RECOMMENDED SAFEGUARDS (A-Z),
CAN BE APPLIED SELECTIVELY
FOR ANY LIFE-ENDING DECISION
Even in situations where no safeguards are required
or suggested by law,
individuals faced with end-of-life choices
might want to apply some of the following recommended safeguards
as a way to make sure that a decision to end someone's life
is a wise and compassionate
rather than some kind of mistake that would result in a premature
For example, if we are required to make
life-or-death decisions for a retarded member of the family,
we will clarify our options
by applying the safeguards discussed below.
When we ask others for their personal and professional opinions,
we are more likely to make
These safeguards are offered as a method for examining all options
near the end of someone's life.
Almost all are non-technical and can be applied
by ordinary people.
These are not
setting up a complicated bureaucracy to review end-of-life decisions.
No death panels are mentioned.
Rather, the application of these 26 recommended safeguards
will call upon the personal and professional opinions
of perhaps two
dozen people for any specific end-of-life situation.
We can also apply these safeguards in the last year
of our own lives.
Perhaps when we are dying,
our thinking might be distorted by our terminal disease or condition.
We will probably have complicated feelings as we face our own deaths.
Therefore, we might want to use some of the safeguards below
to make certain that we are wisely choosing voluntary death
rather than foolishly considering irrational suicide.
And if we are reviewing the plans for the last year
of someone else's life,
the same safeguards can help us to separate
a merciful death
for a friend or relative from a mercy-killing.
Each of the following 26 proposed safeguards for
is linked to a more extensive explanation of how to use that
If we wish to apply a specific safeguard
to an end-of-life situation we are currently considering,
we will probably want to read the more detailed presentation.
FOR MEDICAL CARE
A written statement explaining the patient's
philosophy of life and death
is probably the most basic document for making end-of-life decisions.
Life belongs to each individual patient.
His or her settled values
should shape all medical decisions.
For an overview of what a comprehensive Advance
Directive should cover,
Directives for Medical Care: 24 Important Questions to Answer.
Once the patient has created an Advance Directive
for Medical Care,
he or she will share the Advance Directive with significant others,
chosen as proxies.
And they should create brief statements
expressing their agreement with
the Advance Directive
and (if they are proxies) their commitment to carry forward
values of the patient.
DEATH FROM THE
The patient owns his or her own life and death.
Whenever the patient is still capable of making medical decisions,
any and all serious requests for death should be recorded,
stating the date, time, circumstances, & witnesses.
The patient should also explain why he or she thinks
death at the chosen time
would be better than death
at some later time.
Such requests for death might lead to creative discussions
among all the people concerned with this patient's life and death.
If the patient is no longer capable of making
the duly-authorized proxies then have the power and responsibility
to make any reasonable requests for death on behalf of the patient.
See Safeguard K
below: Requests for Death from the Proxies.
ABILITY TO MAKE MEDICAL DECISIONS
If there is any doubt about the patient's
mental capacities to make medical decisions
decisions that will terminate his or her life—
then the patient's decision for death should be evaluated
by a licensed psychologist or
OF CONDITION AND PROGNOSIS
The most important document created by a medical
will be the physician's summary of the patient's condition and
In order to avoid any confusion, ambiguity, or misunderstanding,
this statement should be put
as well as explained to the satisfaction of those who must decide.
PHYSICIAN REVIEWS THE CONDITION AND PROGNOSIS
Whenever making life-or-death decisions,
it is always wise to seek a second, independent, professional opinion.
This second opinion might be sought from a specialist
in the disease or
condition from which the patient is possibly dying.
If there are differences in these professional opinions,
any such uncertainties should be resolved by further investigation
before the plans for death proceed.
OF TERMINAL ILLNESS OR INCURABLE CONDITION
Even tho the patient need not be in a terminal
condition to request death,
if the disease or condition is likely to lead to death,
the same physicians who have written
the full statements of the
patient's condition and prognosis
might also create a separate document to certify terminal illness
if the patient is likely to die within the next 6 months.
Or such certification could be included in the doctors' other
Certification of terminal illness should specify
whether the projected period of survival includes
life-supports or not.
An important question for any life-ending decision
is whether the patient is suffering in some way that cannot be relieved
and which the patient
Such physical suffering can be explained and documented
by the doctors who are called upon to treat the suffering.
The patient might also be suffering emotionally.
Only the patient can ultimately decide whether such suffering is
But professional efforts to alleviate the mental suffering
should also be documented.
Psychological suffering can be evaluated by both family and doctors.
And if the psychological suffering is so great
as to make the patient incapable of making wise medical decisions,
then the power to decide passes to the authorized proxies.
The proxies will make any life-ending decisions:
Is death now wiser
than death later?
The actual application of comfort care
by medical professionals well trained in the care of the dying
will help to decide which is the wisest course of action.
Sometimes physical and psychological suffering can be so reduced
that the patient and/or proxies no longer believe
that death is the best
choice at this time.
However, in some obvious cases, palliative care
would be useless.
But at least the patient and/or proxies should be
about the benefits of palliative care
and even consult with a palliative-care specialist.
CONSENT FROM THE PATIENT
The patient must have full information
about his or her condition
and all the possible medical treatments that still remain
When the patient has received and understood the medical statements
from the doctors concerning
condition and prognosis,
the patient is empowered to make wise end-of-life choices.
FROM THE PROXIES
If the patient can no longer make
meaningful medical decisions,
then the decision-making power shifts to the proxies,
who have been carefully chosen by the patient
when the patient was still fully able to make all medical choices.
The proxies shall carefully consider all of
the medical facts,
taking into account the opinions of everyone legitimately concerned.
Then the proxies can
decide to make requests for death
in exactly the same ways as such requests were possible
for the patient.
HOSPITAL OR HOSPICE
If the patient is
being treated in a hospital
or receiving terminal care in a hospice program,
any such medical institution will keep careful records
discussions and decisions regarding the care of the patient,
including all explorations of end-of-life choices.
Terminal-care professionals deal with life-ending decisions frequently.
They will not support a premature death.
HOSPITAL OR HOSPICE STAFF MEMBERS
The nurses, doctors, & volunteers who know the
can also create statements
about their discussions
with the patient about end-of-life choices.
Do those who see the patient every day agree with the life-ending
AFFIRMING OR QUESTIONING CHOOSING DEATH
Other persons who
have known the patient for meaningful
periods of time
either agree with the life-ending decision
or question the wisdom of ending the patient's life now.
Even tho these significant other persons might not be directly involved
in the process of making any life-ending decisions
and they will not be responsible for carrying out any terminal choices,
they know of
plans for death well in advance.
And they create written statements either affirming the choice of death
or questioning the wisdom of the end-of-life plans.
What are their considered opinions about the proposed death?
O. A MEMBER
APPROVES OR QUESTIONS CHOOSING DEATH
A member of the
clergy of any religious organization
or the professional leader of an ethical
known by the patient approves or questions the life-ending
If the patient is not part of any such
another similar responsible member of the
might fill this role of neutral
OR OTHER MORAL PRINCIPLES
APPLIED TO THIS
If chosen by the patient, some person (or persons)
with expertise on the doctrine
and/or medical ethics
of the religious organization with which the patient is
could review how those moral principles apply to the
being considered by the patient and/or the proxies for
interpretation of the principles supports a life-ending
such as the withdrawal of life-supports when they are useless,
then a written statement to that effect could be included in the record.
If the religious principles would not support a life-ending
under the current circumstances, such a statement should be included.
If chosen by the patient and/or proxies, some non-religious moral
could be brought to bear on the end-of-life choices.
ETHICS COMMITTEE REVIEWS THE PLANS FOR DEATH
committee of the institution where the patient is being cared for
reviews all of the documents created for the
and approves or questions any life-ending decisions.
The ethics committee should meet with the patient and/or the proxies.
If there is no ethics committee,
a private ethical consultant
can review the plans for death.
R. STATEMENTS FROM
IF INVITED BY
THE PATIENT AND/OR THE PROXIES
If any patients worry that they might be discriminated
because they are members of any group sometimes
disfavored by society,
they can select advocates from their own
who will review the death-planning documents
to make sure that no
discrimination has taken place
because of the group-identity of the patient.
Adding any such statements to the death-planning record
will assure others who are not as close to the patient
that the life-ending
decision was as free as possible from discrimination
and that the patient received terminal care independent
PROSECUTOR BEFORE THE DEATH TAKES PLACE
If those who are considering end-of-life options for
have any doubts about the legality
proposed course of action,
they can opt to send a report of
the death-planning process
to the local
prosecuting authority for review.
They should explain their proposed course of action:
Which pathway towards death is being chosen for this patient?
And the several documents of the death-planning
process already created
might be shared or summarized for the prosecutor
to show that the proposed course of action
violates no laws.
The prosecutor should be
allowed one week to respond.
He or she might reply that the planned death will not harm the
and that all who participate or cooperate in the death as planned
will not be subject to
prosecution for any crime.
Or the prosecutor could ask for additional
to make sure that this death will
If the prosecutor always automatically says "no"
to any proposed life-ending decision,
that prosecutor should be re-educated about end-of-life law.
AND CRIMINAL PENALTIES FOR CAUSING PREMATURE DEATH
Court systems exist all over the Earth
for the purpose of trying potential criminals for possible
And every legitimate life-ending decision
might be distorted by criminal or monetary motives.
Thus civil and criminal procedures and penalties must remain in place
in order to discourage (and perhaps punish) any people
who cause premature death disguised as a legitimate end-of-life
Without careful safeguards, 'pulling the plug' might
actually be a harm.
If only a few people are involved in a proposed ‘voluntary death’,
it might actually be closer to a coerced or manipulated death.
And fulfilling careful safeguards will separate valid merciful deaths
from the dark and harmful mercy-killings that are
all too common.
criminal penalties will remain in place.
Anyone tempted to encourage or cause a premature death
should know that they might be punished
if they harm anyone by making a life-ending decision.
PERIODS FOR REFLECTION
Appropriate periods for further reflection are needed
between the time when the first
life-ending decision is made
and when the final
(a) one week for the
withdrawal of life-support systems,
(b) one year for a voluntary
(c) six months for a merciful
These waiting periods may be adjusted when adequately explained
by the special circumstances of the specific patient.
Spreading the end-of-life discussions over significant
periods of time
encourages all concerned to re-think
FOR THE PATIENT TO RESCIND OR POSTPONE ANY LIFE-ENDING DECISIONS
If the patient has already
begun the death-planning process,
opportunities shall be provided
for the patient to change his or her
The people offering these opportunities shall
that the patient had several occasions to change the plans for death.
Does the patient decline each opportunity to
and reaffirm his or her determination to choose death?
REVIEW THE COMPLETE DEATH-PLANNING RECORDS
Once most of the other statements have
the physicians most responsible for the patient's
will read and
respond to each statement
make a final recommendation.
In some cases, more than one physician will review the plans for death.
RECORDING AND SHARING OF ALL MATERIAL FACTS AND OPINIONS
The death-planning process
should be completely open.
statements of all persons involved
shared freely among everyone who has a
to take part in (or to know about) this end-of-life discussion.
The fact of such open sharing and discussion
—with signed and
recorded opinions from many
should ensure that the process leads to a
—not a hidden or secret conspiracy that might cause a premature
PATIENT MUST BE CONSCIOUS AND ABLE TO ACHIEVE DEATH
If the patient (1) remains conscious until the last
moment of life
and (2) takes some life-ending action by his or her own hand,
these will be strong reasons to believe that this was a timely death.
But remaining conscious and capable to the end should not be required.
DEATH-PLANNING COORDINATOR ORGANIZES THE SAFEGUARDS
the process of planning the patient's
employs a death-planning
or if someone volunteers to organize the death-planning
this level of organization for planning this death
will be impressive evidence that the chosen death is a
And the complete collection of death-planning documents
can be permanently stored in case there is ever any
to review these end-of-life discussions.
records shall not be made available to the public
or to any government officials
(except as might be required by law-enforcement
or to any news-gathering organizations.
This list of 26 recommended safeguards
is organized in a different way in an on-line essay named:
"A New Way to Secure the Right-to-Die:
Laws Against Causing Premature Death":
This essay organizes the safeguards according to who
is primarily responsible
to fulfill each specific safeguard:
SAFEGUARDS TO BE
AND OTHER PROFESSIONAL CONSULTANTS
SAFEGUARDS TO BE FULFILLED BY THE
SAFEGUARDS TO BE FULFILLED BY
PROXIES FOR THE
AND/OR FAMILY MEMBERS
SAFEGUARDS TO BE FULFILLED BY
MEMBERS OF THE CLERGY
SAFEGUARDS TO BE FULFILLED BY THE
SAFEGUARDS TO BE FULFILLED BY THE
The number of
different people who would be involved
in such discussions of end-of-life
choices is estimated here:
"The Number of People Reviewing a Life-Ending Decision
Using the 26 Recommended Safeguards":
A Safeguards Group, consisting of people from all
over the world,
has reviewed these safeguards—one
safeguard each week—
ending in August 2008.
(And these safeguards have been continuously reviewed and revised since
The Safeguards Group next explored a few other safeguards
which have been suggested by the right-to-die movement.
Then they discussed the possible abuses
raised by opponents of the right-to-die.
More information about this Safeguards Group
will be found on
the opening page of the Safeguards Website:
The archives of
this on-line Safeguards Group
illustrate how each safeguard was
Further comments and suggestions for revising these 26 proposed
should be sent to the webmaster:
James Park: e-mail: PARKx032@TC.UMN.EDU
If you would like to read a shorter summary of the
most important safeguards,
go to "Fifteen Safeguards for Life-Ending Decisions":
12-31-2007; Revised 1-6-2008; 1-10-2008; 1-20-2008; 2-5-2008;
3-15-2008; 4-4-2008; 4-16-2008; 5-22-2008; 7-9-2008; 7-31-2008;
8-14-2008; 8-24-2008; 9-9-2008;
6-6-2009; 2-5-2010; 2-11-2010; 5-19-2010; 5-27-2011; 12-17-2011;
1-4-2012; 1-28-2012; 2-3-2012; 2-22-2012; 3-22-2012; 7-28-2012;
8-17-2012; 10-18-2012; 5-1-2013
Go to the Catalog
for Life-Ending Decisions.
This catalog includes the 26 recommended safeguards above,
plus a few more.