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The BEST WAY to Treat People Who Have Lost Their Minds:
Shall Our Laws Permit Natural Dying?

Introduction:
The difference between the best and the least worst.
We must reach a tipping point before we reach a sinking point.

We live in a culture where exercising individual choice to select the best for oneself is unquestionably a revered goal. For some, the all-consuming drive to accumulate money and to attain power serves to maximize their ability to choose what they have diligently concluded is the best. Anyone who solely devotes his or her life to the opposite goal—to help others—is considered a saint. On this continuum, most readers of this volume are likely to be closer to side of giving than to the side of using.

Even givers like to be in control, yet few of us like to acknowledge that we have no control over the most essential aspect of our lives: our mortality. Instead we behave in ways that deny that someday we will ultimately die. Most of us refrain from active planning for how we will die. Our psychological resistance explains in part, the huge failure of the Patient Self-Determination Act of 1990, and of related attempts to encourage people to create Living Wills (written documents that instruct our doctors what specific medical treatment we will want, if in the future we have one of several specific horrible medical and mental conditions).

The title “The Least Worst Death” that Professor Battin used for an important article is unlikely to don the cover of a best-selling book. In contrast, what more aptly describes how people behave is Woody Allen's quip: “I’m not afraid of dying, I just don’t want to be there when it happens.”

People generally manifest reluctance to do what is least worst for them. Knowing this, corporations rarely attempt to increase profits by creating products that appeal to the least worst. Hence it took a federal law to require auto manufacturers to install seat belts as standard equipment, and additional state laws to require passengers to buckle them. It is possible that future laws will require people to authorize trusted individuals or approved organizations to make medical decisions for them if they no longer can. Each person would be required to designate a sequence of healthcare Proxy and alternates. To be effective, however, such laws should require adequate discussion to achieve this important goal: the decisions that others make should ideally be the same as those the patient would have made for him or herself. So what is needed while the patient is still competent? A discussion similar to obtaining a patient’s “fully informed consent” for any other medical procedure. Obviously, the success of such a task is more complicated to accomplish and harder to evaluate than merely observing whether or not a passenger has fastened a seat belt.

Given these significant hurdles, the question is: Where is the BEST WAY to start? Answer: Where (almost) everyone agrees. This book proposes that we begin serious discussions about whether or not we should invoke new laws to Permit Natural Dying for patients who suffer from Devastating Irreversible Brain States; that is, for people who have lost all vestiges of personhood. While this subject may seem a remote “probability” for those who have no relative who resembles Terri Schiavo, in fact, the subject will affect us all.

Almost half of people over the age of 85 have Alzheimer’s or related dementias. The number of afflicted individuals will rise three-fold by mid-century. The cost of treatment will bring the greatest economic and man-power peacetime burden our society has ever seen. The consequences are far reaching; for example, couples whose four parents are alive have a seven out of eight chance that at least one of their parents will turn to them needing total care for a chronic illness like Alzheimer’s disease.

Previous efforts from activist groups who wish to control the timing and manner of their dying (the right-to-choose-to-die groups) have focused on an extremely narrow segment of the population: terminally ill patients who retain full mental competence and have the physical ability to swallow a lethal dose of prescribed medications with no assistance from others.

Previous efforts from politicians and health economists to warn us about the future need to ration increasingly scarce medical, caregiving, and financial resources have focused on other diseases.

But the elephant is in the room. Very few are talking about it. Even fewer are devoting their energy to design effective strategies to deal with it.

The BEST WAY to Treat People Who Have Lost Their Minds: Shall Our Laws Permit Natural Dying? makes no pretense it can solve all these problems of elephant proportions. But hopefully it will strike a resonant chord to provoke meaningful debate that will lead to effective strategic planning. If successful, this book will create a paradigm shift in attitudes and behaviors, a so-called tipping point—before it is too late and society instead reaches a sinking point.