TEN
SAFEGUARDS FOR LIFE-ENDING DECISIONS
Historical Note: The following selection of just ten safeguards
was first created for Richard Cote's book In Search of Gentle Death.
But this appendix had to be dropped because of the book was getting too
long.
Nevertheless this stands as a selection
that might appeal especially to
advocates of the right-to-die.
OUTLINE:
A.
ADVANCE
DIRECTIVE
FOR MEDICAL CARE
G.
UNBEARABLE
SUFFERING
H.
UNBEARABLE
PSYCHOLOGICAL SUFFERING
C.
PSYCHOLOGICAL
CONSULTANT EVALUATES
THE
PATIENT'S ABILITY TO MAKE MEDICAL DECISIONS
B.
REQUESTS
FOR
DEATH FROM THE
PATIENT
D.
PHYSICIAN'S
STATEMENT
OF CONDITION AND PROGNOSIS
E.
INDEPENDENT
PHYSICIAN REVIEWS THE CONDITION AND PROGNOSIS
F.
CERTIFICATION
OF TERMINAL ILLNESS OR INCURABLE CONDITION
U.
WAITING
PERIODS
BEFORE DEATH IS PERMITTED
Y.
THE
PATIENT MUST BE CONSCIOUS AND ABLE TO ACHIEVE DEATH
TEN
SAFEGUARDS FOR LIFE-ENDING DECISIONS
by
James Leonard Park
We ourselves are in search of a gentle, timely death.
We hope to complete our lives in as meaningful a way as possible.
We want to find the middle way between dying too soon and dying too late.
In short, we believe in the right-to-die for ourselves and for everyone
else.
The following guidelines or safeguards will help us to find that gentle
death,
avoiding both premature death
and meaninglessly
prolonging the process of dying.
Also whenever we help others to die, we want to make
sure
that we have helped them to choose the best
pathway towards death.
We do not endorse irrational
suicide.
And we want to avoid bringing any human life to an end prematurely.
The following safeguards are designed as a
practical, workable method
for choosing the best pathways towards death,
both for ourselves and for others whom we might help to die.
Individuals and organizations that help others to die
are already using some
safeguard-procedures.
Which of the following are already being fulfilled?
And which might improve the process of making life-ending decisions?
The following 10 safeguards are selected
from a more comprehensive list of 26 recommended safeguards.
And here they retain the code letters from that original list:
https://s3.amazonaws.com/aws-website-jamesleonardpark---freelibrary-3puxk/SG-A-Z.html
The title of each suggested safeguard
is linked to a more extensive explanation on the Internet.
A. ADVANCE
DIRECTIVE
FOR MEDICAL CARE
When we approach the end of our lives,
our own philosophies of life and death should prevail.
What kinds of medical care do we want?
What treatments would we find useless or futile?
Do we affirm a right-to-die, and if so, in what forms?
Our
deaths belong to us more deeply than anything else we can own.
When
we consider our lives at any given moment,
we usually decide that we want to continue living.
But there might come a time when we decide
that the burdens of
continuing to live are greater than
the benefits we or others
derive from our continued existence.
All of us should formulate our philosophies of
living and dying
while we are still in good health and able to think clearly.
And we should put our decisions about life and death into 'living
wills',
better called "Advance Directives for Medical Care".
The most complete Advance Directive will address
such matters as:
appointing good proxies, quality of life, levels of
personhood,
medical costs, nursing-home placement, & ideal pathways towards
death.
Here is a portal for exploring all dimensions of a comprehensive
Advance Directive:
https://s3.amazonaws.com/aws-website-jamesleonardpark---freelibrary-3puxk/P-AD.html
G.
UNBEARABLE
SUFFERING
As we approach the natural end of our lives,
some parts of our bodies might be causing great pain.
Very likely, we have attempted to cope with
our suffering.
If doctors can relieve our pain or other kind of suffering,
then we will probably want to continue living.
If good pain-control makes our suffering manageable,
then some additional meaningful life is still possible for us.
But what if all available methods of alleviation
no longer work?
Perhaps the pain-and-medication cycle renders us so
incapacitated
that we spend all our waking moments waiting for the next dose.
Or we might have decided that we would prefer to be kept unconscious
rather than be awake to face another hour of suffering.
If we find ourselves choosing between existence with
pain
and unconsciousness without
pain,
this might be a sufficient reason to choose death.
We might find our lives intolerable if we just
alternate between pain
and
sleep.
When we have actually tried the best palliative care
available
and that does not bring us enough relief to continue
living,
then we might reasonably choose a good time to die in the near future.
A timely death might be better than more days of unbearable suffering
followed by a natural death at some later time.
We alone must decide just how much suffering we can
bear.
And when our suffering
exceeds our well-considered limit,
then voluntary death might be the best remaining option.
And as long as we are thinking clearly,
we can always revise our balance of meaning and suffering:
When we are experiencing the actual suffering of our last year of life,
we might be willing to accept more suffering
than we imagined beforehand
if we still find meaning in
continuing to live.
H.
UNBEARABLE
PSYCHOLOGICAL SUFFERING
Likewise, we must evaluate our own
psychological suffering.
And when our mental condition itself
clouds our capacities to make wise medical decisions,
then we will depend even more completely
on the proxies we have chosen in advance
—while we were still
in full possession of our mental powers.
Psychological suffering includes any mental torment
that does not have any physical cause that can be treated.
For example, we might be stricken with grief
because of the loss
of a
loved one.
But usually, our grief will be self-limiting:
After a few years at the most, we should be able to return to normal
life.
But we might be tormented by demons that do not go
away
and that do not yield to any form of treatment:
Is every day another day of fearing dangers that do not exist?
Do we harm ourselves for unintelligible 'reasons'?
If no treatment has been able to alleviate our mental suffering,
then voluntary death or merciful death might be the best solution.
Such a conclusion should be reached only after
the most exhaustive attempts to relieve our mental suffering.
And all such attempts will be well-documented in our medical records.
Only then could our proxies conclude that merciful death
would be better than unrelieved psychological suffering
for the rest of our natural lives.
When our suffering has a large mental component,
such psychological problems themselves
might undermine our abilities to make wise medical decisions.
If so, our decision-making is transferred to (or shared with)
the proxies we have carefully chosen in advance,
while we were still able to make meaningful decision for our lives.
To whatever degree is still possible, our proxies
will cooperate with us
in attempting to choose the wisest options for the rest of our lives.
Our proxies will follow our most rational wishes
while at the same time trying to filter-out our irrational urges,
which might be pushing us toward a self-harming 'decision' for death.
Frequently professional help might
sort out the most difficult situations.
The next safeguard suggests how psychological professionals
might assist us in making wise end-of-life choices.
C.
PSYCHOLOGICAL
CONSULTANT
EVALUATES
THE PATIENT'S ABILITY TO MAKE MEDICAL DECISIONS
Especially when there are strong psychological
reasons for dying,
we will benefit from consulting an open-minded psychological
professional,
such as a psychiatrist or a psychologist.
This consultation will help us to examine our reasons
for choosing death.
And the psychological professional will be able to evaluate
our abilities to make well-reasoned medical decisions
—including any
decisions that will result in our deaths.
Psychiatrists
and psychologists are trained to recognize
the many forms of irrational
thinking that can lead to suicide.
This
consultation might also discover
if we are under any pressure
from relatives to 'choose' death.
Are there psychological or emotional problems (that can be treated)
that are leading us toward an irrational suicide?
The psychological consultant can help us to resolve any such doubts
before approving a voluntary death or a merciful death.
If anyone involved in the process of planning our
deaths
has valid concerns about our capacities to make life-ending decisions,
it would be best to get a professional evaluation of our thinking
process.
As we approach the end of our lives, what is our state of mind?
Have we considered all reasonable alternatives to death?
Are other people pressuring us to 'choose' death?
Might there be some chemical imbalance in our brains,
causing feelings that are leading us towards death?
Are we irrationally suicidal?
Of course, we must determine ahead of time
whether the psychological consultant we choose
is open to a rational choice to end one's life.
Probably 90-95% of people who do actually kill themselves
commit irrational suicide
for foolish 'reasons'.
But our chosen psychological consultant must be open
to the 5-10% of persons who plan to end their lives for good reasons.
If our psychological consultant determines
that we are no longer capable of making wise end-of-life decisions,
then the provisions of our Advance Directives come into force:
Our proxies take over our medical decisions.
And they are empowered to make all of the same decisions
we could have made while still in possession of our full mental
powers.
No matter what the results, the
professional opinion
of this psychological consultant should be put into writing
so that it can become a permanent part of our death-planning record.
This psychological consultant has no veto power.
But his or her professional opinions will be taken into account
by us and by all of the people who are helping us
to make wise end-of-life medical choices.
B. REQUESTS
FOR
DEATH FROM THE
PATIENT
Because personal autonomy comes first when choosing
to die,
we should create clear statements explaining our wishes
to draw our lives to a close under the current
circumstances.
We should summarize our medical condition in our own words.
We have already created our general plans in
our Advance Directives.
And
when we 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 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.
Most reasonable requests for death will be based on
medical facts.
However, our reasons for deciding to end our
lives now
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,
spiritually, 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.
In order to make sure that our requests for death
are serious
they must be made formally
and in front of witnesses.
This will establish that we are still functioning as persons
who are fully capable of making medical decisions.
The neutral witnesses make sure that we were of sound mind
when we decided to put our death-planning into action.
Our requests for death should be separated by
meaningful periods of time,
giving us ample opportunities to reconsider our decision for
death.
The purpose of this safeguard not merely to get some
signature on paper
but to facilitate a thoro
discussion of the pros and cons
of any particular pathway towards death.
It is sometimes too easy to get people of questionable capacity
to put their signatures on any paper that is put in front of 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 any observer to prevent a premature
death.
D.
PHYSICIAN'S
STATEMENT
OF CONDITION AND PROGNOSIS
Careful advocates of the right-to-die always insist
on
some kind of medical statement from a doctor
who has actually examined the patient.
Ideally such a statement would be written by our primary care physician.
But when that person is not cooperating,
another physician who has examined our medical records
as well as physically examined our bodies
should be able to create a summary statement
of our condition and prognosis.
When we are reaching the end of our lives,
we want to know all the relevant medical facts and options.
Thus, we want a written summary of the physical problems we have
and the likely outcomes if we select certain treatments or omit them.
We will refer to our doctors' written professional
opinions
when we make or revise our own statements about our last year of
life.
Written statements from our doctors are important
because we might have misunderstood something
that was communicated to
us only verbally.
Written statements will enable us calmly to consider our
options.
And we can ask for further elaboration and explanation
of some parts of the physicians' statements we do not
understand.
E.
INDEPENDENT
PHYSICIAN REVIEWS THE CONDITION AND PROGNOSIS
Because our lives are precious to us,
we should seek a second professional evaluation of our situation.
This second doctor must be truly independent of the first
in order for us to obtain a new evaluation
rather than just an endorsement of the first doctor's opinion.
Perhaps this second professional review
should come from a specialist who knows more about
the condition that is the most likely cause of our death.
If the statements of all doctors point to the
same conclusion
—for instance, that we are likely to die soon
no matter what new treatments or life-supports are used—
then we should feel more confident about making a life-ending decision.
These doctors are affirming
that in their professional judgments
we have reached the
end of our lives.
And it might be in the best interest of everyone concerned
to allow our lives to expire or to facilitate a peaceful and painless
end.
F. CERTIFICATION
OF TERMINAL ILLNESS OR INCURABLE CONDITION
If and when we are definitely dying,
this fact of terminal illness could be included in the physicians'
statements.
Our they could create and sign separate documents
stating that we have less than 6 months to live.
If we are not terminal, the physicians could explain
that we have a serious
medical condition that cannot be cured.
The over-all purpose of this safeguard
is to make certain that we are really dying or have incurable diseases
before we consider any life-ending decisions.
This written statement from the doctors should
clearly separate
our prognosis with
life-supports and other medical treatments
from our prognosis without
life-supports and further medical treatments.
Some rules do require an official
declaration of terminal illness.
One example of this might be admission
to a hospice program:
Our physician must sign a statement saying
that we are likely to die within the next six months.
Likewise, some right-to-die laws require
an official certification of terminal illness
before we might be eligible for aid-in-dying.
U. WAITING
PERIODS FOR REFLECTION
In order to allow time to reconsider our decisions
for death,
we need meaningful periods to review choosing death.
During these 'thinking periods',
we should be actively
engaged in thinking
about our options
and discussing them with others who are close to us.
We can try new treatments experimentally
without starting the waiting period all over again
if the experiments do not work.
Or we might try some new method of palliative care.
If this symptom-control works,
our projected date of death can be postponed.
Different length of preparation-time
would be appropriate for different kinds of chosen death:
If we are choosing a voluntary death,
perhaps 12 months would not be too long a period
for us to wind up all of our affairs and get ready to die.
If other are choosing a merciful death for us,
the period for reflection might be much shorter.
And if the life-ending decision is to remove life-supports,
the time could be even shorter,
since all of the medical treatments have already been tried
—and
they did not work.
Y.
THE
PATIENT MUST BE CONSCIOUS AND ABLE TO ACHIEVE DEATH
If we choose to die of our own free will—our own
voluntary choice—
then
performing the life-ending action with our own hands
will be dramatic proof that we really chose to die.
Using this safeguard also protects all who
assisted in the process:
Because they did not cause
our death directly by any action,
they will not be charged with assisting a suicide or causing a
premature death.
If the dying patient uses his or her own hands to
bring death,
then there is no doubt that it was an autonomous action.
But perhaps this safeguard is too restrictive.
It should be sufficient for us to leave clear and convincing evidence
that we would have wanted death under the current circumstances.
Then our proxies could carry forward our plans for death
even if we lose some capacity to reaffirm the choice of death
or the physical capacity to bring about our own deaths.
For example, we should not lose the right-to-die
merely because we became
unconscious
before the final action to bring death.
PUTTING SAFEGUARDS INTO
ACTION
When these safeguards are expressed in terms
of what will happen at our own death-beds,
we do not find ourselves resisting them as much
as if they seemed to be government regulations that were imposed on us.
We want our own deaths to be wisely
decided,
not governed by abstract rules and regulations.
And if we are ever involved in helping other people
to die,
we want to know that we will be protected from any legal consequences.
If we fulfill good safeguards for life-ending
decisions,
then it should be clear to any prosecutor that we did the right thing.
And the fulfilled safeguards will be powerful proof
that the death we endorsed was a wise end-of-life medical decision,
not an irrational suicide
by
any stretch of the imagination.
Put another way, fulfilling all reasonable
safeguards
is our stay-out-of-jail card.
And when new laws permitting the right-to-die are written,
we can hope that these and other reasonable safeguards
for life-ending decisions will be incorporated
so that will have wise, workable methods for separating premature deaths
from deaths that will be achieved by the best means at the best time.
Here is a model law called "Causing Premature Death",
which incorporates all 26 of the recommended safeguards:
https://s3.amazonaws.com/aws-website-jamesleonardpark---freelibrary-3puxk/PREM-DTH.html
And here is the complete list of the
best safeguards,
each with an extensive explanation:
https://s3.amazonaws.com/aws-website-jamesleonardpark---freelibrary-3puxk/SG-A-Z.html
Created
September 9 & 10, 2010; Revised 1-19-2011; 5-11-2011; 10-19-2011;
3-10-2012; 2-12-2018; 3-27-2020;
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Leonard Park—Free
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