PROTECTING PATIENTS FROM
FAMILY PRESSURE TO DIE
WHEN EXTENDED DYING BECOMES A BURDEN TO THE FAMILY
The right-to-die
might sometimes become the duty-to-die
when the family of the patient is also suffering thru
a long, drawn-out process of the patient dying.
If the patient is still aware of his or her impact on others,
the patient might worry that prolonged dying
has become a burden
not only to the patient himself or herself
but also a burden to
other family members.
Sometimes families abandon their dying
relatives.
They stop visiting the dying 'loved one' in the hospital.
Or they visit less frequently and stay for shorter periods of time.
Dying can become an emotional burden for the family
as well as for the patient.
And especially if the dying patient is being cared
for at home,
the daily problems of taking care of that person (or former person)
can become overwhelming, especially for an elderly spouse.
There can be a serious tension between
the desire to care for the dying person
and the desire to end the whole ordeal.
Sometimes the family care-giver needs a long rest.
And sometimes it will be a genuine relief
for the care-giver to be able to resume the rest of his or her life.
Even when such burdens are not explicitly
acknowledged,
they should be taken into account.
The family members might all say how wonderful it is
to be able to care for their dying relative.
But deep within their own emotions,
they know that it is also a burden.
Observers should never ignore the burden
dying relatives represent for family members.
However, sometimes the family members become explicit
about their desire to bring the dying process to an end.
They ask the doctor what could be done to shorten the process.
When they are called upon to make medical decisions,
they might be observed to favor the options
that will bring death sooner
rather than later.
THE DANGER OF A 'SUICIDE PACT' BETWEEN LIFE-PARTNERS
Sometimes undue influence takes the form of a
'suicide pact'
between two members of a couple, perhaps a long-time married couple.
When one of them is clearly dying, the other one might agree
to die at the same time
in order to avoid the grief of surviving.
They make a plan to end their lives together,
at the same time, in the same place, and by the same means.
If each partner independently had good reasons to
die,
then this might not be an example of family pressure to die.
But quite often one spouse is healthier than the other
and could physically go on living for a number of years
after the death of the less-healthy spouse.
In heterosexual couples, the man is often the dominant partner.
And he might be the one who convinced his wife
that it would be best for them to die together.
It is nevertheless possible that both persons have
good reasons
to end their lives at about the same time.
And if both voluntary deaths could be approved
by the death-planning process that fulfills the safeguards listed below,
then—in
the considered judgment of several other persons—
a
joint decision for voluntary deaths would be a wise choice.
If each proposed death would be a wise choice at
this time,
then the fact that they can avoid
the additional psychological suffering of bereavement by dying together
would be an additional positive
factor.
One of the major reasons for having any rational choices of death
is to avoid further suffering.
The grief of surviving
a long-time partner
is an additional form of psychological suffering
that can be a legitimate factor in the death-planning process.
(The possible
financial motives are discussed in another worry:
PROTECTING PATIENTS FROM GREEDY RELATIVES:
http://www.tc.umn.edu/~parkx032/SG-GREED.html
And the general problem of discriminating against dependent patients
is discussed here:
PROTECTING VULNERABLE PATIENTS FROM DISCRIMINATION
http://www.tc.umn.edu/~parkx032/SG-VUL.html)
PROTECTING
AGAINST FAMILY PRESSURE TO DIE
Careful safeguards can help to prevent
premature
deaths motivated by family fatigue.
The safeguards that would counter-balance
the desire to get rid of a burdensome relative
call for the considered judgments of neutral persons
who are not burdened on a daily basis by caring for the dying patient.
Sometimes it will be wise to remove the patient
from the daily care of the family
in order to separate the burden
of caring
from the process of deciding what
is best for the patient.
A nursing home might be a better place for the patient to live.
And a hospice program might dramatically reduce family problems.
In many cases, a new living situation with professional support
would be a better option than choosing immediate
death.
And when there is danger of irrational suicide for
one partner of a couple,
some serious thought can be given concerning how to help the surviving
spouse
to continue living after the death of the loved one.
If both partners are nearing the ends of their lives,
the death-planning process should evaluate
the reasons for choosing death for each partner independently.
In other words, the safeguards for life-ending decisions
should be applied to each
patient
without regard to how the other
patient fulfills the safeguards.
If both fulfill the safeguards intended to prevent premature death,
then simultaneous voluntary deaths or merciful deaths could be approved.
Or it might be a merciful death for a partner in a coma
alongside a voluntary death for the partner who can still make medical
decisions.
Whenever there is danger of an irrational 'suicide
pact'
—which
means that one partner would suffer a premature death—
then the safeguards that call for evaluation by persons
who can see beyond the dependence on one spouse on the other
will become even more important.
For example, would their clergy-person approve of both dying together?
Would the prosecuting authority agree that no crimes will be committed
if the joint deaths are carried forward as planned?
Many of the following safeguards call for the
opinions of people
who are not involved in the daily care of the patient(s).
They can be aware of the danger of pressure from the family.
Here
are ten safeguards that will be most effective
against
family fatigue and manipulation by a dominant spouse or partner,
listed in order of effectiveness, beginning with the most powerful.
The
blue title leads to a
complete explanation of that safeguard.
The red comments explain
how that safeguard
deals with the specific problem of family pressure to die.
THE PATIENT
MUST BE CONSCIOUS AND ABLE TO ACHIEVE DEATH
If both partners are conscious and able to make
life-ending decisions,
then they can evaluate for themselves the wisdom of choosing
simultaneous deaths.
The fact that the patient himself or herself takes the final
life-ending action
is not absolute proof that this will be a wise death,
but a conscious choice is strong evidence that this is the best time to
die.
REPORT TO THE
PROSECUTOR BEFORE THE DEATH TAKES PLACE
The office of the prosecutor has experience in
looking for hidden
motives.
When a plan for two people
to die together is offered,
the prosecutor will carefully look for the possibility
that one partner is manipulating the other.
And any experienced prosecutor can look carefully
for any other forms of family pressure to die.
CIVIL AND
CRIMINAL PENALTIES FOR CAUSING PREMATURE DEATH
If one of the life-partners is really being manipulated into death,
then the existence of sanctions
might encourage all who are cooperating in this plan
to make sure that both deaths are wisely chosen.
Anyone who exerts undue pressure to cause another to die prematurely
should be subject to all appropriate civil and criminal penalties.
A
MEMBER OF THE CLERGY APPROVES OR QUESTIONS THE CHOICE FOR DEATH
If a member of the clergy has approved a joint
decision to die at the
same time,
this will be strong evidence for more distant observers
that both deaths were independently justified.
And if a clergy-person approves any other life-ending decision,
this would be further evidence that this death was wisely chosen,
not the result of undue family pressure.
REQUESTS FOR
DEATH FROM THE PATIENT
When both partners make independent requests for death,
each request can be evaluated on its own merits.
Is any alleged request for death really the result of family pressure
to die?
INFORMED
CONSENT FROM THE PATIENT
Likewise fully-informed consent should be obtained from each patient.
And sometimes this question should be discussed privately,
away from any possible family pressure to die.
UNBEARABLE
SUFFERING
The question of suffering can be raised
independently for the two
patients.
If both request death for good reasons,
then choosing the same means and timing of death
might be approved by others.
In every case, the suffering of the patient
must be separated from the suffering of the family.
PHYSICIAN'S
STATEMENT OF CONDITION AND PROGNOSIS
And, of course, any
physicians statements about condition and prognosis
will be issued specifically for each patient.
And just as a physician might have two unrelated patients
dying at the same time,
it is quite possible that two partners
might be coming to the end of their lives at approximately the same
time.
The objective facts about any patient
can be evaluated quite apart from family wishes.
ETHICS
COMMITTEE REVIEWS THE LIFE-ENDING DECISION
An institutional ethics committee will review each
case independent of
the other.
If they agree that wise life-ending decisions are being made for both
patients,
the ethics committee can approve their coordinated dying.
If only one patient has sufficient reasons for choosing to die now,
the ethics committee will not
approve the immediate death of the other
partner.
And the ethics committee can be more dispassionate about the facts
than the family members.
If an institutional ethics committee approves of the life-ending
decision,
then any such decision was probably not the result of family pressure
to die.
STATEMENTS FROM
ADVOCATES FOR
DISADVANTAGED GROUPS
IF INVITED BY
THE PATIENT AND/OR THE PROXIES
Also if either patient has chosen such an advocate,
then a written statement from someone chosen to prevent discrimination
will make sure that no foolish life-ending decisions
are being made for any patient.
And the additional approval of this special advocate
should go a long way toward convincing others
that this was not a chosen death primarily motivated by family pressure
to die.
In very
difficult cases of proposed joint deaths,
some of the other possible
safeguards might clarify the situations.
It is better to examine the proposed deaths
thru too many safeguards
than thru too few.
Whenever it is likely that family pressure will be a factor,
then bring in more neutral observers,
who can reach a reasonable conclusion free of family pressure.
created February 24, 2007; revised
3-11-2008; 8-30-2008; 11-5-2008; 12-9-2008