Healthcare at the End of Life

Medical triumphs of the late 20th century in prolonging life present dilemmas that were not contemplated by the prophets and philosophers of earlier eras, including the founders of Quakerism. These must be addressed today with little guidance beyond the precepts of the Golden Rule and the Ten Commandments. The dilemma arises from the conflict between the impulse to preserve the heartbeat in one’s self and others and the sense that there comes a time when preservation defeats both our altruistic objectives and our desire to exit our lives with dignity. We consider here only how this dilemma affects individuals who have reached a stage of life, which we will call "post-retirement," at which their current labors are no longer essential to the support of themselves or of others. We leave for another day the problems of people below retirement age.

During post-retirement we undergo an inexorable decline in our own enjoyment of existence and in the pleasure that we give to others, and an increase in the psychic and physical burdens that we impose on others (even if we are "paying for them" from savings). If we are guided by the Golden Rule, we must recognize that at some point we should stop consuming the human and physical resources that sustain our metabolism.

It would be convenient if we could entrust to someone else—a physician or pastor, for example—the decision to terminate continuing life support. Unfortunately, not all of these trusted guides are prepared or willing to make these decisions for us, nor does organized society always trust them to do so. We must make these decisions for ourselves. We must do our best to define a point at which our capacity to enjoy or to contribute to the enjoyment of others falls decisively below the physical and psychic burdens that our continued physical existence imposes on others.

A few of us will reach that decisive point while we are mentally and spiritually able to make and execute that decision. A number of neighbors have done so by refusing food or dialysis. We hope to be able to recognize that point in our own lives when it arises, and act accordingly. We believe that individuals in retirement should be free to make and execute such decisions without obstruction or dissuasion by friends or healthcare providers.

Most of us will have no opportunity to act to terminate our survival by our own acts, because we will lose our capacity for decision before we reach the point at which the balance of convenience between surviving and dying favor the latter. Our most available means of avoiding this impasse is to execute a directive that refuses prospectively, in defined circumstances, life-extending routines such as blood transfusions, mechanically assisted respiration, and tube-feeding.

Prospective refusals will not, unfortunately, provide a safe escape from dependent debility for those of us who slip into this state without the occurrence of any of the conditions specified in an advance directive. To deal with such eventualities, "assisted suicide," in which a physician supplies fatal doses of drugs and advises on their self-administration, has been legislatively authorized in Oregon. We believe that Friends who live in states that permit aid in dying may appropriately avail themselves of this alternative, taking due regard of consequences for their families and friends. Many people, including some Friends, believe that God gives us life and only God should take it away. This sincere and widely held position should be honored and respected, but it should not be imposed on the conscience of all others. In Pennsylvania, whose laws are hostile to aid in dying, Friends should respect the legal constraints under which health care professionals must operate, and the medical profession’s fundamental commitment to preserving life.

Friends could be helpful to others by sharing with them what might be called Quaker process: waiting for way to open through thought, contemplation, and prayer; testing one’s ideas on a larger group; asking for the help and support of a clearness committee; and assisting others in formulating advance directives.

So far, we have mentioned what Friends may appropriately do for themselves. We now address what Friends should do to promote the availability of options that we approve. First, Friends can appropriately express themselves through meeting minutes and through additions to Faith and Practice in favor of individual Friends’ determining the point at which they want the prolongation of their physical existence to be discontinued, and of their exercising choice by personal acts and by advance directives.

Should Friends also support legislation that would legalize choices, including aid in dying, that individuals may make? Friends should proceed carefully as way opens, taking care to recognize the valid concerns of those who oppose their position, and seeking provisions to avoid the kinds of abuses that opponents of assisted suicide legitimately fear.

Friends can apply Quaker principles of altruism most effectively by deciding at what point in their own lives the burdens imposed on themselves and others by their continued physical existence outweigh the benefits of continuance. They may implement their considered conclusions by personally foregoing life support or by directive for their future care.

Imogene B. and Richard B. Angell,
Elizabeth Pattison,
Charlotte E. Bartlett,
George A. Perera,
Alfred F. and Georgia M. Conard,
Richard M. and Sarah E. Worth,
Hilda B. Grauman,
Alice Erb,
Mary A. Wood,
Barbara M. and Philip H. Mounts,
Stephen L. Angell,
Mary Faye Glass,
Marian D. and Nelson Fuson,
Blanche Frey,
David L. and Rosemary A. Hewitt,
Elizabeth G. Mather,
Geraldine McNabb

The signers of this statement are all elderly Quakers residing in Quaker retirement communities that belong to the national organization American Association of Homes and Services for the Aging (AAHSA). In 1996, AAHSA published a policy that included the statement, "We are opposed to a physician or any other person assisting another in the taking of their own life." The signers of this article believe this statement fails to recognize the demands of diverse circumstances and does not conform to Friends’ respect for individual conscience.