PULLING THE PLUG:
A PARADIGM FOR LIFE-ENDING DECISIONS
A PARADIGM FOR LIFE-ENDING DECISIONS
by James Leonard Park
As the 21st century advances,
more of us might be supported by machinery and drugs
in the last few days or weeks of our lives.
If we die from some disease or condition
that normally takes months or years to bring death,
then our dependence on life-support systems might be even longer.
If we are being kept alive by some form of medical technology,
then any decisions we make about the best time to die
and about the best means to allow our deaths
will have to include questions about what to do
with the life-support systems in place—keeping us alive.
1. ENDING LIFE-SUPPORTS
—A WELL-ESTABLISHED MEDICAL PROCEDURE.
Medical ethics in the 21st century includes discontinuing life-supports.
And some end-of-life decisions include never starting life-supports
when it is clear in advance that putting us on a ventilator, for example,
will only prolong the process of dying.
If there are no particular reasons to keep us alive for a few more days,
then everyone involved in this end-of-life decision
will probably agree not to extend the process of dying.
And even when there is no clear decline into death
because further deterioration is being prevented by the life-supports,
reasonable people can agree that if there will be no recovery,
there is no point in keeping us in a coma on life-supports indefinitely.
On the other hand, when we are drawing our lives to a close,
we might have some very meaningful things we want to achieve
before the end of our lives.
And usually these will be quite independent
of any objective facts found in our medical charts.
For example, we might have some religious practices or good-byes
that we want to complete before we 'allow nature to take its course'.
We might want to have our sins forgiven before we 'meet our Maker'.
We might want to make amends with estranged family members.
We might want to see a grandchild or great-grandchild before we die.
If we imagine our lives as a movie or play,
we know what scenes we would like to have before the end of the show.
And if we are realistic about the amount of time left,
we will know which projects we can complete within that time-span
and what new projects would be unrealistic.
2. SOME FORMS OF 'PULLING THE PLUG'
ARE MORE CONTROVERSIAL.
'Pulling the plug' on our life-support systems carries no stigma,
as might be the case with taking a lethal chemical to bring death.
Perhaps this is because we can see clearly (and sometimes dramatically)
that 'life' in the intensive care unit (ICU)
has almost no similarities to the life we lived
in all the years leading up to this final scene.
When we are being supported by a heart-lung machine
that is keeping our blood circulating and oxygenated,
we know that this situation cannot continue indefinitely.
Our feelings about 'pulling the plug' are somewhat different
when the life-supports seem more like daily living.
For example, our lives might be sustained
by medication to control our blood-pressure
to keep our hearts and blood vessels operating well.
If we go off that medication, we know that we could easily die
from the cardio-vascular problem now controlled by the drugs.
At least in the advanced parts of the world, if we live long enough,
most of us will be using various medications at the end of our lives.
And we might have so many different prescription drugs
in our bodies that we cannot remember them all.
We might have experienced continual adjustments of our drugs
because of the subtle interactions among them:
One drug causes a particular side-effect,
which needs to be controlled by another drug, etc.
In such situations, when we are ready for our lives to end,
we can simply refuse to take any of the drugs that are keeping us alive.
Our doctors can tell us how long we can expect to live
without the medications that have been assisting our vital functions.
A somewhat more controversial situation arises
when the life-support is a feeding-tube
or other means of supplying food and water.
At the end of our lives, if we cannot eat normally,
then we might be attached (either temporarily or permanently)
to a feeding-tube that puts special foods directly into our stomachs.
Or we might have fluid and nutrition put directly into our veins
—by-passing our digestive systems completely.
But even discontinuing artificial feeding
has now become a part of standard medical practice.
Such decisions should not be taken lightly
and without considering all the implications for everyone involved.
But from the perspective of medical practice
discontinuing artificial nutrition and hydration
is a common method of managing dying.
When we think of our own lives coming to an end
by means of withdrawing or withholding a feeding-tube,
we know that the utmost caution is needed
in the decision-making process that might lead to this action.
Each of us should consider just how such a life-ending decision
should be reached with respect to our own lives.
And we should explain our plans in our Advance Directives for Medical Care.
If we clarify our own medical ethics well in advance of any situation
in which withdrawing a feeding-tube becomes a real option,
then we have considered this method of managing dying,
probably years before it becomes a real-life choice.
4. SINCE WE CAN BE REASONABLE ABOUT 'PULLING THE PLUG',
PERHAPS THE SAME DECISION-MAKING PROCESS
COULD BE APPLIED TO OTHER LIFE-ENDING DECISIONS.
As more of us gain experience with terminating life-supports,
we will become more familiar with the safeguards that should be used
to make sure that any harm to the patient is less than
the harm already being inflicted by the life-support systems themselves.
Of all deaths that now occur in hospitals,
about 80% involve some important elements of choice.
If no choices are made, the patients will continue to be maintained
on life-support systems until they die despite the 'tubes and machines'.
How often are patients 'treated-to-death'?
As a culture, we have not given much attention to life-ending decisions.
But if over half of deaths in America now include some choices,
then we are already making over a million life-ending decisions each year.
Implicit safeguards are already being used for these medical decisions.
And as we become more aware of medical decisions that bring death,
we can make the safeguards more explicit
—perhaps with an eye on other life-ending decisions
that are not so completely within the control of doctors.
As we learn to make wise decisions about terminating life-supports,
we are also learning how to articulate the safeguards
that should be applied to all life-ending decisions.
The right-to-die means being able to make wise decisions
so that we can die at the best time and by the best means.
Pulling the plug is sometimes the wisest end-of-life medical choice.
How has this chapter changed your mind?
Did you once think that 'pulling the plug' was not permitted?
Did you think that once life-supports were started,
it would be wrong to discontinue them?
If someone you love is ever on life-supports,
how would you decide to disconnect the tubes and machines?
If you yourself are ever kept alive by life-supports,
do you now think you could authorize your death by withdrawing them?
James Park is an independent thinker
with deep interest in medical ethics,
especially the many issues that arise at the end of life.
Medical Ethics and Death are two of the ten sections of his website:
James Leonard Park—Free Library
This essay about withdrawing life-supports
as a medical method of managing dying
has become a chapter in a small book entitled:
YOU LIKE TO MEET OTHER SUPPORTERS
OF RIGHT-TO-DIE HOSPICE?
If you agree with disconnecting life-supports as a valid method of managing dying,
consider joining a Facebook Group and Seminar called Right-to-Die Hospice.
This discussion group is completely free of charge.
And members are welcome to join from anywhere.
The above discussion of disconnecting life-support systems
has become Chapter 7 of Right-to-Die Hospice.
Our Facebook Group of the same name will discuss one chapter per week.
Here is a complete description of this on-line gathering of advocates of the right-to-die:
And here is the direct link to our Facebook Group:
FACEBOOK SEMINAR ON SAFEGUARDS FOR LIFE-ENDING DECISIONS
The above exploration of terminating life-support systems
is also Chapter 48 of How to Die: Safeguards for Life-Ending Decisions:
"Pulling the Plug: A Paradigm for Life-Ending Decisions".
you like to join a world-wide Facebook Seminar
that is discussing this book-being-revised?
See the complete description for this first-readers book-club:
Join our Facebook Group called:
Safeguards for Life-Ending Decisions:
A few related essays:
A New Way to Secure the Right-to-Die:
Laws against Causing Premature Death
Losing the Marks of Personhood:
Discussing Degrees of Mental Decline
Directives for Medical Care:
24 Important Questions to Answer
Safeguards for Life-Ending Decisions
this Death be an "Irrational Suicide" or a "Voluntary
this Death be a "Mercy-Killing" or a "Merciful Death"?
Methods of Managing Dying
Methods of Managing Dying in a Right-to-Die Hospice
Why Giving Up Water is Better than other Means of Voluntary Death
Death by Dehydration:
Safeguards to Make Sure it is a Wise Choice
Live Well Now, Omit the Last Month
Your Date of Death:
How to Achieve a Timely Death
—Not too Soon, Not too Late
Medical Uses of Brain-Dead Bodies
Don't Kill Yourself!
Best Books on Terminal Care (from the Doctor's Point of View)
Books on Hospice Care
Terminal Medical Care from the Consumer's Point of View
on Advance Directives for Medical Care
Best Books on Voluntary Death
Best Books on Preparing for Death
Books on Terminal Care
Medical Methods of Managing Dying
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.
to discover 350 reviews
organized into 60 bibliographies.
Return to the DEATH page.
Go to the Medical Ethics index page.
on-line essays by James Park,
organized into 10 subject-areas.
the beginning of this website
James Leonard Park—Free Library