Some systems for enabling a patient to choose a voluntary death
require the patient to be conscious until the last moment before death.

Moreover, the patient must be physically able to perform
whatever actions are necessary to bring about his or her own death.

    The thinking behind this safeguard emphasizes patient autonomy.
The patient (and no one else) is making the life-ending decision.
The patient should be allowed to change his or her mind
up until the very last moment of life.
This is one way to assure that the patient's choice
is the basis for the life-ending action.

    Taking this safeguard a step further is the requirement
that the patient be physically able to take an action that brings death:
to take a lethal drug, to push a button that starts a death-delivering device,
to throw a switch that turns off the flow of a life-sustaining drug,
or to pull a plug on a machine that is keeping him or her alive.
The action taken by the hands of the patient (or some other voluntary action)
will start a physical process that will cause death within a few minutes
—or a few hours at the most.

CHOOSING DEATH FOR PATIENTS
            WHO ARE NO LONGER CONSCIOUS OR CAPABLE

    This safeguard should be applied when it is most appropriate
—for those patients who are fully able to make life-ending decisions
up to and including the last moment of their lives. 

    However this conscious-and-capable safeguard should be optional
for patients who will be somewhat impaired at the end of life.
They should not lose the right to have life-ending decisions made for them
simply because they can no longer make wise decisions about anything.
Proxies (chosen by the patient while still fully able to decide)
should have the same authority to make decisions
as the patient had thru-out most of his or her life. 

    When the patient can no longer re-affirm the life-ending decision,
the prior wishes of the patient become more important.
The Advance Directive for Medical Care was the first place
where the patient explained his or her philosophy of life and death.
Later the patient might have made explicit requests for death.
Some patients will choose death because of unbearable suffering.
Or death might solve unbearable psychological suffering.
Before they became unconscious or less able to make decisions,
they might have given informed consent to the plans for death.

    Each of these prior statements of settled values and wishes
becomes more important if and when the patient
is no longer able to make wise medical choices. 

    Common sense allows the proxies to implement the plans of the patient
if the patient can no longer re-affirm the plans and/or carry them forward.
In other words, this safeguard should be applied selectively,
whenever it make sense in the context of the whole life of the patient.

    An on-line essay argues against the rigid application of this safeguard: 
"Do I Lose the Right-to-Die when I Lose Consciousness?"

    
HOW REQUIRING CONSCIOUSNESS AND ABILITY TO PERFORM
WILL DISCOURAGE IRRATIONAL SUICIDE
AND OTHER FORMS OF PREMATURE DEATH

    This safeguard requiring that the patient be conscious and capable
will not stop most irrational suicides,
since people who kill themselves for foolish reasons
must also remain conscious and able up until the last moment.
If they lose consciousness or if they lose the ability to pull the trigger,
then they will not be able to commit irrational suicide.
At least, they will not be killing themselves foolishly at that time.

    But if this safeguard requires others to observe the final moment of life,
then it does have some potential of saving patients from premature death.
The observers might notice something that was missed by the patient.
New information might become relevant to the plan for death.

    If other people are present to the very end,
then they have some duty to prevent the patient from choosing death
if death is not the best course of action at the time.

    And if the patient is required to perform a death-dealing action,
which is clearly known by the patient to cause death,
then all who observe will have to agree that the patient
took full responsibility for his or her own death.
To the best of their ability, any observers should make sure
that no coercion or manipulation was applied
to make the patient 'choose' death prematurely.
They will witness the offer to change the plan for death
and to choose living for a longer period of time.
If the patient refuses the final offer to change course,
then the patient will be permitted to take the action that brings death.

Created January 23, 2007; revised August 14, 2008; 2-11-2010; 5-9-2010; 9-9-2010;
5-27-2011; 12-17-2011; 2-1-2012; 2-2-2012; 2-23-2012; 3-24-2012; 8-3-2012; 8-23-2012;
3-5-2013; 6-28-2013; 7-13-2014; 5-21-2015; 7-9-2015; 12-28-2015; 2-12-2018;