Wanted: A Guiding Moral/Medical Framework
'Do no harm.'
Decisions regarding end-of-life care are best made within the context of a particular health care situation AND from within a guiding moral framework. In other words, particular decisions are best made within the context of a particular illness or situation, not in some sort of hypothetical situation where: "If this happens to me, then I want that."
Good guessing and good intentions are not enough. Intentions - and deeds, along with Living Wills, and other advance care planning - must also be grounded in solid moral decision-making. It is very important to anchor decision-making on a moral foundation that acknowledges that every human life has inherent dignity and worth, no matter the condition, stage, or the surrounding circumstances of that life. Choosing a good health care proxy with the combination of good judgment and a solid moral framework is another important point. The best person may be someone related to you, or it might be a good friend or trusted confidant.
So, move forward with discussion about your advance directive and durable power of attorney for health care, but do so armed with the aforementioned knowledge, and a guiding moral framework, or as the Hypocratic Oath states: "First, do no harm."
Obviously it is both harmful and immoral to intentionally hasten the moment of death - either by means of assisted suicide or passive or active euthanasia. Allowing death to occur naturally is very different than intending to cause death to occur unnaturally. Thus, if a person is in the end-stages of a terminal disease, and has uncontrolled pain, it is absolutely permissible to control the pain, even if the unintended side-effect is to shorten the life of the dying person. This humane pain control, using only necessary means, is there to assure comfort not kill the patient.
However, if a person is not dying of an underlying pathology, then food and water, warmth and shelter are a natural and humane means of providing comfort - not extraordinary means, and certainly not burdensome treatment. In cases of terminal illness, there is no moral obligation to postpone the moment of death or to seek unnecessarily burdensome, or high risk treatments. A natural death is just that, natural. For many, many centuries, people have died in community, cared for by family members or fellow villagers. Unfortunately, the considerable advances in medical technology of the last 50 years have not been accompanied by considerable advances in medical or social common sense. Heaven knows, medical advances have not been in lockstep with moral advances.
In years past, with the advance of technology, the emphasis was in curing disease more than in comforting and caring for the patient. Using technology to postpone death meant hooking everyone up to as many tubes and machines as possible, for as long as possible, thereby rendering them the opposite of a natural dignified death. This unfortunate situation created a fear in many people that even now they are at risk for being over-treated medically.
Now the converse is true, as the risk for many patients now is being undertreated rather than over-treated. In these days of health care reform, with talk of rationing care and "Quality Adjusted Life Years," senior citizens, the disabled, and the terminally and chronically ill, are more likely to endure discrimination based on not being "comparatively effective" in their functional status, and therefore more likely to receive less care.
Fortunately, with the advent of the modern hospice movement, and the teachings of Elizabeth Kubler Ross and others, the balance of end-of-life care has begun to shift back to the communities. And some semblance of common sense in terms of competent and dignified end-of-life care has returned, though improvements in end of life care must continue apace, and funding of good hospice and palliative care is an imperative.
The moral framework that in the past buttressed both society and medicine, however, is in serious disrepair. Especially in the states of Washington and Oregon, and in the countries of the Netherlands and Switzerland, where the collapse of the common good has been subsumed by the advent of physician assisted suicide and euthanasia. Now, far too many vulnerable people have received the message that their lives are not worthy of being lived, leaving them with the perception : "I feel like I am a burden, so I have an obligation to get out of the way and die."
It is the duty and the responsibility of each of us to reach out to populations at-risk for assisted suicide and provide them with truly compassionate care, while accompanying them on their journey through illness, with the help of excellence in end of life care, and support for caregivers and family members, information, and resources.
2006 Eileen T. Geller. Updated 2009.
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