THE RIGHT-TO-DIE:
26
RECOMMENDED SAFEGUARDS (A-Z),
WHICH
CAN BE APPLIED SELECTIVELY
FOR ANY LIFE-ENDING DECISION
Even in situations where no safeguards are required
or suggested by law,
individuals faced with end-of-life choices
might want to apply some of the following recommended safeguards
as a way to make sure that a decision to end someone's life
is a wise and compassionate
choice
rather than some kind of mistake that would result in a premature
death.
For example, if we are required to make
life-or-death decisions for a retarded member of the family,
we will clarify our options
by applying the safeguards discussed below.
When we ask others for their personal and professional opinions,
we are more likely to make
wise choices.
These safeguards are offered as a method for examining all options
near the end of someone's life.
Almost all are non-technical and can
be applied
by ordinary people.
These are not
government-imposed safeguards,
setting up a complicated bureaucracy to review end-of-life decisions.
No death panels are mentioned.
Rather, the application of these 26 recommended safeguards
will call upon the personal and professional opinions
of perhaps two
dozen people for any specific end-of-life situation.
We can also apply these safeguards in the last year
of our own lives.
Perhaps when we are dying,
our thinking might be distorted by our terminal disease or condition.
We will probably have complicated feelings as we face our own deaths.
Therefore, we might want to use some of the procedures below
to make certain that we are wisely choosing voluntary
death
rather than foolishly considering irrational suicide.
And if we are reviewing the plans for the last year
of someone else's life,
the same safeguard-procedures can help us to separate a merciful
death
for a friend or relative from a mercy-killing.
Each of the following 26 proposed safeguards for
life-ending decisions
is linked to a more extensive explanation of how to use that
safeguard.
If we wish to apply a specific safeguard
to an end-of-life situation we are currently considering,
we will probably want to read the more complete presentation.
A written statement explaining the patient's
philosophy of life and death
is probably the most basic document for making end-of-life decisions.
Life belongs to each individual patient.
His or her settled values
should shape all medical decisions.
Once the patient has created an Advance Directive
for Medical Care,
he or she will share the Advance Directive with significant others —especially those
chosen as proxies.
And they should create brief statements
expressing their agreement with
the Advance Directive
and (if they are proxies) their commitment to carry forward
the settled
values of the patient.
The patient owns his or her own life and death.
Whenever the patient is still able to make medical decisions,
any and all serious requests for death should be recorded,
stating the date, time, circumstances, & witnesses.
The patient should also explain why he or she thinks death at the chosen time
would be better than death
at some later time.
Such requests for death might lead to creative discussions
among all the people concerned with this patient's life and death.
If the patient is no longer able to make
medical decisions,
the duly-authorized proxies then have the power and responsibility
to make any reasonable requests for death on behalf of their patient. See Safeguard
K
below: Requests for Death from the Proxies.
If there is any doubt about the patient's
mental capacities to make medical decisions —including any
decisions that will terminate his or her life—
then the patient's decision for death should be evaluated
by a licensed psychologist or
psychiatrist.
The most important document created by a medical
professional
will be the physician's summary of the patient's situation and future.
In order to avoid any confusion, ambiguity, or misunderstanding,
this statement should be put
into writing
as well as explained to the satisfaction of those who must decide.
Whenever making life-or-death decisions,
it is always wise to seek a second, independent, professional opinion.
This second evaluation might be sought from a specialist
in the disease or
condition from which the patient is possibly dying.
If there are differences in these professional recommendations,
any such uncertainties should be resolved by further investigation
before the plans for death proceed.
Even tho the patient need not be in a terminal
condition to request death,
if the disease or condition is likely to lead to death,
the same physicians who have written
the full statements of the
patient's condition and prognosis
might also create a separate document to certify terminal illness
if the patient is likely to die within the next 6 months.
Or such certification could be included in the doctors' other
statements.
Certification of terminal illness should specify
whether the projected period of survival includes
life-supports or not.
An important question for any life-ending decision
is whether the patient is suffering in some way that cannot be relieved
and which the patient
finds intolerable.
Such physical suffering can be explained and documented
by the doctors who have been treating the suffering.
The patient might also be suffering emotionally.
Only the patient can decide whether such suffering is
intolerable.
But professional efforts to alleviate the mental suffering
should also be documented.
Psychological suffering can be evaluated by both family and doctors.
And if the psychological suffering is so great
as to make the patient incapable of making wise medical decisions,
then the power to decide passes to the authorized proxies.
The proxies will make any life-ending decisions:
Is death now wiser
than death later?
The actual application of comfort care
by medical professionals well trained in the care of the dying
will help to decide which is the wisest course of action.
Sometimes physical and psychological suffering can be so reduced
that the patient and/or proxies no longer believe
that death is the best
choice at this time.
However, in some obvious cases, palliative care
would be useless.
But at least the patient and/or proxies should be fully
informed
about the benefits of palliative care
and even consult with a palliative-care specialist.
The patient must have full information
about his or her condition
and all the possible medical treatments that still remain
open.
When the patient has received and understood the medical statements
from the doctors concerning
condition and prognosis,
the patient is empowered to make wise end-of-life choices.
If the patient can no longer make
meaningful medical decisions,
then the decision-making power shifts to the proxies,
who have been carefully chosen by the patient
when the patient was still fully able to make all medical choices.
The proxies shall carefully consider all of
the medical facts,
taking into account the opinions of everyone legitimately concerned.
Then the proxies can
decide to make requests for death
in the same ways as such requests were once possible
for the patient.
If the patient is
being treated in a hospital
or receiving terminal care in a hospice program,
any such medical institution will keep careful records
of all
discussions and decisions regarding the care of the patient —including all
explorations of end-of-life choices.
Terminal-care professionals deal with life-ending decisions frequently.
They will not support a premature death.
The nurses, doctors, & volunteers who know the
patient well
can also create statements
about their discussions
with the patient about end-of-life choices.
Do those who see the patient every day agree with the life-ending
decision?
Other persons who
have known the patient for meaningful
periods of time
either agree with the life-ending decision
or question the wisdom of ending the patient's life now.
Even tho these significant other persons might not be directly involved
in the process of making any life-ending decisions
and they will not be responsible for carrying out any terminal choices, they
know of
the
plans for death well in advance.
And they create written statements either affirming the choice of death
or questioning the wisdom of the end-of-life plans.
What are their considered opinions about the proposed death?
A member of the
clergy of any religious organization
or the professional leader of an ethical
organization
known by the patient approves or questions the life-ending
decision.
If the patient is not part of any such
organization,
another similar responsible member of the
wider community
might fill this role of neutral
ethical
observer.
If chosen by the patient, some person (or persons)
with expertise on the doctrine
and/or medical ethics
of the religious tradition with which the patient is
affiliated
could review how those moral principles apply to the
end-of-life
decisions
being considered by the patient and/or the proxies for
the patient.
If that
interpretation of the principles supports a life-ending
decision,
such as the withdrawal of life-supports when they are useless,
then a written statement to that effect could be included in the record.
If the religious principles would not support a life-ending
decision
under the current circumstances, such a statement should be included.
If chosen by the patient and/or proxies, some non-religious moral
principles
could be brought to bear on the end-of-life choices.
An ethics
committee of the institution where the patient is receiving care
reviews all of the documents created for the
death-planning process
and approves or questions any life-ending decisions.
The ethics committee should meet with the patient and/or the proxies.
If there is no ethics committee,
a private ethical consultant
can review the plans for death.
If any patients worry that they might be discriminated
against
because they are members of a group sometimes
disfavored by society,
they can select advocates from their own
identity-groups
who will review the death-planning documents to make sure that no
discrimination has taken place
because of the group-identity of the patient.
Adding any such statements to the death-planning record
will assure others who are not as close to the patient
that the life-ending
decision was as free as possible from discrimination
and that the patient received terminal care independent
of group-identity.
If those who are considering end-of-life options for
the patient
have any doubts about the legality
of their
proposed course of action,
they can opt to send a report of
the death-planning process
to the local
prosecuting authority for review.
They should explain their proposed course of action:
Which pathway towards death is being chosen for this patient?
And the several documents of the death-planning
process already created
might be shared or summarized for the prosecutor
to show that the proposed course of action
violates no laws.
The prosecutor should be
allowed one week to respond.
He or she might reply that the planned death will not harm the
patient
and that all who participate or cooperate in the death as planned will not be subject to
prosecution for any crime.
Or the prosecutor could ask for additional
information
to make sure that this death will
not be
premature.
If the prosecutor always automatically says "no"
to any proposed life-ending decisions,
that prosecutor should be re-educated about end-of-life law.
In some cases, it will be better to consult a
private lawyer,
who will evaluate the legality of the proposed life-ending decision.
Court systems exist all over the Earth
for the purpose of trying potential criminals for possible
crimes.
And every legitimate life-ending decision
might be distorted by criminal or monetary motives.
Thus civil and criminal procedures and penalties must remain in place
in order to discourage (and perhaps punish) any people
who cause premature death disguised as a legitimate end-of-life
decision.
Without careful safeguards, 'pulling the plug' might
actually be a harm.
If only a few people are involved in a proposed 'voluntary death',
it might actually be closer to a coerced or manipulated death.
And fulfilling careful safeguards will separate valid merciful deaths
from the dark and harmful mercy-killings that are
all too common.
Civil and
criminal penalties will remain in place.
Anyone tempted to encourage or cause a premature death should know that they might be punished
if they harm anyone by making a premature life-ending decision.
Appropriate periods for further reflection are needed
between the time when the first
life-ending decision is made
and when the final
life-ending act
is performed:
(a) one week for the
withdrawal of life-support systems,
(b) one year for a voluntary
death, or
(c) six months for a merciful
death.
These waiting periods may be adjusted when adequately explained
by the special circumstances of the specific patient.
Spreading the end-of-life discussions over significant
periods of time
encourages all concerned to re-think
their previous
decisions.
If the patient has already
begun the death-planning process,
ample
opportunities should be provided
for the patient to change his or her
mind.
The people offering these opportunities should
document
that the patient had several occasions to change the plans for death.
Does the patient decline each opportunity to
change course
and reaffirm his or her determination to choose death?
Once most of the other statements have
been written,
the physicians most responsible for the patient's
terminal care
will read and
respond to each statement and
make a final recommendation.
In some cases, more than one physician will review the plans for death.
The death-planning process
should be completely open.
The written
statements of all persons involved
should be
shared freely among everyone who has a
legitimate right
to take part in (or to know about) this end-of-life discussion.
The fact of such open sharing and discussion —with signed and
recorded opinions from many
participants—
should ensure that the process leads to a
well-considered decision
—not a hidden or secret conspiracy that might cause a premature
death.
Y. THE
PATIENT MUST BE CONSCIOUS AND ABLE TO ACHIEVE DEATH
If the patient (1) remains conscious until the last
moment of life
and (2) takes some life-ending action with his or her own hands,
these will be strong reasons to believe that this was a timely death.
But remaining conscious and capable to the end should not be required.
If
the process of planning the patient's
death
employs a death-planning
coordinator
or if someone volunteers to organize the death-planning
records,
this level of organization for planning this death
will be impressive evidence that the chosen death is a
wise decision.
And the complete collection of documents for planning this death
can be permanently stored in case there is ever any
future reason
to review these end-of-life discussions.