Customer Reviews

Managing Death

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James M. Hoefler
Managing Death

(Boulder, CO: Westview Press, 1997) 206 pages
(ISBN: 0-8133-2816-0; hardcover)
(Library of Congress call number: R726.H564 1997)

Hoefler documents a broad consensus among almost all groups
(doctors, nurses, hospitals, religious organizations)
that have taken official positions
concerning how to manage the process of dying:

1. Forgoing medical treatment and life-supports is not suicide.
2. Withholding and withdrawing life-supports are ethically the same.
3. Family members can decide for incapacitated patients.
4. Terminal illness is not required
as a precondition for making life-ending decisions.
5. Food and water need not always be provided.

We lack consensus about the following additional issues:

6. Persistent vegetative state (PVS),
wherein patients can be kept 'alive'
sometimes for years with the help of life-support systems.
More than 10,000 patients are in PVS at any given time in the United States.
If we had consensus, many more mechanical systems
supporting bodies in PVS would be disconnected.

7. Severe dementia is a condition in which the patient is no longer able
to make any meaningful decisions about life or death.
The number of such patients is measured in the millions at any given time.
But common sense and public opinion is slowly moving in the direction
of a consensus that the severely demented need not be kept alive by artificial means.
In other advanced countries, they are not routinely put on life-supports
--as is quite common in the United States.
But America as a society does not yet have a consensus
about how to treat former persons who have permanently lost
such capacities as consciousness, memory, language, & autonomy.

Hoefler discusses artificial nutrition and hydration
as end-of-life treatments.
Dying from lack of water is much quicker and easier than starvation.
Two months is a typical time to die from lack of food
--if there are no other physical diseases or problems.
A week or 10 days is all it takes to die
if all water and other fluids are given up.
According to all objective reports, this is a quick and easy death,
often without the need for pain medication.

The following points about voluntary death by dehydration (VDD)
come from this reviewer rather than from James Hoefler:

Giving up water and other fluids has some additional advantages
over other methods of bringing life to an end:

1. The patient can always change his or her mind.
Since it takes at least a week to die using this method,
the patient might see life quite differently
after a few days without food and water.
People tempted to commit irrational suicide
will probably recover from their suicidal urge before they die.
Then they will decide to begin eating and drinking again
--and continue to live indefinitely.
Other people will probably know about this decision to die
--which gives them ample opportunity to intervene
if they do not believe that death at this time is the best option.

2. Doctors do not need to be involved in the dying process at all.
Thus, there are no moral or legal questions
about doctors aiding in the process of dying.
Death by dehydration can be conducted completely at home,
without the need for any special equipment or drugs,
and without the involvement of any health-care institutions.

3. Giving up food and water is completely legal.
There are no laws against choosing this means of dying.
This eliminates all the secrecy involved in underground means of death.

4. Families can be informed ahead of time about the planned death,
so they can gather for the last days of their loved one if they please.

Death by dehydration might become
a preferred method for voluntary death
in the first few decades of the 21st century,
because it does not involve the state
or health-care institutions or personnel.
Patient autonomy is certainly preserved
because the decision to die must be affirmed over and over again
during the last week or 10 days of life.
And when the patient slips into unconsciousness,
the proxies and medical personnel can continue the decision to withhold fluids.

No new legislation is required to permit this method of choosing death.
We already have the power to end our lives in this way.
The danger of irrational suicide is sharply diminished.
(Irrational suicide is a danger in all methods that bring death suddenly.)
The patient will go to sleep at night and wake up again in the morning
several times during the period of dying from dehydration
which will give new perspectives on problems
that might otherwise lead to an irrational suicide.
If this plan for achieving a voluntary death is announced to others,
they might decide to provide new support or better medical care,
which might postpone dying until some later time.

(This reviewer has written a cyber-sermon on this subject:
Search the Internet for: "Voluntary Death by Dehydration".
A website for questions and answers is linked from the bottom of this essay.)

Hoefler hopes that death will be better managed in the future.
He suggests that the following ways to improve the process of dying:

1. New standards of care will be developed for mortally-ill patients.
Then they will no longer suffer the default decision,
which is always to provide maximum aggressive medical care:
Because it can be done, it will be done
--until someone decides otherwise.

2. We will make better use of hospice care.
Now it is often used just for the last week of life--or last few hours.
Taking advantage of hospice services
for several weeks or months
can greatly improve the process of dying.

3. We will develop a clearer concept of medical futility.
Research will show more clearly than ever before
which medical treatments are useful and which are useless
in the various situations in which such treatments might be used.
Not only the medical profession but also the general public
will reach a more reasonable consensus
about when to omit or withdraw
high-tech medical care at the end of life.

4. End-of-life decision-making will become more open and rational.
Both health-care professionals and the general public
will be better educated in order to make wiser end-of-life decisions.
Death can be better managed rather than fought every step of the way.

5. We will reject the slippery-slope arguments
of those who oppose making any life-ending decisions.
By paying close attention to the particulars of each case
rather than trying to enforce rigid rules of morality,
wise decisions will emerge that can be embraced by everyone involved.

6. Advance Directives will be used more fully and wisely,
so that we can choose our own pathways towards death,
rather than being handled according to the standard operating procedures
of the hospital or the medical profession.

Managing Death is a basic and moderate book about process of dying.
Hoefler does not attempt to break new ground.
Rather he clarifies the consensus that we already have achieved
--and projects the elements of a new consensus
that is now beginning to emerge in our collective thinking.

Everyone concerned about the process of dying
should read Managing Death.

If you would like to see other good books favoring improvements in dying,
search the Internet for: "Books on the Right-to-Die".

James Leonard Park, advocate of the right-to-die with careful safeguards.