Introduction

As we go about our daily lives, our minds are often filled with plans for the present and the future -- things we must do, things we would like to do, things we would like to help our loved ones do. Rarely do we have time to consider what might happen if we were somehow rendered permanently unable to realize these plans. In anticipation of such a situation, the living will (also called a "health care directive") was first developed a half-century ago. Today, all states have provisions for some form of health care directive, allowing individuals to exert control over their lives and estates in the event they become incapable of making their own health care decisions.

Background and Characteristics of the Living Will

The living will is, at least in part, a response to medical advancements made in the 20th century. In earlier times, people typically died at home in the company of family. During the 20th century, however, medical science advanced to the point where it could extend life under many circumstances that had formerly been fatal. In some cases, such as with kidney dialysis and various organ transplants, the treatments could significantly extend life while allowing patients to remain alert and active in many of the activities they had always enjoyed. Other treatments, however, left patients in a much more limited condition, keeping the body alive, but unable to restore movement or brain activity. This condition has been called a "persistent vegetative state" -- the person is alive, in the way a plant is alive, but cannot move, speak or exhibit any signs of cognitive activity.

Medicine's ability to keep the body alive without regard to brain function has led to conflicts between health care providers and families of patients in conditions such as irreversible comas. The health care providers believed it was their moral and professional obligation to keep patients alive if at all possible, whereas families of the patients wanted to allow their loved ones to pass on if there was no realistic chance that they could ever regain consciousness. The case of Karen Ann Quinlan gave national attention to this conflict. Quinlan, who suffered irreversible brain damage, was sustained for eight years on a respirator until her parents secured permission from a New Jersey court to disconnect life support. After it was disconnected, however, Quinlan did not die but instead lived another 10 years sustained by a feeding tube. In 1977, the year the Quinlans took their daughter's case to court, California passed the Natural Death Act -- essentially the first living will law. Other states followed.