Framework for tough choices

April 20, 1993

Choices about life and death are never easy, but they turn more difficult when there is confusion about the law. This session the General Assembly passed a measure that should help families come to grips with the decisions about medical care that so often complicate the process of dying.

The Maryland Health Care Decisions Act, which will take effect Oct. 1, updates the state's law on living wills. In addition, the bill provides for an alternative to living wills, allowing Marylanders the power to appoint an agent who can make health care decisions in the event they are no longer able to do so. These "advance directives" give physicians, hospitals, families and the courts a solid basis for knowing a patient's wishes.

In cases where patients make no such provisions, the new law provides for decisions to be made by family members or friends who can prove a close and continuing relationship with the patient, and sets out procedures for determining who can serve as a surrogate. With proper safeguards, this kind of family decision-making is far preferable to constant appeals to the courts.

Any surrogate's decision about life-sustaining procedures must be approved by two physicians who are willing to certify that, to a reasonable degree of medical certainty (not mere probability), the patient has a terminal or end-stage condition or is in a persistent vegetative state. Other safeguards include a provision allowing any health care provider who feels such a decision is inconsistent with generally accepted standards of care to appeal the decision. Family members and qualified surrogates can also file suit in court. Physicians cannot actively assist the death; the law forbids mercy killing.

The reference to "end-stage condition" is one of the more controversial aspects of the bill. This category addresses cases that do not fit traditional definitions of terminal illnesses. An example would be Alzheimer's disease, in which the illness is relentless and inevitably fatal, but in which death is not imminent as it would be in advanced cases of cancer.

The new law is the result of much public discussion and many compromises between those who place great trust in families to make these decisions and those concerned about potential abuses in cases where families are not close or are, in psychological jargon, "dysfunctional." In large part because the bill did draw a great deal of interest from a wide range of groups and individuals, the legislature produced a better, more thoughtful bill, one that will provide a reasonable framework for some of the most difficult decisions life offers.

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