(California Probate Code, Section 4701)[1]



          The following scenario is meant to illustrate your rights and freedom of action and decision-making which are protected under Part 2 "Instructions for Health Care" of the California Advanced Health Care Directive. The implicit context of the exercise of the rights laid out in this section is that you are dying and there are a range of things which may be done to slow down your dying (called "prolonging life"). Since each of the conditions (1) to (5) (under 2.1,a)  end with death, and death is, by reasonable medical opinion, certain,  your freedom to choose to decline medical interventions is completely in accord with the limited goals of medicine, i.e. to cure you or keep you comfortable if curing is not possible. Only the time is uncertain and it is your right to choose the earlier time rather than the later.[2]


Scenario under 2.1, a

        You have the right to edit this section, for example you could choose to cross out the last sentence and thereby allow medical staff to feed and hydrate you with tubes.  If you have not crossed out that sentence and you have fallen into an irreversible coma, or persistent vegetative state(PVS), then you have, by initialing at 2.1 a, decided to accept your death as the natural outcome of your state and have rejected medical intervention since it can neither cure you nor add to your comfort. It should be noted that this decision  on your part is in no way contrary to the traditional moral constraint against suicide since the medical interventions cannot cure you and your dying is due to whatever put you in the states described. If bystanders were to argue that you could be kept alive in the coma or PVS indefinitely, their opinions will not count against your decision, which is essentially to reject interventions which do not cure or add to your comfort and to accept death in the most timely fashion.

        In (2) you see that even should you not be in a coma or PVS, and you are, by competent medical judgment, dying from a cause whose progress medicine can at most slow down, then you still have the freedom noted in (1) above.  For example, your heart and circulation are so damaged by disease and are getting so steadily worse that you will surely die from this disease. . A natural event would be for blood clots to develop and end your life. Medicines can prevent the clotting but not stop the advance of the disease. Your freedom here is to decline these medicines since they neither cure nor add to your comfort. Once again you are simply saying that it is not the job of medicine to drag out the dying process.

         In (3) not much is added. It is just another way of saying that if medical experts have decided that you are heading toward death with this condition, you have decided to reject any mere slowing of the process. The same can be said about (4) because it is not significantly different from (1). It is not simply because you are unconscious, but because your unconsciousness is going to end in death no matter what. So you are free to say: "I don't want any interventions which simply drag out the dying process."

        Sometimes the situations described in (1) to (4) are not so clear, and there may be legitimate differences of opinion about whether some kind of temporary "benefit", which might be considered a temporary "cure" might be possible. For example you might be suffering from advancing kidney or liver disease which is going to kill you fairly soon. At the same time you have a heart condition which very expensive surgery could correct and the resulting improved circulation might slow down but not stop the advance of the kidney or liver disease. Your decision in signing 2.1 a and not crossing out (5) is that you want your agent and medical staff to know that you do not want the heart surgery because, in part, it costs too much for what it can provide by way of benefit. It may be curing your heart, but it is not really curing you since it at most slows down your dying process, which is not what we mean by "curing."



        In sum, what 2.1 a makes clear is that those who are really dying retain the freedom to choose the time of their death where that is possible. Their dying has causes outside of this decision  and outside of their control, so there is no question of suicide here, nor any question of asking medical staff to kill them. The right to choose a more merciful (and even less expensive) time of dying belongs to the dying person. It is not a function of medicine to lengthen the dying process. And the dying person is not introducing any new cause of death, which is what it is to kill a dying person.

[1] The text of Advance Directive Form, including  Section 2.1 a is appended to this document.

[2] Only (5) does not make explicit that death is the endpoint regardless of the medical interventions