The 'Living Will' and Euthanasia: A Doctor-Patient Dialogue

Author: Raymond Voulo, M.D.


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 follows:

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?

That's right.

And there's more. The Living Will places doctors in a legal quandary. If the doctor employs "artificial" or "extraordinary"[1] 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[2] 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 euthanasia.

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?

Exactly, Joe!

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 telling you?

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 family.

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 physician.

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 treatment.

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 continues.

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 injection.

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) 659-7111.