Life-or-death decisions

October 05, 1993

It's never easy facing choices about life and death. But increasing numbers of Americans are encountering the singular anguish of deciding whether to remove life support equipment from a relative or to stop artificially administering the essential nutrients. This month Maryland joined the front ranks of states grappling in a comprehensive way with the choices that face families and with how those choices should be made.

Maryland's Health Care Decision Act, which took effect Oct. 1, updates the state's laws on advance directives -- documents that allow people to state in advance their wishes about life-prolonging medical treatment. These documents include "living wills" that state one's wishes in various circumstances, and health care guardians or proxies, an arrangement preferred by many experts in which people appoint a relative or friend to make decisions for them if they become incapacitated.

Every person should have some kind of advance directive, but relatively few people do. That's where the Maryland law helps break new ground. It is often the people who are least likely to think of how they want to die who end up presenting the most painful decisions about treatment. The hardest cases often come with young people, for whom thoughts of death are far away. A case in point is Nancy Cruzan, the young Missouri woman who slipped into a persistent vegetative state after an automobile accident. Her case led to a Supreme Court decision upholding a person's right to refuse such treatment. The Maryland law wisely sets up a framework to allow families to make decisions in cases where a person has not made his wishes known beforehand.

Perhaps the most publicized aspect of the new law is its inclusion of a new category in which removal of life support can take effect. In addition to the final stages of a terminal illness and a persistent vegetative state, the law includes "end-stage conditions," defined as an advanced, progressive, irreversible condition caused by injury, disease or illness. An example: the last stages of Alzheimer's.

Maryland's new law has much to commend it -- including the wide-ranging community discussion and debate that went into shaping the legislation. But its length and complexity will prove daunting to many people, including health care providers. One good test of legislation is whether the law is easily understandable by the people who have to face these decisions, or whether it is written primarily for legislators who want to clarify every uncertainty. Maryland's law tends toward the latter. Even so, Marylanders now have much clearer guidance on these troubling issues than do most other Americans.

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