FIFTEEN SAFEGUARDS
FOR LIFE-ENDING DECISIONS

SYNOPSIS:

    We cannot avoid death.
But most of us will make important decisions
in choosing our best methods of managing dying.
We might even shape our own life-ending decisions.

    Perhaps all curative treatments will be withdrawn
when such medical care no longer does any good.
If we are being maintained by any life-supports,
such tubes and machines can be disconnected.
Our doctors can even prescribe drugs to keep us asleep
until we die of natural causes.
And all means of providing food and water might be ended.

    However, each kind of life-ending decision is open to abuse.
This chapter proposes some practical safeguards
to prevent possible abuses of all life-ending decisions
while permitting appropriate and reasonable decisions for death.
How can we prevent premature death
while at the same time permitting wise end-of-life medical choices?

    The 15 safeguards below gather the considered opinions of the patient,
the doctors, the family, & any ethical consultants who might be involved
—including (possibly) members of the clergy.
Also there should be appropriate waiting periods, full reporting,
& the possibility of prosecution for those who violate the safeguards
—and as a result cause a premature death.

OUTLINE:

1.  Advance Directives and/or other Requests for Death from the Patient. 

2.  Informed Consent from the Patient and Unbearable Suffering.

3.  Psychological Consultant Certifies that the Patient is Able to Decide.     

4.  Doctor's Summary of Condition and Prognosis.                          

5.  Independent Doctor Confirms the Condition and Prognosis.  

6.  Hospital or Hospice Care.        
 
7.  Significant Others Agree with the Life-Ending Decision.

8.  Requests for Death from the Proxies.           

9.  Member of the Clergy Approves the Life-Ending Decision.            

10.  Statements from Advocates for Disadvantaged Groups.

11.  Ethics Committee Reviews the Life-Ending Decision.      

12.  Review by the Prosecutor (or other Lawyer) before the Death Takes Place.
      
13.  Criminal and Civil Penalties for Causing Premature Death.         

14.  Waiting Periods for Reflection.                         

15.  Complete Reporting of all Material Facts.  

    Note on links: Each of the safeguards introduced in this chapter
has a more extensive explanation on the Internet,
which is linked from the brief description here.



Fifteen Safeguards
for Life-Ending Decisions

by James Leonard Park

       In the 21st century, the style of our dying will change.
Human beings have faced death from the beginning of the human race.
And until recently, we human beings could do little to extend our lives. 
When our bodies wore out or we caught fatal diseases, we died
—just like all the other animals with whom we share the Earth. 

     But in the last 350 years—since the dawn of modern science—
we have gained ever more control over the ways we live and die.  
And now most deaths that take place in modern hospitals 
have some element of choice shaping how death occurs. 

     So we must think more deeply about life-ending decisions. 
Otherwise we will 'decide' by default,
which means allowing the standard operating procedures
of modern medicine to make our end-of-life decisions for us, 
based on generic medical principles we might not share.  


1.  Advance Directives
            and/or other Requests for Death from the Patient.

    All of us must eventually face our own deaths.  
If we have planned ahead for this eventuality, 
we will have created Advance Directives for Medical Care. 
And as we approach the last days of our lives,
we will know the likely causes of our deaths.   
And we can revise our plans accordingly.  

    We might even include explicit requests for death
when we deteriorate into conditions in which
dying now would be better than dying later.  
Any such requests for death should be in writing,
so that everyone who will be involved with our dying
will know our wishes—and the reasons for our choices.  


2.  Informed Consent from the Patient
            and Unbearable Suffering.

    Related to our requests for death
is the basis for these requests in our actual medical condition.
Our doctors have explained our problems and prognosis.
We have considered the available options for further treatment
and we have probably tried the most promising cures.
Only then can be give wise informed consent for death.

    It will help others to understand our life-ending decision
if we explain our suffering in our own words.
If we have physical suffering beyond what we can bear,
then this might be a valid reason for choosing death.

    Likewise, our suffering might be psychological or mental.
When we explain our unbearable psychological suffering,
others who read our explanations might agree with us
that choosing death is better than continuing that inward suffering.

3.  Psychological Consultant
            Certifies that the Patient is Able to Decide.

    If anyone doubts our mental capacity to make end-of-life decisions,
then a psychological professional can evaluate the whole situation.
This consultant will meet with us to make sure
(1) that we have considered all the reasonable alternatives to death,
(2) that we are making a fully-informed choice to end our lives,
(3) that we are not being coerced in any way to 'choose' death, &
(4) that we are not depressed by some bio-chemical imbalance.
This professional opinion should also be put into writing. 


4.  Doctor's Summary of Condition and Prognosis.

    Most of us will receive medical care at the end of our lives.
The doctor in charge of our care should write a summary
of our physical condition and the likely developments
under various options of treatment or non-treatment.

    Everyone involved with our end-of-life choices
should have access to these professional medical statements.



5.  Independent Doctor Confirms the Condition and Prognosis.

    When considering decisions that will bring the patient's life to an end,
a second professional opinion might be helpful.
And this second doctor must examine the patient in person,
not merely review the medical record and affirm the first doctor's opinion.
If this second professional recommendation differs from the first,
deeper investigations might be in order.  

6.  Hospital or Hospice Care.

    When we are seriously considering how to end our lives,
we are probably receiving some form of hospital or hospice care.
Good medical records are being maintained about our care,
including any reports from our doctors of treatments already tried
and new possibilities being considered.

    If we are approaching the natural end of our lives,
we might be receiving palliative care in some hospice program.
And if we decide to shorten the process of our dying,
being under hospice care shows that we tried symptom-control.

    If we have received care in medical institutions,
there will be staff members who can write their own statements
supporting our choice to die now rather than die later.



7.  Significant Others Agree with the Life-Ending Decision.

    The people who have known us for the longest time
—our closest relatives and friends—might review
the written statements from us and all our professional consultants.
Our family will know our values and understand our choices
better than the professionals who enter our lives only at the end.

    The people who have been closest to us during our lives
will have no veto power over our life-ending choices.
But all of their perspectives should be taken into account.  

    And if we have established a Medical Care Decisions Committee,
these persons especially should be asked for their written opinions.
These discussions among our proxies will become especially important
if we lose the capacity to make medical decisions ourselves.

8.  Requests for Death from the Proxies.

    If our disease, illness, or condition makes it impossible
for us to make our own requests for death,
then our duly-authorized proxies have all the same powers
to make medical decisions that we had during most of our lives.
Or if we requested death before we lost our decision-making power,
then our proxies can reaffirm our original decision
—now with even more reasons behind that decision
because we have deteriorated further in our process of dying.

9.  Member of the Clergy Approves the Life-Ending Decision.

    If we have some meaningful connections with organized religion,
we might call upon our religious advisors to join these discussions.
Once again, involving the clergy does not give them a veto.
But if they have been personally involved in our lives,
they should be able to give another valuable perspective
on our choice to end our lives now
rather than merely letting the standard operating procedures
of the doctors and hospital determine how our lives will end.

    If no formal religious leader knows us at the end of our lives,
we might think of some other respected member of the community
who has some meaningful personal connections with us
and who will not be too overwhelmed by the prospect of our death.
This other moral leader might be asked to give
an unbiased opinion about the plans for death.

    If our proposed death poses some difficult moral questions,
we and/or our proxies might ask for
moral analysis from religious or other moral thinkers.
Any relevant writings could be added to our death-planning record.
And if some moral thinkers specifically address our case,
such statements of moral principles might also be included
in the complete record of our process of planning for death.

10.  Statements from Advocates for Disadvantaged Groups.

    If there is any reason to suspect
that we might not be receiving the best care
because we are disabled, belong to a minority group, or are female, etc.,
then we might ask for our case to be reviewed by some individual or group
that knows our situation and the possible discrimination
that might be leading to a premature decision for death.
We can name such advocates in our Advance Directives for Medical Care
—and specify what powers they shall have to review our end-of-life care.

    Of course, any such advocate we choose must be open to all options.
If the advocate believes that black people or disabled people
should never be considered for any form of life-ending decision,
then, there is no point in requesting such a consultation.
If we do not believe in making any end-of-life choices,
we can simply state in our Advance Directives for Medical Care
that we will never approve any life-ending decisions for ourselves.

    This safeguard is completely optional.
Advocates for disadvantaged groups will only become involved
if we and/or our proxies explicitly ask for them to offer their opinions.

11.  Ethics Committee Reviews the Life-Ending Decision.

    At the end of our lives, we might be receiving care in a medical facility.
Does this facility have a medical ethics committee
that has experience with end-of-life decisions?
If so, these consultants might offer fresh perspectives.
And they should review all the written statements
created in fulfilling the other safeguards.
At least one representative of the ethics committee
should meet with us and those who are closest to us
to see if the life-ending decision seems wise to them.  
Once again, the ethics committee has no veto power.
But their statement of agreement will assure everyone
that any life-ending decisions were taken very carefully.



12.  Review by the Prosecutor (or other Lawyer)
            before the Death Takes Place.

    If there is any reason to think that some criminal behavior
might be involved in our end-of-life decisions,
then we can collect our death-planning records
copy them and send them to the prosecuting authority
that would be responsible for bringing criminal charges
if death was chosen prematurely.

    Or a private attorney could conduct the same kind of review:
If this death takes place as planned,
will anyone be charged with violating any laws?

    It is important to do this before death takes place,
so that the prosecuting authority can halt the process
if some harm is on the verge of being committed.

    On the other hand, if everything is in order,
then the prosecuting authority can issue a statement
assuring everyone involved that no criminal changes
will be brought if the planning process is carried forward
as explained in the death-planning documents.

13.  Criminal and Civil Penalties for Causing Premature Death.

    As an additional layer of safety, new laws might be needed
concerning the mistakes and abuses that could arise
in making life-ending decisions.
Immunity from prosecution should be given to all who act in good faith.
But anyone who participates in bringing a life to an end prematurely
should know that there are laws in place,
which could be used to punish any person
who has distorted the process of making life-ending decisions.



14.  Waiting Periods for Reflection.

    When we are making the irreversible decision to end our lives,
we want to be as certain as possible that this is the right choice.
Therefore, meaningful waiting periods should be included
in any process of planning for death.

    In order to make any 'waiting periods' meaningful,
we will not merely allow time to pass.
Rather, we will use all waiting periods
for the active fulfilling of the most meaningful safeguards.

    If we are planning our own deaths,
while we are still fully able to make life-ending decisions,
12 months does not seem an unreasonable time.
One year will give us all the time we need to complete
all of our business and personal relationships.
And we will be able to gather the written statements
of everyone else involved
—possibly including revisions that respond to other statements
and to our changing medical condition.  

    If we have already lost the capacity to decide for ourselves,
then our proxies will take over our medical decisions.
And if our proxies are considering a life-ending process,
then they might need to take up to 6 months to make this decision.
In their written statements, they will clarify how much time
would be needed to fulfill the safeguards they find most relevant
before everyone involved will be convinced
that a chosen death is the best course of action.

    When the method of dying will be withdrawal of life-supports,
the waiting period can be the shortest,
since careful medical procedures are already being followed.
The time required to gather all of the written statements
might be a sufficient waiting period.
In general, this will be about one week.  

    In all cases, most of the deciders should agree
that all appropriate waiting periods have been used
to make sure that no mistakes or abuses will occur.



15. Complete Reporting of all Material Facts.

    The written requests and supporting documents
should all be gathered into one place,
where they can be reviewed by everyone involved.
Perhaps one of the professional consultants
could serve this function of making sure
that all of the material facts are gathered into
a comprehensive death-planning record.  

    When our deaths take place in medical institutions,
these death-planning statements can be made part of the medical record.
And the prosecuting authorities can have access to these records
in case there is any question that a crime might have been committed
under the color of a rational process of making life-ending decisions.

    When our death is going to occur at home,
then it might be wise to submit the death-planning documents
to the prosecuting authority in that jurisdiction
before our death is achieved by the methods we have chosen.  
This will require some changes of procedure
in the office that normally prosecutes crimes.
But after a few years of reviewing life-ending decisions,
they should develop some expertise in spotting crimes-in-the-making
and separating them from rational decisions to draw life to a close.

    The first brave individuals and families who use these safeguards
will develop experience that might be helpful to others
as they also make end-of-life medical choices.



Conclusion

    These safeguards do not suggest any government official
who will approve or disapprove any proposed life-ending decision.
As far as possible, strangers should be kept out of the decision-loop.

    When substantially all of these safeguards have been fulfilled
(with explanations of why some others were not relevant),
then the death should be recorded as having been caused
by the underlying disease or physical condition
that led to the life-ending decisions.
And additional notes could be added explaining:
(1) that the patient chose a shorter process of dying,
(2) that proxies were involved in the life-ending decision, and/or
(3) that life-supporting tubes, machines, & medications were removed
rather than waiting for the complete failure of all bodily systems
even while life-supports were still in use.

    If it seems too complicated to fulfill these safeguards,
consider the complications if a court case results from this death.
Then lawyers and judges who never knew the patient
are required to apply abstract principles
that might have little or nothing to do with
the final end-of-life medical choices.

    These safeguards make the life-ending choice
a collective decision to whatever degree that seems wise.
Personal autonomy is preserved to the end of life.
And mistakes and abuses of this right-to-die are prevented.  

    When such careful safeguard-procedures are used,
even some people who were initially opposed to any 'right-to-die'
will see the wisdom of allowing careful life-ending decisions.



    The above on-line essay has now become Chapter 1 in
Medical Ethics at the End-of-Life.

    If you are serious about safeguards for life-ending decisions,
here is an even more extensive list of such safeguards:
26 Recommended Safeguards for Life-Ending Decisions (A-Z):
https://s3.amazonaws.com/aws-website-jamesleonardpark---freelibrary-3puxk/SG-A-Z.html

    Also, a website has been established to explore all dimensions:
Safeguards for Life-Ending Decisions:
https://s3.amazonaws.com/aws-website-jamesleonardpark---freelibrary-3puxk/SG.html

    And a book has been written,
taking the 26 recommended safeguards as its core:
How to Die: Safeguards for Life-Ending Decisions:
https://s3.amazonaws.com/aws-website-jamesleonardpark---freelibrary-3puxk/HTD.html

    As life-ending decisions become more common in terminal medical care,
it will be ever more relevant to separate the causes of death
from the medical methods of managing dying.
Here is a suggestion for establishing a new line on death-certificates,
which will explain the life-ending decisions
and the medical methods of managing this process of dying:
https://s3.amazonaws.com/aws-website-jamesleonardpark---freelibrary-3puxk/DC-LED.html.
 drafted 12-9-2003; revised 7-27-2005; 2-25-2007; 1-24-2008; 4-6-2008; 5-30-2009;
3-25-2010; 5-6-2010; 8-29-2010; 11-21-2010;
3-12-2011; 6-19-2011; 12-29-2011; 3-9-2012; 9-5-2012;
1-26-2013; 9-13-2013; 10-28-2013;
8-5-2014; 2-26-2015; 5-4-2016; 12-14-2017; 8-17-2018; 11-28-2019; 10-3-2020 

AUTHOR:

    James Park is an independent thinker
with deep interest in medical ethics,
especially the many issues surrounding the end of life. 
Medical Ethics and Death are two of the ten sections of this website:
https://s3.amazonaws.com/aws-website-jamesleonardpark---freelibrary-3puxk/index.html


    Here are a few related on-line essays and chapters:

Advance Directives for Medical Care:
24 Important Questions to Answer

Losing the Marks of Personhood:
Discussing Degrees of Mental Decline

Fifteen Safeguards for Life-Ending Decisions

Will this Death be an "Irrational Suicide" or a "Voluntary Death"?

Will this Death be a "Mercy-Killing" or a "Merciful Death"?

Four Medical Methods of Managing Dying

<>Pulling the Plug:
A Paradigm for Life-Ending Decisions

Why Giving Up Water is Better than other Means of Voluntary Death

Voluntary Death by Dehydration:
Safeguards to Make Sure it is a Wise Choice

Depressed?
Don't Kill Yourself!
   
Further Reading:

Best Books on Voluntary Death


Best Books on Preparing for Death


Books on Terminal Care


Books on Helping Patients to Die


Books Supporting the Right-to-Die
Books Opposing the Right-to-Die


Go to the Right-to-Die Portal.

Return to the DEATH page.

Go to the Medical Ethics index page.

Go to on-line essays by James Park,
organized into 10 subject-areas.

Go to the beginning of this website
James Leonard Park—Free Library