Ethics and Controversy Regarding Living Wills

A living will is a document that indicates a patient’s wishes regarding their health care and how they want to be treated should they become seriously ill and unable to make or communicate a decision of their choice. However there is some evidence that it is much more difficult to anticipate a person’s state of mind when dying than had been thought, and equally as hard, if not impossible should one be in a coma. In order to understand both sides of the issue we must take a look at both sides.

In 1969 Louis Kutner, an American lawyer, first introduced the concept of the living will. A living will is considered to be only valid in situations where the patient a terminal illness, which is described as a medical complication that is incurable or irreversible without the administration of life-sustaining devices and procedures.

The living will sets out a person’s wishes regarding their health care and how they want to be treated should they become seriously ill or incapable of communicating their desires. It is a part of planning in event of a serious illness or disability. Such a document may be helpful to medical professionals and family when the patient is at the point they can no longer make their own choices. The living will is a request in advance telling the doctors to not give certain medical treatments it is not an instrument of euthanasia. A living will need not block treatment, but specify to doctors to continue treatment until the patient is dead, regardless of suffering or pain.

The living will has become a philosophical problem. To make a living will sensible we have to take into assumption that the wishes of the person are the same when they became incompetent as when they wrote the will. As I stated earlier there is evidence that it is much harder to anticipate a person’s state of mind when dying (or when receiving significant medical treatment) than had been thought, and even harder should one be in a coma. Some believe that ‘an individual is as discontinuous from itself at a later time as it is from other individuals’. If this is believed then it is not logical to accept the usefulness of a living will.

Advantages of the living will are:

They respect the patient’s human rights, and their right to reject medical treatment

Creating them encourages debates regarding end of life decisions

The doctors are more likely to give appropriate treatment after knowing the patient’s wishes

Helps in difficult decision making by the medical professionals

The patient’s family and friends do not have to make the difficult decisions

Disadvantages of the living will are:

Writing them can be very depressing

It can be very difficult for a healthy person the adequately imagine or decide what they want in the situations where a living will would take effect

Translating the words of a living will into medical action could be difficult

Patients may change their minds and not remember to change their living wills

If the living will is not available at the time it is needed it is of no use to the patient, doctors or family

It is believed that Kerrie Woolthorton is the first person to use a successful suicide attempt. The 26 year old wrote her will, then three days after took poison and called for an ambulance. The will stated that no attempts to be made to prolong her life, that she was to be made as comfortable as possible and not to be left to die alone.

If doctors had chosen to keep Woolthorton alive, they may have encountered some legal action. If doctors had gone against Woothorton’s wishes and interfered it would have been interpreted as an assault. Nevertheless might there be a moral case for ignoring a living will under such circumstances?

One immediate concern is whether or not the patient is sufficiently competent to make a decision this important. One must be careful not to judge the competence of the individual by the content of the decision. In most cases individuals are the best judge as to whether their life is worth living. If a person to chooses to end their life in circumstances in which we would choose to live our lives, it is not sufficient to judge them as incompetent. Thinking of the decision foolishness and imprudent, still does not make it an incompetent decision. In this case the coroner was clear that Woolhorton had the capacity to consent and had full knowledge of the consequences of her actions.

The other side of the argument put for by the “ProLife Alliance,” is the

“so- called thank you theory”. Meaning that in some cases people saved under similar circumstances are glad to be rescued, a policy of general interference with the person’s stated wishes is justified.

What if the person has obligations to other people? Let’s say children? Let’s say the person was in a serious automobile accident and on life support, with a living will stating not to be kept on life support. Do the doctors have the right to make the decision to try to keep a person alive and maybe have a chance to improve their health in order to fulfill those obligations?

There remains to be unanswered questions. At the time to decide to let the person die according to the will to their wishes whether the patient desires to die now. Is that their intent? Wills should be updated periodically. What about the competence at the time that the will was written, it is a ethical question that the parent, spouse or physician must consider. Can a very smart 16-year-old effectively choose to die? What counts as taking no steps to resuscitate or to prevent death? Will there be a legal problem of action versus inaction? Is removing a tube “not preventing” or “not taking steps”? What happens should the parent(s) or spouse veto the decision to honor the will? How does one handle that legally, ethically and morally?

According to Jay E. Kantor et al.’s (1997) letter in response to a news article

Documents Like Living Wills Are Rarely of Aid, Study Says “:It is my experience that an increasing number of patients are coming to hospitals with these advance directives. However, the concept is new, and many patients, their surrogates and hospital providers do not understand how such directives are to be implemented.

Moreover, advance directives carry only general statements about the patient’s treatment wishes. Providers and surrogates must extrapolate from those statements. That requires training in ethics, which most providers lack.”

It is common in the intensive care unit to withdraw and limit life support, although how this decision can be reached is varied and arbitrary. Physicians often discuss these decision with relatives as an attempt to respect the patient’s desires despite the fact that evidence suggests that the relatives may not correctly reflect the patient’s desires. This is where living wills come into play. Others argue that legalizing advance decisions is euthanasia by the back door.

In October 2007 living wills became legal in England and Wales as part of the 2005 Mental Capacity Act. This is the case in the USA for many years. Three states had statutory living will documents only; these states do allow for appointment of a health care agent for limited end-of-life decisions. Three states had statutory durable power of attorney for health care documents only, 32 states had both statutory living will and durable power of attorney for health care documents, and 13 had statutory forms which combine both types of directives in one document.

Discussion

In October 2007 living wills became legal in England and Wales as part of the 2005 Mental Capacity Act. This is the case in the USA for many years.

Are living wills legal documents? What happens when they are contested by relatives? What if a person writes a living will when they are young, they have changed their mind and have forgotten all about it? What about the moral issues is it considered wrong to take a person off of life support when there is a chance they may come out of a coma?