In this section, I’ll explore two strategies people can use to control their final passage and so promote a “good death.” The first is an option that our society strongly encourages: People should make their wishes known in writing about their treatment preferences should they become mentally incapacitated. The second approach is controversial: People should be allowed to get help if they want to end their lives.

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An advance directive, is the name for any written document spelling out instructions with regard to life-prolonging treatment when people are irretrievably ill and cannot communicate their wishes. There are four basic types of advance directives: two that the individual drafts and two that are filled out by other people, called surrogates, when the ill person is seriously mentally impaired.

Advance directives have an admirable goal. Ideally, they provide a road map so that family members and doctors are not forced to guess what care the permanently incapacitated person might want. However, there are issues with regard to these documents too.

One difficulty is that people are naturally reluctant to think about their death (Ko & Lee, 2014). Do you or your parents have an advance directive? Even in the Netherlands, where people can choose to take their lives, less than 1 in 10 people does (as reported in van Wijmen and others, 2014).

The good news is that most older adults in the United States now have advance directives, a quantum leap from the situation a decade ago (Silveira, Wiitala, & Piette, 2014). But minorities and low-income elderly are particularly leery of filling out these documents (Ko & Lee, 2014). Imagine, for instance, that you are an African American and well aware of the sordid history of health discrimination against your group. Would you want to write a document telling medical personnel what not to do?

There are also serious problems with the most well-known advance directive, the living will. Because living wills are vague, these documents are subject to misinterpretations (Cicirelli, 2007): Does “no aggressive treatments” mean not putting in the feeding tube that has allowed my aunt to survive for 4 years after brain surgery? When your grandma wrote she wanted “No heroic measures,” what exactly did she mean?

While we might think the solution would be to come up with specific checklists (“I don’t want to be on a ventilator, but I do want a feeding tube”), can we expect people to make these detailed decisions? How many of you really know what being on a ventilator or having a feeding tube entails? Moreover, while you might say “no heroic measures” if you are healthy, your decisions are apt to be different when you are battling a fatal disease. Therefore, the best strategy is to have a series of evolving discussions with loved ones, and then choose a designated family member who, in consultation with the physician, makes the final choice (see, McMahan and others, 2013; van Wijmen & others, 2014).

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This means the best advance directive is a durable power of attorney for health care. Granted, deciding on a single family member to carry out one’s wishes can lead to jealousy. (“Why did Mom choose my brother and not me?”) It doesn’t ensure mistakes won’t occur. Suppose after giving your “so called” reliable daughter power of attorney, that child elopes with a money-grubbing third husband and you realize you made the wrong choice? Still, having a defined proxy—but making sure to sit down and discuss your wishes with the family—can reduce the conflicts when you believe that Mom’s suffering should not be prolonged, while your brother insists that treatment continue at all costs. These sibling disagreements are tailor-made to poison family relationships for years (or life).

By now, some readers may be getting uneasy, not about keeping people alive too long, but about the opposite problem—letting them die too soon. Let’s ratchet up the anxiety as we move to the next step in the search for death with dignity: helping people take their own lives.

Dr. Cox, a British rheumatologist, had a warm relationship with Mrs. Boyles, who had been his patient for 13 years. Mrs. Boyles was terminally ill, in excruciating pain and begged Dr. Cox to end her life: “Her pain was . . . grindingly severe. . . . [It] did not respond to increasingly large doses of opioids. Dr. Cox had reassured her that she would not be allowed to suffer terrible pain during her final days but was unable to honor that pledge. . . . As an act of compassion, he injected two ampoules of potassium chloride (a fatal drug). . . . The patient died a few minutes later peacefully in the presence of her (grateful) sons. . . .” Then the ward sister, out of a sense of duty . . . reported the action to the police. Told to “disregard the doctor’s motives” but only rule on his “intent to kill,” a jury . . . convicted Dr. Cox “amid scenes of great emotional distress in the court.”

(as reported in Begley, 2008; quotes are from pp. 436 and 438)

How do you feel about this doctor’s decision, the reaction of his nurse, and the jury’s judgment? If you were like many people in Great Britain, you would have been outraged, believing that Dr. Cox was a hero because he acted on his mission to relieve human suffering rather than follow an unjust law (recall Kohlberg’s post-conventional stage, in Chapter 9).

Let’s first make some distinctions. Passive euthanasia, withdrawing potentially life-saving interventions, such as a feeding tube, is perfectly legal. (That’s what advance directives specify.) But the step Dr. Cox took qualified as active euthanasia,—taking action to help a person die. Active euthanasia is illegal in every nation except Belgium, Luxembourg, and the Netherlands. However, as of this writing (early 2015) a variation on active euthanasia called physician-assisted suicide is legal in Switzerland, Oregon, Montana, Vermont, and Washington State. Under strict conditions, at a terminally ill patient’s request, physicians can prescribe a medication the individual can personally take to bring on death.

As the judge in the above trial spelled out, the distinction between the two types of euthanasia lies in intentions (Dickens, Boyle, & Ganzini, 2008). When we withdraw some heroic measure, we don’t specifically wish for death. When doctors give a patient a lethal dose of a drug or, as in physician-assisted suicide, prescribe a lethal substance for a terminally ill person, they want that individual to die.

Although active euthanasia is almost universally against the law, surveys suggest practices that hasten death do routinely occur (Chambaere and others, 2011; Seale, 2009). To take a classic example, doctors may sedate a dying patient beyond the point required for pain control, and so “accelerate” that person’s death (Cellarius, 2011). Polls show increasingly widespread public acceptance of active euthanasia in Western E.U. nations over the past 30 years. But this is not the case in Central and Eastern Europe, where significant fractions of citizens still believe terminating the lives of people is never justified (Cohen and others, 2013). Why?

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One reason is that killing violates the principle that only God can give or take a life. So the fact that in Central and Eastern Europe people are more apt to be religious partly explains this East–West attitude split. Apart from religious considerations, there are other reasons to be leery about taking this step.

Critics fear that legalizing euthanasia may open the gates to allowing doctors and families to “pull the plug” on people who are impaired but don’t want to die (Verbakel & Jaspers, 2010). Even when someone requests help to end his life, a patient might sometimes be pressured into making that decision by unscrupulous relatives who are anxious to get an inheritance and don’t want to wait till the person dies. Governments might be tempted to push through euthanasia legislation to spare the expense of treating seriously disabled citizens—offering another possible reason why residents living in more authoritarian, less democratic Eastern European nations are more apt to oppose this idea (Cohen and others, 2013).

Older people, unfortunately, are apt to be against physician-assisted dying, based on personal encounters: “She (my niece) thought that I should be euthanized,” reported one horrified woman. “And she actually said to me (when I was ill), ‘if you were my dog I would shoot you to put you out of your misery’” (Malpas and others, 2014, p. 356).

Another issue relates to where to draw the line. Should we allow people to kill themselves when they have a painful chronic condition, but may not be fatally ill? Suppose the person is simply chronically depressed. Can permitting suicide ever be an ethically acceptable choice (see Berghmans, Widdershoven, & Widdershoven-Heerding, 2013; Gillett & Chamberlain, 2013; Wittwer, 2013)?

There are excellent arguments on the other side. Should patients be forced to unwillingly endure the pain and humiliation of dying when physicians have the tools to mercifully end life? Knowing the agony that terminal disease can cause, is it humane to stand by and let nature take its course? Do you believe that legalizing active euthanasia or physician-assisted suicide is a true advance in caring for the dying or its opposite, the beginning of a “slippery slope” that might end in sanctioning the killing of anyone whose quality of life is impaired?

There obviously is an age component to the “slippery slope” of withholding care. As I suggested earlier, people with DNR or DNH orders in their charts are typically elderly, near the end of their natural lives. We already use passive euthanasia at the upper end of the lifespan on a case-by-case basis, holding off from giving aggressive treatments to people we deem “too frail.” Should we formally adopt the principle “don’t use death-defying strategies” for people after they reach a certain age?

Daniel Callahan (1988), a prominent biomedical ethicist, argues that the answer must be yes. According to Callahan, there is a time when “the never-to-be-finished fight against death” must stop. Let’s now read Callahan’s arguments in favor of age-based rationing of care:

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Age-based rationing of health care is poised to become an important developed world issue as the baby boomers flood into later life, and governments grapple with the astronomical health-care costs involved in keeping frail elderly people alive for years. As I mentioned in Chapter 14, we cannot count on medical miracles to cure the many physical problems that are the downside to living to our eighties and beyond.

Do you think Callahan is “telling it like it should be” from a logical, rational point of view, or do his proposals give you chills? Should we rely on markers such as life expectancy or quality of life to allocate who does or doesn’t deserve to get care?

Whatever your answer to these compelling questions, you might notice that this chapter is devoted to one core lifespan concern. As we approach death, our life comes full circle, and we care only about what mattered during our first year of life—being connected to the people we most love. True, self-efficacy is important. But, when we come right down to it, attachment trumps everything else!

Question 15.12

1. Go for it! But fill out a living will.

2. Go for it! But you need to regularly discuss your preferences with each of us and complete a durable power of attorney.

3. Avoid advance directives like the plague because your preferences will never be fulfilled.

b

Question 15.13

Jamal’s case: We are free to make decisions about how to live our lives, so it doesn’t make logical sense that we can’t decide when our lives should end. Plus, it’s cruel to torture fatally ill people, forcing them to suffer fruitless, unwanted pain when we can easily provide a merciful death. Latoya’s argument: I’m worried that greedy relatives might pressure ill people into deciding to die “for the good of the family” (that is, to save the family money). I believe that legalizing physician-assisted suicide leaves the door open to governments deciding to kill people when they think the quality of their life is not good. Furthermore, only God can take a life!

Question 15.14

Here your answers may vary in interesting ways. Enjoy the discussion!