PROTECTING PATIENTS FROM
BEING PUT TO DEATH WITHOUT AUTHORIZATION

    Critics of the right-to-die as practiced in the Netherlands
often point out that a certain percentage of deaths facilitated by doctors
are recorded as "without explicit request".
This could be interpreted to mean that Dutch doctors
are taking it upon themselves to decide
which patients should be given lethal injections
and which patients should not.

    And if there are a few cases of patients in a coma
being given drugs that will cause death,
such cases should be investigated more deeply.
Perhaps some premature deaths were caused by these physicians.

    If death is achieved without proper authorization,
then a crime has been committed under almost any country's law.
And where such crimes are happening,
better safeguards are needed
to prevent any further unauthorized deaths.

    Other countries need not follow the pattern of Holland.
If there are problems created by the Dutch system,
then these can be corrected when other countries
(or any states of the US or Australia)
create new laws concerning the right-to-die.

    However, what was most likely happening
under this category of "without explicit request"
was that patients had already discussed their desire to die
if and when there was no hope of recovery.
But the patients waited too long:
When they had already passed into a semi-conscious state
or a completely unconscious state,
they could no longer give explicit permission for their own deaths
at the exact moment that their death were to be achieved.

    Also, the family members of these patients
were probably also consulted to see if they agreed
that a peaceful death achieved by drugs given by the physician
would be better than letting nature take its (sometimes long) course.
Perhaps Dutch law does not explicitly allow such proxy decision-making,
but we can all see the value of allowing such decisions
under safeguards that make sure that no harm
is being inflicted upon the patient who will soon be dead.

    Especially when the patient has given explicit prior authorization,
there should be no barrier to the duly-authorized proxies giving their approval
if the patient has slipped past the point
of being able to make a meaningful life-ending decision.

    The worry here seems to be that some doctors or government bureaucrats
will decide that certain patients should die.
They look at a list of patients and mark some of them for death.
This could be the most basic meaning of
'putting patients to death without authorization'.

    The way to prevent such behavior is to make clear
exactly who has the authority to make life-ending decisions.
Several safeguards for life-ending decisions
explicitly address this question of making decisions at the bed-side.

    A good set of safeguards would prohibit all unauthorized decisions for death
while at the same time setting forth careful procedures
by which patients and/or their proxies can make wise life-ending decisions.

PROTECTING PATIENTS FROM BEING PUT TO DEATH WITHOUT AUTHORIZATION

    The following 22 safeguards make sure that the proper decision-makers
are identified and empowered to make the life-ending decisions.
And they exclude people who should not have any power to put strangers to death.

    These safeguards are arranged
with the most powerful and meaningful at the beginning.
The blue title leads to a complete explanation of that safeguard.
The red comments explain how that safeguard deals with the specific danger
of patients being put to death without proper authorization.

KEEPING GOVERNMENT OFFICIALS, THE MEDIA,
            & OTHER STRANGERS OUT OF THE LOOP

    Because strangers are the most likely
to approve of the deaths of people they do not know,
all such government officials, media employees,
and others who have no right to review private medical records
should have no role in making life-ending decisions—or trying to prevent them.

ADVANCE DIRECTIVE FOR MEDICAL CARE

    The patient whose death is being considered is the central decider.
He or she will have set forth in writing his or her principles of medical ethics
as they apply to his or her life and death
in an Advance Directive for Medical Care.
As completely as possible, the patient will have spelled out
the conditions under which death would be the best choice.
In short, an Advance Directive authorizes wise life-ending decisions.
When the prescribed conditions are met,
then carrying forward the plans for death
will not result in a premature death.

REQUESTS FOR DEATH FROM THE PATIENT

    And when the patient makes an explicit request for death
under the terminal conditions as they have emerged,
then there is even less reason to believe
that this death might have been decided without proper authorization.

INFORMED CONSENT FROM THE PATIENT

    When the patient gives informed consent for his or her death,
could anything be more obvious?

UNBEARABLE SUFFERING

    The patient might have explained the exact nature of the suffering
that is leading him or her to choose a specific pathway towards death.

UNBEARABLE PSYCHOLOGICAL SUFFERING

    And psychological factors are also relevant for the patient to use
in deciding when would be the best time to die.
When the patient has explained these reasons
for choosing death now rather than death later,
he or she gives authorization for the life-ending decisions.

THE PATIENT MUST BE CONSCIOUS AND ABLE TO ACHIEVE DEATH

    And if the patient remains conscious to the last moment of life
and able to take any necessary life-ending actions,
this would be dramatic proof that at least at that last moment
the patient really wanted to die.
The authorization is coming from the patient
—not from anyone else, anywhere.

PHYSICIAN'S STATEMENT OF CONDITION AND PROGNOSIS

    When a physician has created a written statement
of the condition and prognosis of the patient,
this is the medical background for any further decisions.
           
INDEPENDENT PHYSICIAN REVIEWS THE CONDITION AND PROGNOSIS

    And the fact that an independent physician has issued another statement
should go a long way toward overcoming any doubts
that this patient might be put to death without authorization.

HOSPITAL OR HOSPICE ENROLLMENT

    Deaths that occur in hospitals and hospices are well-documented.
The safeguards implicit in such terminal care
goes a long way toward assuring doubters
that the death was correctly chosen and authorized.

STATEMENTS WRITTEN BY HOSPITAL OR HOSPICE STAFF MEMBERS

    And when the staff people who cared for the patient at the end
have voluntarily added their own written statements,
this will show that they also approved the life-ending decisions,
based on their day-to-day knowledge of the condition of the patient.
Their cooperation shows that this death was wisely chosen,
not committed without proper authorization.

PALLIATIVE CARE TRIAL

    When the patient has actually experienced the benefits of palliative care,
this will show that terminal care was carefully provided.
There was no rush to cause a premature death.

CERTIFICATION OF TERMINAL ILLNESS OR CONDITION

    When there is careful certification that this patient has a terminal condition,
this is strong evidence that the basic reason for choosing death
was not some abstract decision imposed by a stranger.

PSYCHOLOGICAL CONSULTANT EVALUATES
           THE PATIENT'S ABILITY TO MAKE MEDICAL DECISIONS

    And a careful evaluation of the patient's abilities to make medical decisions
and the recording of the fact that the patient has actually decided to die
should assure any and all distant critics
that this was not an unauthorized, premature death.

REQUESTS FOR DEATH FROM THE PROXIES

    When the patient can no longer decide,
any terminal-care decisions must be made by the proxies.
Their recorded requests—along with their explanations of the need for death—
will be direct evidence against any claim of an unauthorized death.

STATEMENTS FROM FAMILY MEMBERS
            AFFIRMING OR QUESTIONING THE CHOSEN DEATH

    And family members who were not chosen as proxies
can also explain their reasons for supporting the life-ending decisions.
When it is known that family members also approved choosing death,
what basis might there be for claims of an unauthorized death?
STATEMENTS FROM ADVOCATES FOR DISADVANTAGED GROUPS
             IF INVITED BY THE PATIENT AND/OR THE PROXIES

    And when the patient belongs to an identifiable group
that has sometimes suffered discrimination in the past,
a special advocate might have been appointed to review the plans for death.
If and when this person appointed to protect against discrimination
also approved the plans for death,
then there is even less reason to suspect that this death was not duly authorized.

ETHICS COMMITTEE REVIEWS THE LIFE-ENDING DECISION

    An institutional ethics committee knows how to review plans for death.
Precisely because they are not emotionally involved with the patient,
they can be more objective about the reasons for choosing death at this time.
And they might notice any outside pressures
that could be rushing the patient into death.

A MEMBER OF THE CLERGY APPROVES OR QUESTIONS THE CHOICE FOR DEATH

    When it is known that a member of the clergy has reviewed the plans for death
and has reached the conclusion that death now is better than death later,
then this should be strong evidence that this death was not premature.

RELIGIOUS OR OTHER MORAL PRINCIPLES
            APPLIED TO THIS LIFE-ENDING DECISION

    And when the religious or other moral principles
have been explicitly applied to this life-ending decision,
any distant critics should turn their attention to other cases.
This death was chosen with the most careful attention to morality.
And the resulting written documents exist
if and when their might be a prosecution for any crime.
These documents exploring the morality
of this life-ending decision are never made public,
but the fact that they exist can be disclosed if that seems to be wise.

REPORT TO THE PROSECUTOR BEFORE THE DEATH TAKES PLACE

    When the people who are planning this death
have created a careful written record of their planning process,
they can summarize their methods for the prosecutor.
This public official is the one responsible for bringing any criminal charges
if and when there is good reason to believe
that some harm has been committed against the patient.
Once again, the death planning record is not made public.
But it might be disclosed that the prosecutor has reviewed the record
and decided that there is no reason
to object to the plans for death
or to open a criminal investigation.

CIVIL AND CRIMINAL PENALTIES FOR CAUSING PREMATURE DEATH

    And if ever some criminal conspiracy
has slipped past all of the above systems of review,
there is always the possibility of opening an investigation
after the death has taken place.
Civil and criminal penalties remain in place
as sanctions against anyone who participates
in a conspiracy to put someone to death without proper authorization.

    The above 22 safeguards should be entirely sufficient to prove
that a timely death was wisely chosen.
But there might be some special situation
in which one of the other 13 safeguards might be relevant to use.
See the complete catalog of 35 safeguards for life-ending decisions:
http://www.tc.umn.edu/~parkx032/SG-CAT.html
created March 1, 2007; revised 3-22-2007; 11-12-2008; 1-22-2009

Go to other dangers, mistakes, & abuses of the right-to-die.




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