At the latest Mednesp, the Congress of the Brazilian Medical-Spiritist Association (AME-Brasil), in Rio de Janeiro, when the Charter of Bioethical Principles was updated, one important issue was discussed: the Living Will (or Advance Decision). It is a set of decisions a patient makes while still health, pointing out the actions it would like or not to be taken if and when he became seriously ill and was not able to manifest his or her wishes. This matter prompts two important questions: What ethical limits must be observed? Is there any spiritual paradigm to be considered?

Doctor José Roberto Pereira Santos (photo), coordinator of the Bioethics Department of AME-Brasil, spoke to us about this issue.

What is Living Will or Advance Decision?

It is a document written by a person in complete control of its mental faculties with the aim of laying out the treatments, procedures and type of care he or she wishes or not to receive once he has a life-threatening untreatable illness and that person is no longer capable of freely expressing his or her will. The Living Will is also known as Advance Decision. For example: the person decides at the age of 32, when he or she is enjoying good physical and mental health, to write a document stating that if he or she has an accident and gets into a coma, after a period of time (which is clearly stated in the document) he or she will not be put on a ventilator in an intensive care unit.

With the Living Will, there is no requirement for a lawyer or any other formality. For it to be valid, it must be handwritten or typed and signed by the person in question without any amendments. It is recommended that three other witnesses sign it and that it be registered at a notary. 

In the United States the Living Will is legally binding, while in other countries it is accepted, but is not a legal document. As a result, a number of decisions has ben taken in those countries allowing passive euthanasia, when doctors suspending feeding or hydrating a patient in irreversible coma who has made that option before getting ill.

Why has this issue become a source of concern for Brazilian doctors?

With advances in medical technology and new intensive treatments, the number of patients surviving chronic illnesses and serious clinical situations, such as heart attacks and strokes, has increased steadly. Those patients remain totally dependent of other people for their survival and many fear that they will go through unbearable physical suffering in those conditions. They believe they will be condemned to a slow, painful death. And they understand that, by making a clear statement on that matter while they are still healthy, the family will be able to make an easier, more straightforward decision.

Concerned about this situation, the Brazilian Federal Medicine Council published in 2012 a resolution that supports the Living Will, allowing doctors to take into account the decisions taken by a patient when previously registered in a document. That decision led to a backlash in the legal and medical sectors, as we understand that this decision opens a door for the legalisation of euthanasia and that the Medical Council does not have powers to deliberate on that matter.

What does AME-Brasil say about that matter?

The Living Will is in accordance with a utilitarian, hedonist approach to life, where pain and suffering are seen as something to be avoided rather than faced. Life, according to that approach, is directed towards easy and immediate pleasures, and it may be discarded when such goals are not longer achievable.

This is not about seeking a dignified way of dying, therefore, as dignity requires a purpose and goal for life. Dignified are those who face suffering and pain without the need to seek death to avoid them.

Life is not made only of joys and achievements, but also of difficulties, pain and suffering. The meaning of life is life itself.

We, Spiritist doctors, are against the Living Will. We are in favour of orthothanasia, or natural death (in the context of a patient who is in a terminal state). We are in favour of palliative care. We understand that the Living Will is a utilitarian and selfish measure, which shows the lack of faith in Divine Providence. It is not right for us to choose when and how we are going to die or if there will be pain or not in our death. We cannot dispose of our life, as it belongs to God. Pain and suffering are the result of our acts (law of action and reaction) and the best way to make sure we have a dignified death is by living with dignity, following the example of Jesus.

Doctors must do all within their power to preserve life and alleviate the suffering of patients. It is not the role of professionals in this noble function to refuse treatment knowing that will lead to death, regardless of what the patient wishes. In many cases, patients find a new meaning in life and new values when they go through pain and suffering, and that could have made him or her alter the wish stated years before.

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