SAFEGUARD
N FOR LIFE-ENDING DECISIONS
STATEMENTS FROM FAMILY MEMBERS
AFFIRMING OR QUESTIONING CHOOSING DEATH
The autonomy of the individual who is dying
must be respected above the opinions of others,
but sometimes the thinking of people who want to die is
distorted.
Such inadequate or mistaken reasoning will be most easily detected
by those who have known the patient for the longest time.
So, while others will have no
veto power over the life-ending decision,
their carefully-considered opinions should be taken into account
as a safeguard against irrational suicide.
If the patient is suicidally
depressed
and the reasons for being depressed can be corrected,
then it is much better to solve the problems behind the depression
than to allow the patient to kill himself or herself.
Family and friends will review all the written
statements from:
the patient,
the psychological
consultant, the doctors,
the members
of the clergy, the ethics
committee,
& one
another.
Then each will write his or her own statement,
expressing either agreement or disagreement with the plans for death.
In short, the significant others will read thru
the death-planning record that has been created up to that date.
And as new statements are added by others,
family members and friends might decide to revise their own
statements.
Usually the appropriate 'significant others'
will be obvious:
The people who have known the patient for the longest period of time
will be the ones best able to understand and support
the decision of the patient to bring life to an end at this
time.
Which relatives and friends will actually gather at the death-bed?
And the views of the patient and the
significant others
should have more weight than the views of their consultants.
The doctors, the psychological consultants, and ethical consultants
have their professional perspectives on the situation.
But the people who have known the patient for the longest time
will be best able to evaluate the wisdom of the life-ending
decision.
Over the years of knowing one another, these
significant others
will have had the most opportunities to discuss life and death,
including, of course, the patient's views concerning the right-to-die,
expressed in a variety of circumstances.
Discussions might have been stimulated by right-to-die cases in the
news
or evoked by members of the family who died either well or miserably.
Some of these discussions will be casual and others more serious.
Some will be similar to the patient's current situation and others
not.
But all such discussions will be evidence of the patient's views,
expressed not just in the current situation but over a period of
years.
To encourage the clear definition of who has
decision-making power,
doctors, hospitals, nursing homes, & other health-care providers
should encourage all patients to
designate in writing legal proxies,
either individuals or specifically-formed Medical Care Decisions
Committees,
who will decide for the patient if the patient becomes incapable.
As proof that the patient and family have
considered all options,
they should hold documented discussions of the proposed death.
Such discussions probably will come before the significant others
write their own statements of understanding and support.
And if the patient can participate in such deliberations,
this will be further proof to all concerned
that the life-or-death decision was not reached casually.
These discussions could easily be recorded by
some electronic means.
If that does not seem wise, someone should at least take notes,
recording who was present and what their main views were.
Something as important as choosing death
will probably require several discussions among the people
concerned.
They need time between discussions to read the death-planning record
and to consider the opinions of everyone else involved.
The fact that the proxies have had several documented discussions
should make it plain to all that this was a careful decision,
not an emotional reaction
to a sudden health-crisis.
If some of the proxies cannot attend these
discussions,
the documentation will help them to catch up with the others.
They can listen to the sound recording, view the video recording,
or read the
notes (which might be available in some electronic form).
And they can express their views by phone, by e-mail, or in letters.
As long as the patient can express his or
her own views,
the patient's philosophy of life-and-death should be uppermost.
And whenever possible, the patient with make all medical
decisions.
But if the patient can no longer weigh options and make choices,
then the duly-authorized proxies must accept the burden of deciding
based on their personal knowledge of what the patient
would have wanted
under the current circumstances.
These deciders will take into account the
professional opinions
gathered in the process of considering the possibility of choosing
death.
But they are not bound
by any such professional recommendations.
The best decisions will be made by proxies close to the patient,
who can defend the best interests of the patient.
The duly-authorized proxies shall make the decision
—drawing on the professional opinions of their consultants as
appropriate.
Written statements should be provided by:
(1) spouse and/or others who have been close to the patient every day;
(2) siblings of the patient, especially those close in
recent years;
(3) children and step-children who wish to be heard;
(4) friends who have been close enough in recent years
to have participated in other major life-decisions of the patient;
(5) other persons who have known the patient in meaningful ways
and who can explain why their views should be heard.
If the patient created a Medical
Care
Decisions Committee (MCDC),
these specifically-selected persons are the most obvious ones
to write statements of understanding and support for the patient.
When we create our own Medical Care Decisions Committees,
we will necessarily choose to include
some people and exclude
others.
The basic reasons for these selections and exclusions
will be compatibility with
our own medical ethics.
Thus there might be persons who are close to us by blood or marriage
but who are not close
to us philosophically or ethically.
And we do have every right to exclude such persons
from having any role in our medical decisions.
For example, we might have relatives
who are unalterably opposed to any chosen death.
They have every right to hold those views for themselves,
but if we know such views in advance (and if we disagree with them),
we should exclude such relatives from the death-planning process.
We should do this respectfully when we form our MCDCs.
Such careful definition of who
has a voice and who
does not
will prevent much family conflict if there are ethical differences.
Someone should summarize these discussions for
the record.
Such a summary would indicate how many hours
were devoted to considering the options
and who participated in each discussion.
Perhaps at least 100 human-hours should be devoted to a simple
death.
More hours might be needed if there are disagreements.
("Human-hours" here means the total number of hours spent
by all persons concerned with the proposed death.
For instance, if five people talk for a total of 10 hours,
this means that 50 human-hours have been devoted to this decision.)
After most of this discussion has been
completed,
each person involved can write an independent statement.
If some find that their views are identical,
they can sign their names to the same written statement.
This seems close to the Supreme Court issuing its
opinions:
If all nine Justices agree, one writes the opinion and the others
concur.
If some agree for different reasons, they write concurring opinions.
Those who disagree with the majority can write dissenting opinions.
All the opinions are read by all the other Justices.
And before publication, all Justices can revise their written opinions.
In making life-ending decisions,
each member of the Medical Care Decisions Committee
should express himself or herself completely before any vote.
If some members have dissenting opinions about the proposed death,
they should clear their consciences at this point,
even if they know their dissents will not affect the outcome.
If such discussions and documentations seem
too complicated,
we might ask how we would like to have our own deaths decided.
Most of us would prefer too
much care for our deaths than too little.
Inviting the participation of significant
others
is the best safeguard against possible manipulation.
Some relative (or group of relatives) might wish the patient dead
in order to receive their inheritance immediately
or to prevent the estate from being dissipated by medical expenses.
A business colleague might wish a partner out of the way.
Crime-fiction is full of such motives for murder:
If someone is forced to 'choose
death',
murder is not necessary.
However, if everyone who cares about the
patient participates,
and if diverse professionals examine the planning process,
it should be possible to prevent any 'railroading' into death.
A number
of
different individuals will know about the proposed death.
If one of them suspects manipulation, he or she should discuss it
with the others involved in planning for this death.
The possibility that the patient is being rushed into death
should be explored until all reasonable doubts have been resolved.
If the others involved in the planning process
will not listen,
then the person who suspects inappropriate influences
can turn to the law-enforcement authorities
(county attorney or agencies responsible for protecting vulnerable
adults)
to prevent a premature death.
The waiting
periods
suggested in another
safeguard
should allow sufficient time for all mixed motives to be uncovered.
If history shows these safeguards do not prevent manipulation,
additional safeguards might be needed.
We want to uncover all illegitimate 'reasons' for the patient's death
that do not genuinely serve the best interests of the patient.
HOW SIGNIFICANT OTHERS CAN DISCOURAGE
IRRATIONAL SUICIDE
AND OTHER FORMS OF PREMATURE DEATH
If the patient is on the verge of irrational suicide
or another life-ending decision that would be premature,
the participation of several persons deeply involved in
the patient's life
will detect and delay any and all such
inappropriate courses of action.
Several heads all working on the same end-of-life problems
are likely to create a better decision
than just one person
and one doctor
making
a decision that results in
death.
created January 17,
2007; revised 2-21-2008; 3-15-2008; 5-14-2008;
2-6-2010; 5-27-2011;
12-15-2011;
1-29-2012; 2-22-2012; 2-23-2012; 8-2-2012; 8-22-2012; 11-15-2012;
5-22-2013; 6-27-2013; 2-19-2015; 5-31-2018; 3-14-2019; 6-17-2020;
Involving
several significant other people in the end-of-life discussions
should
prevent less-thoughtful and disorganized life-ending decisions.
The
explanation above is Safeguard N in
How
to Die:
Safeguards for Life-Ending Decisions:
"Statements
from Family Members Affirming or Questioning Choosing Death".