THE "LIVING WILL" and EUTHANASIA: A DOCTOR-PATIENT DIALOGUE
By Raymond Voulo, M.D.
Recently, while reminiscing about the "good old days" of what once was
called the art of medicine, I remembered how, in contrast to today,
patients trusted their doctors enough to seek guidance on difficult
questions concerning medical treatment.
Longing for those times, I envisioned the following exchange between
myself and an imaginary patient "Joe" concerning the burning issues of the
"Living Will" and euthanasia. I imagined Joe's questions and my answers as
Doc, what's this Living Will that I've been hearing so much about lately?
Joe, the Living Will is a legal document that would go into effect if you
became unable to direct your medical care. It would prevent me, under
civil penalty, from using "artificial means" to keep you alive in the
event of certain illnesses. Since it is a legal document, Joe, every word
in it has significance. Allow me to read to you part of a sample Living
Will: "If I am permanently unconscious or there is no reasonable
expectation of my recovery from a seriously incapacitating or lethal
illness or condition, I do not wish to be kept alive by artificial means."
What are "artificial means"?
"Artificial means," Joe, include not only respirators, but also food and
fluid--the most basic necessities of life--administered through feeding
tubes. What's so "artificial" about food and water?
And that's not the only misleading use of language, Joe. The phrase
"permanently unconscious" is purely a judgmental designation fraught with
error. Medical history abounds with instances of spontaneous recovery from
so-called "permanently unconscious states." In many of these cases good
nursing care plus the provision of food and fluid through feeding tubes
were all that was necessary for recovery. Now these would be withheld
under the Living Will.
Also, Joe, the words "reasonable expectation of recovery" are much too
vague. What would fulfill such a definition? When a patient's chances of
recovering are 50-50, 30-70, 10-90? Even vaguer is the phrase "seriously
incapacitating illness." Stroke with paralysis, diabetes, and injuries
causing amputation all could be called seriously incapacitating--and this
list can easily be expanded.
Another danger, Joe, is that the Living Will commands obedience from the
"attending physician." The "attending physician" need not be me, your
personal physician, but any physician assigned to your case in an
emergency situation. His notion of a "reasonable chance of recovery" or a
"seriously incapacitating illness" may not be yours or mine.
So by signing a Living Will, I might be putting my fate into the hands of
a doctor I don't know and who might not have my best interest in mind?
And there's more. The Living Will places doctors in a legal quandary. If
the doctor employs "artificial" or "extraordinary" means in cases when
only a minimal chance of survival exists, and the patient dies, the
surviving family could make the claim that the condition was an incurable
condition from the very beginning and that the doctor, therefore, violated
the "Living Will." On the other hand, if the patient survives with a major
disability, the patient could make a claim that the doctor inappropriately
used "extraordinary means" in a "seriously incapacitating" illness. In
marginal cases, therefore, it would become legally advantageous for the
doctor not to try to save the patient at all.
Conversely, both doctors and hospitals may feel obliged to use heroic
measures on patients who have not signed "Living Wills" even when these
measures are not indicated, again in fear of legal action--a phenomenon
similar to what we have seen in the treatment of patients who have not
signed a "Do Not Resuscitate" order. This could force patients to sign
Living Wills purely defensively, and would thus further entrench
Doc, what you're saying is that if I had signed a "Living Will" and was
judged "permanently unconscious" you would be prevented from feeding me
through a feeding tube, and that I would die of starvation even though I
had some chance of recovering?
But, Doc, before this "Living Will" business, didn't I always have the
right to refuse a respirator or any other medical treatment simply by
Absolutely, Joe, and you continue to have that right without a Living
Will. If you're unconscious, your family can make that decision for you.
You've always had the right to refuse treatment, you have it now and you
will always have it, the Living Will notwithstanding.
Then why do people sign these Living Wills?
Chiefly due to fear and confusion propagated by groups in favor of
euthanasia. These groups want you to believe, Joe, that if you suffer from
an incurable disease, and you're at the end of your life, breathing your
last breaths, I, your doctor, would have a breathing tube put in your
trachea, against your will, put you on a respirator and keep you alive
indefinitely, allowing you and your family to continue suffering. Joe,
this is not true now, never was true, and never will be true. You don't
need a Living Will to prevent that, you need trust in your doctor and
Well, Doc, it sounds to me like this Living Will could be a dangerous
thing, and that it really doesn't give me any options that I don't already
have--so who's pushing for this Living Will and why?
Joe, the Living Will is the brainchild of the euthanasia movement. They
know that if removing or withholding fluid and nutrition from patients
becomes accepted and decriminalized (assisted suicide is now illegal and
punishable), a major barrier to active euthanasia will have fallen. Step
two will be the observation that death by starvation is a painful,
drawn-out experience, and that therefore physicians should be permitted to
administer lethal injections to "mercifully" end life.
Still, Doc, isn't it more humane to withhold food and fluid from patients
who will never recover, rather than have them linger on?
Joe, death by deliberate starvation and dehydration is a very painful
experience-- physically painful for the patient and emotionally painful
for the health care worker (usually a nurse, rarely a doctor) who has to
watch it run its course. Even for an unconscious patient, we cannot rule
out pain. Providing patients with food and fluid is basic human care, not
medical treatment, even if that nutrition is provided by way of a feeding
tube. It should not be optional, just as keeping patients clean, clothed
and comfortable is not optional--so far.
Food and fluid are not pharmaceuticals; they don't cure anything, but
alleviate starvation and dehydration caused by their absence. Supplying
food and water by feeding tube to a helpless, living human being is no
different than feeding an equally helpless newborn by way of a baby
bottle--which is just as "artificial" as a feeding tube. What those who
advocate withholding feeding are really saying about people in so- called
"persistent vegetative states" and other helpless, non-dying patients is
that their lives are not worth the trouble or expense involved.
Doc, how did this whole euthanasia thing get started?
Euthanasia in our time began in Germany with the publication there in 1920
of a book titled The Release of the Destruction of Lives Devoid of Value
by Karl Bindig, a leading German jurist, and Alfred Hoche, a renowned
The book's concept of "lives devoid of value" or "life unworthy of life"
quickly gained currency in the medical and legal professions. Soon
afterwards, in 1921, 1922 and 1923, wounded German World War I veterans
who obstinately refused to die were the first to be put to death by
euthanasia. As the decade wore on, the practice was extended to other
invalids, the handicapped and the mentally retarded.
With this groundwork accomplished by the time Hitler took power, it was a
small step to justify the extermination of other groups of people deemed
"burdensome" or "subhuman"--such as Jews and Gypsies--and the result was,
of course, the Holocaust.
In more recent times the Netherlands has legalized euthanasia, with the
result that sick elderly are fearful of entering hospitals for necessary
Do you think it could happen in our country?
Joe, euthanasia is here, now. At least 43 states already have Living Will
statutes. There has been a series of court decisions mandating the
starvation and dehydration of tube- fed patients. Legislatures in states
such as New Hampshire are pushing to decriminalize active euthanasia.
What accounts for this trend?
Much of it is economic in origin. You see, since the release of the
abortion holocaust in our country, there are about 1.5 million preborn
children destroyed every year out of the 6.2 million conceived. This means
that between 25 and 28 percent of pregnancies end in abortion. As the
years progress, this translates into a loss of one quarter or more of the
potential work force.
Right now we have five people on the work force for every one person on
Social Security, and you know about the problems we're having in "cost
containment" in health care. It's predicted that in the year 2010 there
will be three people on the work force to every one on Social
Security--and in 2040 the ratio will be only two to one, if abortion
When you add to these figures the fact that people are living longer (in
1969 the average age of nursing home patients was 64, today it's 81),
further increasing the number of elderly, it becomes obvious that the
strain on our social welfare and health care systems will soon be
tremendous--and the pressure on elderly patients to "get out of the way"
will increase accordingly.
Already, Joe, there are politicians like ex-Governor Lamm of Colorado who
stated that some old people "live too long" and have a "duty to die" when
their medical needs become financially burdensome.
We have Dr. Sackett of Florida who, when asked what the Living Will
legislation he was advocating would accomplish, answered that it would
save the State of Florida five billion dollars in ten years. In such a
view, human life is nothing more than a commodity to be disposed of when
it becomes too expensive to maintain.
Doc, I have the right to control my own body, so don't doctors have an
obligation to do whatever I or my relatives tell them to do?
Well, Joe, now we come down to the nitty-gritty of this whole matter.
Where does life come from? Who "owns life" and where does life go in the
end? The real answer to your question, Joe, is based on the previously
secure principle that all human life has intrinsic value simply because it
is human life, because it comes from God and is therefore sacred. We do
not own it, it belongs to God and is returned to God.
You will say that this is a religious approach. Yes, it is. It is also one
of the foundation stones for all laws of our nation, because it is
contained in the Declaration of Independence, which states that all men
are endowed by their Creator (God) with human life. The Declaration
further states that this gift of life is "unalienable"--meaning that we
cannot give it away or sign it away; nor can it be taken from us without
due process. This is the very basis of the equality between black and
white, rich and poor, born and preborn, wanted and unwanted. We should not
be forced to abandon this truth just because it is at the same time a
Judeo-Christian principle. The anti-life cult demands that we do so, by
once again perverting the meaning of the rule of separation of Church and
State. But abandoning this principle of the sanctity of life because it is
supposedly just a religious prejudice would simply mean accepting the
anti-life religions of atheism and nihilism, which were known to our
founding fathers and rejected by them in the Declaration of Independence.
Violating the sanctity of human life as we did in Roe v. Wade has called
forth the slaughter of over 26 million helpless, innocent preborn
children, the infanticide of unwanted newborns, and a plague of child
abuse. Inevitably, too, this has led to the desire to annihilate the
unwanted elderly and comatose by starvation and eventually by lethal
Joe, when will we ever learn?
1. The term "extraordinary" as it is used in Living Wills usually refers
to a specific medical procedure (nasogastric or gastrostomy feedings) or
to the use of a specific apparatus (respirator) which, in the specific
medical situation under consideration, may in reality be a lifesaving
procedure and therefore really an ethically ordinary means and morally
mandatory. The terminology is purposefully confused even further by
labeling these procedures (nasogastric or gastrostomy feedings, respirator
use) as "artificial" means and therefore to be omitted even when their
omission would directly and purposefully cause the death of the patient.
2. "Heroic" in this context means the use of all available medical means
at all times, even when medically and ethically not indicated, solely to
avoid legal repercussions.
Raymond J. Voulo, M.D., is a physician in private practice living in Port
Washington, New York.
Uploaded from American Life League Electronic Bulletin Board (703)