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Ethical Episodes

Advance Directive

by Joel Marks

I don’t think I am more preoccupied with death and dying than the average soul, but a certain low-grade anxiety does permeate my psyche on account of two morbid eventualities: species extinction by asteroid and meeting my personal demise in a hospital ward. Having discussed the former in Issues 79 and 86, I will herein take up the latter. ‘Advance directives’ or ‘living wills’ regarding end-of-life care are increasingly popular, and mine is unequivocal: I do not want to linger in a state of helplessness. The more chilling prospect is for the lingering to be conscious, but even if I were to be unconscious, the lingering would seem worse than pointless since it would reduce my personal financial legacy and squander social resources that could be better utilized elsewhere.

While I know that many share my intuition about these matters, the fact remains that no country on Earth unambiguously sanctions the sort of death I would desire under these circumstances. Hence my anxiety. All it would take is someone to find me lying in the street or in my home and call an ambulance for me to end up in the clutches of a system that will then have absolute control over my mode of exit. The ambulance might as well be a paddy wagon taking me to prison. Or I could check myself into a hospital, not realizing the terminal severity of what ails me. And then I would be stuck.

This is vividly on my mind at present because of witnessing this very thing happen to a dear friend. Due to needing to attend to numerous matters by way of wrapping up a life, she had failed to make suitable arrangements to relocate to Geneva or some other locale that is friendly to the dying, in time to avoid being carted off to the local hospice when she could no longer care for herself. Thereupon her condition steadily deteriorated, but in its own good time. Meanwhile she was left for a month in a state of unadulterated misery – not in sufficient physical pain to warrant total drugged oblivion, not wishing to be given happy drugs (if they would even work), finally refusing any visitors because there was nothing more she wanted to talk about with anybody, confined to her bed when she only wished she could go outside for a walk, surrounded by others dying, too weak to read, having no appetite, with nothing to ponder except the prospect of a possibly painful death by failure of one or another organ, and finally starving herself to death since nobody else could legally kill her. (And thank God they allowed her to starve!) I will never forget her frequent refrain on the telephone: “All I want is for this to be over.”

There are certainly many relevant considerations that could tend against what we as individuals want in this type of situation. For example, it is quite understandable that many medical professionals would balk at assisting others to die, not to mention outright killing them. This is reminiscent of the refusal of many physicians and nurses to carry out the executions of condemned criminals, and of others to perform abortions, and of conscientious objectors to be soldiers. Nobody should be forced to kill. But nobody should be forced to live either. The working compromise at present seems to be to permit people to die, and sometimes speed it along a little, albeit indirectly in the process of pain-killing. Even these practices are not universal, but even when available they did not help my friend in her predicament.

It seems to me the solution is obvious. Let there be a medical specialty of assisting in and inducing death. Like any other specialty, it would be voluntary for the aspiring practitioners. Future Doctors (or Nurses) Kevorkian might feel called by a special sense of mission to relieve this widespread cause of suffering in the world.

The advantages to the patient who is in this extremity, and indeed to all of us even at the peak of health, would be significant, yet in broad brush a commonplace of modern society. We would know that were we to face a particular kind of medical situation, we would have recourse to a relevant kind of medical expertise. Just as most of us do not wish to extract our own teeth and are incapable of performing our own heart surgery, so we would prefer not to have to depend on our own devices for a quick and easy death. How much better to have access to competent individuals with professional or institutional backing. What a comfort to know that there is an alternative to jumping out of a window or firing a shotgun into one’s mouth, not to mention having to burden a friend or a relative with the task of killing us. Another source of relief would be reducing the possibility of failure due to the ignorance or inexperience of oneself or one’s friend, for even the use of pills or asphyxiation could go awry and result in a permanent mental or physical crippling rather than a fatality.

My ideal in this regard is that we have the prerogative of such thanatological services even prior to our final debilitation. I would like to know that I have the option, upon some terminal pronouncement (duly second-opinionated), to depart these mundane premises while at the top of my game. Why should we, a species that has the knowledge and ability to direct its own fate in many circumstances, be condemned to anticipate and experience a severely diminished capacity for independence and enjoyment, in unpleasant or unfamiliar surroundings to boot, as our final mode of existence? I would like to be fully functioning when I share a last good time with my friends, after which I would call up Dr Kevorkian to make a house call or put me up at his spa.

Joel Marks is Professor Emeritus of Philosophy at the University of New Haven and a Bioethics Center Scholar at Yale University. Be sure to check out his website www.TheEasyVegan.com before you check out.