The following analysis and commentary
of the safeguards used by the Final Exit Network
was created after several leaders of this aid-in-dying organization
were arrested for (among other things) 'assisting a suicide'.
(These were the Georgia criminal trials of 2009-2011.)

    This critique was created by James Leonard Park,
a strong advocate of the right-to-die
but an even stronger advocate of
using careful safeguards for all life-ending decisions.

    The following explicit safeguards have been removed
from the website of the Final Exit Network as of April 2015,
but there is no indication that the basic principles have been revised.

    The standards for receiving help from the Final Exit Network
appear here in red.
The comments from James Park appear in black.

{These criteria were still on the Final Exit Network website as of March 10, 2010,
just after the four leaders were indicted in Georgia.
Still no changes as of November 2011.
But they all disappeared some time before April 2015.
Thus, these safeguards were still in place in 2007,
when the events behind the Minnesota Final Exit trial occurred,
even tho the trial in Minnesota did not take place until May 2015.}

SIX CRITERIA FOR ACCEPTANCE INTO THE PROGRAM

1. You must be cognitively functional.

    The Final Exit Network will only advise persons
who are mentally able to understand that they are
considering the possibility of deciding to end their lives.
This means that the Final Exit Network
will not participate in any death-planning process
where the patient has already become unconscious
or is in a persistent vegetative state.
'Euthanasia' when performed by someone other than the patient is not included.
Mercy-killing and merciful death are not covered
because both of these are performed by someone other than the patient.

    The basic reason for using this safeguard
is to assure that the patient himself or herself
is really making a free and informed choice for death.
If the mental capacities of the patient are questionable
at the time of making the life-ending decision,
then there can be no further advice from the Final Exit Network.

    Requiring mental capacity also eliminates all patients
who are suffering from Alzheimer's disease
or some other form of mental impairment
at the end of their lives.
If they are no longer making other major decisions for their lives
—such as handling their own finances—
are they capable of making life-ending decisions?

    This safeguard is needed not for the benefit of the patient
but in order to protect the other people who might be helping the patient to die.

    It should be possible to suspend this safeguard
if all of its underlying reasons are still fulfilled:
Is it clear that the patient wanted a voluntary death or a merciful death
before the patient lost the capacity to make any further medical decisions
—including the decision to die?
And if the patient created written (or otherwise recorded) proof
that he or she wanted to die under the given circumstances,
then this safeguard should not stand in the way of carrying forward the decision to die.
This well-considered choice to exercise the right-to-die was made
while the patient was still clearly able to make a life-ending decision.

    Further exploration of this possible problem will be found here:
"Do I Lose the Right-to-Die when I Lose Consciousness?":
https://s3.amazonaws.com/aws-website-jamesleonardpark---freelibrary-3puxk/CY-CONSC.html

    It seems that the Final Exit Network is saying "yes":
We do lose the right-to-die when we can no longer take
the necessary actions to end our own lives.

    However, this position results from the odd legal situation
that permits someone to commit suicide (whether rational or irrational)
while at the same time prohibiting anyone else from 'assisting a suicide'.

    Advocates of the right-to-die look forward to changes in law
that will permit more active participation by helpers.

    Right now, in most places on Earth,
the patient must be able to make the final decision.
Exceptions to this rule include:

    (1) increasing pain medication
with the knowledge that this will shorten the process of dying.
This decision can be made by the doctors
with the approval of the authorized proxies
even if the patient is no longer able to make meaningful medical decisions.

    (2) terminal sedation,
which keeps the patient unconscious until natural death.
This life-ending decision can also be taken by doctors
in consultation with the family and/or other proxies
even when the patient is already unconscious most of the time.

    (3) disconnecting life-supports,
which could allow death to come sooner rather than later.
Once again, this decision can be taken by the doctors
with the consent of the authorized proxies
when the patient is no longer "cognitively functional".

    (4) merciful death by dehydration,
which would normally be coordinated with any of the first three options.
The immediate cause of death might be the lack of water in the body.
And this decision to discontinue fluids of every kind can be taken
without the explicit, contemporary, & continuous consent of the patient.

    When the Final Exit Network (or other aid-in-dying organization)
updates its principles for helping dying patients,
this requirement of being cognitively functional
might be elaborated to include the following recommended safeguards:

SAFEGUARD B  Requests for Death from the Patient

SAFEGUARD C  Psychological Consultant Evaluates the Patient's Ability to Make Medical Decisions

SAFEGUARD J  Informed Consent from the Patient

SAFEGUARD V  Opportunities for the Patient to Rescind or Postpone the Life-Ending Decision

SAFEGUARD Y  The Patient Must Be Conscious and Able to Achieve Death

2. You must be physically strong enough to perform the required tasks.

    This second safeguard makes this requirement explicit:
The patient must have enough strength in his or her hands
to be able to use the chosen method of bringing death.
Other members of the Final Exit Network might be present.
In fact, there might be a trained Exit Guide
coaching the patient about the chosen method of death.
But the hands of the Exit Guild (or other persons present)
must not perform the final actions that bring death.

    This safeguard also has a dual purpose:

    If the patient physically takes the action that will bring death,
then it is more clearly a voluntary death.
Up until that last moment, the patient could change his or her mind
and decide not to go ahead with the death as planned.
The patient's fatal action might have been omitted.
And therefore, the patient will continue to live,
because the lethal chemical was not taken
or the inert gas was not turned on.

    Likewise, as with the first safeguard,
requiring the patient himself or herself to take the life-ending action
should protect all others present from any legal consequences
which could arise if they used their own hands to bring about death.

    The Final Exit Network is here hoping that
no one will be charged with assisting a suicide
because the patient himself or herself 'committed suicide'.
But a careful reading of most laws against assisting a suicide
also reveals that aiding, encouraging, advising suicide, etc.
is also punishable as a crime.

    Thus the person who purchased a hand-gun
and provided it to the suicidal person
could be charged with assisting a suicide even if the gun-purchaser
was not present when the suicidal person pulled the trigger
and killed himself or herself.

3. You must have an incurable condition which causes intolerable suffering.

    This third safeguard asks only about the condition of the patient.
It does not specifically mention mental or emotional suffering,
but such non-physical torment is included in "intolerable suffering".
However, mental, emotional, or psychiatric suffering must be completely documented
—as by means of a medical record that shows
years of attempts to treat the intolerable psychological suffering.

    And this safeguard has carefully avoided the mine-field of 'terminal illness'.
Many other sets of safeguards for life-ending decisions
do require that the patient be officially declared to have a 'terminal illness or condition'.
In such usage, 'terminal illness or condition' usually means
having less than 6 months left in one's life.

    However, 'incurable condition' is more inclusive than 'terminal illness'.
The patient is a candidate for voluntary death
if the patient has some problem
that cannot be cured by further medical treatment.

    The following phrase "which causes intolerable suffering"
might have been created specifically to be a non-restrictive clause.
That would mean that the suffering might be incidental to the condition.
If the authors had used the following phrase "that causes intolerable suffering",
it would be a restrictive clause,
meaning that the condition must be both incurable and causing intolerable suffering.
This is the most likely meaning intended in this safeguard:
The patient must have a condition (whether physical or mental)
that cannot be cured by any known methods
AND that is causing suffering that the patient finds intolerable.

    The Final Exit Network is mainly interested in discovering
whether the patient has some condition that cannot be cured.
In addition to being incurable,
the condition is causing so much suffering
that the patient wishes to end his or her life
as a way to end the suffering.

    A more careful set of safeguards (proposed by the present author)
would substitute 7 separate safeguards for this one:

SAFEGUARD C  Psychological Consultant Evaluates the Patient's Ability to Make Medical Decisions

SAFEGUARD D  Physician's Statement of Condition and Prognosis

SAFEGUARD E  Independent Physician Reviews the Condition and Prognosis

SAFEGUARD J  Informed Consent from the Patient

4. You must understand the "window of opportunity"
which exists while you still have the mental and physical capability
to perform the required activities.

    This is not really an additional safeguard.
It merely underlines the determination of the Final Exit Network
never to give advice about methods of dying
to someone who has now lost either the mental capacity (safeguard 1)
or the physical ability (safeguard 2)
to perform the actions required to bring about his own her own death.

    This is a dangerous element of advice
because it could encourage someone who believes in the right-to-die
to choose to die before it would be absolutely necessary
just to be sure to take advantage of this "window of opportunity".
How often does such advice lead to premature death?

    What all reasonable persons should wish for themselves
is a death that is not too early and not too late.
Thus the twin dangers to be avoided are dying too soon and dying too late.
We want to die NOT TOO SOON and NOT TOO LATE.
The ideal death would be at the best time.
This ideal might be called a timely death.
We want to have whatever years of meaningful life we can achieve
while at the same time choosing to end our lives
before the period of meaningless existence begins.

    If other reasonable safeguards have been fulfilled,
then it should be possible for others who have been duly authorized to do so
to carry forward the plans for death
even after the patient has lost either the mental or the physical capacity
to carry forward the plans himself or herself.

    In standard end-of-life care in a hospital,
the patient does not lose the right to have life-supports disconnected
just because the patient has become unconscious.
In fact, in most cases of "pulling the plug",
the patient is already too far down the pathway towards death
to be able to participate meaningfully in this life-ending decision.

    This "window of opportunity" warning has been made necessary
by the specific legal systems
that make it difficult for others to help in the process of dying.
When others can help to bring about death,
—as in the case of disconnecting life-support systems—
then this 'window of opportunity' is widened into the future
and the possibility of choosing death too soon is less likely.

    Here are the most important additional safeguards,
which could make this "window of opportunity" provision unnecessary:

SAFEGUARD A  Advance Directive for Medical Care

SAFEGUARD B  Requests for Death from the Patient

SAFEGUARD C  Psychological Consultant Evaluates the Patient's Ability to Make Medical Decisions

SAFEGUARD N  Statements from Family Members Affirming or Questioning Choosing Death 

SAFEGUARD O  A Member of the Clergy Approves or Questions Choosing Death

5. You must be able to procure the items required for your use.

    This safeguard is included more to protect the Final Exit Network
than to prevent the patient from choosing death prematurely.
The Final Exit Network wants to have none of its fingerprints
(both literal and figurative) on any of the implements for causing death.

    Of course, any individual or organization that helps other people to die
must protect itself if it wishes to continue to provide this service
to additional patients in the future.
Each particular legal system on the planet Earth
has it own way of dealing with people who help others to die.
Where the helpers are in extreme danger,
they must take extraordinary measures to protect themselves.

    In addition, if the patient has independently obtained the means of death,
this shows clear determination on the part of the patient to end his or her life.
But such an action might not rise to the level of 'informed consent',
since this safeguard asks nothing about the mental processes
that led the patient to obtain some means of causing death.
All people who are planning irrational suicide
are also able to obtain any equipment needed for their deaths.

6. You must be approved by our Medical Director.

    This might be the most important of these 6 safeguards,
since it seems to suggest that there will be some medical review
of the patient's reasons for wanting to die now rather than die later.
But nothing is said here about the criteria the Medical Director
will use to approve some voluntary deaths
and disapprove deaths that would be premature.
Presumably the Final Exit Network has turned down many requests
from people who were merely temporarily depressed.
Not everyone who has a death-wish will be assisted by the Final Exit Network.

    The above 6 safeguards used by the Final Exit Network
do not mention how records of their fulfillment will be kept.
A careful aid-in-dying organization
would have a well-established system of record-keeping.
There would be a file for each client.
(The Final Exit Network does have good record keeping, with a file for each client.)
And there would be a place in each file to show when and how each safeguard was fulfilled.
Such records would be as private as any medical records.
But if there is ever any reason to raise doubts about the choices,
the record of safeguards fulfilled could be presented to the prosecuting authority
to prove that this death was wisely decided
rather than automatically or casually granted. 

    Read a more complete explanation of this principle:
"Open Safeguards Kept Private":
https://s3.amazonaws.com/aws-website-jamesleonardpark---freelibrary-3puxk/SG-OPEN.html
And read an even more explicit safeguard:
"Keeping Government Officials, the Media, & other Strangers Out of the Loop":
https://s3.amazonaws.com/aws-website-jamesleonardpark---freelibrary-3puxk/SG-KEEP.html

    If and when the Final Exit Network decides to operate above ground,
for instance by establishing one or more full-range hospices
(which would provide all of the traditional end-of-life supports and care
as well as allow patients to choose any of the legal pathways towards death),
then better record-keeping will be a part of this institutional maturation.

    Other parts of the Final Exit Network website refer to an
Evaluation Committee and a Medical Committee,
which will look at the reasons for choosing death.
Perhaps their criteria and tests should also be made explicit and public.
But, once again, the details of any specific client should never be made public.
Only the principles for making life-and-death decisions should be disclosed.

    As of April 2015, a Medical Committee reviews each request for help.
This probably replaces the Medical Director,
who might have been acting alone in the early years.
The Medical Committee uses "official written criteria",
but these are not disclosed on the website.

CIRCUMSTANCES FOR DENYING ACCEPTANCE INTO THE EXIT GUIDE PROGRAM

1. When security of those who may be present at the time of death cannot be guaranteed.

    This first regulation on the negative side
is also to protect the organization rather than the patient.
It will also protect any other relatives who might be present at the chosen death.
And this provision assumes that this will be another underground death.
The planning and carrying-forward of this death must take place in complete secrecy.
If there is any chance that someone might 'blow the whistle',
then the Final Exit Network will withdraw from the case.
The hope is that there will never by any investigation into the real causes of death
and that the death will be recorded as having occurred from 'natural causes'.

    Of course, any organization that helps people to die
at the best time and by the best means
will have to protect itself if it wants to continue in operation.
Protecting the assisting organization is a way of protecting future patients
when they might need to be assisted at the end of their lives.

    But this is not a forward-looking provision. 
When the right-to-die is publicly recognized,
then the activities advised by the Final Exit Network
will be as public and above-board as any other life-ending decisions:
increasing pain medication, terminal sedation,
withdrawing life-supports, or voluntary death by dehydration.
See "Four Legal Methods of Choosing Death":
https://s3.amazonaws.com/aws-website-jamesleonardpark---freelibrary-3puxk/CY-L-END.html

    Tight 'security' is not needed when the means of choosing death are completely legal.
Why hide anything from the police and the prosecutor
if the behavior is a genuine benefit to the dying patient?
Careful documentation of the life-ending decisions
should be capable of convincing any open-minded person
that this death was wisely and compassionately chosen.

    However, the training of local police officers
usually does not include any discussion of end-of-life decision-making.
And even local prosecutors (who are lawyers)
usually have no special expertise in end-of-life issues.
Thus, the vague and ambiguous 'assisting suicide' laws
must be applied by public employees
who have only a layperson's understanding of 'suicide'.

2. When family, friends, or caregivers know about the patient's plans and are strongly opposed.

    The Final Exit Network does not want to become embroiled in any bedside debates
about the wisdom of choosing the pathway towards death advised by the Exit Guide.
Thus, there will be questions about which other people are in favor and which are opposed.
If the people closest to the patient are not in agreement,
advice from the Final Exit Network will be withheld.

    Rather than withdrawing from cases where there might be differences of opinion,
the Final Exit Network could create a system of safeguards
which would make crystal clear just which persons
have the authority to make life-ending decisions.
This is exactly the situation faced by doctors in end-of-life care:
Sometimes there are different factions favoring one course or action or another.
The doctor does not "throw up his hands" and decide to do nothing.
Rather, he might consult legal counsel to get an legal opinion
about just who has the power to make medical decisions.
Usually it will be the patient himself or herself.
And if the patient no longer has the abilities needed to make medical decisions,
there will be some person or persons officially appointed to be proxy decision-makers.

    The Final Exit Network should do the same thing:
Keep the decision-making process open and above-board,
rather than hidden and secret.
This life-or-death decision will be made by
the person or persons legally empowered to decide.
It will take a bit longer when there are disagreements within a family, for example,
but even people with difficult family-constellations have the right-to-die.
The Final Exit Network should not neglect or ignore them
because of possible controversy.
The case of Terri Schiavo clearly illustrates a family divided about terminal care.
But it was ultimately settled when her husband was legally declared the decision-maker
and the judge ordered the removal of the feeding-tube.

3. When the Exit Guide is uncomfortable with either of the above circumstances.

    This is an extremely arbitrary and subjective criterion.
Perhaps one Exit Guide would be willing to proceed as planned
whereas another would not feel 'comfortable'.
Life-ending decisions should never be comfortable.

    Once again, this 'safeguard' does not focus on what is best for the patient.
Here we are concerned with the feelings of the Exit Guides
and perhaps the reputation of the Final Exit Network itself. 

    Life-ending decisions should not hinge on whether 'security'
is so tight that no one else will ever discover the true cause of death.
And no detractors should have veto power over the right-to-die
just because they do not agree with this form of liberty.

    Everyone would be more comfortable with the death-planning process
if there were open and public safeguards, privately fulfilled.
The news media and other strangers have no right to look at our medical records.
Likewise, our end-of-life deliberations should remain completely private.
But it should be known that specific safeguards were fulfilled
in the process of choosing the best pathway towards death for a specific patient.

    All aid-in-dying individuals and organizations
should publish in advance exactly what (privately fulfilled) safeguards
are being used to prevent mistakes and abuses of the right-to-die.

    Only when there are good reasons to believe that a crime has been committed
(a harm violating the rights of the person now dead)
would the public prosecutor be given access to the medical records,
including any death-planning records,
so that the possibility of a crime can be more completely investigated.

    All 26 of these safeguards are open and above-board.
None of them suggests concealing facts from the police or the prosecutors.
In fact, one of the safeguards suggests review by the prosecutor
before the death takes place!
Then all involved will know in advance whether or not
there will be any legal fall-out from their participation
in the process of making end-of- life decisions.

    Involving the public prosecutor in the death-planning process
is such a radical departure from underground aid-in-dying
that some of the most experienced helpers will not be able to change gears.
But a more open process of making life-ending decisions
will empower millions of more people to embrace the right-to-die.

    Some potential clients of the Final Exit Network
would be discouraged by a more open process,
but these would most likely be the questionable deaths in any case.
And thousands of more obvious patients
needing support while dying would be helped.
The total number of people being helped might actually increase
if the Final Exit Network adopts more open and public safeguards.

APRIL 2015 UPDATE CONCERNING SAFEGUARDS

    As noted above, the presentation of safeguards disappeared from the website
of the Final Exit Network sometime between 2012 and 2015.
Instead we have the following criteria now mentioned:
mentally competent, physically able to self-deliver without illegal help,
suffering intolerably, making a voluntary and repeated choice,
based on irreversible physical illness or a chronic condition,
which leaves the candidate-for-death with a quality of life
that is no longer acceptable.
This revision probably does not change the basic principles
now applied by the Final Exit Network
in deciding which applicants will be accepted into the program.

GENERAL COMMENTS ABOUT THE SAFEGUARDS
ARTICULATED BY THE FINAL EXIT NETWORK

    What is fundamentally missing from this list of safeguards
is clear operational methods for separating
foolish irrational suicides
from wise medical decisions at the end of life.

    The Final Exit Network would not approve of a teen-age girl killing herself
because her one-time boyfriend has 'fallen in love' with another girl.
This would be an example of a foolish irrational suicide.
And the number of irrational suicides
probably exceeds the number of voluntary deaths
by about 10 to 1.
See Will this Death be an "Irrational Suicide" or a "Voluntary Death"?
https://s3.amazonaws.com/aws-website-jamesleonardpark---freelibrary-3puxk/CY-IS-VD.html

    Thus, any reasonable aid-in-dying organization
will find itself turning down more applicants for death than it approves.

    The fundamental thrust of the safeguards should be:
How can we prevent premature death
while at the same time allowing reasonable end-of-life decisions?
The 26 safeguards linked above do precisely this.
How far do the Final Exit Network safeguards go in this direction?

    A much better set of safeguards could be created.
And any such new set would be more specific and include details,
so that it could easily be proven in a court of law
that each specific safeguard had been fulfilled.
As said before, most cases would never lead to prosecution.
And hence all of the details of the life-ending decisions
would be as private as any other medical records.

     The 2009-2011 criminal prosecutions of leaders and members of the Final Exit Network
would probably have been completely avoided
if there had been a good set of public safeguards in place
and if the safeguards had actually been followed and fulfilled.

RESPONSE FROM THE FINAL EXIT NETWORK

    Before it was first published on the Internet,
this analysis and critique of the safeguards used by the Final Exit Network
was reviewed by a member of the Advisory Board of the Final Exit Network.
Her suggestions for improvement have been incorporated above.
And any suggestions from anyone else will also be welcome.
All aid-in-dying individuals and organizations
should have careful safeguards to prevent mistakes, abuses, & errors of judgment.

AUTHOR:

    James Leonard Park is an advocate of the right-to-die with careful safeguards.
His longest book is How to Die: Safeguards for Life-Ending Decisions,
which is built around 26 recommended guidelines
for making wise, end-of-life medical decisions.
Several safeguards and chapters from this book
are linked in this presentation, critique, & replacements
for the safeguards used by the Final Exit Network.

    The above analysis of the Final Exit Network safeguards
does not necessarily represent the views of the Final Exit Network.
The Final Exit Network can easily be found on the Internet.