SAFEGUARD
FOR LIFE-ENDING DECISIONS
REQUESTS FOR DEATH FROM THE PATIENT
Our advance directives will outline our general plans for
the
end of our lives.
And when we actually begin what will probably be the last year of our
lives,
we should expand our advance directives to explain
how our medical ethics apply to the new situation created
when we know what disease or condition is likely to end our lives.
This updated explanation of our plans for death
should refer to the doctors' statements of our condition and prognosis
and restate in our own words how we understand what is going to happen
to us.
If we have misunderstood our physical condition and its likely outcome,
then any request for death might be premature.
Such possible misunderstandings will be uncovered
when we explain our reasons for requesting death.
All reasonable requests for death must take into account
all of the established medical facts.
Our reasons for deciding to end our lives
under certain conditions
instead of waiting for a natural death
might have many factors that are not medical.
We can ask ourselves:
Are we ready to
die—emotionally, socially,
philosophically?
What last few things must be accomplished
before we will be ready to draw our lives to a close?
In many cases, our personal reasons for choosing death
will be more important than the medical facts.
And it will help those who care about us to understand our decision
if we state these personal factors explicitly in writing.
Our requests for death express in the
fullest
possible way
our personal autonomy and self-determination—our right-to-die.
In order to make sure that our requests for death are serious
they must be made formally
and in front of witnesses.
If we have lost the power to speak, our in-person requests
can be made by some other reliable means of communication.
We can mark "yes" or "no" answers to a series of written questions.
Or we can blink our answers to a set of questions
that require consistent answers to the same themes expressed in
different ways.
If we can still write, the witnesses will observe us writing in our own
hand-writing
or using some electronic means of creating words on paper
that make certain that the requests are coming from our free choices.
Such methods are intended to establish
that we are still functioning as persons who are capable of
making
medical decisions.
These in-person requests for
death
must be witnessed by neutral observers
who can swear that we were of sound mind when we answered
and that we did unambiguously request death.
Besides these requests made verbally (or by some
other in-person process),
there should be written requests for death that are signed and dated.
We are usually more serious about requests we put into
writing
and to which we attach our signatures.
All of our written requests for death should also have the names and
signatures
of the people who witnessed us creating and signing these requests.
Witnesses to such formal, written requests for death
are also affirming that they believe we were freely expressing
our well-informed
decision to choose a particular pathway toward death.
And there might be specific regulations about
who can be witnesses.
The general idea is to make sure that the requests for death
are really
coming from the patient
and were not influenced by undue pressure
from anyone who might have a personal reason for wanting the patient
dead.
Thus, usually employees of the health-care institution are not allowed
as witnesses.
And any people who might benefit financially
from the patient's death
are also not good witnesses.
The requests for death must also be separated in time
in order to make sure that it is not just a temporary response to a
sudden new situation.
This is the reason for waiting periods
between requests,
which are discussed here as a separate safeguard.
The patient's requests for death should be formal
and explicit,
explaining in the patient's own words the basic reasons for choosing
death.
Do these requests for death show that the patient is giving informed
consent?
And were these separate requests for death
repeated over
a sufficiently long period of time
to show that the decision for death is not temporary but persistent?
HOW FORMAL REQUESTS FOR DEATH FROM THE PATIENT
DISCOURAGE IRRATIONAL SUICIDE
AND OTHER FORMS OF PREMATURE DEATH
When the patient makes formal requests for death
both verbally and in writing,
then these requests are taken very seriously by all who are aware of
them.
When a patient is in despair or in pain,
such factors undermine
the validity of the request for death.
And persons who sometimes have suicidal urges
should be protected from themselves
until the irrational urge to kill themselves has passed.
Making sure that any requests for death are formal and serious
will go a long way toward preventing irrational suicides,
which are often impulsive
and capricious rather than well-planned,
which are not based on a
good grasp of reality,
which will harm the
patient rather than benefit
the patient,
and which others will regard as tragic and regrettable
rather than admirable and
commendable.
When a patient writes a suicide note,
this is not a qualified request for death.
And all who are aware of such self-destructive plans
should attempt to prevent irrational suicide.
Thus, those who receive the requests for death from the patient
are expected to evaluate the rationality of the choices expressed.
Other kinds of mistakes and abuses of the
right-to-die
will also be discouraged when the requests for death is put into
writing.
For example, when the patient feels pressure from family members
to choose a premature death,
the neutral witnesses to the requests for death
will question the wisdom of that 'choice'.
The witnesses should ask the patient to explain in his or her own words
why death at this time
is better than death at a later
time.
The purpose of this safeguard not merely to get some
signature on paper
but to facilitate a thorough
discussion of the pros and cons
of any particular pathway toward death.
It is sometimes too easy to get people of questionable capacity
to put their signatures on any paper that is put before them.
If the 'choice' would lead to a premature death
as perceived by any of the neutral observers and witnesses,
then they should not agree to witness that 'request for death'.
If the request for death is not rational, not based in well-proven
facts,
then this is an opportunity for all observers to prevent a premature
death.
Whenever doubts are raised anywhere in the process
of creating and witnessing requests for death from the patient,
these doubts must be resolved by deeper investigation
before any plans for death are carried forward.
Created January 2007,
revised 2-13-2007; 1-26-2008