FOUR LEGAL METHODS OF CHOOSING DEATH

FOUR LEGAL METHODS OF CHOOSING DEATH

{alternate title: Legal Ways to End Our Lives}

by James Park

            http://www.tc.umn.edu/~parkx032/

1. Increasing Pain Medication.

2. Terminal Sedation.

3. Withdrawing Treatments and Life-Supports.

4. Voluntary Dehydration.

SUMMARY

HOW MANY DEATHS ARE ACHIEVED BY EACH METHOD?

METHODS OF DYING AND CAUSES OF DEATH

    As we approach the end of our lives, we will probably be receiving various forms of medical care.
Our specific medical problems and the care selected to treat them will help to decide which pathways towards death would be best for us.
Are we already receiving medication for pain?
Are we already lying in a hospital bed?
What treatments and life-supports are keeping us alive?
Would it be easy to give up food and water?

    Once it becomes clear to all that we are dying, we can cooperate with our doctors to select specific actions that will bring death as gently as possible.

    The following four life-ending choices can help to bring a peaceful death at the best time.
These four kinds of action are all completely legal within all of the states of the United States and also in most advanced countries of the world.
And even where the legal status of these end-of-life options is uncertain, moral thinking is moving toward affirming these choices.

1. Increasing Pain Medication.

   If we are under the care of doctors as we approach death and if we are already receiving some kind of medication for our pain, it is entirely within the law and good medical practice everywhere for our doctors to increase our pain-medication even if this higher dose will shorten the process of dying.

   When considering the amount of medication to administer, the patient, proxies, & doctor should be clear about the purposes for which the medication is being increased.

   If there is still some realistic hope of recovery, then caution is appropriate when deciding the dose of pain-reliever.
Too much of any medication could be harmful.
And if we—the patients—are hoping to return to ordinary life, or just hoping to have at least a few more days of meaningful living, then we do not want the additional problems of having our bodies or brains damaged by too much of any drug.

   However, if we are not expected to recover and return to ordinary life, and/or if the burden of the pain is greater than the benefit of the additional time, then the possible side-effects of pain-relievers need not concern anyone.

     One side-effect of pain-relievers is dependence on the drug, which could also be called 'addiction'.
But why worry about drug-dependence if we will never recover?
Limiting medication because of the side-effect of drug-dependence is not relevant in terminal care.
And standard protocols limiting such drugs should not be applied.

   When we have entered the last phase of our lives—namely the downward pathway towards death—then the only relevant considerations are the effects of the drugs on our bodies and minds between now and the hour of our death.

     In other words, decisions that are part of terminal care differ sharply from medical decisions aimed at recovery.
We could even say that some of the decisions taken as part of terminal care are life-ending decisions.
And if we are actually making decisions that will bring our lives to an end, then we should be explicit about this new purpose for medical care.

   This is the sense in which we might consider the consequence of shortening the process of dying.
Medications that can control pain often also suppress several vital functions, including the abilities of our brain-stems to control our heart-beat and breathing.
When large doses of morphine (for instance) are prescribed, the doctor knows that one of the side-effects of this drug is that our lives will probably be shortened by a few days.

     We might say that increasing pain-medication is a life-shortening decision rather than a life-ending decision because the higher dose of pain-relievers will not immediately end our lives.
Rather, one predictable result will be fewer days of terminal suffering.
And the pain-medication itself will reduce the severity of that suffering.
We might spend much of our last few days sleeping.

   This decision to increase pain-killing drugs does not involve any new decision-makers.
The same people who first authorized, ordered, & administered the drugs will simply increase the dose to some reasonable level that will achieve the wished-for result of less suffering while the natural processes of dying proceed.

   Increased pain-medication can assure a more peaceful death, even if that death comes a few days sooner than it would have if we had made no decision to increase the pain-killers.
And our doctors can predict how many days we will survive with the increased dose of pain-medication.

    One traditional way of examining the details of the decision to increase pain-medication was called the principle of double-effect:
There is one action—a reasonable increase in pain-medication.
But there are two effects—less pain and a shorter process of dying.
Traditional ethics and law approve the action if it is taken primarily to achieve a good result—here the reduction of terminal pain—even if the second effect—here the shortening of life—is an easily-foreseen result.

    Modern thinking has moved away from the principle of double-effect because it is so problematic to discover real intentions.
How can we know how much the doctor intended death?

    But a reasonable increase in pain-relievers—within the parameters of standard terminal care—should not create any legal problems for anyone involved.

    If there is any question about the amounts of pain-medication to use, consult with other physicians specializing in terminal care and have them record their professional opinions also.
Increasing drugs prescribed for pain is one of the most common end-of-life medical choices.

2. Terminal Sedation.

     Another way to use sedative drugs is to administer enough medication to keep the patient completely unconscious until death occurs.
This method would be appropriate when the burdens of the dying process exceed the benefits of being awake.
In the most extreme situations, every moment of conscious life might be meaningless suffering and torment.

     If there is no hope of recovery from the medical condition that will ultimately cause our deaths, and if every conscious moment between now and death will only be agony, then the truly compassionate practice would be to keep us asleep until the natural processes of dying are finished.

     And as noted in the first option—increasing pain-medication—the drugs themselves will probably shorten the process of dying.

     Terminal sedation is clearly a decision that acknowledges that death is coming within a few days at most.
And the proxies for the dying person have decided that it is better to keep the patient unconscious than for the patient to have even a few more moments of suffering.
Also, a timely death might mean earlier rather than later under these circumstances.

     Once terminal sedation has been chosen as the pathway towards death, then other medical decisions also follow logically:
Unconscious patients can no longer eat or drink normally.
And there is no point in continuing to give food and fluids by tubes because that would only prolong the process of dying.
Also, if any other life-support systems are being used, they can be discontinued when terminal sedation begins.
Or the terminal sedation might begin when the life-supports are disconnected, especially if there will probably be suffering and distress as a result of removing the life-supports.

     The family and friends can even begin their process of grieving,
since it is known with absolute certainty that death is coming.
They can even begin the orderly process of arranging the funeral or memorial service since the approximate day of death will be known in advance.

     Terminal sedation might seem an unnecessary step in some cases.
Occasionally the family will ask why the process must take so long, since everyone knows that death is coming in a week or less.
And if and when new laws allow merciful death—defined as purposely ending the life of another when proper safeguards have been fulfilled—then a lethal injection could bring death immediately instead of starting terminal sedation and waiting for the natural end.
How long will it take before such means of merciful death are permitted?
Each legal jurisdiction on the Earth must change its laws to make such forms of merciful death permitted, legal options.

3. Withdrawing Treatments and Life-Supports.

     Modern science has created an ever-increasing array of technical means to support life:
heart-lung machines, mechanical respirators, drugs to control every natural process of the body, means of providing fluids and nutrition to the body, ways of clearing toxins from the blood, etc.
And there is no end in sight for further advances in medical technology.

     In fact, if we end our days in a hospital, it is very likely that we will have some form of life-support.
And in the developed world, most deaths now take place in hospitals.
Thus, one legal way to end our lives is to turn off the machines and disconnect the tubes.

     Such a life-ending decision should not be taken easily or lightly.
Very careful consideration of all possible means of recovery should be explored before we give up hope for a cure and decide to end medical treatments and disconnect the life-supports.

    Because receiving medical care and being connected to life-supports usually means that we are in a hospital, there are already good safeguards in place to make sure that withdrawal does not take place accidentally or casually.
A series of medical cures will already have been attempted.
And new treatments can always be proposed.
But will they really save us from death?
Eventually in almost every case, there comes a time to consider
ending all medical treatment and turning off the machines.

     Doctors will be the main technical advisors for such decisions.
But according to law as practiced in the Western world, the decision to end treatments and life-supports must be taken by the patient.
If the patient is no longer able to make medical decisions, then the duly-authorized proxies for the patient must make the decision to withdraw the life-supports.

     When one of the life-supports was a respirator, death will follow almost immediately when the breathing-machine is disconnected.
The same is true if machines were performing the functions of the heart.
Without blood circulating, death will come immediately.

     When the main form of life-support was a feeding-tube, then it might take a few days for the body to shut down.
And if there is any possibility of suffering due to disconnecting any machines, tubes, or other life-supports, such suffering can be prevented by appropriate drugs.
If necessary, the patient can be kept completely unconscious during what remains of the dying process.
This might be called "terminal sedation" if it is going to take any significant time for death to occur.

     Disconnecting life-support systems used to be controversial because it was too active a means of allowing death to occur.
But modern thinking about life-support systems now allows the decision to discontinue (or never start) all life-supports.

     Another worry that has mostly passed from medical practice regards the question of beginning life-supports:
Once a patient has been attached to life-supports, is it morally wrong to disconnect the machines?
The universal answer in medical ethics now is that beginning to use any system of life-supports does not require that they remain in place until natural death occurs—with the tubes and machines still attached and operating.

     Thus, if we are asked to authorize some form of life-support, we should not worry that we will be prevented from disconnect the tubes and machines later if they do no good.
In many cases, it is wise to use life-support systems as a temporary measure while specific cures are attempted.
But when all means of saving us from death have been tried, then it might be appropriate to disconnect the life-support systems and "to let nature take its course".

     Life-support systems were originally invented to sustain life while the body of an accident victim, for instance, was given medical care so that he or she could return to normal life.
Also life-support systems maintain vital functions during surgery.
But increasingly life-support systems have become the standard equipment of dying.
Dying patients are routinely put into the Intensive Care Unit (ICU), where they are connected to several different machines at once.
But when it becomes clear that recovery is not going to happen, and/or if the patient finds the burdens of life-supports intolerable, then the machines are turned off and death takes place.

     In fact, disconnecting life-support systems has become so routine that this action is seldom mentioned on death-certificates.
The death is recorded as caused by the underlying disease or condition that put the patient into the hospital in the first place.
Disconnecting the life-supports was simply the last step in medical care.

    More discussion of terminating life-supports appears here:
Pulling the Plug: A Paradigm for Life-Ending Decisions
http://www.tc.umn.edu/%7Eparkx032/CY-PLUG.html

4. Voluntary Dehydration.

     The first three legal means of ending our lives—increasing pain-medication, terminal sedation, & ending medical treatments and life-supports—all include actions by physicians, usually in hospitals.
But giving up eating and drinking is a legal means of death anyone can use anywhere.

     If and when we have carefully determined that death is the best option, we can achieve a peaceful death simply by giving up fluids and food.
Depending on the condition of our body, death will come in a week or two.

    Good palliative care can limit the various kinds of distress associated with dying by dehydration.

     The advantages of this pathway towards death are explored in
Voluntary Death by Dehydration:
Why Giving Up Water is Better than Other Means of Voluntary Death
http://www.tc.umn.edu/%7Eparkx032/CY-VD-H2.html

    Another cyber-sermon explores 26 suggested safeguards:
VOLUNTARY DEATH BY DEHYDRATION:
Safeguards to Make Sure it is a Wise Choice
http://www.tc.umn.edu/%7Eparkx032/CY-VDD-SG.html

     And a website has been established called:
Voluntary Death by Dehydration—Questions & Answers:
http://www.tc.umn.edu/~parkx032/VDD-Q&A.html.

SUMMARY

     These four legal means of drawing our lives to a close could be expanded to include other permitted means of choosing a voluntary death or a merciful death.
But these are four means that we can recommend because they are not as likely to be misused to bring death too soon.
When considering the various ways we might end our lives, we should consider the possible misuse of any such means to commit irrational suicide or to commit a mercy-killing.
Assisting an irrational suicide or committing a mercy-killing should both remain outlawed, punishable, criminal acts because they definitely harm the victims.

    Here is a proposed law that would permit wise end-of-life medical decisions while at the time prohibiting causing premature death.

    Increasing pain-medication, beginning terminal sedation, withdrawing all curative treatments and life-supports, & choosing terminal dehydration are all reasonable and wise ways to draw a human life to a peaceful and painless close.
Medical ethics already recognizes the validity of these methods.
Legal authorities know that each of these actions—when taken with careful safeguards—is a fully permitted choice at the end of life.

    The reason these four legal and moral means of choosing death were selected —while thousands of other means of bringing death were omitted—is that each of these includes implicit safeguards to prevent abuses and mistakes.
The first three methods—increasing pain-medication, terminal sedation, & withdrawing curative treatments and life-supports—all take place within medical institutions where good record-keeping and professional standards of care will prevent abuses of these methods of choosing death.
The fourth method—voluntary death by dehydration—contains within the very process of continually deciding not to eat or drink many safeguards that will discourage irrational suicide and other forms of premature death.

    When other methods of choosing death are discussed, safeguards to prevent abuses and mistakes need to be included.
Here is a catalog of a dozen possible dangers, perils, & worries, each of which is addressed by a specific set of safeguards:
http://www.tc.umn.edu/~parkx032/SG-ABUSE.html

HOW MANY DEATHS ARE ACHIEVED BY EACH METHOD?

    About half of all deaths in countries with advanced medical systems probably use some combination of these means of choosing death.

    If we back up to view ourselves from the distance of the moon, we notice that all human beings die—100%.
So, how many deaths follow the pathways described above?
However we categorize the pathways towards death, they must total 100%.

    In those places on Earth that have advanced medical systems, most deaths take place under some kind of medical care, in a hospital, nursing home, hospice, etc.

    Unexpected, accidental, or violent deaths take place elsewhere.
Of all deaths, such sudden deaths probably amount to 20%.

    Thus, about 80% of all deaths take place under some kind of medical care.

    0. Deaths with Maximum Medical Care: 25-30% of all deaths.

    Many deaths take place while maximum medical care is still being used.
These patients are 'treated-to-death'.
All of their medical care is based on the hope that they will recover.
Even when that hope of recovery is disappearingly small, medical treatments are intended to save the patient from death.
But the patient dies no matter what methods are used.
In the surgical suite or the intensive care unit, the doctors are still working to save their patient when the patient dies despite their best efforts.

    1. Increasing Pain Medication: 20-25% of all deaths.

    The purpose of pain-medication is always to reduce pain.
But there comes a point in the downward journey towards death when the pain-management turns away from recovery towards comfort.
The doctors stop worrying about the adverse side-effects of the pain-killers.
If the patient is not expected to return to ordinary life, why worry about drug-dependence or 'addiction' or even about suppressing vital functions such as heart-beat and breathing?

    Careful doctors will discuss this change of purpose for the drugs with the patient if the patient can still deal with such medical matters.
If the patient is unconscious, the proxies decide.
Here the decision to increase pain-killers is a life-ending decision.
The purpose of medical care shifts from cure to comfort.

    With increased pain-medication, the patient will be awake part of the time.
And the patient might be able to eat and drink normally.

    The standards describing reasonable amounts of drugs no longer apply.
Higher doses will probably shorten the process of dying.
But to protect the professional status of the doctors and nurses, the new dose will not cause immediate death.
An earlier death is expected but not intended.

    Of course, everyone can see that such subtle lines are difficult to draw.
In retrospect, will it be correct to say that the timing of this death was affected by the amounts of pain-killing drugs that were used?
Where such medical choices are acknowledged, the recorded cause of death will be the underlying disease or condition.
And the process of dying was shortened by the drugs.

    2. Terminal Sedation: 5-10% of all deaths.

    The doctor recommends keeping the patient unconscious for the rest of the patient's natural life—until death comes.

    When terminal sedation is decided by the doctors and the proxies, there is no point in continuing food and fluids, since these will only prolong the process of dying.
Terminal sedation is clearly a life-ending decision.
When this process begins, there is no uncertainly about the outcome:
The patient will be dead within a few days.
The doctor can predict how long dying will take,
which depends on the condition of the patient's body
when terminal sedation begins and life-supports are withdrawn.

    3. Withdrawing Treatments and Life-Supports: 10-15% of all deaths.

    Many deaths in hospitals take place when it becomes clear that medical treatment is not going to prevent death.
The life-supports in place are only going to prolong the dying-process.

    Therefore, with the permission of the proxies (perhaps even the patient), all of the medical means of curing are discontinued.
There will be no more curative medical procedures.
When life-supports are in use, including drugs to maintain vital functions, they are all discontinued at the same time.
However, any means of comfort care can be continued if the patient might have a moment of conscious suffering.

    The life-supports withdrawn might be providing oxygen or nutrition.
If the patient was supported by a respirator, death will follow immediately.
If the patient had artificial means of providing food and water, death will come a few days later.
The doctor will normally explain how long it will take for the patient to die after withdrawal of all medical treatments and life-supports.

    The family can begin their preparations for a funeral or memorial service as well as all other after-death events because the likely date of death will be known.
Withdrawing all forms of medical treatments and all means of life-support is definitely a life-ending decision.

    4. Other Chosen Deaths: 5 % of all deaths.

    When the patient is not being supported by any kind of life-supports that can be disconnected or turned off, then the patient, the proxies, & the doctors can all agree (if the patient is not going to recover), that the best pathway towards death is to give up water and other fluids.

    A small percentage of patients choose voluntary death by sleeping pills.

     Where any form of physician aid-in-dying is permitted, those deaths would be included in this category.
In Holland 2% of all deaths are achieved by what they still call "euthanasia" and "physician-assisted suicide".

    These totals should add up to 100%.
But some additional methods of dying could be added.

    Irrational suicides should be included in the 20% of unexpected deaths.

SUMMARY AND STATISTICAL PROBLEMS

    20% unexpected, accidental, or violent death

    25-30% treated-to-death in a hospital

    20-25% increasing pain-medication

    5-10% terminal sedation

    10-15% withdrawing treatments and life-supports

    5% other chosen deaths

    These estimates for countries with advanced medical care are based on similar numbers collected in Holland, which might have some of the best records available.
But much more research is needed to get the picture for other countries.

    The statistical categories for summarizing all deaths will have to be defined very carefully in order to decide just where to include a particular death.
Many deaths that take place under medical care include more than one of the means of choosing death described above.
For example, when life-supports are withdrawn, drugs are often given to alleviate the suffering that results.
Also when terminal sedation is ordered by the doctor, this usually also includes ending all food and water, since the unconscious patient cannot eat or drink.
And supplying food and water artificially will only unnecessarily prolong the dying process.
If the patient is on any other forms of life-support, these will normally be ended when terminal sedation begins.

    Such statistical questions will be settled by asking:
Which means of drawing life to a close was the primary action?

    And while we are talking statistics, none of the specific means of choosing death will create any changes in the statistics of the causes of death.
Those causes will still be listed on the death-certificates as cancer, heart disease, multi-organ failure, etc.
These four legal means of choosing death were merely the pathways.

METHODS OF DYING AND CAUSES OF DEATH

    Before the advent of modern medical care, there was no concept of the methods of dying, just the causes of death.
But now that about half of all deaths in the advanced parts of the world are achieved using some meaningful elements of choice, some distinctions between methods and causes are needed.

    The ‘causes of death’ will still be recorded on our death-certificates as the underlying diseases, organ-deterioration, accidents, etc. which are the medical explanation of why our lives came to an end.

    But in addition to the medical reasons we could no longer survive we might have chosen methods by which our lives were drawn to a close.

    The most common causes of death are:
heart and circulation failure, cancer, multi-organ failure, breathing disorders.

    The most common chosen methods of dying are:
ending curative treatments and life-supports (including food and water), increasing pain-medication, terminal sedation, and voluntary dehydration.

     Among the chosen methods of dying, most are first suggested by the terminal-care physician.
When it becomes clear to the doctor that we cannot be saved from death, the physician who is most responsible for our care at the end of life will suggest or recommend some combination of changes of medical care that clearly acknowledge that we are dying.

    Especially if we are already receiving some drugs to control our pain and other distressing symptoms at the end of life, the doctor might order that the doses of these medications be increased---now without worry about the side-effects, since we will never return to normal life.

    The doctor might even recommend terminal sedation, which means using drugs to keep us unconscious until natural death.

    If terminal sedation is selected as our method of dying, then food and water are usually also discontinued, since such means of support will only prolong the dying process.
If there are any other kinds of life-supports being used, these will usually also be terminated at the same time.
Medical procedures and drugs intended to prevent death will be stopped.

    And even if there are no other forms of life-support in use, we might all agree to stop providing food and water by any means.
If the doctor is the one who recommends this change of care, it will be called “medical dehydration”.
If the choice comes primarily from the patient and/or the proxies, it might be called “voluntary dehydration”.

    Even if we do not have any disease or condition that would likely cause our deaths within a predictable number of days, we can choose voluntary death by dehydration if no other change in medical support would lead to death.

    If we choose voluntary death by dehydration, our cause of death and method of dying would be the same:
Our death-certificates will record that we died by voluntary dehydration.
And if there were good reasons for us to die at the time, perhaps proven by the safeguards we fulfilled, then our deaths might be recorded as voluntary deaths rather than irrational suicides, which will continue to be a regular cause of death.

    If there were any relevant medical conditions behind our decision to choose a voluntary death (or for our proxies to choose a merciful death for us), these should also be explained on our certificates of death.

    For example, if we were known by be dying from incurable cancer, then cancer should be listed as the cause of death, even if we decided to shorten the process of dying by any combination of the available methods of dying.

    If, on the other hand, we did not have any terminal disease or condition, we still have the right to end our own lives at the best time.
The agreement and cooperation of other people might have been achieved in fulfilling safeguards for life-ending decisions.
Our reasons for wanting to choose death now rather than later might not be any facts recorded in our medical records.
But our death-planning records should give amble explanation.

    As the right-to-die is more widely acknowledged on the planet Earth, most deaths will be achieved with some cooperation from our doctors.
At least our doctors will be responsible for giving us the medical facts about our current situation and our likely futures under various methods of treatment that might be tried.

    But if we still have our wits about us as we approach death, we have the right to choose our own best methods of dying.
The underlying causes of death are beyond our control.
But we do not need to be merely passive victims of whatever medical conditions are ultimately going to claim our lives.
We can choose our own best pathway towards death.

LAWS THAT EXPLICITLY RECOGNIZE THESE MEANS OF CHOOSING DEATH

    Sometimes these long-acknowledged principles of medical care are explicitly embodied in the laws of the various states of the USA and in the national laws of other countries.
When any such laws are identified, they can be linked from here.
The modifications of some laws might help other jurisdictions to make wise revisions, which will acknowledge that these four means of choosing death are completely legal and moral.

    In Minnesota, the changes were embodied in the revised law against assisted suicide:
http://www.tc.umn.edu/~parkx032/MN-SUIC.html

    Please send links for other laws (from anywhere in the world) which explicitly endorse these methods of choosing a wise and compassionate death.
Send information to: James Park, e-mail: parkx032@umn.edu.

drafted 10-13-2005; revised 10-24-2005; 11-25-2005; 8-10-2006;
2-19-2008; 3-3-2008; 3-4-2008; 7-31-2008; 11-21-2008; 6-5-2009; 8-17-2009; 3-27-2010; 3-11-2011; 11-11-2011;
1-6-2012; 2-1-2012; 2-24-2012; 3-3-2012; 3-8-2012; 3-10-2012; 3-18-2012; 4-12-2012

AUTHOR:

James Park is an independent existential philosopher with deep interest in end-of-life issues.
Much more information about him will be found on his website
—An Existential Philosopher's Museum:
http://www.tc.umn.edu/~parkx032/

The above presentation of four pathways towards death has become Chapter 32 of
How to Die: Safeguards for the Right-to-Die:
"Four Legal Methods of Choosing Death".

Here are a few related cyber-sermons by James Park:

Pulling the Plug:
A Paradigm for Life-Ending Decisions .

Losing the Marks of Personhood:
Discussing Degrees of Mental Decline .