability to be aware of myself
and my environment for at least a part of each day;
2. memory—the capacity to recall who I am
and to recognize the people around me;
3. language—the ability to understand the English language
and at least some capacity to respond to questions put to me;
4. autonomy—the ability to formulate and carry forward
plans and purposes I have created.

    Each section of "Death of the Self" includes specific questions
which may be helpful in determining the degree to which
I retain or have lost these capacities of personhood.
When I have permanently ceased to be a person according to my tests,
health-care and/or other life-support measures to keep me 'alive'
should not be continued for more than one year.
A much shorter period would probably be wise
if it is certain I will never return to being a person.

    When deciding whether or not to authorize a proposed treatment,
my MCDC shall ask the doctors and each other
whether the therapy will return me to functioning as a person.
Sometimes medicine is practiced merely with an eye to
preserving the life of the patient.
Mere survival is the goal.
And when the body continues to breathe for a few more days,
that is taken as a sign of medical success.
But I want to be alive as a person,
not merely maintained as an organism.
If and when I cannot be restored to my life as a person,
my MCDC should call a halt to further medical interventions.

    For example, I would not want surgery to remove yet another tumor
if it is already known that I have so much cancer in me
that it will kill me before I can return to living a meaningful life.
And if that period of meaningful life after such surgery would be short,
then the surgery is probably not justified.
I have laid out some rules-of-thumb for such decisions
from the financial point of view in Chapter 10 of this Advance Directive.

    If I cannot return to living a meaningful life
as a fully-functioning person,
if I can no longer pursue the purposes I found meaningful
during most of my adult life,
I request that my life be brought to an end.

    Once I have been declared dead according to my own definition
—permanent unconsciousness, (which I explain fully in Chapter 19)—
my remains should be used for organ and tissue donation,
medical experiments, anatomical study, etc.,
as described in Chapters 20 & 21 of this Advance Directive.

    I am not asking my Medical Care Decisions Committee
to violate any laws that may apply.
Nor am I asking any medical personnel or facility
responsible for my care to violate any laws.
But I hope that by the time
the provisions of this Advance Directive come into force
the State of Minnesota (or other state in which I may reside)
will have changed its laws to permit (under appropriate safeguards)
voluntary death, assisted voluntary death, and merciful death.
And even if such practices are not yet officially recognized by law,
I wish all concerned persons to know by this Advance Directive
that if I have permanently ceased to be a person
according to my own criteria laid out in "Death of the Self",
my body should be peacefully anesthetized, I should be declared dead,
and my remains should be used as I have directed
in my essay included as an appendix "The Living Cadaver:
The Medical Uses of Permanently Unconscious Bodies".
The dispositions of my remains is discussed more fully
in PART V of this Advance Directive for Medical Care.

    The personal expression of my own medical ethics
and personal philosophy contained in this Advance Directive
and the three essays appended
may be used to bend or extend the law
as may seem wise to the members of my MCDC.
My moral permission contained herein
shows that I believed in my full right to die
before such a right was officially recognized in law.

Question 5. Where would you draw the line between
a quality of life worth preserving
and the remnants of biological life that should be mercifully shut down?

Chapter 5 I Request All Treatments that Will
Prolong and Preserve my Life as a Person

    All health care proposed for me should be questioned
with respect to its benefits to me as a person.
If the proposed procedures will merely prolong my process of dying,
I do not want them.
But if there is a good chance that such procedures
will return me to being a functioning person,
according to my own criteria, then they should be pursued.

    As of this date, I expect my life to last until about 2040,
which would mean that I will die at age 99.

    As I now project four more decades of life,
I want almost everything that medicine can provide
that will keep me functioning as a person
and/or restore me to being a person
if I should temporarily lose some of the marks of personhood.

    As I move closer to the end of my life,
I will revise this statement with more knowledge of
the specific medical problems likely to cause my death.

    Also, as medical science progresses,
new forms of medical treatment will become available.

    Each decision about appropriate health care
should be a cost-benefit analysis:
What are the costs in hours and dollars?
What are the burdens on me as the patient?
What benefits will the proposed actions grant me as a person?
What burdens will the proposed treatments
impose on those who care about me?
And what are the benefits to them?

    Appropriate health care will always prolong my life as a person.
If treatments are proposed because they are standard medical practice
or because they can be done,
but they provide no benefit to me as a person,
then they should be omitted.
I can easily imagine situations in which medical procedures
would merely preserve some remnants of biological life in my body
after my life as a person is over.
If this is ever the prospect for me,
I hereby grant full and free permission for my MCDC
to decide to terminate whatever life remains in my body
in order to realize my other settled values
(such as benefits to others from the use of my remains)
that I have expressed in this Advance Directive,
including appended writings.

Question 6. How do you want to be treated if you get Alzheimer's disease
or some other condition that limits your mental abilities?

Chapter 6 If I Get Alzheimer's Disease
or a Similar Condition that Limits My Mental Capacities

    Alzheimer's disease or other similar conditions
that limit the proper functioning of my brain may come on slowly.
It is quite possible that I will never experience mental degeneration.
But if I do, this chapter will be very important.
When I first composed these thoughts in 1996,
it was a convincing proof that James Park's mind
was operating quite well at that time.
Since then, I have revised and reaffirmed these views a numer of times.
The views I have consistently held as a fully-functioning person
should determine my treatment at a later time in my life
if I become a former person according to my own criteria.

    My most elaborate and extensive treatment of this possibility is contained
in the appendix called "Death of the Self: Becoming a Former Person".
I will continue to revise that essay,
keeping it the best representation of my views.
"Death of the Self" asks the question abstractly:
How would we recognize personhood in anyone?
And this chapter of my Advance Directive will apply those criteria
to the problem of deciding when I have become a former person.

    At this point in my life—age 62—I have no signs of Alzheimer's.
And because I am in good health, I do not expect this to develop.
But if I live long enough, small strokes or other brain problems
might rob me of my mental powers bit by bit—or perhaps all at once.

    If I develop any brain diseases or conditions,
I want them treated, of course,
to the full capacities of medical science as then developed.
Good ways to delay or even reverse Alzheimer's disease
may be discovered by the second or third decade of the 21st century,
when it might be relevant to my condition.
I approve whatever treatments might be appropriate.

    The first mental capacities I might lose are the ones I discuss
in the autonomy section of my essay on personhood:
"When Is a Person? Pre-Persons and Former Persons?"
I have lost my autonomy when I no longer lay plans
(such as my project of writing this book) and carry them out.
In a sense, this might be a return to childhood,
which was also a time when I functioned without much autonomy.
During childhood my parents made important decisions for me.
The basic difference between childhood and the possibly-senile phase
is that I grew out of my childhood 'innocence', 
but growing out of senility is not as likely.
Senility usually continues to go down hill.

    Living as a child was certainly an enjoyable phase of my life.
And while I am still able to function at least at the level of a child,
I should probably be kept alive.
But I may regress mentally and behaviorally to the point
where I must be watched every minute I am awake
to make sure that I do no harm to myself or to others.
When my life becomes a problem rather than a joy,
that might be the time to declare my functional life at an end
and to make plans to bring my life to a peaceful conclusion.

    Before this point for ending my life comes,
there will be preliminary milestones that mark such degeneration.
Perhaps I will no longer be able to pass the driving test
because my mind does not operate as well as it does now.
And I may lose the capacity to handle my financial affairs.
If others must take over such parts of my life,
these will be signs that I am moving toward becoming a former person.
It may even be necessary for someone to be appointed my legal guardian
because I can no longer handle the practical details of my life.

    I imagine Alzheimer's disease to be similar to dreaming.
In dreams, lots of impossible things happen to me and around me.
I try to solve problems that can never be solved.
I am always glad to awaken from such dreams:
I abandon my confusing dream-projects
and return to the real world, to meet the real challenges of living.

    Sometimes when I am still dreaming,
I recognize that my thoughts are distorted,
which leads me to say that I must be dreaming.
But this does not always cause me to awaken.
I sometimes just go into another story, another level of dreaming.
I wonder if being senile is like dreaming from one level to another
without the possibility of awakening.

    Another early sign of Alzheimer's disease and like disorders
will be the loss of language ability.
Even now when I am merely tired,
I forget how to spell some words that I have used all my life.
When I return to a better level of functioning,
I remember how to spell them once again.

    There are some brain problems that take away
only the possibility of creating language,
while the capacity to understand language remains.
If this happens to me, it will certainly be a serious limitation,
but it will not mean that I have ceased to be a full person.

    Memory loss is another important sign of brain dysfunction.
At first I will be able to recognize my own memory loss;
I may notice some facts slipping out of my random-access memory.
But later, my memory loss may be so severe
that I no longer realize that I have lost most of my memory.
In such cases, the people around me
will be able to evaluate my loss of faculties better than I can.
Thus I give the responsibility to evaluate my mental functions
to others whose capacities as full persons are not in question.

    If and when the early signs of brain dysfunction appear,
we will seek medical help to slow the decline or perhaps reverse it.
But if Alzheimer's disease or some similar condition
is likely to be a fact of my life for the rest of my days,
it is time for me to confer with my Medical Care Decisions Committee
and map out plans for the rest of my life.
This will be a good time for us to use the questions for proxies
embodied in my essay on personhood appended to this Advance Directive.
That essay will enable my MCDC to evaluate my persohood in four areas:
(1) consciousness & self-consciousness; (2) memory;
(3) language & communication; and (4) autonomy.

    If my MCDC and their medical advisors agree
that I am declining as a person, let the end-of-life discussions begin.
If I can still participate meaningfully in these discussions,
I would like to be included.
But I foresee the possibility that I may have lost so much
of what now makes me a full person
that I will not understand the words that I now write.
In that case, my MCDC will have to work out the last phase of my life
without any new input from me.
But I hope that they will consider what I wrote about the subject
(while I will still clearly a fully-competent and intelligent person)
to be my contribution to the discussion.
My writings are the best representation of my settled values.

    Because my personal decline may be slow
—taking place over a period of several years—
it may be difficult to draw a precise line
separating my life as a person from my later life as a former person.
But those who knew me as a fully-functioning person
will be in the best position to see the contrast in retrospect.
The people I have selected to be members of my MCDC
are responsible for deciding when to declare
that I have died as a self—that I have become a former person.

    Using the Questions for Proxies in my essay on personhood,
my MCDC will decide when I have ceased to be a person.
(I see them siting in a circle, reading each of the 200 questions,
putting "James" into the blanks in each question.
For example, Question 83 in the autonomy section:
"How well does James process information
and reach rational conclusions?")
And if good medical advice agrees that such losses are permanent,
they should begin the process of drawing my life to a close,
following the plans laid forth years in advance in my essay
"The Living Cadaver: Medical Uses of Permanently Unconscious Bodies"
and the instructions in PART V of this Advance Directive.

    I realize this will be going beyond generic medical ethics
as they stand now and when the 'living cadaver' essay is published,
but that is the way we make progress in medical ethics.
Someone suggests a change and others discuss it
to help decide whether it is a wise revision of past practices.
And if the patient himself or herself has already given permission
to be treated in the unusual way, this should make it much easier
for those who must carry out the unusual procedures
to be assured that they are doing the right thing:
Not only will they have thought carefully about
such a frontier question in medical ethics,
but they will have the additional advantage
of having the patient's explicit request
to be treated in some unusual ways
—beyond the generic medical ethics of that day.

    If I permanently lose my personhood,
I request that all remaining consciousness in my brain be shut down.
When there is a 100% certainty that consciousness can never return,
my life as a person will be completely and permanently finished.
(Chapter 19 explains my preferred definition of death.)
(PART V explains the disposition of my remains.)

    If I am not able to participate in the decision to end my life,
my MCDC will be responsible for setting the exact date of my death.
And this should be coordinated carefully
with the preparations of the medical institution
that has agreed in advance to use my body
as best suits the purposes of medical science
and others who may receive my usable organs.

    In short, if I get Alzheimer's or a similar brain disease
or some other brain condition that cannot be repaired,
I want my MCDC to set the date of my death
at the most appropriate time for all concerned
—both the people who knew me and cared about me during my life
and the medical people who have accepted my anatomical gift.
This date will come after I have mostly ceased to be a person
(according to my own carefully-drafted criteria and tests)
and before I have spent too much time
in a meaningless existence as a former person.

    I write this statement years in advance of need,
while my mind is still functioning fully and sharply.
Clearly this planning is not itself the product of a diseased brain.
I may not have the capacity at the end of my life
to understand or participate in carrying out this plan for my death,
but it will still be a valid plan, because I have discussed it with
the members of my MCDC and they have agreed in advance
to carry out my plans to the best of their abilities.
This Advance Directive gives them full legal authority
to carry out my plan for the end of my life
—even if I am the first person to donate my remains in such a way.
My moral, philosophical, and legal permission is herein contained.
My medical ethics say this is a much better way to handle my remains
than any of the standard ways of disposing of human bodies.

    This will seem to most people a radical departure from tradition.
But when there is no hope of living a meaningful life as a person,
this is the best way for my remains to benefit other persons.
The deepest respect for the person I was when I wrote these words
is to carry out my careful, compassionate plan for using my remains.
If I become a former person, I donate my body to benefit others.
Instead of waiting for further deterioration,
I authorize and encourage my MCDC to have my body wisely used.
When my life as a person is over,
I willingly give my body for the benefit of others.
If there is ever a direct, irreconcilable conflict between the views expressed
in this Advance Directive (or a future revisions of it) and the views expressed
by a James Park whose decision-making capacity is questionable,
then the views contained in this Advance Directive shall prevail
—even if this means shortening my life as a former person.
If I become senile, for example,
my views then will not be as well-thought-thru as my views are now
—as I write and revise my Advance Directive.

PART III Pain Control, Nursing Home,
Financial Limits, & Medical Information

Question 7. If you are in serious pain, what do you want done?

Chapter 7 Pain Control

    If I am conscious and in pain beyond what I can endure
(judged by myself rather than observers if I can still communicate),
I request that sufficient pain-medication be given to relieve the pain,
even if the amount needed renders me continuously unconscious
and even if this medication might also shorten my life.

    We now know that it is possible to administer enough anesthetic
so that even the most severe pain cannot be felt.
This is done routinely during surgery.
I have had two abdominal surgeries to remove parts of my colon,
but I did not feel anything during the hours of these operations.
I did not awaken. And I have no memories of those hours.
I was so completely unconscious
that even the major cutting done by the surgeon did not awaken me.
I will probably not be that deeply unconscious again until I am dead.
We agree to such periods of unconsciousness
because we hope that surgery will return us to meaningful life.

    I have lived an almost pain-free life for 62 years now.
My cancer did not cause any pain.
And everything else in my body works well, causing no pain.
Thus I have no track-record of bearing pain.
I do not know just where I might cross the line
into a condition of intolerable pain.
And I do not know how I will respond to pain-relievers,
since I have such limited experiences with them.

    But it seems logical to postulate some point
where the pain will be too great to justify continued existence.
If heavy sedation is required to keep me free of pain,
it might also cancel out everything I regard as me.
If pain-killers cancel my personhood,
and there is no prospect of solving the cause of the pain,
then my life as a person may be over.

    Just keeping my body 'alive' in a coma would not be meaningful.
Other people may see some value in keeping an unconscious body 'alive',
but in my view, if I am 'alive' in a permanent coma,
that is indistinguishable from being dead.

    Right now I do not think that I would want to be kept alive
if all of my conscious moments were filled with pain.
Pain has a powerful way of forcing
all other contents of consciousness into the background.
Perhaps when I am in pain, I would be able to make
some emergency decisions, such as how to avoid further pain.

    But if I had only a pain-filled life to look forward to,
I might consider this a life not worth living.
If my life comes to such a pass,
I may be able to decide that the time has come to end my life.
And if I cannot decide, then these thoughts will have to stand
as my best attempt to explain my philosophy of pain-control.

    The same chemicals that block pain also render us unconscious.
So we may have to choose between pain and consciousness.
And life without consciousness is meaningless to me.
Thus I will accept pain-medication only as a temporary measure.
After such periods, I would hope to return to a pain-free life
without the help of pain-medications.

    In my case, there is no need to worry about addictive medications,
since if I recover, I will have no inclination to seek illegal drugs.
When I had cancer surgery in 1993 and 1994,
both times I had a morphine pump during the recovery periods.
I did not especially like the effects of this drug;
and I had no interest in anything like morphine
after it was no longer needed to relieve my post-operative pain.

    Receiving pain-control drugs at the end of life will not be a problem either,
because permanent unconsciousness caused by drugs
is my ideal way to approach the moment of the declaration of my death.
This will allow my tissues and organs to be harvested
while they are still in the best possible condition.

    If I am in pain that cannot be controlled
except in ways that make my life as a person impossible,
then I would prefer death.
 

Question 8. Do you want to be put into a nursing home?
If so, for how long, under what conditions, and for what purposes?

Chapter 8 Nursing-Home Placement

    In my view, the most valid use of nursing homes
is for a period of recuperation after an accident or surgery.
In some cases, this could even be a long period of recovery.
If there is good reason to believe
that I can return to a meaningful life outside of the institution,
then a nursing home might be a good place for me.
I fully approve of such temporary placements.

    But nursing homes are more often the last residence
of people who are on the way to death.
And they are placed in nursing homes
because they cannot take care of themselves
due to either physical or mental limitations
from which they will never recover.

    I would agree to live in a nursing home
if I found it necessary because of some physical limitations
that could best be dealt with in those circumstances.
And this kind of placement would be my own choice
—while I am still fully capable of making such decisions.

    But placement in a nursing home because of mental limitations
would be a decision to be made by my Medical Care Decisions Committee.
And they might decide that it would be better to end my life.
They will make such a decision by asking the questions
in my essay on personhood appended to this Advance Directive.
If they determine that I have already become a former person,
and that I am not likely to return to being a full person,
then I freely authorize them to begin planning the end of my life.
I recommend that my MCDC follow the safeguards explained in
my appended essay "Ten Safeguards for Life-Ending Decisions" .

    Or they might decide to put me in a nursing home temporarily,
to see how well I adjust to those living conditions.
If I seem to enjoy living in a nursing home,
they could extend my life a few months at a time.
If I affirm it as a meaningful way of life for me,
then that living arrangement should continue.

    But if I do not seem to be happy in a nursing home,
then it will be the responsibility of the members of my MCDC
to remove me from the nursing home and to transfer me
either to die at home as described in the next chapter (9)
or to die in the medical institution that has already agreed
to accept my remains to be used as a living cadaver, Chapter 21.

    I do not want my body kept alive in a nursing home
after my life as a person is over.
Too many people are kept 'alive' as vegetables
for years after they have ceased to be human persons.
When it is custodial care of a body with few signs of personhood,
then it might be time to bring that life to an end.
Usually such maintenance is based on a 'respect for life'.
Others may define proper respect at the end of their lives,
but I want to be respected as the person I was during my best years.
I explicitly do not choose to have my body kept alive
as a 'living memorial' to the person I once was.

    Thus, I do not approve any indefinite placement in a nursing home.
If I am ever placed in a nursing home, there should be a definite plan
to re-evaluate my situation by a date certain.
My MCDC may also consider financial factors in nursing-home placement.
And when the original purposes
for which I was placed in a nursing home no longer apply,
then the next decision might be for merciful death.
I am not putting any definite time-limit on nursing-home-care,
but one year as a former person should be plenty of time to see
if I will return to being a full person who wants to continue living.

    To preserve my life in a nursing home, I must still be a person.
Do I still have consciousness, memory, language, & autonomy?
Do I have some of these marks of personhood at least part of the time?
I have always valued my life as a person.
And I want to have as much meaningful life as possible.
Each additional day of my life actualizes more meaning.
But toward the end of my life, the opportunities for meaning
might be less and the amount of suffering might be more.

    While I am in possession of my full powers of reason,
I will gage the relative amounts of suffering and meaning in my life.
And in some lucid moments, I may notice that
there were no moments of meaning in the past week of my life.
When I can no longer make such evaluations for myself,
my MCDC will have to ask such questions.
As I see it now, maintaining my body alive for one hour
of meaningful life in a week is a very poor trade-off.
If the proportion of meaningful hours were that poor,
then my plan for a merciful death and body-donation should begin.
And those who respect my autonomy as the person I now am
will allow such plans to be carried out.
Certainly, when there are no moments of lucid, meaningful life,
then I should be allowed to die according to my careful plans.

    As I have said elsewhere (Chapter 14 of this Advance Directive),
my body should not be kept alive for more than 12 months
after I have ceased to be a person by my own criteria.
In many cases, a period of much less than a year as a former person
will be completely sufficient to be assured
that the person James Park will never return to my body.
One month might be a reasonable period of waiting for recovery.
Especially if I am in my 90s,
I will not worry about losing a few days of my remaining life.
And when the quality of my daily life is low, no one should fret
about shortening the number of months of such existence.

    My criteria for personhood can be understood
by any person who is still able to think.
But my MCDC should ask for professional advice
about the possibility that I may regain some or all
of the capacities that made me a person during most of my life.
Will I once again exercise my powers
of consciousness, memory, language, & autonomy?

    As I think of the most important right-to-die cases in recent years,
I know I would have 'pulled the plug' years before it was actually done.

    Nancy Cruzan 'lived' for almost 8 years
after she lost consciousness in an automobile accident.
All those years of her 'life' were completely meaningless for her
according to my philosophy of life and death.
However, I would have wanted to determine
with as much certainty as possible that she would not recover,
which might have taken a few months at the most.
But when no meaningful life remains,
all life-supports should have been disconnected.
In my view, life as a person is certainly over
for someone in a persistent vegetative state.

    Karen Ann Quinlan 'lived' almost 10 years
in a persistent vegetative state.
Her feeding tube should have been removed years earlier.
Proper respect for the lives of these women
did not consist in keeping their bodies 'alive'
long after their lives as persons were over.
I never want anything like that to happen to me.
And this Advance Directive makes this clear in several ways.

    But there are many conditions between
full personhood and persistent vegetative state.
If my condition prevents me from making my own choices,
my MCDC will have to make wise decisions,
based on my medical ethics as expressed in this Advance Directive.

    And finally, here are my thoughts
on the quality of my life in a nursing home:
If I am put in a nursing home, I will be cared for by strangers
who are providing that care because they are being paid.
They will probably have no appreciation of my prior life.
The information that I was a philosopher may be available to them,
and perhaps they could look it up if they were really interested,
but that would not be relevant to their daily interactions with me.
They will know my body better they know my mind (as it used to be).
And if my mind is gone, they cannot know me as a person.
Reading about me would be the same as reading about a dead person.
And if I could not recall the best years of my life,
I also would have become a spectator of the life of James Park.

    My nursing-home care will probably be paid for by the tax-payers.
I would prefer that such money be spent in more meaningful ways,
rather than preserving the last vestiges of life in my body.
As I approve of 'pulling the plug' for other people
whose lives have lost all possible personal meaning,
so I would approve the same choice being made for me.
The time and money spent tending my body
can be used more meaningfully.

Question 9. Where would you prefer to die?

Chapter 9 I Prefer to Die at Home by Anesthesia

    If I am still living in my own home or apartment
when it comes time for me to die,
I would request that my life be brought to an end
at a time convenient for me and for those who care about me
by the administration of an anesthesia
that will render me permanently unconscious.

    Then my unconscious body can be moved to the medical institution
that has already prepared to receive this donation of a 'living cadaver'.
Some evaluations of my body can be done while I am still alive,
but I have decided that I would prefer not to be awake
for any of the procedures that might be disturbing
to me and/or to the people around me at the time of my death.
No medical equipment should be attached at home,
with the possible exception of an IV tube for the anesthetic.

    My voluntary death or merciful death at home
by means of an anesthetic that renders me permanently unconscious
will also make my death easier for others.
They will not have to go to an unfamiliar hospital.
They will not remember my death as occurring in unfamiliar surroundings.

    My death will be declared at home
by a doctor who has already agreed to my criterion of death,
namely permanent unconsciousness. (See Chapter 19.)
This means that my friends and relatives
will not have to follow my body to the hospital
where it will be used as I have explained
in Chapters 20 and 21 of this Advance Directive.
Such removal to the hospital would be equivalent to
a body being taken to the mortuary after a death at home.
I hope all will agree that my death took place
when my consciousness went out for the last time.
What happens after that in the hospital
is like what happens in a mortuary after death.

    All who want to be present at my death will be there.
The after-death family-events can begin immediately.
If there has been sufficient time to arrange my memorial service,
it can be held the same day as my death.
As soon as my death is declared and my body removed,
everyone should go to the place where that service is scheduled.

    Because I have donated my body as a 'living cadaver',
my friends and relatives will have no further concerns for my body
after it is taken from my home by the medical staff.
And all expenses thereafter will also be borne by others
—whoever will benefit from the use of my remains after my death.

Question 10. Do you want to put a financial limit on your terminal care?

Chapter 10 Financial Limits on My Terminal Care

    Because the last year of my life is likely to have
the highest cost and the lowest quality,
I hereby direct my MCDC to consider the costs of my medical care,
no matter what the source of such payments.
It is most likely to be the tax-payers, thru Medicare and/or MinnesotaCare.

    Here are some general guidelines:
My life-time health-care expenditures should be less than $1 million.
This will be an estimated figure,
since no single agency is keeping a total of my health-care expenses.
But if I am receiving very expensive care toward the end of my life,
my MCDC can easily guess if I am approaching my million dollar limit.

    Another guideline asks about the costs and benefits of a particular procedure.
For example, in 1993-94, it cost about $33,000 to save me from dying of cancer.
Since these treatments have added more than 10 meaningful years to my life,
the cost was justified according to the following guidelines.

    For each additional meaningful year of life gained
as the result of some course of medical treatment,
the cost of that treatment should not be more than 7 times
the average annual medical cost for Americans.
In 2004, the average cost of medical care is $7,000 per American.
So in 2004 dollars, each additional meaningful year of life gained
by a particular course of treatment should not cost more than $49,000.

    Later in my life, the same kind of treatment
would have yielded fewer additional years of meaningful life.
When I consider my own health-care choices while I am still able,
I will apply this standard to myself:
If the cost of a particular course of treatment
is greater than the total health-care costs of 7 average people,
then it is time to pull the financial plug on my health care.
This would probably not result in immediate death.
It might be possible to provide supportive care for me
even tho curative care would be too expensive in my view.

    And when my MCDC must make such choices
(because I have become a former person
who can on longer decide for myself), it will probably mean
that the meaningful years of my life have already come to an end.
So expensive medical procedure would not be justified.
If no additional meaningful years of life can be obtained,
then all curative medical treatments should end.

    Thus, when my MCDC is faced with medical-treatment choices
that would cost more than the financial limits I have suggested here,
it will be reasonable for my MCDC to begin the death-planning process
rather than authorize the wasteful expenditures of money
on James Park, who has now become a former person
with little chance of returning to being a full person.

Question 11. How much do you want to know
about your medical condition and prognosis?

Chapter 11 I Want the Whole Truth about My Medical Condition

    Because I have spent a good part of my adult life
working with medical ethics, especially with issues surrounding death,
I do not need to be protected from the thought of my own death.
I seriously faced this possibility when I had cancer in 1993.
I knew all of the facts of my case then,
which enabled me to make medical decisions
that have proven to be the correct ones so far.

    I respect and understand the need others may have
for a 'softer' version of their medical information.
Their psychological well-being may depend on being kept hopeful.
But being in control of my own destiny
is more important to me than having false hopes.
I know from experience, that the more I know about my condition,
the better I feel, even if the information is unpleasant.

    When I had cancer, I read over 20 books on the subject.
I did not want to deny the facts even for a moment.
I did not consider any folk medicine or miracle cures.
Rather, I chose the scientifically-tested treatments:
surgery, radiation, & a small amount of chemotherapy.

    I do not know what disease or disorder will end my life,
but as I affirmed when I had cancer, I still believe in the right to die.
And even if I die from 'old age'
—the closing down of several of my body's systems at once—
I want to know everything about my medical condition in order to make
the wisest possible decisions about when and how to end my life.

    Because of my experience with a life-threatening disease,
I know that I can psychologically handle the full truth.
So, my past record of dealing with medical information
should give my doctors full confidence
that they can share everything with me as soon as they know it.

    While I remain aware of myself at least part of each day,
I want to know the whole truth about my medical condition.
The full facts will empower me to make important decisions
—not just the necessary medical choices
but also other end-of-life actions such as
communicating with other people,
closing down important life-projects, giving away possessions, etc.—
many of which the doctors will know nothing about.
In my case, it will be better for me to know the whole truth
rather than to be 'kept hopeful' to help my body fight the disease.
I cope better when I believe I have all the facts
— when I am not guessing
how much is being withheld 'for my own good'.

    Also the proxies I have chosen to make up my MCDC
are ready, willing, & able to hear the whole truth.
One of them is a physical therapist.
Another has worked in doctors' offices.
Two of them lost a son during an operation to correct a heart defect.
All of us have had experience with doctors and hospitals.
We are a medically-literate group of people.

    The medical information should be disclosed to all of us at once,
beginning with whoever happens to be available when the news is known.
There is no need to channel the information in any particular way.

    If I become unconscious, if I have become a former person,
or if I am otherwise unable to understand the medical information,
it should be given directly to the chairperson of my MCDC
—or to other members if that is more convenient.

    Because of my plans to donate my organs and/or my whole body,
I will want to start the process of evaluating my body
as soon as I know that I am within a few months of my death.
(PART V discusses my plans for dispositon of my remains.)

    Also, because I am a member of the one-month-less club
(See Chapter 18), I plan to bring my life to a close
approximately one month before it would otherwise happen
under standard medical care.
So I will want to know that the end is near
somewhat sooner than people who plan to live to the bitter end.

    When I had cancer, I did read parts of my medical chart,
which I found helpful in making my medical decisions.
Some things are easier to understand in the written form.
So I hope that my doctors will keep my written medical information
in a form that can be read and understood by laypeople.
But we will probably not need to see all the written information.
The most important issue will be the prognosis for the rest of my life.
I want the best possible estimate of the duration of my life
—and the quality that I will experience during those last days.

PART IV. Life-Ending Decisions

Question 12. When should all curative treatments be ended?

Chapter 12 Ending Curative Treatments

    All treatments should benefit me as a person.
When it becomes clear that my life as a full person is over,
when there is little reasonable hope that I will recover
enough to resume the quality of life that has been important to me,
then the purpose of my medical care should shift from cure to support.
Supportive care will attempt to make my last days comfortable,
without purporting to cure whatever ails me.

    I want no medical support that merely prolongs my dying.
I hope that my MCDC will have a frank discussion
of the purposes of medical care before they authorize any procedures.
If the proposed procedures can return me to a functioning person,
I approve of trying them.
But I do not approve of any measures
that merely prolong my life as a former person.
I have lived well during the best years of my life,
so it is not difficult for me to give up some last declining days.

    Surgery is one example of curative treatment I do not want
if I have become a former person.
Most surgery is intended to restore the body to a level of functioning
desired by someone who will continue to live a normal life.
If a proposed surgery would only add a few months to my life,
then it would probably not pass the financial test in Chapter 9.
And if it would not restore me to functioning as a person,
then it is against my medical ethics.

    As of today, I hope to live until about 2040,
which means that I will die at age 99.
During these 4 more decades of life, I want all appropriate procedures
that will preserve my life as a functioning person
or restore me to full personhood if I lose my capacities temporarily.

    As I move closer to the end of my life,
I will revise this statement with more insight
into the specific likely causes of my death.

    Also, medical science will progress
so that new forms of medical treatment may become available
for whatever diseases or conditions are threatening to end my life.

    Each health-care decision for me should be examined
by asking the following questions:
Will this procedure restore personal life or merely prolong dying?
What burdens are imposed on James Park by these treatments?
What benefits are likely for James Park as a person?
What burdens are imposed on others who care about him?
What benefits do they perceive for themselves from such medical care?

Question 13. When should Do-Not-Resuscitate orders be written for you?

Chapter 13 Writing Do-Not-Resuscitate Orders

    As soon as my MCDC has determined that there is
no reasonable hope of restoring me to a fully functioning person,
Do-Not-Resuscitate orders should be entered into my medical chart.
This means that in case some sudden accident
or failure of bodily systems threatens to cause my death,
no efforts shall be made to prevent my natural death.
But I do approve in advance any efforts at this point
which are intended to preserve my tissues and organs for donation
and to allow my body to be used as a living cadaver.

    And if I am officially declared to be in a terminal condition,
Do-Not-Resuscitate orders should be written for me immediately.
This allows any life-threatening event to run its natural course,
resulting in my death from natural causes.
I explain in Chapters 20 and 21 that I prefer death by anesthesia
in order to donate my body as a living cadaver,
but if natural death comes before that is possible,
the dying process should not be interrupted.
I should be declared dead according to my criteria of death
(which are explained in Chapter 19 below)
or according to other-—more conventional—criteria.
And all appropriate procedures should be started immediately
to maintain my unconscious body for transplanting my organs
and other use as a living cadaver—if this is possible.

    Do-Not-Resuscitate orders are not a life-ending decision.
Even if I have Do-Not-Resuscitate orders in my chart,
my body may not have a death-dealing crisis,
and I may recover completely to resume a meaningful life as a person.
So all persons concerned should be aware
that deciding not to prevent a natural death if it comes
is not the same as deciding that my life is over.

    All life-ending decisions should be discussed
openly and frankly by considering the options
that will actively or passively bring an end to my life.
The Do-Not-Resuscitate decision is not a 'polite' way
of deciding that my life has come to an end.

    Many chapters in this section of my Advance Directive
are explicitly about making life-ending decisions for me.
I want my MCDC and my doctors to be completely honest
about what is being decided for me.
If the goal is to bring my life to a peaceful and painless end,
then let that be clearly stated in the discussion.
Do-Not-Resuscitate orders are not a life-ending decision.
But every life-ending decision should include DNR orders.

Question 14. How long should you be maintained on life-support systems?

Chapter 14 Maintaining Me on Life-Support Systems

    I approve of life-supports as temporary measures only.
Therefore, I hereby direct that my MCDC approve life-support systems
only if there is a definite time limit stated in the consent form.
(If there is no space for specifying a termination date,
I hereby instruct my proxies to
write such a provision into the consent form before signing.
If this creates problems for the hospital,
emergency life-supports can be continued until the hospital
agrees to accept a temporary authorization of life-supports.)

    Temporary authorization of life-supports will, of course,
allow my proxies to re-approve the life-supports later
if there seems to be good reason to do so.
In most acute situations, one week should be enough time
to determine whether my condition will improve.
My proxies should ask the doctors how soon results should be evident.

    I do not approve using 'life-supports' as 'dying-supports'
—measures that merely prolong the dying process
because no one knows what else to do.
All too often, 'life-support systems' are attached to the dying
for an indefinite period of time—or permanently,
which means that the machines will remain attached
until the patient dies despite such 'life-supports'.
I explicitly rule out such a use of 'life-supports' in my case.

    Life-supports should be used for me only in a restorative mode
—only if there is reasonable hope
of restoring me to functioning as a person.
If after some temporary period on life-supports,
it does not seem likely that I will recover,
I should be rendered permanently unconscious
(as described in Chapters 20 and 21 below)
and the organ-supports continued
in order to preserve my body as a living cadaver.
I have underlined the word organ above
because I realize that the same machines used to preserve my life
will also preserve my organs after I have been declared dead.
But when I have been declared dead,
the organ-systems will be maintained by machines
solely for the purposes of others, no longer to benefit me.
And the continuing costs of organ-support
will be paid by the transplant program
and/or medical science program that uses my remains as a living cadaver.

Question 15. Should food and water ever be withdrawn or withheld
in order to shorten the process of your dying?

Chapter 15 Withdrawing and Withholding Food and Water

    If I have permanently ceased to function as a person
(as described elaborately in my appended essay on personhood),
and if there is no reasonable hope
that I will ever become a full person again,
then all curative medical treatments
and all supportive medical care should be discontinued.
This explicitly includes any of the several ways in which
water (or other fluids) and food (defined as any means of nutrition)
may be provided to my body.
(Only pain medication and other comfort-measures
would be appropriate at this point if I am still conscious.)

    I realize that the withdrawal of food and water
will result in my death within a short time.
But if my life as a person has already come to an end,
and if there is little hope that I will ever be a person again,
then the termination of these means of life-support
is the first step in preparing for the disposal of my body.

    As I said in Chapter 14, on life-support systems,
the same measures and machinery will be useful
to preserve my organs and tissues for use by others
and to preserve my whole body as a living cadaver for medical science.
Thus, I approve continuing nutrition and hydration
after I have been declared dead
for the purpose of keeping my remains as useful as possible
for the purposes I define in Chapters 20 and 21.

    But it should be made clear to all that James Park is dead.
And the continued food and water supplied to my remains
are being provided merely to keep my body as useful as possible
for the purposes of organ-donation and use as a living cadaver.

    If it is not possible to use my body as I have wished,
and if more active means of ending my life are not possible
(as described in the next chapter),
then I entirely approve and endorse
the withdrawing and withholding food and water
as a means of bringing my life to an end.
This should be understood by all as a passive means of ending my life.
What kills me will not be the withholding of the food and water
but the underlying disease or condition
that has made it impossible for me to continue a meaningful life.

Question 16. Do you endorse more active means of ending your life?
Do you believe you have a right to die? Voluntary death? Merciful Death?

Chapter 16 More Active Means of Ending My Life:
Voluntary Death and Merciful Death

    I believe I have the right to die.
And I do not believe that I lose this right
to determine the end of my life
simply because I have become incapable of making further decisions
or fallen into a persistent vegetative state or other state of coma.

    Several states of the United States are struggling
to revise their laws concerning the right to die.
While I acknowledge the right of others to hold different views,
my own views fall at the liberal end of the spectrum.
Even before Minnesota changes its laws concerning the right to die,
I claim my right to decide the end of my life
under the right to privacy contained in the US Constitution
and under the right to refuse treatment within the common law.
When state laws are finally revised,
the rights I claim in this Advance Directive for Medical Care
will become even more explicitly recognized by law.

    Once my MCDC has decided that my life as a person is over,
and that it is no longer appropriate to attempt to sustain my life,
then I approve all possible means
of shortening the process of my dying.
In light of my wish to donate my remains as a living cadaver,
the best means of closing down my consciousness permanently
will be the preferred means of ending my life.
The time for giving the lethal anesthesia
or performing the neurosurgery to end my consciousness
shall be coordinated with the people
who will receive my body after my death is declared.
This will also allow all who care about me
to be informed of the planned day and time of my death
at least a few days in advance.

    Instead of leaving the moment and means of my death to chance,
I am proposing and endorsing a rational decision
about ending my conscious life
so that my body can be used to benefit others.

    One way I see my death coming is the following:
When my MCDC has determined that my life as a person is over,
they should direct and authorize all necessary procedures
that will prepare my body to be used as a living cadaver.
First the drugs will be given or surgery performed
to bring a permanent end to my consciousness
—preventing any chance of consciousness returning to my brain.
Immediately thereafter, my death shall be declared,
based on the criterion of permanent unconsciousness.
(This definition of death is explained in Chapter 19 below.)

    Then the transplant and tissue-recovery teams
will swing into action,
harvesting any and all organs for immediate transplant
into the bodies of patients waiting in adjoining operating rooms.
They can be prepared for transplant in advance
because the exact date and time of my death will be scheduled.

    As said in Chapter 14, about life-support systems,
the same machinery and procedures which formerly supported my life
will become (after my death is declared) organ-support systems.
When my death is declared, my remains immediately become
the property of the medical institution involved.
And all costs associated with maintaining and using my organs
immediately shift to that medical institution
and/or the parties who will benefit from the harvesting of my organs
and/or the use of my body as a living cadaver.

    (This concern about who pays to maintain the living cadaver
is not primarily an economic issue.
Ending the payment for medical care symbolizes the end of my life.
And the payer of my medical care is not responsible for
any costs incurred in disposing of the remains.
Legally the living cadaver will have the same status as a dead body.
And this should help all concerned to believe that James Park
really has died—and his remains have been donated to medical science.)

    This is only one possible scenario for the end of my life.
It is the one I prefer.
But if conditions I cannot now foresee make such donation impossible,
this story illustrates my medical ethics for the end of my life.
When my life as a person is over,
my MCDC will devise and approve the best way
for my consciousness to be permanently closed down
and for my remains to be used for the benefit of others.
And even if nothing can be used from my body,
then the means of death can be as active as described in this scenario.

    The above way of ending my life assumes
that I will not be aware enough to participate in planning my death.
But I may remain an autonomous person up to my last day.
In that case, my death will be described more accurately
as a voluntary death (planned and decided by me) rather than
a merciful death (decided and planned by others appointed by me).

    Allow me to explain my philosophy of the right to die.
I divide this right to self-determination into 3 sub-categories:
Voluntary death, assisted voluntary death, & merciful death.

    Voluntary death means choosing the time and mode of my own death.
But voluntary death differs from irrational suicide in three ways:
(1) Voluntary death is rational; suicide is irrational.
(2) Voluntary death is carefully and compassionately planned;
suicide is often capricious, triggered by a sudden crisis in one's life.
And irrational suicide is often committed
without making the death easy for others.
(3) Voluntary death is regarded by others as admirable and commendable;
irrational suicide is almost always regarded as tragic and regrettable.
(Further discussion of this distinction will be found
in "Working for the Right to Die" , Chapter 12 of my book
Becoming More Authentic: The Positive Side of Existentialism.
See also "Ten Safeguards for Life-Ending Decisions".

    Assisted voluntary death means choosing one's own death
but needing cooperation and perhaps assistance from others.
As proved by the writings referred to above,
created years before this philosophy was needed for my own death,
I have planned my death well in advance,
taking other people's feelings into account.
I will be ushered into death by others who agree with me
that the proper time to end my life has arrived.
I think that my death will attract more admiration than regret.
It will be an assisted voluntary death
if I cannot accomplish all of the steps by myself.

    Merciful death means choosing the time and mode of death for others
after weighing all the relevant factors,
including the prior wishes expressed by the person whose death it is
—for instance in an Advance Directive like this one.
When the dying individual has already become incapable
of participating in the decision to end his or her life,
then the decision must be taken and the actions performed by others.
In writing Advance Directives for Medical Care,
we can state the conditions under which we want merciful death (if ever).

    I fully endorse all three forms of the right to die.
My essay "Ten Safeguards for Life-Ending Decisions"
suggests a system of careful documentation
to make sure that the right to die is not abused by anyone.
When death by choice becomes a completely open process,
making the reasons evident to everyone involved,
the right to die should be accepted even by people initially opposed.
I expect complete acceptance of the right to die
to have been achieved (in the Western world as least)
sometime in the middle of the 21st century,
perhaps by the time I will claim my right to die.

Question 17. Under what conditions would you request death?

Chapter 17 The Conditions under which I Request Death

    This chapter stands as a good summary of
the most important points in this Advance Directive for Medical Care.
(As a point of historical interest,
this is the sixth edition of this statement.)

    I, James Leonard Park, expect and hope that I will be able to make
my own decisions about the proper time and mode for my death.
Thru-out my adult life, I have affirmed my right to choose my own death,
as illustrated in my essay "The Case for Voluntary Death",
published in the Minnesota Daily in 1976.

    But should I become unconscious (either temporarily or permanently)
or otherwise incapable of making medical decisions for myself,
I have established a Medical Care Decisions Committee,
which is empowered to make all medical decisions for me.
In addition to their own good judgment,
they shall take into account my views concerning life and death.

    I have always identified with my life as a person
rather than believing that my body was my self.
(Of course, my body has been the only carrier of my person.
And when my body can no longer sustain life,
I will certainly be dead as a person.
The person James Park cannot exist independent of my body.)
But it might happen that I will die as a person
before the complete death of my body.
My criteria for personhood are explained in detail
in my appended essay "Death of the Self: Becoming a Former Person".
The four criteria that define when I am still a person are:
(1) consciousness, (2) memory, (3) language, & (4) autonomy.

    (1) Consciousness and self-consciousness are central to personhood.
If I am unconscious most of the time, my life as a person is mostly over.
(2) Memory enables me to know who I am and who others around me are.
If I have lost most of my memory,
disconnecting me from everything that has been meaningful in my life,
this would be good reason for my MCDC to consider merciful death for me.
(3) Language is the main tool by which I have conducted my life.
If my mind can no longer process language,
my meaningful life may be over.
(4) Autonomy is the power to plan and conduct my life.
If I can no longer organize and direct my own life,
perhaps I have lost enough of my personhood
to make merciful death the best option.

    If I have lost most of these capacities that define persons,
for instance, if I am in a coma or a persistent vegetative state,
and if there is little hope of recovering my powers as a person,
then I should be consider essentially dead
—or at least a good candidate for the merciful death I hereby request.

    I prefer a peaceful and painless death by anesthesia,
the least destructive means of death,
which will leave my body in the best shape
so that my organs can be transplanted into other people
and/or my whole body used as a living cadaver
for practice surgery, anatomical study, medical experiments, etc.
Anyone who wants to keep my body 'alive' after I am dead as a person
stands in fundamental disagreement with my philosophy of life.

    During my adult years, I have valued my existence as a person.
If the life of the person who was James Park, who read books,
shared ideas, related lovingly and deeply with many people,
who wrote books and sought to help others to become more Authentic
and open to the possibility of Existential Freedom
—if this person no longer exists and does not seem likely to reappear,
then whatever physical life remains should be mercifully shut down.

    This situation might arise from a stroke that wiped my memory clean.
If my body is ever inhabited by a consciousness
that has no recognition of the purposes and values pursued by James Park,
and if that person does not wish to live
or is not capable of making such a decision,
then my body should be peacefully anesthetized
and used as a living cadaver,
as I have explained more fully in my appended essay
"The Living Cadaver: Medical Uses of Permanently Unconscious Bodies".

    If I can no longer be the person I have chosen to be,
then I should be considered dead, by my own definition:
The person James Park will have ceased to be.
You who survive me will be charged with answering this question:
Does this body contain the person James Park
or has that person ceased to be,
so that we can now lay to rest his physical remains?

    If, however, there is a reasonable hope
that I might be returned to being a full person,
to pursue the purposes I considered important in life,
then I should receive the medical care
that can restore me to personhood.

Question 18. Do you wish to join the One-Month-Less Club?

Chapter 18 The One-Month-Less Club

    I am the founder and first member of the One-Month-Less Club.
We are people who have chosen to live one month less
than we would under standard medical care.
The last month of almost everyone's life
is the most costly and the least meaningful.

    Because I have been an informal member of the One-Month-Less Club
for most of my adult life, I have striven to live well each day
so that the fact of losing one month off the end of my life
will not be a great loss to me or to anyone else.

    Under normal conditions of standard medical care,
my last month of life would have a very low quality.
The doctors and nurses would be doing their best
to preserve any signs of life still left in my body.
But if I were forced to live thru that last month,
I would not be able to pursue any of the purposes of my life.
Because I have tried to live a meaningful life each week,
making the best possible use of all my healthy years,
dropping the last month of medical care will be a small loss.

    Interpersonally, I have organized my life
so that others who care about me will be able
to complete everything they wish to do with me in a timely fashion,
instead of waiting until I am on my death-bed.
I have appreciated the expressions of support and affection
from others thru-out my adult life.
And I plan to continue to put the best parts
of my interpersonal life into my healthy years.

    We members of the One-Month-Less Club
will not simply wait (perhaps in pain)
for the Grim Reaper to come and take us away.
We will go out to meet him on the road when the time comes.
And whenever we remember, during the healthy years of our lives,
that we have signed up for membership in the One-Month-Less Club,
we will encourage ourselves to live now
instead of postponing important things until later
—which might make us want to cling to that last month of life
because we have so many projects we never completed,
so much living we kept postponing until it was too late.

    If we live well, 'checking out' one month early
will be good for us and for those who love us.
And when we join the One-Month-Less Club in our Advance Directives,
all the people who care about us will be informed well in advance
that we do not intend to cling to 'life' to the last possible moment.
This should help us all to put first things first, to live well now
—and then to die well at the most appropriate time.

Question 19. Which definition of death should apply to you?

Chapter 19 Permanent Unconsciousness
is My Preferred Definition of Death

    I expect that permanent unconsciousness
will be accepted as a definition of death sometime in the 21st century.
If I die before such a new definition is accepted,
I hereby state that I want the permanent cessation of consciousness
to be counted as equivalent to death in my case.
Thus I may be asking for a departure
from standard medical practice for my specific case.
But the fact that I have given this permission in advance
should make it possible for at least one doctor to declare me dead
on the basis of permanent loss of consciousness
before this criterion is accepted as a standard definition of death.
The reason it is especially important to use this definition
in my case is that I want to donate my body as a 'living cadaver',
as explained in the next two chapters.

    Here is my argument for accepting the end of conscious life
as a satisfactory definition of death:
From my point of view, as the person who has died,
being permanently unconscious,
not being able to have a single thought or feeling,
being in an irreversible coma, is equivalent to being dead.
If I have fallen into a coma from which I will never awaken,
or if surgical or chemical means have been applied to my brain
to prevent the return of consciousness,
then I, as the dead person, cannot distinguish this from death.
Some biological processes might continue, but I will be dead.
And those who have known me while I was alive
should have no problem accepting the fact
that once my consciousness has gone out forever,
the person who was James Park is completely, permanently dead.

    By signing their agreement to this Advance Directive at the end,
the members of my Medical Care Decisions Committee
state that they agree to have this definition of death applied to me
and that they will raise absolutely no objections
to this definition being used in my case,
even if it has not yet become general practice within medicine.

    According to some understandings, a persistent vegetative state
is not the quite same as being permanently unconscious.
If I am in a persistent vegetative state,
most of my brainstem may still be operating,
regulating my heartbeat and breathing,
even tho my life as a person is completely over.
If I will never emerge from PVS, I am clearly a former person,
having lost all four of the marks of personhood:
consciousness, memory, language, & autonomy.

    If I am in a persistent vegetative state
and if this state cannot be defined as being dead,
then I instruct my MCDC to direct
that surgical and/or chemical measures be taken
that will guarantee that I will never return to consciousness.
Then my death can be declared on the basis of permanent unconsciousness.

    If my plan to donate my body as a living cadaver is not possible,
then a persistent vegetative state
shall still be a sufficient condition for granting me a merciful death.
I direct that all life-supports be withdrawn,
including nutrition and hydration (food and water),
and that the last vestiges of biological life be permitted to disappear.

    Restating my medical ethics: If I come to the end of my life
before the criterion of permanent unconsciousness
has become an acceptable definition of death,
I request that my physician go beyond
the "ordinary standards of medical practice" and declare me dead
if for any reason I enter a coma from which I will never awaken.
If I am in a state close to permanent sleep,
my medical ethics say that I should be declared dead
and my remains used as described
in the next two chapters of this Advance Directive.

    For a period of some years before permanent unconsciousness
is generally recognized as a definition of death,
good medical practice will permit using this criterion
for declaring death if there are good reasons for using it.
Organ transplantation and other use of bodies of former persons
who are permanently unconscious will be accepted as good reasons
for such a departure from standard procedure.
As I said at the beginning of this Advance Directive,
this document expresses my personal medical ethics.
And following these explicit instructions just in my case
will not set a precedent for declaring anyone else dead.

    I request this exception that I be declared dead
when I become permanently unconscious with completely informed consent.
And this choice of a definition of death for me
is endorsed in their separate statements
by the members of my Medical Care Decisions Committee.
These five people are the only persons
who have any possible standing to object to using this definition.
Therefore, all worry about lawsuits is removed.
If the doctor wishes an additional statement of immunity
from any legal action as the result of following this Directive,
my Medical Care Decisions Committee will sign
whatever documents are needed to guarantee that there will be
no adverse consequences for any doctor who uses
permanent unconsciousness as a criterion for declaring James Park dead.

PART V Dispostion of My Remains

Question 20. Do you wish to donate your organs
to other persons who need them?

Chapter 20 I Wish to Donate My Organs So that Others May Live

    As I sit at this computer in 2004,
all of my organs seem to be working quite well.
Of course, I have never seen any of my internal organs,
but I know they are there.
And the fact that I am in good health
suggests that my organs are working fine.

    After I am finished with my organs,
I hope that they will find new homes in the bodies of other people
whose original organs have (for some reason) ceased to function.
(And there is even an outside possibility
that I will need to receive an organ donated by someone else.)

    As I get older my organs also get older.
And with each successive revision of this Advance Directive,
I will have to ask whether my organs might still have
enough life in them to be worth transplanting into others.

    But for the present, if I die within the next few years,
there is a very good chance
that many of my organs could be transplanted.

   To facilitate the removal of my transplantable organs,
I have decided to have my life come to an end by anesthesia.
I will decide the timing of my death
if I am still capable when the decision must be made.
My MCDC will decide the exact time if I am not longer capable.

    In either case, the timing of my death
should be coordinated with the transplant team
that has located the best recipients for my transplantable organs.
After my death has been declared
on the basis of permanent unconsciousness
(as described in Chapter 19 of this Advance Directive),
my body becomes the property of the medical institution
that has agreed in advance to transplant my organs.
And my body may be transported to the transplant location
or the recipients can be gathered near the place
where my life will be brought to a peaceful end.
When everyone is ready, both James Park, the donor,
and the recipients can be given general anesthesia.
My anesthesia will be intended to render me permanently unconscious
—without the possibility of ever having another thought or feeling.
Then I will be declared dead on the basis of permanent unconsciousness;
and the transplants can take place.

    This plan for donating my organs departs only a little
from procedures already followed for transplanting human organs.
The main difference is that I approve of planning and timing
the exact moment of my death by anesthesia
so that the maximum benefit to others can be achieved.

Question 21. Will you donate your body
for use in medical science or education?

Chapter 21 I Wish to Donate My Whole Body as a Living Cadaver

    I realize that the requests I make in this chapter
depart significantly from current standard practices
in medical research and the education of doctors and nurses.
And I realize that ethics committees will have to discuss
this form of anatomical gift before it can take place.
Such discussion could even take 10 or 20 years.
As I get older, my organs will be less useful
for transplant into living persons,
but my body may be just as useful
for anatomical study, practice surgery, etc.

    I have already described my wish to be declared dead
on the criterion of permanent unconsciousness (Chapter 19).
In my case, this might be a permanent unconsciousness
that was intentionally created (with this explicit approval from me
and/or from my Medical Care Decisions Committee).
The medical team that has agreed to use my remains as a living cadaver
will decide which means of rendering me permanently unconscious
will correlate best with the uses they have planned for my body.
In any case, irreversible measures must be taken to assure
that James Park will never have another moment of consciousness
—not even on the level of dreaming.

    When my death is declared, my remains become the property
of the medical institution that has agreed in advance
to accept this unusual form of anatomical gift.
No further approvals need be sought from my MCDC
for any use of my remains.
And all costs from the moment of death
will be borne by the medical institution itself,
which, of course, may pass such costs on to others
who will benefit from the use of my body as a living cadaver.
(This transfer of ownership and the costs for maintaining
the remains is practical but also symbolic.
The source of funds for my health care
will not pay for maintaining the living cadaver
after I have been declared dead.
The people who knew me during my life
should go ahead with their plans for my memorial, etc.
just as they would if I had died in a more ordinary way.)

    My survivors only retain the residual right
to receive whatever is cremated
after the remains have fulfilled their purpose as a living cadaver
(possibly followed by further use as a dead cadaver).
The cremated remains may be delivered to my survivors
up to a year after my death.

    My essay "The Living Cadaver:
Medical Uses of Permanently Unconscious Bodies" (appended)
details several ways in which a living cadaver might be used.
To give a sense of my meaning, I will name a few here:
organ and tissue transplantation (discussed in Chapter 20);
testing of new surgical procedures;
practice surgery for surgeons-in-training;
all forms of medical research too dangerous for living people;
testing of new drugs on diseases intentionally given to my remains;
and anatomical study of a body that has some vital functions.
The living-cadaver team will have planned and scheduled
all uses in advance, in order to get maximum benefit from my remains.

    I realize that this plan goes beyond standard medical practice
of the time in which this plan was first created.
But progress in medical ethics takes place
when someone suggests new medical policies or procedures
that might do more good than harm.
Since I will have been declared dead,
I will have no further interest (in the legal sense)
in what happens to my physical remains.
And since I will be dead, nothing can harm me as a person.
Only after-death harms would be possible
—such as the desecration of a dead body
or the violation of an estate will.
I would not expect anything like that to happen,
since the living cadaver will be kept in a hospital bed
while it is being used to benefit medical science and education.
Several people will be using the living cadaver at once.
But they can be less worried when operating on a living cadaver
than when operating on a living person,
because they know a cadaver will not suffer if they make mistakes.

    Once again, agreement to accept this gift of a living cadaver
does not establish a new precedent.
This could be an exception allowed by the institutional ethics committee
because it was explicitly requested by the deceased (me)
and completely approved by my Medical Care Decisions Committee,
who are the only people with any possible standing to object
to using my body as a living cadaver after my death.
The members of my MCDC have all agreed in advance with this plan.
And they have put their approval into writing.
(See Appendix A for statements of agreement from my MCDC.)

    Those who agree to accept this unusual anatomical gift
need not think they are changing their own standards of medical ethics.
They might decide to see it as a permissible exception to the rule,
allowed because of the explicit legal authorization
to use my remains as a living cadaver.

    Because I make this very unusual request
to donate my body as a 'living cadaver',
I would like to meet the team that will be coordinating
the use of my body after I am declared dead.
This will happen while they are doing a preliminary evaluation
of the best ways to use my living cadaver.
Such discussions should also benefit the living-cadaver team,
especially if they have any doubts about this kind of donation.
I want all of them to be completely convinced
that they are doing the right thing,
even tho it goes against medical tradition
and breaks new ground in medical ethics.
They should all read my essay on the 'living cadaver'
and ask me any questions they like
to make sure that this is a free and rational gift,
not some morbid fascination with death and cadavers, etc.

    I am the sole owner of my body. And after my death is declared,
I want my remains to be used by medical science as a living cadaver.

Question 22. What other decisions have you made about your remains?

Chapter 22 Final Disposition of My Remains

    After my remains have been put to the best use
in organ donation and as a living cadaver,
then whatever remains will be cremated by the medical institution
and delivered to the chair of my Medical Care Decisions Committee
(or another member if the chair cannot receive my ashes).
We realize that this might occur up to a year after my death
because my remains might also be used as a normal dead cadaver
after it has lost all of its vital functions.

    My ashes shall be buried in a place selected by me
and known to the people who will do the burying.
I hope it will be an appropriate end of a long and meaningful life,
followed by a few months of other uses of my body after my death.
And if some of my organs survive in other people, so much the better.  

PART VI Philosophical-Spiritual Perspectives
& Readiness for Death

Question 23. What philosophical, ethical, or religious beliefs do you hold
that are relevant to your medical care and end-of-life decisions?

Chapter 23 Respect for My Life as a Person;
My Death with Dignity and Meaning

    I believe in the dignity of the human person.
And I define my own personhood as that period of life
when I have consciousness, memory, language, & autonomy.
If and when I cease to be a person according to these criteria,
then the proper respect for me as the person I used to be
would be to carry forward my wishes about bringing my life to a close.
This philosophy is expressed more fully in the appendix on personhood.

    Chapter 17 of this Advance Directive,
"The Conditions Under which I Request Death",
is another place where my philosophy of life and death will be found.

    I also include as a philosophical appendix my essay
"Ten Safeguards for Life-Ending Decisions".
I hope all 10 of these safeguards are fulfilled
in the death-planning process that draws my life to a close.

    I do not believe in an immortal soul.
Rather I believe in the human spirit.
The capacities of our spirits emerge gradually
as we become more fully persons:
self-awareness, altruism, self-transcendence, freedom,
creativity, love, awareness of our Existential Predicament,
and glimpses of joy and fulfillment.
These are explored more fully in my small book
Spirituality for Humanists: Six Capacities of Our Human Spirits.
[Minneapolis, MN: www.existentialbooks.com, 1995—second edition]

    I believe these capacities of spirit gradually disappear
if we have a slow decline into death.
In short, our spiritual capacities depend on our human minds.
As our brains deteriorate, we lose our former spiritual capacities.

    If I am unconscious for some period before I am declared dead,
the end of my life as a person of spirit
can be confidently dated as the last day I was conscious.
There is no way to save my spirit
except by saving my brain and its functions as a mind.

    Thus respect for the person I was
should not take the form of an exaggerated respect for my body
after I have become a former person,
after I have entered a persistent vegetative state,
after I have become permanently unconscious, or
after my body shows no further signs of life.

    I will be happy to be remembered as the person I was,
including the spiritual capacities I expressed during my life.
But I am quite confident that after consciousness has ceased
(and perhaps some time before the end of conscious life),
my life as a person of spirit will also be completely over—forever.

    People who believe in an immortal soul might be expected
to want to keep their bodies alive longer than I would
—perhaps because they believe
the soul wants to stay on earth as long as possible.
But such metaphysical beliefs do not apply in my case.
And I would never choose for myself any medical treatment
based on the assumption that I have an unkillable soul.

    As I continue to read, think, & write about these issues,
future editions of this Advance Directive for Medical Care
will include or refer to new statements that may have a bearing
on this philosophical section of my 'living will'.

    I expect those who care about me at the end of my life
to respect my wish to have a dignified and meaningful death,
not a drawn-out, losing struggle against biological collapse.
I want to be remembered as a living person,
who pursued meaningful projects during the best parts of my life.

    The last weeks or months of terminal care
and preparation for death should be a brief period of closure,
which should not detract from the meaning of my life.
I do not want to be kept 'alive' by whatever means possible
when my continued existence no longer serves my purposes as a person
—and no longer serves any purposes for other persons either.
When I have had as much meaningful life as possible
or when I rationally and compassionately choose to end my life,
please let me die.
 

Question 24. Are you ready to die now? If yes, explain.
If no, what preparations (practical, interpersonal, spiritual)
would make you more ready to die?
What projects do you wish to compete before you die?

Chapter 24 My Readiness for Death; Living Well to the End

    I have sought to live so that I gave my best time
to the most important projects of my life.
Because I have constantly reminded myself that I am going to die,
I have attempted to construct every day and every year of my life
around the goals and values that make my life meaningful.
In other words, living in the face of death
has enabled me to be ready for death at any time.

    When my life as a person comes to an end,
there will probably be many unfinished projects,
meaningful activities I could have completed with more time.
But because I have put my most distinctive talents
and meanings into action first,
the unfinished projects should be somewhere lower in my priorities.

    My encounter with colon cancer in 1993-94
has enabled me to focus my life a bit more clearly.
And because I have had a life-threatening disease,
I have had a dress-rehearsal of my coming death.
In my case, the practical problems of drawing my life to an end
were not entangled in the psychological-emotional
and spiritual problems often associated with dying.

    The 'fear of death' is really a complex of three phenomena:
(1) the practical and medical problems connected with physical dying,
(2) the psychological-emotional fear of ceasing-to-be, and
(3) ontological anxiety, which underlies the first two dimensions
and which is one way of experiencing our Existential Predicament.

    These three dimensions of the 'fear of death'
and my spiritual readiness for death are explained more fully in
"An Existential Understanding of Death:
A Phenomenology of Ontological Anxiety" ,
which is also the 9th chapter of my largest book,
Our Existential Predicament:
Loneliness, Depression, Anxiety, & Death .
[Minneapolis, MN: www.existentialbooks.com, 2001—fourth edition]

    I am alive now in every sense.
And I wish to continue living as long as my body
will support my mind and spirit.
I am involved in many meaningful projects and activities:
reading, thinking, writing, teaching, speaking, loving.
I hope to live well to the end of my life.
Living in the shadow of death helps me to live more meaningfully.
Because of my spiritual preparedness and because I am living well,
I hope to be ready to meet my death when it comes.

PART VII State Form and Legal Status

Chapter 25 The Minnesota Health Care Directive

    The following answers are given to conform to the Minnesota Form, 
as revised in 1998.
The preceding 24 chapters give more complete answers
to all of the issues raised in the Minnesota Health Care Directive.
And they will be referred to in my answers to this form.

    The Minnesota Health Care Directive
begins with the full identification of the person making the directive:
NAME: James Leonard Park
ADDRESS: 1816 Stevens Avenue South, Apartment 25;
Minneapolis, Minnesota 55430-3822
PHONE: 612-871-7275
DATE OF BIRTH: {omitted from this Internet version}
SOCIAL SECURITY NUMBER: {omited from this Internet version}

(See Chapter 1 for a full explanation of the scope of this Directive.)

 PART I: Naming An Agent 

    I have created a Medical Care Decisions Committee (MCDC).
Its members are named
and the powers and duties of this MCDC
are explained fully in Chapters 2 and 3 above.

PART II: Health Care Instructions
   
    My medical ethics and health care instructions
are contained in all of the chapters of this Advance Directive.
See the table of contents at the beginning for specific issues,
some of which are asked for here in the Minnesota Form,
such as pain control, life-prolonging treatments, 
when to write Do-Not Resuscitate orders,
the costs of my health care.

    The Minnesota Health Care Instructions Worksheet
also asks about religious and spiritual beliefs.
My comprehensive answers to these questions
are contained in Chapters 23 & 24 above.

    I discuss quality-of-life issues in Chapter 17.

    My preferred place and means of death
are discussed in Chapters 8 & 9.

    My wishes about organ donation, etc.
are discussed in Chapters 20 & 21.

PART III: Making This Document Legal

    This document is made a legally-enforceable directive
by the signature and witness page below.

Chapter 26 Legal Status of this Advance Directive for Medical Care

FOUR LEGAL FOUNDATIONS FOR THIS ADVANCE DIRECTIVE

    1. The Minnesota health care directive statute,
Minnesota Statutes 145C,
grants the authority to make such an Advance Directive.
And the requirements of that law are fulfilled in Chapter 25.
This law also grants immunity to any medical personnel
who follow an Advance Directive in good faith.
It is the intent of this comprehensive Advance Directive
to extend that immunity to any and all actions requested herein,
which may not be explicitly covered by the Minnesota statute.

     2. Common law is that large body of legal precedents
based on court decisions and long-recognized rights
that have been in force for centuries in those countries
that began with the English common law as their system of civil order.
The most relevant common law principle for this Advance Directive
is the right to refuse any and all medical treatments.
Even before the states began to pass 'living will' statutes,
the patient-physician relationship was voluntary from both sides.
This meant that each patient had the right to accept or refuse
any treatment offered by members of the medical profession.

    Almost all states now have 'living will' statutes.
But they differ in detail from one another.
And the state legislatures always have the power to change such laws.
But state laws cannot take away
the rights we, the people, already have under common law.

    Thus this Advance Directive is valid in every state
—first on the basis of what that state has in its statutes
and second on the basis of common law.
Where my Advance Directive goes beyond the specific provisions
of any state law, it depends on the common law—and the US Constitution.

    3. The Constitution of the United States has been found
to guarantee the right to privacy to all persons living in the USA.
The right to privacy was the basis the US Supreme Court used
to overturn state laws banning or controlling abortion.
And Federal courts are now beginning to overturn state laws
that formerly controlled the right to die,
such as laws against assisting and aiding a suicide.

    4. The Constitution of the State of Minnesota
may also be found to be a relevant basis of the rights
articulated and claimed in this Advance Directive for Medical Care.

IMMUNITY FOR MEDICAL PERSONNEL

    By writing and signing their statements of agreement,
the members of my MCDC agree to all the terms of this 'living will'.
And they extend immunity to doctors and other medical personnel
who follow this Advance Directive and the choices made by my MCDC,
even if that immunity is not explicitly contained
in the law of the state in which any medical decisions must be made.
No other persons have any right to sue on my behalf,
so the approval of my MCDC for any medical treatment
or termination of treatment grants unchallengeable permission,
with immunity from all civil and criminal actions
for persons acting in good faith.

    The 5 people who make up my Medical Care Decisions Committee
are the only persons who have any legal standing to sue on my behalf
for non-compliance with this Advance Directive
or for any malpractice associated with my medical care.
All others who may claim standing to make a civil or criminal complaint
are hereby explicitly excluded from any such rights
to sue or to complain in my name or in the name of my estate.

SEPARABILITY

    If any part or parts of this Advance Directive are found to be
invalid, illegal, impossible, inoperative,
incomprehensible, or otherwise non-applicable,
the rest of the document remains in force.
In other words, if some section or request is not possible to fulfill,
my whole Advance Directive is not thereby invalidated.
My Medical Care Decisions Committee is still empowered
to carry out my wishes to the best of their abilities.

    For example, if this Advance Directive is challenged
because it goes beyond or contradicts
some provision of Minnesota Statute 145C
---the Minnesota Health Care Directive Law---
the powers of my Medical Care Decisions Committee
remains valid under the common law, the US Constitution,
and the Constitution of the State of Minnesota.
No matter what laws might be changed in the future,  
this Advance Directive remains my explicit instructions
to my agent concerning how medical decisions should be made for me
when I am not able to make medical decisions
or when I cannot express my wishes.

[signature and witnesses page]
 

    I, James Leonard Park, am the sole author
of this Advance Directive for Medical Care, which comprises 47 pages.
It is a full and true representation of my views on my medical care
as of this date.
I retain the right to revise or revoke any part of this Advance Directive,
while I remain a person capable of making medical decisions.
I have signed this 'living will'
in the presence of the witnesses signing below.
 
 
 

Signed                                                               Date
 

_____________________________________________ _________________
 
 
 

Witnesses:
 

    I certify that the declarant voluntarily signed this declaration
in my presence and that the declarant is personally known to me.
I am not named as a proxy by the declaration,
and to the best of my knowledge, I am not entitled to any part
of the estate of the declarant under a will or by operation of law.
 
 
 

Signature of witness
 

_____________________________________________________
 

Address of witness
 

______________________________________________________
 
 
 
 
 
 
 

Signature of witness
 

______________________________________________________
 

Address of witness
 

________________________________________________________
 

Appendix A: Statements of Agreement
from the Members of My Medical Care Decisions Commitee

    I _________________, agree to serve as a member of James Park's
Medical Care Decisions Committee as described in his Advance Directive.
I have read and discussed this documented dated _____2004.
I agree to carry out the provisions contained therein to the best of my ability.
And I further agree to grant immunity
from any and all civil actions or criminal complaints
to any and all medical personnel who follow the instructions given by me
as a member of James Park's Medical Care Decisions Committee.
 

Signed _______________________________ Date ____________________ 

[It would be even more powerful and impressive if each member of my MCDC

were to write his or her own individualized statement of agreement and support.

I could provide a separate page for each of the 5 members.]
 

[I will also try to get the doctor who will take charge of my terminal care

to write and sign a similar statement

agreeing to carry out my Advance Directive for Medical Care.]

     As indicated at the beginning of this 'living will',
an updated version of this Advance Directive is available in
Your Last Year: Creating Your Own Advance Directive for Medical Care.