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Advance Directives i

advance_2.jpgIntroduction

Today legislation requires patients to provide doctors, clinics, hospitals etc. with “advance directives.” An advance directive is a document by which a person makes provision for health care decisions in the event that, in the future, he or she is no longer competent to make such decisions for himself or herself.

Advance directives are of two main types: (1) the “living will” and (2) the “durable power of attorney for health care.” There is a third type called a MOST form (medical order for scope of treatment), which is fast becoming the form of choice in the US.  It combines into one form living will provisions, DNR orders, designate of proxy care giver and has a doctor’s signature making it a MEDICAL ORDER, hence the name.

Living will

What it is. This is a signed, witnessed or notarized document that a person executes to direct that specified life-sustaining treatments be withheld or withdrawn if he or she is in a terminal condition and unable to make health-care decisions for herself or  himself. To be legally binding, a document of this kind must ordinarily be witnessed and sealed by notary public.

 Serious problems. Since an attending physician who may be unfamiliar with the signer’s wishes and values has the authority to carry out the directives of the will, its terms may be interpreted in a way not envisioned by its signer. Moreover, the language used in such documents is often vague and general, and fails to distinguish clearly the difference between a choice to commit suicide by forgoing or withholding treatment precisely as a way of ending one’s life or the non-suicidal intention to forgo treatment because of the treatment’s uselessness or burdensomeness. Frequently, models of a living will are promoted by supporters of euthanasia, using language that is easy to interpret in a way favorable to euthanasia.  Thus the organization known as Compassion & Choices, created by merger with the Hemlock Society, is committed to secure the legalization of euthanasia and physician-assisted suicide. This organization on its website offers  models of pro-euthanasia and assisted suicide living wills (website https://www.compassionandchoices.org/ [1]).

Because of this and because a living will is prepared before a person will be in a situation calling for careful judgment about the appropriateness or non-appropriateness of specific treatments, John Finnis, a strong defender of the inviolability of innocent human life and the great good of human life itself, has written a devastating criticism of living will legislation in England. [2] [2]

The Durable Power of Attorney

What it is. This is a signed, witnessed or notarized document in which the signer designates an agent to make health care decisions for himself or herself in the event that he or she becomes incompetent.

Care in choosing agent; advantages. The agent must be chosen with great care since he will have great power and authority to make decisions about whether health care is to be provided, withheld or withdrawn. The major advantage of appointing a health care decisions agent is that it leaves decision making in the hands of a person of one’s own choosing.  The signer of such a document has the obligation to discuss his or her values, wishes and instructions with the agent before and at the time the document is signed, and should choose an agent willing to respect and carry out the signer’s wishes. Thus pro-life people will want their agent to value human life, including bodily life, as good and a precious gift from God, no matter how heavily burdened, and will repudiate euthanasia and/or assisted suicide, which is rooted in the belief that a person’s life is a burden and that death removes this burden.

In 2009 the Roman Catholic Bishops of Maryland and Wilmington, DE published a pastoral letter, Comfort & Consolation: Care of the Sick and the Dying in which they offer criteria for  selecting a health care agent with the power of attorney (see pages 27-29). Their criteria were proposed specifically for Catholics. Here I adapt them for all who oppose withholding/withdrawing treatments in order to kill a person intentionally:

·      Appoint a person who has the strength of character to make good judgments in painful circumstances and discuss specifics with that person (and also with your primary physician).

·      No one should agree to act as an agent for another person if that person would expect or require the agent to do anything that he would directly and intentionally choose in order to cause death, nor should he choose to withhold or withdraw a treatment not because it is useless (futile) or excessively burdensome but rather as a means intentionally and directly to cause death for allegedly merciful reasons.

·      Appoint someone who is likely to be available to care for you in the distant future. Since this is so, it may be advisable to name alternate agents, in the event that your first choice proves unable or unwilling to act for you when the need arises.

·      In general one should avoid stating that he wants to reject certain treatments under all circumstances or stating without qualification that she want medical remedies restricted in the event that he/she become permanently unconscious or terminally ill. Such stipulation can amount to providing a premature self-diagnosis. The person should allow his health care agent and physician latitude to offer appropriate care based on the individual’s actual condition.

·      Include a provision regarding treatment at the time of imminent death. A person on the verge of death can refuse a treatment which would result in only a burdensome prolongation of life. Your advance directive should authorize your agent to observe this norm.

·      Periodically review the provisions of your directive and make copies of your directive and distribute them to your agent and each of your health care providers and anyone else you deem appropriate.

 

The Parents Rights Council (formerly known as the International Anti-Euthanasia Task Force)  has developed a very worthwhile document called the “Protective Medical Decisions Document” (PMDD). This can be downloaded from the Parents Rights Council’s website http://www.patientsrightscouncil.org/site/ [3]. This is a durable power of attorney for health care document specifically prohibiting suicide, assisted suicide and euthanasia. Among its provisions are the following:

I wish to receive medical treatment appropriate to my condition which offers a reasonable hope of benefit. I direct that food and water be provided to me unless death is inevitable and truly imminent so that the effort to sustain my life is futile or unless I am unable to assimilate food or fluids. I ask that, even in the face of death, I be provided with ordinary nursing and medical care, including pain relief, appropriate to my condition. Nothing should be done which will directly and intentionally cause my death, nor should anything be omitted when such omissions would directly and intentionally cause my death. Euthanasia (an action or omission that of itself or by intent causes death), whether by commission or omission, is not permitted.

In conclusion, I advise persons not to sign living wills. Rather appoint a person whom you trust to be your agent by giving him or her durable power of attorney and consider making use of the Protective Medical Decisions Document available from the Parents Rights Council.



[1] [4] This article is adapted from pp. 302-305 of my Catholic Bioethics and the Gift of Human Life (Second ed.: Our Sunday Visitor, 2008). I have, however, inserted some new material, e.g., that on Compassion & Choices.

[2] [4] See Finnis, “Living Will Legislation,” in Euthanasia, Clinical Practice and the Law, ed. Luke Formally (London: The Linacre Centre for Health Care Ethics, 1994).

(c) 2011 Culture of Life Foundation.  Reproduction granted with attribution.