A Living Will Is a Pathway to Euthanasia
In 2014, a controversy erupted in the United Kingdom over a new policy in their national health care system. Called “the Liverpool Care Pathway,” it was touted as a way to ensure that people receive high-quality end-of-life care. The reality turned out to be far different and terribly sinister. Whatever its designers may have intended, in practice it was killing patients by denying them basic care—it was a pathway to euthanasia.
There have been many suggestions that the Liverpool Care Pathway continues to guide end-of-life care in the UK, albeit unofficially and sub rosa. Its mirror image certainly thrives here in the United States in the form of “living wills” that—however well-intentioned—serve as pathways to euthanasia for untold numbers of patients who are nearing the end of their natural lives. These legally binding documents often bind the unsuspecting patient to an unwanted and immoral death at the hands of medical professionals.
Definitions
The term “living will” is often misunderstood and confused with other end-of-life planning documents. We also have to understand the correct definition of euthanasia.
A living will is a form of advance directive that sets forth a person’s wishes about what medical treatments should be provided or withheld, in the event that they are incapacitated and cannot give consent.1 Every state has different legal requirements for the valid execution of a living will. But all share the underlying legal principle that, if validly executed, its provisions are binding. Physicians who violate the terms of the living will—by providing unwanted treatment or denying required treatment—can be held legally liable for battery.
A living will is different from a health care proxy or medical power of attorney. Those documents appoint an agent to act on behalf of an incapacitated patient. The proxy form can include instructions about the patient’s preferences. But the appointed agent has the authority to make decisions in the patient’s best interests.2
Euthanasia is defined as “an action or an omission which of itself or by intention causes death, in order that all suffering may in this way be eliminated.”3 It can be termed “active” if an affirmative action is done to cause death, such as an intentional administration of a lethal dose of opiates to a patient. It would be “passive” if death is caused by inaction, for instance by deliberately with-holding food or water from a patient with the intent of causing death.
Although euthanasia is formally illegal in every jurisdiction in America as a form of homicide, the reality is that euthanasia takes place all the time, facilitated by incautious use of living wills and other flawed advance directives.
Anti-Life Cultural Values
To understand how this is possible, it is vital to understand how cultural values that are strongly biased against life have become pervasive in the American health care system. This has a profound effect on the way chronically or terminally ill patients and people with disabilities are treated.
One of the best and most succinct diagnoses can be found in the Vatican letter from 2020, Samaritanus bonus. The document points to three major “cultural obstacles that obscure the sacred value of every human life.” The first is worth quoting at length because it lies in the background of any discussion of end-of-life care:
the notion of ‘dignified death’ as measured by the standard of the ‘quality of life’
. . . In this perspective, life is viewed as worthwhile only if it has, in the judgment of the individual or of third parties, an acceptable degree of quality as measured by the possession or lack of particular psychological or physical functions, or sometimes simply by the presence of psychological discomfort. According to this view, a life whose quality seems poor does not deserve to continue. Human life is thus no longer recognized as a value in itself.4
It is undeniable that modern society does not see human life as sacred and certainly does not see any sacredness in frailty or sickness. Instead, our culture’s ethical values are depressingly utilitarian, dominated by an emphasis on economic value or productivity. Anyone’s life that does not measure up to those standards is denigrated.
This bias is particularly dangerous given that a large percentage of the population will at some point be considered “disabled” due to illness, injury, or just age. The health care system has consistently underserved people with disabilities.5 Large percentages of doctors harbor implicit ableist bias that leads them to routinely underestimate the value that disabled people place on their lives and their “quality of life.” A 2022 study found that persons with disabilities “often receive substandard care, and in some cases are refused care,” with the result of “worse physical health and greater burden of chronic disease.” The study concluded that “physicians’ biases and discriminatory attitudes appear to play a significant role” in these disparities.6
People whose lives are not valuable in worldly terms or who have lost functionality are easily dismissed as “better off dead.” The United Nations Special Rapporteur on the Rights of Persons with Disabilities put it bluntly in an annual report: “The hegemony of ableism in society has perpetuated the idea that living with a disability is a life not worth living.”7
The second cultural obstacle identified by the Congregation is a false com-passion that leads to a rejection of “unbearable suffering.” Since that term is inherently subjective, this really means a rejection of any kind of suffering that an individual does not want. This leads to the wicked idea that if we can’t eliminate the suffering, it is better to eliminate the sufferer.8 Euthanasia and assisted suicide then become attractive “solutions” to this perversely created “problem.”
The slipperiness of this concept can be seen in the official statistics from the jurisdictions that have legalized assisted suicide or euthanasia. For ex-ample, in Canada, over 95 percent of patients who requested “medical aid in dying” cited “loss of ability to engage in meaningful activities” as a form of “suffering that is intolerable to them.” High percentages cited other subjective factors like “loss of independence” or “loss of dignity.”9 While much of this suffering is the result of an underlying illness, such a loose definition provides an open door to death on request.
The last cultural obstacle identified by the Vatican is individualism. An ethos of radical autonomy perceives limits or rules as oppression. It encourages people to view themselves in isolation from others, with no obligations to anyone else or any standards of morality. This leads to “the most hidden malady of our time: solitude or privacy.” This is particularly dangerous as people age in isolation from family or friends. It makes them susceptible to despair over the value of continued life.
Radical individualism also necessarily feeds the idea that anything—including ending one’s own life—is permissible if you consent to it, including liberation from one’s own body when it is fragile or ill. This finds expression in a legal right to decline any kind of unwanted health care, even if it will cause your death as a result.10 This right to decline life-sustaining treatment is the bedrock legal principle that underlies living wills and other advance directives.
Anti-Life Biases in Living Wills
Living wills are deeply embedded in typical end-of-life planning11. They are routinely suggested by attorneys and by Medicare as part of advanced care planning. But living wills share the anti-life bias that is so prevalent in society at large and thus function as a pathway to euthanasia.
The danger is inherent in the nature of the living will and how it operates. It is usually completed well ahead of any terminal illness, often many years before it will come into effect. With very few exceptions, there is no way that a person can make a balanced and rational decision about all the potential benefits and burdens that a treatment might present at a specific time, much less a decision that is properly guided by sound moral principles.
Nobody would ever recommend that a person make important financial decisions in such an uninformed and speculative way. We all understand that nobody can foretell the future of the stock market, interest rates, etc. Yet it is indicative of the anti-life bias of living wills that people are encouraged to make life-and-death decisions based on pure speculation about what they might want, despite the total lack of pertinent timely information.
This plays directly into the pervasive social fear and bias about disability discussed above. Living wills play on those fears. The term “living will” is itself a misnomer, since the documents really encourage people to plan for death rather than for continued life.
This can be seen in four living will forms that are readily available online:12
1. The New York Living Will from the New York State Attorney General’s Office.13
2. The New York Advance Directive from CaringInfo, which is the form that is linked from the websites of both AARP and Compassion and Choices (the leading national pro-euthanasia organization).14
3. “My Particular Wishes” from Compassion and Choices.15
4. “Five Wishes” from Aging With Dignity.16
All of these documents share the same fundamental flaw. They encourage the executor to issue unconditional and utterly inflexible instructions to decline potential treatments. There is no openness to a careful contemporary evaluation of benefits and burdens, which is not only the rational way to make momentous decisions about life and death but is also the best way to make sound moral choices.17 This can lead to the deliberate denial of treatments that would benefit a patient with the effect, if not the intention, of deliberately and directly ending their life—euthanasia.
These documents also give a great deal of power to those who will interpret their terms. This opens the door to a person acting against the patient’s well-being by refusing beneficial treatments and causing their untimely death. For example, the Five Wishes document uses a term “life-support treatment,” which it defines vaguely as “any medical procedure, device, or medication to keep me alive” and specifically includes assisted food and hydration and antibiotics. It then goes on to say, “I want to have life-support treatment if my doctor believes it could help. But I want my doctor to stop giving me life-support treatment if it is not helping my health condition or symptoms.” Yet the document never defines what is “helpful,” which could mean anything from “alleviate my symptoms” to “cure my disease” to “give me more time with my family.”
It is extremely risky to leave that calculus in the hands of a doctor who shares the anti-life mentality described above. This empowers the doctor to implement the deeply anti-life “futile care theory,” which involves an inherently subjective judgment that “cannot be meaningfully defined.”18 A doctor who follows this approach decides that a treatment is ineffective in improving a patient’s quality of life and withholds life-sustaining care, often with-out even discussing it with patients or their surrogates.19 Futile care theory is a fancy way to dress up euthanasia in intellectual clothing.
The principal reason all these living wills can lead to a patient being euthanized is the failure to recognize the special case of medically assisted food and hydration. Unlike many other kinds of medical interventions, food and water are a form of care for basic human needs.20 They rarely present any real burdens on a patient and provide benefits that are obviously essential for life. Under virtually all circumstances, we would be horrified to cause a person’s death by dehydration or starvation. Yet each of these living wills explicitly presents the patient with the choice to refuse assisted nutrition or hydration and would thus explicitly permit euthanasia by starvation or dehydration.
This reflects the fact that, for many years, it has been standard practice for incapacitated patients to be denied food and water, even when they are not imminently dying and unable to assimilate it.21 It is very common for people who have been in the position of making decisions for an elderly or terminally ill patient to be offered—or even encouraged—to cease providing food and water as an act of “mercy” to allow an easy and quick death. The patient is often given a dose of opiates to induce unconsciousness, which conceals the effects of dehydration.22
In such cases, denial of food and water is euthanasia by definition—failing to provide an ordinary means of sustaining life with the specific intent of causing death. “Death by starvation or dehydration is, in fact, the only possible outcome as a result of [the withdrawal of food and water]. In this sense it ends up becoming, if done knowingly and willingly, true and proper euthanasia by omission.”23 The cause of death is not any underlying condition, but rather a human decision and act to withdraw an essential life-sustaining form of care. Since the traditional legal principle is that one is presumed to intend the natural and foreseeable consequences of their actions, it is hard to see how the deliberate denial of food and water to a non-terminal patient is anything other than intentional euthanasia.
This flaw is exacerbated in two of the living will forms that offer the choice of denying food and water without any conditions or limits (from the New York State Attorney General and CaringInfo). Five Wishes suggests it for patients who are in a coma or have “permanent and severe brain damage . . . and life-support treatment would only delay the moment of my death.” But neither a coma nor brain damage is invariably fatal, so the document would allow the intentional death by starvation and dehydration for a non-terminal patient—again, euthanasia by effect and implicitly by intent.
Interestingly, the living will from the adamantly pro-euthanasia organization Compassion and Choices suggests that the patient could choose nutrition or hydration under a “trial period.” However, it defines the purpose of that period as evaluating whether the care “quickly reverses my condition.” That is an impossible qualification for food and water to satisfy, since they sustain life and cannot cure a person.
Even worse is Compassion and Choices’ “Dementia Values and Priorities Tool,” which is intended as an addendum to the living will. It calls for the denial of food and water if the patient merely shows that “I no longer ap-pear to desire food or drink turn my head or otherwise avoid being fed or giving fluids” or “I do not open my mouth to accept food or drink without prompting and all food or drink must be provided by a caregiver (hand or spoon-feeding).”24 Anyone who has spoon-fed a baby or an elderly person knows how common those events are.
Only one of the living wills explicitly rules out euthanasia. The Five Wish-es document states that “I do not want anything done or omitted by my doctors or nurses with the intention of taking my life.” But the document permits the patient himself to decline “life support treatment,” which is defined to include “food and water supplied by medical device” as well as antibiotics and “anything else meant to keep me alive.” That language by definition would permit the patient to require euthanasia in the event of incapacity.
Certainly, a person can use a living will in a morally and pragmatically responsible way that shows esteem for human life in principle. But in general, living wills reflect a profound pessimism about the value of human life. They embody all the anti-life social attitudes about end-of-life care identified in Samaritanus bonus. They fail to uphold the inherent worth of human life but instead reflect an attitude of disdain for life when it is weak or impaired. They communicate that suffering is an evil that can never have any value and that any means are legitimate to eliminate it. And they give full legal effect to absolute patient autonomy and individualism without regard to any external moral standards.
What Is the Alternative?
This criticism of living wills should not discourage people from planning ahead for the possibility that they may become incapacitated. There is a better alternative—the health care proxy.
Every state has some kind of legal framework for the appointment of a person (the “proxy” or surrogate) who can make medical decisions for us if we are unable to do so. Ironically, the living will forms discussed above all offer the option of appointing a proxy.
The best approach, though, is to execute a proxy without a living will. That does not tie the hands of the surrogate but still gives clear directions about the patient’s moral and personal beliefs. It allows a person who is or may someday be a patient to enlist the help of someone who cares and who respects the patient’s values.
Responsible use of a health care proxy involves some good formation in moral values. The Catholic approach is probably the most fully formed and coherent body of bioethics and offers good guidance for Catholics and non-Catholics alike who are seeking sound pro-life advice.25
Legalization of assisted suicide is advancing in America, and we are witnessing the disaster of legalized euthanasia in Canada and other countries. The general acceptance of living wills contributes to these trends, and they should thus be avoided by anyone dedicated to the cause of life. We must be vigilant about anything that will take us further down that pathway.
NOTES
1. Legal Information Institute, living will, Wex Legal Dictionary and Encyclopedia, https://www. law.cornell.edu/wex/living_will (last visited March 11, 2026).
2. E.g., N.Y. Pub. Health § 2982(2).
3. Congregation for the Doctrine of the Faith, Declaration on Euthanasia, Part II.
4. Congregation for the Doctrine of the Faith, Samaritanus Bonus (On the Care of Persons in the Critical and Terminal Phases of Life).
5. National Council on Disability, National Disability Policy: A Progress Report, 2024 (October 31, 2024), https://www.ncd.gov/assets/uploads/reports/2024/ncd-2024-progress-report.pdf.
6. Tara Lagu, et al., “I Am Not the Doctor For You’: Physicians’ Attitudes About Caring For People With Disabilities,” 41 Health Affairs 1387 (2022).
7. United Nations Special Rapporteur on the Rights of Persons with Disabilities, Rights of persons with disabilities, ¶73 (Dec. 17, 2019), https://docs.un.org/en/A/HRC/43/41.
8. E.g., Wesley J. Smith, “Teenager Dies after Requesting Euthanasia for Post-Rape PTSD, Anorexia,” National Review (June 4, 2019), https://www.nationalreview.com/corner/teenager-euthanized-for-post-rape-ptsd-anorexia/ (“Once a society accepts killing is an acceptable way to eliminate human suffering, there is no limit as to the categories of suffering that will eventually justify eliminating the sufferer.”).
9. Health Canada, Sixth Annual Report on Medical Assistance in Dying in Canada.
10. (Nov. 28, 2025), https://www.canada.ca/en/health-canada/services/publications/health-system-services/annual-report-medical-assistance-dying-2024.html#a3.
11. E.g., Cruzan v. Director, Mo. Dept. of Health, 497 U.S. 231, 269 (1990).
12. Medicare, “Advance care planning,” https://www.medicare.gov/coverage/advance-care-planning (last visited March 11, 2026).
13. New York forms were chosen because the author is a New York attorney. Other states have comparable forms.
14. https://ag.ny.gov/sites/default/files/livingwill-template-fillin.pdf.
15. https://www.caringinfo.org/wp-content/uploads/New_York.pdf.
16. https://compassionandchoices.org/wp-content/uploads/2024/03/My-Particular-Wishes-Only-FINAL-6.29.20.pdf. This is one component of a much larger advance directive planning tool. This section was chosen because it focuses on life-sustaining treatments.
17. https://www.fivewishes.org/five-wishes-sample.pdf.
18. See, e.g., United States Conference of Catholic Bishops, Ethical and Religious Directives for Catholic Health Care Services 7th Edition ¶33 (2025).
19. Peter A. Clark, “Medical Futility: Legal and Ethical Analysis,” AMA Journal of Ethics (May 2007), https://journalofethics.ama-assn.org/article/medical-futility-legal-and-ethical-analysis/2007-05.
20. Wesley J. Smith, “Stealth Medical Futility: You Can’t Handle the Truth,” The Center for Bioethics and Culture Network (Jan. 25, 2013), https://cbc-network.org/2013/01/stealth-medical-futility-you-cant-handle-the-truth/cant-handle-the-truth/.
21. Ethical and Religious Directives at ¶54.
22. Wesley Smith, “Dehydration Nation,” Human Life Review, Fall 2003, at 69.
23. Note that the use of sedation to alleviate symptoms of distress while a person is dying (“palliative sedation”) is not objectionable, but sedation to facilitate the death of a patient by dehydration (“terminal sedation”) is a form of euthanasia. Alex Schadenberg, “The Proper Use of Palliative Sedation is not Euthanasia” (July 20, 2011), https://alexschadenberg.blogspot.com/2011/07/proper-use-of-palliative-sedation-is.html (last visited March 11, 2026).
24. Pope St. John Paul II, “Life-Sustaining Treatments and Vegetative State: Scientific Advances and Ethical Dilemmas” (March 20, 2004), https://www.vatican.va/content/john-paul-ii/en/speeches/2004/ march/documents/hf_jp-ii_spe_20040320_congress-fiamc.html.
25. Compassion and Choices, “Dementia Values and Priorities Tool,” https://compassionandchoices. org/dementia-values-tool/ (last visited March 11, 2026).
26. See, e.g., the New York State Catholic Conference, which has resources for all states (https:// www.catholicendoflife.org/) or the National Catholic Bioethics Center (https://www.ncbcenter.org/ store/catholic-guide-to-end-of-life-decisions-english-pdf-download
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Original Bio:
Edward Mechmann is an attorney and Director of Public Policy for the Archdiocese of New York.
