Chapter 5 - The Ethical Debate

			       CHAPTER 5

			   THE ETHICAL DEBATE		     page 77

	  The ethics of assisted suicide and euthanasia are squarely

    before the public eye.  A steady drumbeat of media attention and

    mounting concern about control at life's end have generated serious

    consideration of legalizing the practices.  Public discussion has

    centered on the desire for control over the timing and manner of

    death, amidst warnings about the potential abuse or harm of

    overriding society's long-standing prohibitions against assisting

    suicide or directly causing another person's death.

	  Concurrent with this public debate, but in many ways separate

    from it, has been the discussion of assisted suicide and euthanasia

    in the medical and ethical literature.  In this debate, some assert

    that both assisted suicide and euthanasia are morally wrong and

    should not be provided, regardless of the circumstances of the

    particular case.  Others hold that assisted suicide or euthanasia

    are ethically legitimate in rare and exceptional cases, but that

    professional standards and the law should not be changed to

    authorize either practice.  Finally, some advocate that assisted

    suicide, or both assisted suicide and euthanasia, should be

    recognized as legally and morally acceptable options in the care of

    dying or severely ill patients.(1)

An Historical Perspective

	  For thousands of years, philosophers and religious thinkers

    have addressed the ethics of suicide.  These debates have rested on

    broad principles about duties to self and to society as well as

    fundamental questions of the value of human life.  Many great

    thinkers of Western intellectual history have contributed to this


    (1)  Through most of this chapter, arguments are schematically

	 presented as those of "proponents" of legalizing assistcd

	 suicide and euthanasia and "opponents" of legalizing these

	 practices. Each category groups together diverse views in order

	 to provide an overview of a debate marked by complex and nuanced


    page 78		    WHEN DEATH IS SOUGHT

    debate, ranging from Plato and Aristotle in ancient Greece to

    Augustine and Thomas Aquinas in the Middle Ages, and Locke, Hume,

    and Kant in more modern times.(2)

	  Some views and practices surrounding suicide were rooted in

    particular cultures and beliefs that have little relevance for

    contemporary society.  For example, in the warrior society of the

    Vikings, only those who died violently could enter paradise, or

    Valhalla.  The greatest honor was death in battle; suicide was the

    second best alternative.(3) Likewise, the ancient Scythians believed

    that suicide was a great honor when individuals became too old for

    their nomadic way of life, thereby sparing the younger members of

    the tribe the burden of carrying or killing them.  In other eras and

    civilizations, the debate about suicide touched on values that

    influenced the course of Western thought and still resonate to

    contemporary perspectives on suicide.

	  The word "euthanasia" derives from Greek, although as used in

    ancient Greece, the term meant simply "good death," not the practice

    of killing a person for benevolent motives.(4) In ancient Greece,

    euthanasia was not practiced, and suicide itself was generally

    disfavored.(5) Some Greek philosophers, however, argued that suicide

    would be acceptable under exceptional circumstances.  Plato, for

    example, believed that suicide was generally cowardly and unjust but

    that it could be an ethically acceptable act if an individual had an

    immoral and incorrigible character, had committed a disgraceful

    action, or had lost control over his or her actions due to grief or



     (2)  It is notable that the current debate about assisted

	  suicide, even among academic commentators, has drawn so little

	  from this rich history.  For an excellent discussion of the

	  intellectual history of suicide, see B. A. Brody,

	  "Introduction," in Suicide and Euthanasia:  Historical and

	  Contemporary Themes, ed.  B. A. Brody (Dordrecht:  Kluwer

	  Academic Publishers, 1989), 1. For an engaging literary history

	  of suicide, see A, Alvarez, The Savage God (New York:  Random

	  House, 1971).

     (3)  Those who died peacefully in their beds of old age or

	  illness were eternally excluded from Valhalla, Alvarez,


     (4)  According to one author, no Greek philosopher "cver

	  discusses euthanasia in our contemporary sense of the word."  J.

	  M. Cooper, "Greek Philosophers on Euthanasia and Suicide," in

	  Suicide and Euthanasia, ed.  Brody, 14.  See also P. Carrick,

	  Medical Ethics in Antiquity (Dordrecht:  D. Reidet, YJuwer,

	  1985), 127-31.

     (5)  A. Alvarez suggests that although suicide was

	  taboo, the Greeks tolerated suicide in some circumstances.

	  Noting the Greek practice of burying the corpse of a suicide

	  outside the city limits with its hand cut off, Alvarez argues

	  that this practice was "linked with the more profound Greek

	  horror of killing one's own kin.  By inference, suicide was an

	  extreme case of this, and the language barely distinguishes

	  between self-murder and murder of kindred."  Alvarez points out

	  that many suicides in Greek literature reflect acceptance and

	  even admiration of the act.  Alvarez, 58.

     (6)  Plato, Laws, chap. 9, 854, 873; see Cooper, 17-19.  Plato

	  also argued that, in most cases, suicide would represent

	  abandonment of one's duty and would violate divinely mandated

	  responsibilities.  Plato, Phacdo, 62.  In contrast to Plato,

	  Aristotle believed that suicide was unjust under all

	  circumstances, because it deprived the community of a citizen.

	  Aristotle, Nicomachean Ethics, chap. 5, 1138a; Cooper, 19-23.

      CHAPTER 5 - THE ETHICAL DEBATE			  page 79

    Unlike contemporary proponents of assisted suicide and

    euthanasia, who regard individual self-determination as central,

    Plato considered the individual's desire to live or die largely

    irrelevant to determining whether suicide might be an appropriate

    act.  An objective evaluation of the individual's moral worthiness,

    not the individual's decision about the value of continued life, was


	  In contrast to Plato, the Stoics of the later Hellenistic and

    Roman eras focused more strongly on the welfare of the individual

    than on the community.  They believed that, while life in general

    should be lived fully, suicide could be appropriate in certain rare

    circumstances when deprivation or illness no longer allowed for a

    "natural" life.(8) The Stoics did not, however, maintain that

    suicide would be justified whenever an individual loses the desire

    to live.  Unlike contemporary proponents of a right to suicide

    assistance, the Stoics believed that suicide was appropriate only

    when the individual loses the ability to pursue the life that nature


	  Since ancient times, Jewish and Christian thinkers have

    opposed suicide as inconsistent with the human good and with

    responsibilities to God.  In the thirteenth century, Thomas Aquinas

    espoused Catholic teaching about suicide in arguments that would

    shape Christian thought about suicide for centuries.


     (7)  Plato's suggestion that medical treatment should not be provided

	  to severly ill and disabled patients reflects a similar objective

	  view.  In the Republic (chap.3, 406-7), Plato argues that no

	  treatment should be provided to prolong the life of severly

	  ill or disabled individuals, because they represent a burden

	  to themselves and others.  As with suicide, the individual's

	  subjective feelings about the merits of continued life had

	  no bearing on the appropriatness of continued medical treatment.

	  Interestingly, Plato did not apply this analysis to the

	  severly ill and disabled elderly, who, he argued, should be

	  permitted to live regardless of their ability to contribute

	  to the community.  See Cooper, 13.

     (8)  Cooper, 24-29,36n.

     (9)  Some Roman Stoics such as Seneca, however, argued that the

	  individual should have broad discretion to end his or her own

	  life.  He criticized those who "maintain that one should

	  not offer violence to one's own life, and hold it accursed

	  for a man to be the means of his own destruction; we should

	  wait, say they, for the end decreed by nature. But one who

	  says this does not see that he is shutting off the path of

	  freedom.  The best thing which eternal law ever ordained was

	  that it allowd to us one entrance into life, but many

	  exits." In Carrick, 145.

      page 80		       WHEN DEATH IS SOUGHT

    Aquinas condemned suicide as wrong because it contravenes

    one's duty to oneself and the natural inclination of

    self-perpetuation; because it injures other people and the community

    of which the individual is a part; and because it violates God's

    authority over life, which is God's gift.(10) This position

    exemplified attitudes about suicide that prevailed from the Middle

    Ages through the Renaissance and Reformation.(11)

	  By the sixteenth century, philosophers began to challenge the

    generally accepted religious condemnation of suicide.  Michel de

    Montaigne, a sixteenth-century philosopher, argued that suicide was

    not a question of Christian belief but a matter of personal choice.

    In an essay presenting arguments on both sides of the issue, he

    concluded that suicide was an acceptable moral choice in some

    circumstances, noting that "pain and the fear of a worse death seem

    to me the most excusable incitements."(12) Other writers employed

    more theological arguments to challenge the religious prohibition on

    suicide.  In the early seventeenth century, for example, John Donne

    asserted that while suicide is morally wrong in many cases, it can

    be acceptable if performed with the intention of glorifying God, not

    serving self-interest.  Donne acknowledged the merit of laws against

    suicide that discouraged the practice, but he argued that civil and

    common laws ordinarily admit of some exceptions, suggesting that

    suicide could be morally acceptable in certain cases.(13)

	  In the eighteenth century, David Hume made the first

    unapologetic defense of the moral permissibility of suicide on

    grounds of individual autonomy and social benefit.  He asserted that

    even if a person's death would weaken the community, suicide would


    (10)  Thomas Aquinas, Summa Theologiae, II-II, 64; D. W.

	  Amundsen, "Suicide and Early Christian Values," in Suicide and

	  Euthanasia, ed.  Brody, 142-44; T. L. Beauchamp, "Suicide in the

	  Age of Reason," in Suicide and Euthanasia, ed.  Brody, 190-93.

    (11)  These principles continue to influence contemporary religious

	  and secular views about suicide.  See the discussion below in

	  this chapter.

    (12)  G. B. Ferngren, "The Ethics of Suicide in the

	  Renaissance and Reformation," in Suicide and Euthanasia, ed.

	  Brody, 159-61.  As Ferngren notes, suicide and euthanasia were

	  discussed a generation earlier in satirical works by Erasmus

	  and Thomas More, but it is unclear whether the authors intended to

	  advocate these practices.  Ferngren, 157-59.

    (13)  Donne articulated these views in an essay entitled

	  Biathanalos, which was published only after his death.  He did

	  not want it published during his lifetime, perhaps reflecting

	  his discomfort with views that challenged the prevailing

	  Christian ethics of his time.  In Biathanatos, Donne

	  acknowledges that he battled his own urge to commit suicide.

	  "Whenever any affliction assails me, me thinks I have the keys

	  of my prison in mine own hand, and no remedy presents itself so

	  soon to my heart as mine own sword."  In Ferngren, 169.

    CHAPTER 5 - THE ETHICAL DEBATE			      page 81

    be morally permissible if the good it afforded the individual

    outweighed the loss to society.  Moreover, suicide would be

    laudatory if the person's death would benefit the group and the

    individual.  Hume did not advocate that all suicides are justified,

    but argued that when life is most plagued by suffering, suicide is

    most acceptable.(14)

	  Other philosophers of the Age of Reason, such as John Locke

    and Immanuel Kant, opposed suicide.  Locke argued that life, like

    liberty, represents an inalienable right, which cannot be taken

    from, or given away by, an individual.(15) For Kant, suicide was a

    paradigmatic example of an action that violates moral

    responsibility.  Kant believed that the proper end of rational

    beings requires self-preservation, and that suicide would therefore

    be inconsistent with the fundamental value of human life.(16) Like

    some contemporary opponents of assisted suicide and euthanasia, Kant

    argued that taking one's own life was inconsistent with the notion

    of autonomy, properly understood.  Autonomy, in Kant's view, does

    not mean the freedom to do whatever one wants, but instead depends

    on the knowing subjugation of one's desires and inclinations to

    one's rational understanding of universally valid moral rules.(17)

	  Essays advocating active euthanasia in the context of modern

    medicine first appeared in the United States and England in the

    1870s.  In an 1870 work, schoolmaster and essayist Samuel D.

    Williams argued that "in all cases of hopeless and painful illness

    it should be the recognized duty of the medical attendant, whenever

    so desired by the patient, to administer chloroform, or such other

    anaesthetics as may by and by supersede chloroform, so as to destroy


    (14)  D. Hume, "On Suicide," in Ethical Issues in Death and

	  Dying, ed.  T. L. Beauchamp and S. Perlin (Englewood Cliffs,

	  N.J.:  Prentice-Hall, 1978),105-10; T. L. Beauchamp, "An

	  Analysis of Hume and Aquinas on Suicide," in Ethical Issues in

	  Death and Dying, ed.  Beauchamp and Perlin, 111-21; Beauchamp,

	  "Age of Reason," 199-205.

    (15)  Ferngren, 173-75.

    (16)  See II. Kant, Grounding for the Metaphysics of Morals, 3d ed.,

	  trans.  J. W. Ellington (Indianapolis:  Hackett, 1993); and

	  the discussion in Beauchamp, "Age of Reason," 206-15.

    (17)  For Kant, the fundamental moral law was expressed in the

	  "categorical imperative":  "Act only according to that maxim

	  whereby you can at the same time will that it should become a

	  universal law," or, in another formulation, "Act in such a way

	  that you treat humanity, whether in your own person or in the

	  person of another, always at the same time as an end and never

	  simply as a means."  Ellington translation, pp. 30, 36-1 Ak.

	  421, 429.

     page 82		      WHEN DEATH IS SOUGHT

    consciousness at once, and put the sufferer at once to a quick

    and painless end."(18) Support for euthanasia at this time was

    animated in part by the philosophy of social Darwinism and concerns

    with eugenics -- improving the biological stock of the community.

    In 1873, essayist Lionel A. Tollemache asserted that euthanasia

    could serve the patient's interests and benefit society in

    appropriate cases by removing an individual who was "unhealthy,

    unhappy, and useless."(19)

	  Over the course of the following decades, essays discussing

    euthanasia continued to appear in medical and popular journals.  The

    British Parliament debated a bill to legalize euthanasia in 1936.

    In the United States, similar proposals were introduced in state

    legislatures during the first half of the twentieth century,

    including New York State in 1947.  The Euthanasia Society of

    America, an organization advocating such proposals, was founded in

    1938.(20) Following World War II, however, the term "euthanasia"

    became disfavored due to sensitivity about Nazi practices.

Distinguishing Assisted Suicide and Euthanasia

	  Contemporary discussion has not focused primarily on the

    ethics of suicide itself, but on assistance to commit suicide and

    the direct killing of another person for benevolent motives.

    Actions that intentionally cause death are often referred to as

    active euthanasia, or simply as euthanasia.  Euthanasia performed at

    the explicit request of a patient is referred to as "voluntary"

    euthanasia.  Euthanasia of a child or an adult who lacks the

    capacity to consent or refuse is often termed "nonvoluntary."(21)

	  In addition, the terms "euthanasia" and "passive euthanasia"

    are sometimes used to describe withholding or withdrawal of

    life-sustaining treatment.  For example, Roman Catholic authorities


    (18)  "Euthanasia," in W. B. Fye, "Active Euthanasia:  An

	  Historical Survey of Its Origins and Introduction into

	  Medical Thought," Bulletin of the history of Medicine 52 (1978):

	  498.  Similar arguments were advanced in the 1936 debate on a

	  bill to legalize euthanasia in the British House of Lords; see

	  S. J. Reiser, A. J. Dyck, and W. J. Curran, Ethics in Medicine:

	  Historical Perspectives and Contemporary Concerns (Cambridge:

	  MIT Press, 1977), 498.

    (19)  "The New Cure for Incurables," in Fye, 499.

    (20)   J. Fletcher, Morals and Medicine (Princeton:  Princeton

	   University Press, 1954); J. Fletcher, "The Courts and

	   Euthanasia," Law, Medicine and Health Care 15 (1987/98):


    (21)   Involuntary euthanasia, performed over a patient's explicit

	   objection, has not been endorsed by anyone in the current


    CHAPTER 5 - THE ETHICAL DEBATE			      page 83

    often use the word "euthanasia" to refer to inappropriate

    decisions to withhold or to stop treatment.(22) This report uses the

    term "euthanasia" to refer only to active steps, such as a lethal

    injection, to end a patient's life.

	  In assisted suicide, one person contributes to the death of

    another, but the person who dies directly takes his or her own life.

    Many individuals hold similar positions on assisted suicide and

    euthanasia.  Others find assisted suicide more acceptable, either

    because of the nature of the actions or because of differences they

    see in the societal impact and potential harm of the two practices.

	  For some, assisted suicide and euthanasia differ

    intrinsically.  A physician who writes a prescription for a lethal

    dose of medication, for example, is less directly involved in the

    patient's death than a physician who actually administers medication

    that causes death.  With assisted suicide, the patient takes his or

    her own life, usually when the physician is not present.

    Accordingly, factors such as the physician's intentions may be more

    complex.  In some cases, a physician may intend to make it possible

    for a patient to commit suicide so that the patient feels a greater

    sense of control, but may hope that the patient does not take this

    final step.  In addition, because the patient's own actions

    intervene between the physician's actions and the patient's death,

    the physician's causal responsibility may be less clear.(23)

	  Some regard physician-assisted suicide as less subject to

    abuse than euthanasia.  When assisted suicide occurs, the final act

    is solely the patient's.  It would therefore be more difficult to


    (22)  The Vatican's 1980 "Declaration on Euthenasia" describes

	  euthanasia 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."  In President's Commission for the Study of

	  Ethical Problems in Medicine and Biomedical and Behavioral

	  Research, Deciding to Forego Life-Sustaining Treatment

	  (Washington:  U.S.  Government Printing Office, 1993), 303.

	  Appropriate decisions to forgo extraordinary or

	  disproportionately burdensome treatment would not be considered

	  euthanasia, however.  Ibid.  This report does not discuss the

	  criteria that characterize appropriate decisions to forgo

	  life-sustaining treatment.  The Task Force has addressed this

	  issue in previous reports.  See New York State Task Force on

	  Life and the Law, When Others Must Choose:  Deciding for

	  Patients Without Capacity (New York:  New York State Task

	  Force on Life and the law, 1992) and Life-Sustaining Treatment:

	  Making Decisions and Appointing a Health Care Agent (New York:

	  New York State Task Force on Life and the Law, 1987).

    (23)  See R. F. Weir, "The Morality of Physician-Assisted

	  Suicide," Law, Medicine and Health Care 20 (1992):  116-26.

    page 84	      WHEN DEATH IS SOUGHT

    pressure or convince a patient to commit suicide than to

    secure agreement to euthanasia.(24) Further, a patient who requests

    assistance in suicide but then becomes ambivalent could simply put

    off the final step.  By contrast, some patients would be too

    embarrassed or intimidated to express uncertainty to a physician on

    the verge of giving a lethal injection, or would be concerned that

    the doctor might be hesitant to administer the injection at a later


	  Some note that the potential for intimidation or influence

    stems not only from the doctor's actions in euthanasia, but also

    from his or her presence at the time of death.  Some individuals

    therefore distinguish cases when a physician assists a suicide by

    providing information or a prescription, which they believe should

    be permitted, from instances when the physician is present at the

    time of the suicide and directly aids or supervises the act, posing

    a greater risk.(26) Others are not troubled by this risk, and

    believe that the physician's presence could express caring and a

    desire to accompany the patient in the final moments of life.(27)

	  For others, no decisive distinction can be drawn between

    assisted suicide and voluntary euthanasia.  Whatever differences may

    exist do not justify a policy of accepting one practice while

    forbidding the other.  This view is shared by some who support

    both practices and by others who oppose both.(28)	Proponents of


    (24)   D. E. Meier, "Physician-Assisted Dying:  Theory and

	   Reality," Journal of Clinical Ethics 3 (1992):  35.

    (25)   J. Glover, Causing Death and Saving Life (Harmondsworth,

	   England:  Penguin Books, 1977), 184.  Howard Brody writes:

	   "There are psychological reasons to prefer patient control over

	   physician-assisted lethal injection whenever possible. The normal

	   human response to facing the last moment before death, when one

	   has control over the choice, ought to be ambivalence.  The

	   bottle of pills allows full recognition and expression of that

	   ambivalence:  I, the patient, can sleep on it, and the pills

	   will still be there in the morning; I do not lose my means of

	   escape through the delay.  But if I am terminally ill of cancer

	   in the Netherlands and summon my family physician to my house to

	   administer the fatal dose, I am powerfully motivated to deny any

	   ambivalence I may feel."  H. Brody, "Assisted Death - A

	   Compassionate Response to Medical Failure," New England Journal

	   of Medicine 327 (1992):1384-88.

    (26)   D. T. Watts and T. Howell, "Assisted Suicide Is Not

	   Euthanasia," Journal of ihe American Geriatrics Society 40

	   (1992):  1043.

    (27)   T. E. Quill, C. K. Cassel, and D. E. Meier, "Care of the

	   Hopelessly Ill:  Proposed Clinical Criteria for Physician-

	   Assisted Suicide," New England Journal of Medicine 327 (1992):


    (28)   Among supporters of the practices, see E. H. Loewy,

	   "Healing and Killing, Harming and Not Harming,"

	   "Journal of Clinical Ethics3(1992):30; G. C. Graberand

	   J. Chassman, "Assisted Suicide Is Not Voluntary Active

	   Euthanasia, but It's Awfully close, "Journal of the American

	   Geriatrics Society 41 (1993):88-89.  An opponet of

	   both practices likewise argues: "If the right to control the

	   time and manner of one's death - the right to shape one's

	   death in the most humane and dignified manner one chooses -

	   is well founded, how can it be denied to someone simply

	   because she is unable to perform the final act by herself?"

	   Y. Kamisar, "Are Laws Against Assisted Suicide Unconstitutional?"

	   Hastings Center Report 23, no.3(1993):35.

     CHAPTER 5 - THE ETHICAL DEBATE			       page 85

    the practices believe that the risks of error and abuse are

    similar in both practices, and can be minimized with appropriate

    safeguards.(29) Many who oppose both assisted suicide and euthanasia

    agree that the practices pose similar risks, but reject these risks

    as unacceptable.(30)

	  Most of those who emphasize the basic similarities between

    assisted suicide and voluntary active euthanasia nevertheless

    acknowledge some difference in degree between the two practices.

    Some claim that while both should be allowed, assisted suicide would

    be a preferable option in any particular case, in order to minimize

    the possibility of error.(31) Others oppose both practices but view

    active euthanasia as more problematic.(32) As discussed above,

    American law draws a clear distinction between the two types of

    action, treating euthanasia as a far more serious offense.  In New

    York and many other states, while both practices are felonies,

    assisting suicide is generally classified as manslaughter, while

    euthanasia constitutes second-degree murder.(33)

The Appeal to Autonomy

	  American society has long embraced individual liberty and the

    freedom to make personal choices as fundamental values.  These

    values have always been pursued within a social context, accompanied

    by commitments to promote the overall good of society and protect

    vulnerable individuals from harm.  For some, the exercise of


    (29)  D. Brock, "Voluntary Active Euthanasia," Hastings Center Report

	  22, no.2(1992):10;Graber and Chassman, 88.

    (30)  Kamisar, 35.

    (31)  E.g., Glover, 184; 1-1.  Brody, 1384-88.  As Dr.  Aadri

	  Heiner of the Netherlands describes his practice, "I will bring

	  a small glass bottle, and I will hand it over and say, "This is

	  for you.'  he has [to] drink it by [him]self.  ...  And

	  that makes me very sure that it is his own wish."  "Choosing

	  Death," Health Quarterly, broadcast March 23, 1993.

    (32)  See American Medical Association, Council on Ethical and

	  Judicial Affairs, "Decisions Near the End of Life," Journal of

	  the American Medical Association 267 (1992):2233.

    (33)  See chapter 4, p. 63.

    page 86		    WHEN DEATH IS SOUGHT

    autonomy must also be balanced against other fundamental values

    embraced by society, including our reverence for human life.  The

    current debate about assisted suicide and euthanasia also presents

    questions about the way autonomy can best be realized, and the

    manner in which the tension between autonomy and other ethical and

    societal values should be resolved.

	  One strand of the debate about assisted suicide and euthanasia

    has focused on whether the value of self-determination, which

    undergirds the right to refuse treatment, provides the basis for a

    right to assisted suicide or euthanasia as well.  Would the

    self-determination of severely ill patients actually be promoted in

    practice if assisted suicide and euthanasia were legalized?  Does

    contributing to another person's death manifest respect for that

    person's autonomy?  Questions have also been posed about the impact

    of legalizing assisted suicide and euthanasia on the

    self-determination and well-being of individuals who do not seek out

    these options.


	  Proponents of assisted suicide and euthanasia maintain that

    respect for individual self-determination mandates the legalization

    of these practices.  Individuals have a fundamental right to direct

    the course of their lives, a right that should encompass control

    over the timing and circumstances of their death.  While few if any

    advocates argue for an absolute right to commit suicide, most

    believe that in appropriate cases suicide can minimize suffering or

    enhance human dignity, and that people in these circumstances should

    have the right to take their own lives.(34)

	  Proponents suggest that a physician's participation in

    assisted suicide or euthanasia can support a choice embraced by the

    patient, consistent with his or her own value system.  Individual

    beliefs about the meaning of life and the significance of death vary

    greatly.  For proponents, establishing assisted suicide and

    euthanasia as accepted alternatives would respect this diversity.

    As stated by one commentator:

		    There is no single, objectively correct

	      answer for everyone as to when, if at all,

	      one's life becomes all things considered a

	      burden and unwanted.  If self-determination is

	      a fundamental value, then the great

	      variability among people on this question

	      makes it especially important that individuals

	      control the manner, circumstances, and timing

	      of their death and dying.(35)


     (34)  M. Battin, "Voluntary Euthanasia and the Risks of Abuse,"

	   Law, Medicine and Health Care 20 (1992):  134; M. P. Battin,

	   "Suicide:  A Fundamental Human Right?" in Suicide:  The

	   Philosophical Issues, ed.  M. P. Battin and D. J. Mayo (New

	   York:  St.  Martin's Press, 1980), 267-85.  See also J. Arras,

	   "The Right to Die on the Slippery Slope," Social Theory and

	   Practice 8 (1982):  285-328, noting arguments on both sides of

	   this issue.

      CHAPTER 5 - THE ETHICAL DEBATE				page 87

	  Some proponents promote legalizing assisted suicide and

    voluntary euthanasia as an affirmative step to grant individuals

    further control over their dying process.(36) For others, the

    decisive principle is the right to be free of state interference

    when individuals voluntarily choose to end their lives.(37)When

    differences on basic issues such as life and death go deep and

    involve profound values, a tolerant, pluralistic society must allow

    each individual to decide.  Many believe that, even

    if pain can be alleviated, the individual's right to control his or

    her death should prevail.

		    "I wouldn't want to be kept alive that

	      way" has become a modern motto in American

	      society.  Pain management and hospice care are

	      better than ever before.  But for some people

	      they are simply the trees.  The forest is that

	      they no longer want to live, and they believe

	      the decision to die belongs to them alone.(39)


	  Some believe that assisted suicide and euthanasia can promote

    autonomy, at least in some cases, but that the dangers of the

    practices are overriding.  For others, the value of human life


    (35)  Brock, 11.  See similarly R. Dworkin, Life's Dominion (New

	  York:  Knopf, 1993), 208-11; C. K. Cassel and D. E. Meier,

	  "Morals and Moralism in the Debate over Euthanasia and Assisted

	  Suicide," New England Journal of Medicine 323 (1990):  751.

    (36)  Weir, 124.  Dick Lehr reports that in every case of

	  assisted suicide that health care professionals discussed in

	  interviews, "patients were middle- to-upper class, accustomed to

	  being in charge."  An oncologist who had assisted suicide stated

	  that "these are usually very intelligent people, in control of

	  their life - white, executive, rich, always leaders of the pack,

	  can't be dependent on people a lot."  D. Lehr, "Death and the

	  Doctor's Hand," Boston Globe, April 26,1993.

    (37)  As stated by one philosopher, "One will need to live with

	  individuals' deciding with consenting others when to end their

	  lives, not because such is good, but because one does not have

	  the authority coercively to stop individuals from acting

	  together in such ways."  H. T. Engelhardt, Jr., "Fashioning an

	  Ethics for Life and Death in a Post-Modern Society," listings

	  Center Report 19, no. 1 (1989):  S9.  See also J. Rachels, The

	  End of Life (New York:  Oxford University Press, 1986), 181-82.

    (38)  Dworkin, 217.

    (39)  A. Quindlen, "Death:The Best Seller," New York Times,

	  August 14,1991, A19.

    page 88		     WHEN DEATH IS SOUGHT

    outweighs the claim to autonomy, and argues decisively against

    permitting suicide assistance or direct killing, even with

    benevolent motives.  Still others assert that seeking to end one's

    life intrinsically contradicts the value of autonomy.  Like the

    "freedom" to sell oneself into slavery, the freedom to end one's

    life should be limited for the sake of freedom.

	  Many reject euthanasia because it violates the fundamental

    prohibition against killing.  They understand this prohibition,

    except in defense of self or others, to be a basic moral and social

    principle.  This view is expressed within the context of diverse

    religious, philosophical, and personal perspectives.(40) Rooted in

    religious beliefs about the value and meaning of human life, it also

    resonates to and informs secular values and attitudes, including our

    laws proscribing murder.

	  Assisted suicide is opposed by many for similar reasons;

    although it does not violate the ban against killing directly, it

    renders human life dispensable and implicates physicians or others

    in participating in the death of the patient.  Some emphasize that

    assisted suicide and euthanasia are not simply nonintervention in

    the private choice of another person.  The participation of a second

    person makes assisted suicide and euthanasia social and communal

    acts, ones in which social, moral, and legal principles must be

    considered.(41) A physician who assists a patient's death affirms,


     (40)  See, e.g., R. M. Veatch, Death, Dying, and the Biological

	   Revolution, rev. cd.  (New Haven:  Yale University Press,

	   1989), 69-72.  Among the Biblical statements of this prohibition

	   are Exodus 20:13, Deuteronomy 5:17, and Genesis 9:5-6.  Many

	   religious traditions understand these statements as prohibiting

	   suicide and assisted suicide as well as direct killing.  For an

	   overview of the attitudes of diverse religious traditions, see

	   R. Hamel, ed., Active Euthanasia, Religion, and the Public

	   Debate (Chicago:  Park Ridge Center, 1991)- and C. S. Campbell,

	   "Religious Ethics and Active Euthanasia in a Pluralistic

	   Society," Kennedy Institute of Ethics Journal 2 (1992):  253-77.

	   On the significance of religiously influenced views for public

	   policy deliberations, see, e.g., S. Hauerwas, Suffering Presence

	   (Notre Dame:  University of Notre Dame Press, 1986), 105; Joseph

	   Cardinal Bernadin, "Euthanasia:  Ethical and Legal Challenge,"

	   Origins 18 (1988):  52-1 J. Stout, Ethics After Babel (Boston:

	   Beacon Press, 1988); D. Callahan and C. S. Campbell, eds.,

	   "Theology, Religious Traditions, and Bioethics," Hastings

	   Center Report 20, no. 4 suppl.  (1990); S. L. Carter, The

	   Culture of Disbelief (New York:  Basic Books, 1993).

     (41)  See, e.g., Callahan, 52-53; T. L. Beauchamp and J. F.

	   Childress, Principles of Biomedical Ethics, 3d ed.  (New York:

	   Oxford University Press, 1989), 227.  Many religious traditions,

	   including Roman Catholicism, challenge the notion of an

	   autonomous right to end one's life, appealing to the social

	   nature of human life and the mutual dependence of individuals in

	   society.  See, e.g., Bernadin, 55.  This point is also advocated

	   in secular terms.

      CHAPTER 5 - THE ETHICAL DEBATE				page 89

    or at least accepts, the patient's choice, actively contributing to

    the outcome.(42) Some believe that one person should never be

    granted this power over the life and death of another, even a

    consenting other; it is intrinsically offensive to human dignity, in

    the way that consensual slavery would be.(43) Others are more

    pragmatically concerned about the influence physicians would

    exercise in the decision-making process.(44)

	  For some, assisted suicide and euthanasia are not inherently

    incompatible with self-determination, but they believe that the

    practices as applied in the daily routines of medical practice and

    family life would undermine the autonomy of many individuals.  In

    many cases, a patient who requests euthanasia or assisted suicide

    may have undiagnosed major clinical depression or another

    psychiatric disorder that prevents him or her from formulating a

    rational, independent choice.  Other patients may feel compelled to

    end their lives because they lack real alternatives, due to

    inadequate medical treatment or personal support.(45) Offering


    (42)   Opponents argue that the patient's request for suicide

	   assistance is not just a way to obtain drugs: The request might

	   represent a desire for companionship in pursuing a difficult

	   course of action; a wish for confirmation of a decision about

	   which the patient is unsure; inquiry of the physician's opinion

	   on an issue about which the patient is ambivalent; an appeal

	   for the physician's reassurance that he or she is committed to

	   the patient and believes that the patient's life is worthwhile;

	   or simply an expression of desperation and a cry for help.  See,

	   e.g., E. D. Caine and Y. C. Conwell, "Self-Determined Death, the

	   Physician, and Medical Priorities:  Is There Time to Talk,"

	   Journal of the American Medical Association 270 (1993):  875-76.

	   See also Glover, 183.

     (43)  As stated by Daniel Callahan, "No human being, whatever the

	   motives, should have that kind of ultimate power over the fate

	   of another.  It is to create the wrong kind of relationship

	   between people, a community that sanctions private killings

	   between and among its members in pursuit of their individual

	   goals and values." 1).  Callahan, "Can We Return Death to

	   Disease?"  Hastings Center Report 19, no. 1 (1989):  S5.

     (44)  Edmund D. Pellegrino argues that while the doctor appears

	   to place the initiative in the patient's hands and be merely

	   "open" to suicide under the right circumstances, the physician

	   actually retains control:  "Ultimately, the determination of the

	   right circumstances is in the physician's hands.  The physician

	   controls the availability and timing of the means whereby the

	   patient kills himself.  Physicians also judge whether patients

	   are clinically depressed, their suffering really unbearable, and

	   their psychological and spiritual crises resolvable. Finally,

	   the physician's assessment determines whether the patient is in

	   the 'extreme' category that, per se, justifies suicide

	   assistance."  "Compassion Needs Reason Too," Journal of the

	   American Medical Association 270 (1993):  874.

    (45)   See, e.g., Arras, 311-13; J. Teno and J. Lynn, "Voluntary

	   Active Euthanasia:  Individual Case and Public Policy," Journal

	   of the American Geriatrics Society 39 (1991):  827-30;

	   H. Hendin and G. Klerman, "Physician- Assisted Suicide: The

	   Dangers of Legalization," American Journal of Psychiatry 150

	   (1993):  143-45; D. W. McKinney, "Euthanasia as Public Policy:

	   Rights and Risks," The Berry Street Essay, delivered in New

	   Haven, Conn., June 22, 1989, Unitarian Universalist General

	   Assembly, 9. See also the sections discussing suicide and

	   depression in chapter 1.

    page 90		     WHEN DEATH IS SOUGHT

    suicide assistance, but not good medical care, could be especially

    troubling for some segments of the population.  As expressed by one

    doctor who manages a Latino health clinic, legalizing assisted

    suicide would pose special dangers for members of minority

    populations whose primary concern is access to needed care, not

    assistance to die more quickly.

		    In the abstract, it sounds like a

	      wonderful idea, but in a practical sense it

	      would be a disaster.  My concern is for

	      Latinos and other minority groups that might

	      get disproportionately counseled to opt for

	      physician-assisted suicide.(46)

	  Diverse religious traditions oppose assisted suicide and

    euthanasia because the practices violate the basic value of human

    life, seen as God's gift.  From the perspective of many religions,

    suicide itself is not an ethically sanctioned choice.  Many

    religious traditions reject assisted suicide and euthanasia based on

    their understanding of general values, including appreciation for

    the life and value of each individual, the individual's

    responsibility to the community, and society's obligations towards

    all of its members, especially the poor and vulnerable.  Many

    religions understand life itself as something that is entrusted to

    persons by God, entailing a sense of individual responsibility that

    is often expressed in terms of "stewardship."  Differing religious

    perspectives also share a commitment to compassion for patients and

    others who are suffering.(47) They believe that this compassion

    should be expressed by offering care and companionship, not assisted

    death or medical killing, to the severely ill.

	  As articulated in the 1980 Vatican Declaration on Euthanasia,

    and affirmed in recent speeches by Pope John Paul II, the Catholic

    Church firmly rejects assisted suicide and euthanasia.(48)


    (46)  Dr.  Nicolas Parkhurst Carballeira, Director of the

	  Boston-based Latino Health Institute, in Lehr, April 26, 1993.

	  A recent study found that patients treated at centers that serve

	  predominantly minority patients were three times more likely

	  than those treated elsewhere to receive inadequate pain

	  treatment.  Elderly individuals and women were also more likely

	  than others to receive poor pain treatment.  C. S. Cleeland et

	  al., "Pain and Its Treatment in Outpatients With Metastatic

	  Cancer," New England Journal of Medicine 330 (1994):  592-96.

    (47)  See, e.g., H. Arkes et al., "Always to Care, Never to

	  Kill," First Things no, 18 (1992):  4547; Hamel, ed., 45-77.

    (48)  Speaking in the United States in 1993, the Pope condemned

	  euthanasia, stating:  "In the modern metropolis, life - God's

	  first gift, and the fundamental right of every individual, on

	  which all other rights are based - is often treated as just one

	  more commodity" "The Prayer Vigil," Origns 23 (1993):  184.

	  See also "Contributors to the Formation of Society:  Ad Limina

	  Address," Origins 23 (1993):  486-87; "Veritatis Splendor,"

	  Origins 23 (1993):  321, par. 80.

    CHAPTER 5 - THE ETHICAL DEBATE			      page 91

    Similar views are expressed by representatives of all branches of

    Judaism.(49) Many Protestant denominations, such as the American

    Lutheran Church and the Episcopal Church, also oppose the practices

    as ethically unacceptable.(50) The Unitarian-Universalist

    Association, however, has expressed support for legalizing the


Benefiting the Patient

	  Individuals suffer from diverse causes.  They may experience

    pain, physical discomfort, and psychological distress.(52) Relieving

    suffering is widely recognized as a basic moral value and a goal of

    medicine in particular.(53) The debate about euthanasia and assisted

    suicide turns in part on a judgment about how to help suffering

    individuals most effectively while protecting them and others from



    (49)  For further discussion of Jewish views on assisted suicide

	  and euthanasia, see, e.g., I. Bettan et al., "Euthanasia," in

	  American Reform Response, ed.  W. Jacob (New York:  Central

	  Conference of American Rabbis, 1983), 261-71; J. D. Bleich "Life

	  as an Intrinsic Rather Than Instrumental Good: The

	  'Spiritual' Case Against Euthanasia," Issues in Law and Medicine

	  9 (1993):  13949; B. A. Brody, "A Historical Introduction to

	  Jewish Casuistry on Suicide and Euthanasia," in Suicide and

	  Euthanasia, ed.  Brody, 39-75; E. N. Dorff, "Rabbi, I Want to

	  Die:  Euthanasia and the Jewish Tradition," in Choosing Death in

	  America (Philadelphia:  Westminster/John Knox, forthcoming); D.

	  M. Feldman and F. Rosner, ed., Compendium on Medical Ethics, 6th

	  ed.  (New York:  Federation of Jewish Philanthropies of New

	  York, 1984), 101-2; I. Jakobovits, Jewish Medical Ethics, 2d ed.

	  (New York:  Bloch, 1975).

    (50)  As stated in a report of the American Lutheran Church:

	  "Some might maintain that active euthanasia can represent an

	  appropriate course of action if motivated by the desire to end

	  suffering.  Christian stewardship of life, however, mandates

	  treasuring and preserving the life which God has given, be it

	  our own life or the life of some other person. nis view is

	  supported by the affirmation that meaning and hope are possible

	  in all of life's situations, even those involving great

	  suffering."  "Death and Dying," 1982, in Hamel, ed., 63.  See

	  also Hamel, ed., 52-71.

    (51)  The 1988 Unitarian Universalist General Assembly issued a

	  statement resolving "That Unitarian Universalists advocate the

	  right to self-determination in dying, and the release from civil

	  or criminal penalties of those who, under proper safeguards, act

	  to honor the right of terminally ill patients to select the time

	  of their own deaths."  In Hamel, ed., 68-69. This resolution has

	  been criticized by some within the Unitarian Universalist

	  Association, including Donald McKinney.  McKinney.

    (52)  See chapter 3 for discussion of current approaches in pain

	  and palliative care.  See also K. M. Foley, "The Relationship of

	  Pain and Symptom Management to Patient Requests for

	  Physician-Assisted Suicide," Journal of Pain and Symptom

	  Management 6 (1991):  289-97.

    (53)  See, e.g., R. S. Smith, "Ethical Issues Surrounding Cancer

	  Pain," in Current and Emerging Issues in Cancer Pain:  Research

	  and Practice, ed.  C. R. Chapman and K. M. Foley (New York:

	  Raven Press, 1993), 385-92.

    page 92		     WHEN DEATH IS SOUGHT

	  In the debate about assisted suicide and euthanasia,

    compassion for patients in pain or with unrelieved suffering is a

    common moral and social ground.  Disagreement centers on how society

    can best care for these patients, and the consequences for others if

    the practices are permitted.  The debate hinges in part on

    assumptions about the number of patients affected, the availability

    of pain relief, and the effect of legalizing assisted suicide and

    euthanasia on the provision of palliative care.  At the core are

    basic differences about what compassion demands for suffering

    individuals.  Disagreement exists too about whether the availability

    of assisted suicide or euthanasia would reassure or threaten ill and

    disabled patients.


	  Those who support euthanasia and/or physician-assisted suicide

    believe that such actions are the most effective way to help some

    patients experiencing intractable pain or intolerable psychological

    distress.  They regard these actions as essential to fulfill a

    commitment to relieve suffering.  Indeed, many feel that, in

    appropriate circumstances, a physician's desire to act

    compassionately towards his or her patient provides the strongest

    rationale for the practices.

	  Contemporary advocates argue that, despite advances in

    palliative medicine and hospice care, a small number of patients

    continue to suffer from severe pain and other physical symptoms that

    available medical therapies cannot reduce to a tolerable level.(54)

    Studies have shown that large numbers of patients receive poor

    palliative care; while state-of-the-art treatment could manage their

    pain and discomfort, they are not receiving and are unlikely to

    receive this care.  In these cases, euthanasia or assisted suicide

    would directly end the patient's suffering.(55)

	  In addition to physical pain and discomfort, patients

    experience psychological and personal suffering, which is less

    amenable to medical treatment.  As articulated by several doctors,

    "The most frightening aspect of death for many is not physical pain,

    but the prospect of losing control and independence and of dying in

    an undignified, un[a]esthetic, absurd, and existentially

    unacceptable condition."(56) Some patients suffer because of losses


    (54)  At least short of anesthetizing the patient to a sleep-like

	  state; see p. 93, n. 60.

    (55)  G. A. Kasting, "The Nonnecessity of Euthanasia," in

	  Physician-Assisted Death, ed.  J. M. Humber, R. F. Almeder, and

	  G. A. Kasting (Totowa, N.J.:  Humana Press, 1993), 2545; Weir,

	  123-24; Rachels, 152-54.

    (56)  Quill, Cassel, and Meier, 1383.

    CHAPTER 5 - THE ETHICAL DEBATE			      page 93

    that have already occurred or because of anticipated losses and

    decline.  Others may experience anxiety, loneliness, helplessness,

    anger, and despair.  Proponents of assisted suicide and euthanasia

    assert that only the patient can determine when suffering renders

    continued life intolerable.(57)

	  The number of patients who would receive assistance to commit

    suicide or euthanasia is unknown.  Most advocates assert that these

    actions would be appropriate only in rare cases, and that relatively

    few patients would be directly affected.  They argue, however, that

    many individuals who never use the practices would benefit.  Some

    patients would feel better cared for and more secure if they knew

    that their physician would provide a lethal injection or supply of

    pills if they requested these means to escape suffering.(58) Knowing

    that assisted suicide or euthanasia is available would also reassure

    members of society in general, including those who are not severely

    ill.  "While relatively few might be likely to seek assistance with

    suicide if stricken with a debilitating illness, a substantial

    number might take solace knowing they could request such



	  Those who oppose legalizing assisted suicide and euthanasia

    are also deeply concerned about the needs of terminally and severely

    ill patients.  They believe that society all too often abandons

    these patients, adding to their suffering and sense of despair.

    However, they reject assisted suicide and euthanasia as unacceptable

    or harmful responses to these patients in need.  They also believe

    that the likely harm to many patients far exceeds the benefits that

    would be conferred.  Advances in pain control have rendered cases of

    intolerable and untreatable pain extremely rare.  In exceptional

    cases in which symptoms cannot be controlled adequately while the

    patient is alert, sedation to a sleep-like state would remain an

    option.(60).  Allowing assisted suicide or euthanasia, especially


    (57)  Brock, 11; Weir, 123; Kasting.

    (58)  F. G. Miller and J. C. Fletcher, "The Case for Legalizcd

	  Euthanasia Perspectives in Bioloy and Medicine 36 (1993):163-64;

	  Quill, Cassel, and Meier, 1382.

    (59)  Watts and Howell, 1044-45.

    (60)  N. Coyle et al., "Character of Terminal Illness in the

	  Advanced Cancer Patient:  Pain and Other Symptoms During the

	  Last Four Weeks of Life," Journal of Pain and Symptom Management

	  5 (1990):  83-93; Foley; Teno and Lynn.  Watts and Howell

	  (1045), in advocating assisted suicide, write:  "We concede that

	  there is another alternative:  terminally ill patients who

	  cannot avoid pain while awake may be given continuous anesthetic

	  levels of medication.  But this is exactly the sort of dying

	  process we believe many in our society want to avoid."  In

	  contrast, Leon R. Kass states:  "It will be pointed out [that]

	  full analgesia induces drowsiness and blunts or distorts

	  awareness.  How can that be a desired outcome of treatment?

	  Fair enough.  But then the rationale for requesting death begins

	  to shift from relieving experienced suffering to ending a life

	  no longer valued by its bearer or, let us be frank, by the

	  onlookers."  "Neither for Love nor Money:  Why Doctors Must Not

	  Kill," Public Interest 94 (1989):  33.  Palliative care experts

	  report that while sedation seems objectionable to many healthy

	  individuals contemplating it in the abstract, most terminally

	  ill patients and families find it acceptable.  Nessa M. Coyle,

	  R. N., Director, Supportive Care Program, Pain Service,

	  Department of Neurology, Memorial Sloan-Kettering Cancer Center,

	  oral communication, March 11, 1993.  While continual sedation

	  can be an important option for patients in severe and

	  intractable physical pain, it is a less practical option for

	  patients whose suffering is primarily psychological and who may

	  have years to live.  Quill, Cassel, and Meier.

    page 94		     WHEN DEATH IS SOUGHT

    given the current state of palliative care, would deny patients the

    treatment and support that should be a routine part of medical

    practice.  It also would lead to the death of some patients whose

    pain could be alleviated.(61)

	  Health care professionals can do much to help relieve

    psychological suffering by providing humane care and personal

    support.(62) Opponents believe that assisting a patient's suicide or

    performing euthanasia in an attempt to relieve psychological anguish

    or despair will rarely serve the patient's interests.  For some,

    this is an evident contradiction; causing death can never constitute

    a benefit.(63) Others maintain that assisted suicide and euthanasia

    could alleviate psychological suffering in rare cases, but believe

    that the advantages of allowing the practices are outweighed by the

    potential harm to many other patients.(64)

	  Significant too is the concern that suicide should not be

    pursued as a means to care for, or "treat," patients who suffer


    (61)  Reflecting on this danger in the United States, Alexander M.

	  Capron writes:  "'The difficulties in developing caring and

	  creative means of responding to suffering discourage society as

	  well as health care providers from greater efforts.  A policy of

	  active euthanasia can become another means of such avoidance...

	  I could not rid my mind of the images of care provided in our

	  hard-pressed public hospitals and in many nursing homes, where

	  compassionate professionals could easily regard a swift and

	  painless death as the best alternative for a large number of

	  patients."  "Euthanasia in the Netherlands:  American

	  Observations," Hastings Center Report 22, no. 2 (1992):  32.

    (62)  See, e.g., N. Coyle, "The Euthanasia and Physician-Assisted

	  Suicide Debate:  Issues for Nursing," Oncolog Nursing Forum 19,

	  no. 7 suppl.  (1992):  4445; and discussion above, chapter 3.

	  Most proponents of assisted suicide and euthanasia would agree

	  with this statement but still believe that the practices should

	  be available at the patient's option.

    (63)  As argued by Leon Kass:  "To intend and to act for

	  someone's good requires his continued existence to receive the

	  benefit."  Kass, 40.

    (64)  P. A. Singer and M. Siegler, "Euthanasia - A Critique," New

	  England Journal of Medicine 322 (1990):  1881-83.

     CHAPTER 5 - THE ETHICAL DEBATE			       page 95

    because of psychological reasons.  Society has long

    discouraged suicide as a remedy for psychological suffering, even

    though many individuals who consider suicide are anguished and find

    relief in the prospect of death.(65) Even for patients who are

    suffering and seek assistance in ending life, complying with the

    request may provide the wrong kind of "assistance," causing some

    patients to end their lives prematurely.  Two physicians report

    that, while many hospice patients at times express a desire for

    death, almost none make serious and persistent requests for active

    euthanasia.  They write:

		    New patients to hospice often state they

	      want to "get it over with."  At face value,

	      this may seem a request for active euthanasia.

	      However, these requests are often an

	      expression of the patient's concerns regarding

	      pain, suffering, and isolation, and their

	      fears about whether their dying will be

	      prolonged by technology.  Furthermore, these

	      requests may be attempts by the patient to see

	      if anyone really cares whether he or she

	      lives.  Meeting such a request with ready

	      acceptance could be disastrous for the patient

	      who interprets the response as confirmation of

	      his or her worthlessness.(66)

	  Others note that even if all patients are assumed to make

    rational and beneficial choices for themselves, giving patients the

    option of choosing to end life would change the way they and those

    around them perceive their lives.  Specifically, a patient could no

    longer stay alive by default, without needing to justify his or her

    continued existence.  The patient will be seen (by others and

    himself or herself) as responsible for the choice to stay alive, and

    as needing to justify that choice.  Given societal attitudes about

    handicaps and dependence, "the burden of proof will lie heavily on

    the patient who thinks that his terminal illness or chronic

    disability is not a sufficient reason for dying."(67)


     (65)  As explained by one sociologist who studied suicide:  "It

	   is undeniable that all persons - 100 percent - who commit

	   suicide are perturbed and experiencing unbearable psychological

	   pain."  E. S. Shneidman, "Rational Suicide and Psychiatric

	   Disorders,"New England Journal of Medicine 326 (1992):  889.

	   Two psychiatrists offer a similar opinion; see Hendin and

	   Klerman, 144.

     (66)  Teno and Lynn, 828.

     (67)  This argument is well developed by J. David Velleman,

	   "Against the Right to Die," Journal of Medicine and Philosophy

	   17 (1992):  665-81.  While Velleman argues against establishing

	   a law or policy permitting euthanasia, he believes that some

	   patients would benefit from death and welcome euthanasia and

	   that in such cases rules against euthanasia should not be


    page 96		     WHEN DEATH IS SOUGHT

	  Severely ill patients depend on others not only for physical

    care, but for conversation, respect, and meaningful human

    interaction.  In some cases, family members may encourage patients

    to "choose" the option of dying.(68) More commonly, even without

    such pressure, a patient may assume that friends and family regard

    the choice to remain alive as irrational or selfish.  As expressed

    by one commentator, "The patient may rationally judge that he's

    better off taking the option of euthanasia, even though he would

    have been best off not having the option at all.  ...  To offer the

    option of dying may be to give people new reasons for dying."(69)

	  Many opponents believe that establishing an option of assisted

    suicide or euthanasia would have negative consequences not only for

    patients who receive assisted dying, but for many others who would

    not use either practice.  The option of assisted suicide or

    euthanasia could distract attention from the care that some patients

    might otherwise be offered.  Especially if a patient's symptoms

    persist despite initial attempts to alleviate them, the effort and

    expense of more aggressive treatment and support may seem less

    compelling.(70) Officially sanctioning these practices might also

    provide an excuse for those wanting to spend less money and effort

    to treat severely and terminally ill patients, such as patients with

    acquired immunodeficiency syndrome (AIDS).(71)

Societal Consequences

	  Decisions about euthanasia and assisted suicide touch upon

    fundamental societal values and standards.  They entail questions

    about why we value human life, when life may be taken, and what

    obligations we owe to others.  Legalizing assisted suicide or

    euthanasia would represent a dramatic change, and is likely to cause

    both intended and unintended consequences.

	  Those who favor or oppose legalizing assisted suicide and

    euthanasia differ both in their prediction of societal consequences


    (68)  See Kamisar, 37; and also the concerns noted in M. P.

	  Battin, "Manipulated Suicide," in Suicide:  The Philosophical

	  Issues, ed.  Battin and Mayo, 169-82.

    (69)  Velleman, 675-76.

    (70)  A. J. Dyck, "Physician-Assisted Suicide - Is It Ethical?"

	  Harvard Divinity Bulletin 21, no. 4 (1992):  16.

    (71)  Donald McKinney argues that even if relatively few patients

	  avail themselves of the choice, officially sanctioning the

	  option may alter public perceptions, making improvement in

	  palliative care and increased social support for suffering

	  patients seem less urgent.  McKinney, 7-8.

    CHAPTER 5 - THE ETHICAL DEBATE			      page 97

    and in the way that they evaluate possible outcomes.(72) They

    disagree, for example, about the effect of the practices on

    society's respect for the value of the lives of others, especially

    those who are most frail and ill.  They also differ about whether

    expansion of a policy of voluntary euthanasia to include

    nonvoluntary euthanasia would benefit or threaten vulnerable members

    of society, and whether mistakes or abuses in a relatively small

    number of cases would constitute a moral outrage or the unfortunate

    but unavoidable imperfections of any human activity.  Finally,

    proponents and opponents disagree about how the burden of proof

    should fall in deciding public policy.  If the societal consequences

    of authorizing assisted suicide or euthanasia are uncertain, should

    society allow these practices until such time as harmful effects can

    be proven, or should the practices remain prohibited unless society

    can assure itself that they would not cause unacceptable social



	  Proponents believe that legalizing assisted suicide and

    euthanasia would not produce harmful consequences for society as a

    whole, and that potential dangers can be minimized by appropriate

    safeguards.  For example, some argue that, despite current

    prohibitions, assisted suicide now occurs.  Openly permitting

    assisted suicide in accord with required safeguards might therefore

    encourage physicians to communicate more freely with their patients

    and to consult with professional colleagues.  Mandated consultation

    with a licensed psychiatrist would improve the diagnosis and

    treatment of many patients who are depressed.(74) As a result,

    allowing the practice in carefully defined circumstances would lead

    to greater professional accountability and fewer cases of abuse.(75)


    (72)  See Brock, 14.

    (73)  Similar arguments about potential consequences and the

	  "burden of proof" in the absence of unproven but probable risks

	  have been raised in the debate on Surrogate motherhood.  See New

	  York State Task Force on Life and the Law, Surrogate Parenting.-

	  Analysis and Recommedations for Public Policy (New York:  New

	  York State Task Force on Life and the Law, 1988) 73-74,116- 17.

    (74)  Some opponents, though, emphasize the difficulty of

	  diagnosing depression among severely ill patients, and argue

	  that mandated psychiatric consultation would fail to identify

	  some cases of depression.  See chapters 1 and 8.

    (75)  Cassel and Meier, 751.  Data on the number of cases of

	  assisted suicide and euthanasia currently occurring are

	  difficult to obtain, especially because the practices are

	  illegal.  Information about cases of assisted suicide and

	  euthanasia has largely been presented in anecdotal reports.

	  See Lehr.

    page 98		     WHEN DEATH IS SOUGHT

	  Many who favor legalizing physician-assisted suicide see

    little distinction between assisted suicide and euthanasia.  Both

    practices rest on commitments to respect autonomy and prevent

    suffering.  Some acknowledge that a practice of euthanasia with the

    patient's consent is likely to lead to euthanasia for patients

    incapable of expressing consent or refusal.  They believe that

    nonvoluntary euthanasia would be appropriate when it reflects some

    information about the patient's own wishes or when it relieves the

    patient's suffering.(76) Others accept euthanasia for patients too

    ill or too young to decide for themselves because they see no value

    in continued life for severely disabled individuals who irreversibly

    lack the ability to experience life consciously or to relate to

    others.  Essentially, some believe that these individuals do not

    "have a life" in the sense in which life is treasured.(77)

	  Advocates of legalizing assisted suicide and/or euthanasia

    maintain that although some abuses will occur, the number of

    inappropriate deaths would be small, and the opportunity to

    alleviate suffering in other cases outweighs this cost.  The

    potential for abuse suggests the need for safeguards, but should not

    preclude legalizing assisted suicide and euthanasia.  For them,

    claims about negative consequences for the medical profession or the

    broader society seem uncertain and speculative.(78)


    (76)  Brock, 20.

    (77)  See, e.g., Rachels, 24-33, 64-67, 178-80; P. Singer,

	  Practical Ethics (Cambridge:  Cambridge University Press,

	  1979), 138-39.

    (78)  Concerns about the potential consequences of a change in

	  policy are often discussed in terms of "slippery slope"

	  arguments:  allowing a given practice will tend to lead to

	  acceptance of other actions that are objectionable.  A

	  logical or conceptual version of a slippery-slope argument

	  would claim that there is no distinction in principle between

	  two actions; for example, that if voluntary euthanasia is

	  allowed, there would be no principled basis for not allowing

	  nonvoluntary euthanasia.  Causal or empirical versions of the

	  argument maintain that allowing a certain type of action

	  would tend to lead in practice to another, objectionable

	  action; for example, that if voluntary euthanasia is allowed,

	  society would be more likely to accept nonvoluntary

	  euthanasia. The empirical version of the argument can rarely

	  prove that a given result (e.g., nonvoluntary euthanasia) is

	  certain to follow.  Those utilizing such arguments maintain

	  that they may nevertheless establish that allowing one type

	  of action poses a significant or unacceptable risk that the

	  problematic result will occur.  See Arras; Beauchamp and

	  Childress, 139-41; W. van der Burg, "The Slippery-Slope

	  Argument," Ethics 102 (1991):  42-65; B. Freedman, "The

	  Slippery-Slope Argument Reconstructed," Journal of Clinical

	  Ethics 3 (1992):  293-97; B. Williams, "Which Slopes Are

	  Slippery?" in Moral Dilemmas in Modern Medicine, ed.  M.

	  Lockwood (New York:  Oxford University Press, 1985), 126-37.

    CHAPTER 5 - THE ETHICAL DEBATE			      page 99

	  Some advocates of legalizing assisted suicide or euthanasia

    favor prospective guidelines:  for example, requiring that the

    attending physician consult with colleagues and that the patient

    voluntarily and repeatedly request assisted suicide or euthanasia,

    receive psychological evaluation and counseling, and experience

    intolerable suffering with no hope for relief.(79) Proposals also

    stipulate requirements for the patient's medical condition:  for

    example, that assisted suicide or euthanasia would be allowed only

    if a patient is terminally ill or has an incurable disease.  Others

    recommend that a panel or committee review the patient's request

    before assisted suicide or euthanasia is performed.(80)

	  Under some proposals, assisting suicide or performing

    euthanasia would remain a violation of criminal law, but guidelines

    would specify types of cases that would not subject physicians to

    any penalty.  Physicians would be able to avoid punishment by

    proving that they acted appropriately in exceptional circumstances;

    a showing that the physician responded compassionately and

    competently to a voluntary request by a competent patient would

    constitute a defense to criminal prosecution.(81) Finally, some

    advocates have suggested a trial period of voluntary active

    euthanasia or measures to legalize the practice in a few states, in

    order to gain data on the consequences of the practice.(82)


	  For many, the potential for error and abuse in particular

    cases, the risks to vulnerable individuals, and the profound effect

    on society's values present the most compelling reasons against

    allowing assisted suicide and euthanasia.  Most immediately, the

    practices create enormous potential for abuse in particular cases.

    Some decisions to contribute to a patient's death may be

    well-intentioned but hasty and possibly mistaken.  In other cases,

    patients may be pressured to consent to euthanasia when their care

    is expensive or burdensome to others.  As one commentator has

    argued, "Advocating legal sanction of euthanasia at a time and in a

    society where access to care is so limited and its cost so critical,

    the so-called `right to die' all too easily becomes a duty to



    (79)    Various safeguards are suggested in Hemlock Society

	    U.S.A., "Model Aid-in-Dying Act," 1993; M. Battin, "Voluntary

	    Euthanasia and the Risks of Abuse;" Weir, "Morality," 124-25;

	    H. Rigter, "Euthanasia and the Netherlands," Hastings Center

	    Report 19, no. 1 (1989):  S31-32; Quill, Cassel, and Meier,

	    1381-82.  For a discussion and critique of guidelines

	    proposed by Quill, Meier and Cassel, see chapter 6, pp.


    (80)    See, e.g., Brody, 1387.

    (81)    This is the way the law is structured in the

	    Netherlands, although most agree that physicians are not

	    reporting many cases of euthanasia despite the legal

	    requirement to do so.

    (82)    See, e.g., Brock, 20; Glover.

    page 100		      WHEN DEATH IS SOUGHT

	  Some warn that individuals who are disadvantaged or members of

    minority groups would be especially susceptible to such pressures.

    Others note the widely recognized failure of our health care system

    to provide minimally acceptable health care to the poor and

    disadvantaged.  Especially in overburdened facilities serving the

    rural and urban poor, the lack of available options may effectively

    pressure patients into assisted suicide or euthanasia.(84) For some

    opponents, cases of abuse, even if relatively infrequent, would

    count decisively against a policy authorizing assisted suicide and


	  Opponents also believe that the practice would expand,

    presenting even more profound dangers.  A policy of allowing

    assisted suicide or euthanasia only when a patient voluntarily

    requests an assisted death, and a physician also judges that

    assisted suicide or euthanasia are appropriate to relieve suffering,

    is inherently unstable.  The reasons for allowing these practices

    when supported by both a patient's request and a physician's

    judgment would lead to allowing the practices when either condition

    is met.(86) The value of self-determination supports compliance with

    any voluntary request by a patient with decision-making capacity.

    Moreover, any serious request would reflect psychological suffering

    that the patient considers unbearable.  Suggested restrictions on

    the practices, such as requiring that patients have a terminal or

    degenerative illness, would be seen as arbitrary limits on patients'

    autonomy.(87) In particular cases, and more broadly over time,


    (83)  McKinney, 9. Similarly, David Velleman asserts that some

	  patients will choose to die out of conccrn for the resources

	  of family members or society, and that to accept such a

	  "gift" can be problematic.  "Establishing the right to die is

	  tantamount to saying, to those who might contemplate dying

	  for the social good, that such favors all never be refused."

	  Velleman, 678-79.

    (84)  As argued by John Arras, "Insofar as we sustain unjust

	  conditions, including profoundly inequitable systems of

	  terminal health care, we thereby heighten the impoverished

	  person's sense of being truly a 'dead end case.'  By failing

	  to alleviate or eliminate those social conditions that would

	  make a quick death look relatively attractive, we become

	  deeply implicated in this choice for death."  Arras, 312.

    (85)  Singer and Siegler maintain, "Even one case of involuntary

	  euthanasia would represent a great harm."  Singer and

	  Siegler, 1883.

    (86)  See Dyck; Kamisar.

    (87)  As argued by Benjamin Freedman (293), societal acceptance

	  of decisions to forgo life-sustaining treatment began with

	  decisions made directly by terminally ill patients; over time

	  the courts and policymakers concluded that it is

	  inappropriate or infeasible to make such criteria decisive

	  for purposes of public policy.  Daniel Callahan adds that it

	  would be difficult to enforce restrictions on euthanasia

	  because of the privacy of the interaction between doctor and

	  patient.  Callahan, "When Self-Determination Runs Amok," 54.

	  Some express concern that legalizing assisted suicide and

	  euthanasia would render it more difficult to forgo

	  life-sustaining treatment.  Restrictions on euthanasia might

	  be applied to decisions to forgo treatment, and all decisions

	  at life's end might become subject to overly intrusive

	  review.  S. M. Wolf, "Holding the Line on Euthanasia,"

	  Hastings Center Report 19, no. 1 (1989):  S13-15; McKinney,


    CHAPTER 5 - THE ETHICAL DEBATE			     page 101

    assisted suicide and euthanasia would be provided based on any

    serious voluntary request by a competent patient, regardless of his

    or her medical condition.(88)

	  Opponents similarly argue that restrictions requiring the

    patient's informed choice would be difficult to maintain.  If

    intentionally contributing to or causing death is an appropriate

    course of treatment for suffering patients, then physicians should

    be able to provide this treatment to patients unable to make the

    request themselves.(89) The resulting policy of euthanasia for

    children and incompetent adults is regarded as intrinsically wrong,

    or as an option that poses an extraordinarily high risk of abuse.

	  Some believe that legalizing assisted suicide and euthanasia

    would have a subtle but widespread impact on society.  They fear a

    general reduction of respect for human life if official barriers to

    killing are removed.(90) Others are especially fearful of the effect

    on the disabled and other vulnerable persons in society at large.

		    Instead of the message a humane society

	      sends to its members -- "Everybody has the

	      right to be around, we want to keep you with

	      us, every one of you" -- the society that

	      embraces euthanasia, even the "mildest" and

	      most "voluntary" forms of it, tells people:

	      "We wouldn't mind getting rid of you."  This

	      message reaches not only the elderly and the

	      sick, but all the weak and dependent.(91)


     (88)  Among others, Yale Kamisar asserts that, if assisted

	   suicide is allowed for patients with a terminal or

	   degenerative illness, it would seem unfair to exclude others,

	   such as a quadriplegic or severely injured accident victim.

	   He continues:  "Why stop there?  If a competent person comes

	   to the unhappy conclusion that his existence is unbearable

	   and freely, clearly, and repeatedly requests assisted

	   suicide, why should he be rebuffed because he does not

	   'qualify' under somebody else's standards?"  Kamisar, 36-37.

	   In a recent case in the Netherlands, a court approved a

	   psychiatrist's assistance of suicide for a patient who was

	   depressed and experiencing psychological suffering, but had

	   no other medical illness.  W. Drozdiak, "Dutch Seek Freer

	   Mercy Killing:, Court Case Could Ease Limits on Assisted

	   Suicide, Euthanasia," Washington Post, October 29,1993, A29.

     (89)  Callahan, "When Self-Determination Runs Amok," 54; Dyck,

	   17; Capron, 31.  Some point to the Dutch experience as

	   evidence that the practice would expand.  See the discussion

	   in chapter 6, pp. 132-34.

    (90)   See, e.g., Beauchamp and Childress, 141; Dyck, 17.						   -102-

    page 102		      WHEN DEATH IS SOUGHT

	  Some who oppose legalizing euthanasia believe that acts of

    voluntary euthanasia are morally acceptable in exceptional cases,

    such as when a terminally ill patient suffering from intolerable and

    untreatable pain makes an informed request.  On balance, however,

    they conclude that conscientious objection and leniency in the

    judicial process would be appropriate in these cases, but such

    exceptional cases cannot justify explicit changes in the law or

    moral rules that bar active and intentional killing.  However strong

    our compassion for patients in these rare circumstances, it cannot

    support fundamental changes to society's moral code, with

    potentially disastrous and irreversible consequences.(92)

	  Similarly, some argue that even if actions of assisting

    suicide in particular cases are morally justified or excusable, it

    would be difficult or impossible to craft a policy that resulted in

    assisted suicide only in those cases.  A policy that allowed

    sensitive physicians to assist suicide indirectly in exceptional

    cases, after lengthy discussions with a patient, would also allow

    less thoughtful physicians to aid suicides after perfunctory

    conversations.  Accordingly, a former president of Concern for

    Dying, an advocacy organization for patients' rights, suggests:

		    A deliberate act to assist someone in

	      taking her/his life -- however merciful the

	      intent -- should not be sanctioned by law.

	      Rather it should be left a private act, with

	      society able to be called in to judgment when

	      and if the motive should be impugned.  This is

	      not a neat and precise system of justice to be

	      sure, but one that continues to afford the

	      least possibility of abuse.(93)


    (91)   R. Fenigsen, "A Case Against Dutch Euthanasia," Hastings

	   Center Reporl 19, no. 1 (1989):  S26.  Richard Doerflinger

	   similarly argues:  "Elderly and disabled patients are often

	   invited by our achievement-oriented society to see themselves

	   as useless burdens.  ...  In this climate, simply offering

	   the option of 'self-deliverance' shifts a burden of proof, so

	   that helpless patients must ask themselves why they are not

	   availing themselves of it."  "Assisted Suicide:  Pro-Choice

	   or Anti-Life?"  Hastings Center Report 19, no. 1 (1989):

	   S16-19.  Hendin and Klerman assert that for society to

	   authorize assisted suicide would in effect endorse "the view

	   of those who are depressed and suicidal that death is the

	   preferred solution to the problems of illness, age, and

	   depression."  Hendin and Klerman, 145.

     (92)  See Veatch, 73-75; J. F. Childress, "Civil Disobedience,

	   Conscientious Objection, and Evasive Noncompliance:  A

	   Framework for the Analysis and Assessment of Illegal Actions

	   in Health Care," Journal of Medical Philosophy 10 (1985):


     (93)   McKinney, 7.

    CHAPTER 5 - THE ETHICAL DEBATE			     page 103

The Role and Responsibilities of Physicians

	  While any person can aid suicide or cause death, the current

    debate about assisted suicide and euthanasia generally centers on

    the actions of physicians.  Long-standing medical tradition,

    exemplified by the Hippocratic Oath, enjoins physicians not to harm

    patients, and in particular not to "give a deadly drug to anybody if

    asked for it, nor ... make a suggestion to this effect."(94) The

    oath also commits the physician to employ therapeutic measures to

    benefit the patient.(95)

	  The issues of assisted suicide and euthanasia confront some

    physicians in a dramatic and deeply personal way, as they consider

    how best to respond to a patient's suffering, or to an explicit

    request for assistance in ending life.  In these as in other cases,

    some physicians feel a conflict between their personal commitments

    and conscientious judgment in a particular case, and policies

    designed to prevent harm or abuse for patients generally.

	  The debate about assisted suicide and euthanasia raises

    complex questions about the duties of physicians and the goals of

    the medical profession.  What is a physician's obligation when a

    patient requests assisted suicide or euthanasia?  How does this

    obligation relate to the overall goals of medicine?  What impact

    would the practices have on the social role of physicians and on the

    physician-patient relationship?  In response to the growing public

    debate, the organized medical community has focused on the special

    questions posed for its profession.


    (94)   In T. L. Beauchamp and J. F. Childress, Principles of

	   Biomedical Ethics, 2d ed.  (New York:  Oxford University

	   Press, 1983), 330. ne Hippocratic Oath dates back to

	   approximately the fourth century B.C.  Although doctors no

	   longer swear by the god Apollo, the oath has been regarded as

	   a central statement about the ethical responsibilities of

	   physicians throughout the history of Western medicine.

	   Nonetheless, not all aspects of the oath are universally

	   honored as prescriptions in contemporary medical practice.

	   For example, many physicians reject the oath's proscription

	   against abortion.

     (95)  Ibid.  The oath specifies, "I will apply dietetic

	   measures for the benefit of the sick according to my

	   ability and judgment."

  page 104		    WHEN DEATH IS SOUGHT


	  Physicians and others who advocate assisted suicide and

    euthanasia believe that the practices are consistent with the

    professional role and responsibilities of physicians.  They assert

    that the physician's responsibility to care for patients should be

    understood broadly in terms of promoting patients'

    self-determination and enhancing their well-being.  Accordingly, it

    would be appropriate for a physician to assist suicide or perform

    euthanasia when these actions are chosen by and would benefit a

    patient.(96) Others believe that "alleviating suffering, curing

    disease, and not causing death are important and simultaneous

    obligations."(97) If suffering can be eliminated only by causing

    death, a physician would face conflicting obligations, requiring a

    personal choice about which obligation is most compelling under the


	  Some proponents regard assisted suicide as less threatening to

    professional integrity than euthanasia.(98) They believe that

    removing rules against physician-assisted suicide would offer

    physicians an important option in responding to the personal

    experiences and values of each patient.  In appropriate cases, a

    physician's willingness to discuss this alternative and assist

    suicide would demonstrate commitment to the patient throughout the

    course of life, including the moment of death.

	  Some proponents maintain that physicians should have a special

    role in contributing to patients' deaths because they have access to

    drugs and the expertise to cause death quickly and painlessly.(99)

    Other individuals, such as family members and friends, may be

    reluctant to cause or contribute to a patient's death.  In addition,

    the moral authority of physicians enables them to aid patients

    seeking to end their lives in less tangible ways.

		    Historically, in the United States

	      suicide has carried a strong negative stigma

	      that many today believe unwarranted.  Seeking

	      a physician's assistance, or what can almost

	      seem a physician's blessing, may be a way of

	      trying to remove that stigma and show others

	      that the decision for suicide was made with

	      due seriousness and was justified under the

	      circumstances.  The physician's involvement

	      provides a kind of social approval, or more

	      accurately helps counter what would otherwise

	      be unwarranted social disapproval.(100)


     (96)  Brock, 16-17.

     (97)  Loewy, 31.

     (98)  Diane E. Meier argues that euthanasia and assisted

	   suicide "would likely have a substantially different impact

	   on the ethos of the medical profession."  Meier, 35.

     (99)  See, e.g., Brock, 21.

    (100)  Ibid.

    CHAPTER 5 - THE ETHICAL DEBATE			     page 105

	  Some urge that only physicians should be authorized to assist

    suicide or perform euthanasia.  Physicians can discuss the patient's

    medical condition, explore alternative means for alleviating pain

    and suffering, and determine whether the patient's judgment is

    significantly impaired by psychiatric conditions.  Physicians can

    also use their technical skills to provide or administer a lethal

    dose that leads to a rapid and painless death.  Finally, limiting

    the number of people authorized to assist suicide or perform

    euthanasia would enhance accountability and protect against


	  Others frame the argument for assisted suicide and euthanasia

    more broadly.  Another person, such as a family member, might be

    best able to help the patient achieve relief through death.  The

    patient may not have an established relationship with a physician,

    or the patient's physician may be unwilling to comply with the

    patient's request.  In several prominent cases, family members or

    friends, motivated by compassion, have assisted suicide or caused

    death.  According to some advocates, "mercy-killing" should be

    established in general as an acceptable defense to criminal


	  Opponents Many physicians and others who oppose assisted

    suicide and euthanasia believe that the practices undermine the

    integrity of medicine and the patient-physician relationship.

    Medicine is devoted to healing and the promotion of human wholeness;

    to use medical techniques in order to achieve death violates its

    fundamental values.  Even in the absence of widespread abuse, some

    argue that allowing physicians to act as "beneficent executioners"

    would undermine patients' trust, and change the way that both the

    public and physicians view medicine.(103)


    (101)  See, e.g., Weir, 125.

    (102)  Rachels, 2-6, 28-33,168-70.

    (103)  As expressed by a group of four physicians:  "If

	   physicians become killers or are even merely licensed to

	   kill, the profession - and, therewith, each individual 104Sec

	   physician- will never again be worthy of trust and

	   respect as healer and comforter and protector of life in

	   all its fraility." W. Gaylin et al., "Doctors Must Not

	   Kill," Journal of American Medical Association 259 (1988):

	   2139040.See also McKinney,  6-8; D. Orentlichter,

	   "Physician Participation in Assisted Suicide," Journal

	   of the American Medical Association 262 (1989):1844-45.

	   Some physicians writing near the beginning of the

	   century expressed similar concerns.  If part of the

	   doctor's role was to cause death in specified cases,

	   "his very presence would necessarily be associated

	   the idea of death.  He would enter the sick room,

	   into which he should bring life and hope, with the

	   dark shadow of death behind him." "The Right to Die,"

	   in Reiser, Dyck and Curran, 491.

      page 106			WHEN DEATH IS SOUGHT

	  Some believe that, while physicians may be motivated by

    compassion in some cases, a physician abandons the patient in a

    profound sense when he or she deliberately causes the patient's

    death.(104) Others note that professionals such as physicians have

    great power and enjoy significant discretion to use that power

    prudently.  Strict boundaries to prevent the misuse of power are

    therefore necessary.  General professional limits may in some cases

    impinge on an individual physician's personal sense of vocation, but

    are needed to maintain public confidence in the profession and guard

    against abuse.(105)

	  Some object that assisted suicide and euthanasia would be used

    as a "quick fix" of the kind that is too prevalent in contemporary

    medical practice.

		    Having adopted a largely technical

	      approach to healing, having medicalized so

	      much of the end of life, doctors are being

	      asked ... provide a final technical solution

	      for the evil of human finitude and for their

	      own technical failure:  If you cannot cure me,

	      kill me.(106)

	  Others note that relying on medical practices to assist

    suicide removes a natural psychological barrier to the act, leading

    some individuals to end their lives without facing the full

    implications of the act.(107) Some believe that a judgment about


    (104)  See P. Ramsey, The Patient as Person (New Flaven:  Yale

	   University Press, 1970).

    (105)  Kass, 35.

    (106)  Ibid.

    (107)  A. Alvarez writes that "Modern drugs not only have made

	   suicide more or less painless, they have also made it seem

	   magical.  A man who takes a knife and slices deliberately

	   across his throat is murdering himself.  But when someone

	   lies down in front of an unlit gas oven or swallows sleeping

	   pills, he seems not so much to be dying as merely seeking

	   oblivion for a while."  Alvarez, 137.  Writing about ancient

	   Greece, Paul Carrick notes that the development of hemlock

	   contributed to a change in the conception of suicide, and to

	   an increase in the suicide rate.  Carrick, 130.

     CHAPTER 5 - THE ETHICAL DEBATE			       page 107

    whether to assist suicide or perform euthanasia is not essentially a

    medical judgment, and falls outside the parameters of the

    patient-physician relationship.(108) They object to the notion that

    physicians would be granted special authority to assist suicide or

    perform euthanasia.

	  Some believe that assisted suicide or euthanasia performed by

    physicians would be more problematic than similar actions by other

    individuals.  Because of the risks of abuse and threats to the

    integrity of the medical profession, it would be particularly

    objectionable for physicians to participate in these actions.  A

    group of four physicians writes:  "We must say to the broader

    community that if it insists on tolerating or legalizing active

    euthanasia, it will have to find nonphysicians to do its


	  Finally, some object in particular to the concept of killing

    as a form of healing or death as cure, arguing that such views

    resonate with periods in history when the medical profession was

    used to end human life.  While the practice of mass murder in Nazi

    Germany differs from contemporary proposals for euthanasia, it began

    with the active killing of the severely ill, and built on earlier

    proposals advanced by leading German physicians and academics in the

    1920s, before the Nazis took power.  Like policies currently

    advocated in the United States, these proposals were limited to the

    incurably ill, and mandated safeguards such as review panels.(110)


    (108)  "Are doctors now to be given the right to make judgments

	   about the kinds of life worth living and to give their

	   blessing to suicide for those they judge wanting?  What

	   conceivable competence, technical or moral, could doctors

	   claim to play such a role?"  Callahan, "When

	   Self-Determination Runs Amok," 55.

     (109) Gaylin et al., 2140.  For some, physician participation in

	   assisted suicide and euthanasia raises similar concerns to

	   physician participation in capital punishment:  whatever an

	   individual physician's personal beliefs about the practice,

	   to act as a physician in a way that contributes to a person's

	   death would violate one's professional responsibilities.  For

	   a recent statement on participation in capital punishment,

	   see American Medical Association, Council on Ethical and

	   Judicial Affairs, "Physician Participation in Capital

	   Punishment," Journal of the American Medical Association 270

	   (1993):  365-68.  An argument for distinguishing between

	   physician involvement in capital punishment and physician

	   involvement in euthanasia may be found in Loewy, 29-34.

    (110)  Capron, 32-33; R. J. Lifton, The Nazi Doctors:

	   Medical Killing and the Psychology of Genocide (New York:

	   Basic Books, 1986), 45-50-1 Veatch, 66-67.  Lifton, while

	   distinguishing Nazi "euthanasia" from euthanasia in the

	   Anglo-American context, traces the significance of concepts

	   such as "life unworthy of life" and "killing as a therapeutic

	   imperative" in removing social and psychological barriers

	   against killing and advancing the Nazi program of genocide.

	   "The medicalization of killing - the imagery of killing in

	   the name of healing - was crucial to that terrible step."

	   Lifton, 14-15, 46.  See also the recent translation of Karl

	   Binding and Alfred Roche's 1920 work, "Permitting the

	   Destruction of Unworthy Life:  Its Extent and Form," trans.

	   W. E. Wright, P. G. Derr, and R. Salomon, Issues in Law and

	   Medicine 8 (1992):  231-65.

    page 108		      WHEN DEATH IS SOUGHT

The Views of Medical Organizations

	  In recent years, professional organizations -- including the

    American Medical Association, the American College of Physicians,

    and the American Geriatrics Society -- have joined the public debate

    about assisted suicide and euthanasia.  The positions embraced by

    these organizations share several elements.  The organizations

    consistently distinguish assisted suicide and euthanasia from the

    withdrawing or withholding of treatment, and from the provision of

    palliative treatments or other medical care that risk fatal side


	  Professional organizations report that most pain and suffering

    can be alleviated, but that some patients find their situation so

    intolerable that they request assisted suicide or euthanasia.

    Physicians should respond to these patients by exploring their

    concerns, investigating whether the patient is suffering from

    depression, and improving palliative care when needed.  The

    organizations generally recognize that assisted suicide or

    euthanasia might be beneficial to a small number of patients.  They

    note, however, that such actions are illegal, and they express

    concern that allowing these practices could damage the

    physician-patient relationship and pose serious risks to vulnerable

    members of society.(112)

	  Within the framework of this consensus, medical societies have

    offered somewhat differing views.  While not supporting assisted

    suicide and euthanasia, the American College of Physicians Ethics

    Manual does not explicitly reject all such actions.  The manual

    recommends that physicians respond to patient requests for

    euthanasia or assisted suicide by seeking to ascertain and respond

    to the patient's concerns.(113) In contrast, the American Geriatrics


    (111)  American Medical Association; American College of

	   Physicians, "American College of Physicians Ethics Manual,"

	   3d ed., Annals of Internal Medicine 117 (1992):  953-54;

	   American Geriatrics Society, Public Policy Committee,

	   "Voluntary Active Euthanasia," Journal of the American

	   Geriatrics Society 39 (1991):  826.

    (112)  Ibid.

    (113)  As stated in the ACP manual:  "In most cases, the

	   patient will withdraw the request when pain management,

	   depression, and other concerns have been addressed, but

	   occasionally the issue of physician-assisted suicide needs to

	   be explored in depth.  However, our society has not yet

	   arrived at a consensus on assisted suicide and most

	   jurisdictions have specific laws prohibiting such action.

	   Physicians and patients must continue to search together for

	   answers to these problems without violating the physician's

	   personal and professional values and without abandoning the

	   patient to struggle alone."  American College of Physicians,


    CHAPTER 5 - THE ETHICAL DEBATE			      page 109

    Society strongly urges physicians not to provide interventions that

    directly and intentionally cause the patient's death.  It also

    recommends that the current legal prohibition of physician

    assistance to commit suicide and euthanasia should not be


	  The Council on Ethical and Judicial Affairs of the American

    Medical Association similarly states that "physicians must not

    perform euthanasia or participate in assisted suicide."  While these

    actions may seem beneficial for patients in some sympathetic cases,

    authorizing physicians to perform them would pose unacceptable risks

    of allowing mistaken or coerced deaths.  It could also gradually

    distort both public perceptions of medical practice and the practice

    of medicine itself.(115)

Killing and Allowing to Die

	  The debate about euthanasia and assisted suicide takes place

    against the backdrop of changes in medical practice.  Medical

    developments have increased the number and range of treatment

    decisions that must be made near the end of life.  Decisions to

    withhold and withdraw life-sustaining treatment in accord with the

    patient's wishes and interests have become widely accepted in

    principle, and to an increasing extent in practice.  As a result,

    many physicians have participated in decisions and actions to end

    life-sustaining treatment, giving them a sense of control over the

    timing and manner of a patient's death.

	  Some believe that such actions are essentially similar to

    assisted suicide and euthanasia.  They challenge the commonly


    (114)  As set forth in the organization's policy statement,

	   "Active euthanasia might reasonably be preferred by a few

	   patients with intractable pain or other overwhelming symptoms;

	   however, the benefit of allowing this choice must be weighed

	   against possible abuse of euthanasia on the frail, disabled,

	   and economically disadvantaged members of society. The

	   American Geriatrics Society also expressed its concern that

	   allowing euthanasia could also lessen patients' trust in

	   physicians, and further weaken society's commitment to

	   provide adequate resources for supportive care.  American

	   Geriatrics Society, 826.

    (115)  American Medical Association.  The Committee on

	   Bioethical Issues of the Medical Society of the State of New

	   York articulates a similar position in "Physician-Assisted

	   Suicide," New York State Journal of Medicine 92 (1992):  391.

	   The National Hospice Organization has adopted a resolution

	   rejecting the practice of euthanasia and assisted suicide.

	   The resolution "reaffirms the hospice philosophy that hospice

	   care neither hastens nor postpones death," and advocates

	   hospice care as an alternative to euthanasia and assisted

	   suicide.  Resolution approved by the delegates of the

	   National Hospice Organization, Annual Meeting, November 8,

	   1990, Detroit, Michigan.

	   The American Nurses Association has not issued a formal

	   position statement on assisted suicidc and euthanasia.  Some

	   nurses have argued that ANA position papers would suggest a

	   position opposing euthanasia.  N. Coyle, 44.

    page 110		      WHEN DEATH IS SOUGHT

    accepted distinction between intentional killing, which is viewed as

    always wrong, and allowing to die, which is accepted in many cases.

    Many of those who reject this distinction support policies

    authorizing assisted suicide and euthanasia.(116) The current debate

    about assisted suicide and euthanasia poses questions about whether

    killing and allowing to die are intrinsically different on ethical

    grounds, and whether the practices should be distinguished for

    purposes of social policy.

Against the Distinction

	  Some claim that forgoing treatment cannot be distinguished in

    principle from taking affirmative steps to end a patient's life

    because the intentions, motives, and outcomes are identical in both

    cases.  They argue that in each instance, the decision maker seeks

    the patient's death and is motivated by compassion, and the same

    result occurs.(117) Some supporters of assisted suicide and

    euthanasia assert that society currently accepts decisions to forgo

    life-sustaining treatment that effectively constitute killing; for

    example, withdrawing a respirator or failing to provide artificial

    nutrition and hydration.

	  Even if this characterization of current practice is rejected,

    they argue, killing (or more generally, contributing to a person's

    death) should not be seen as intrinsically immoral.  Ending a

    person's life is wrong in most cases because it deprives a person of


    (116)  Others who reject the distinction oppose decisions to

	   forgo life-sustaining treatment, as well as assisted suicide

	   and euthanasia.  Discussion about distinguishing between

	   killing and allowing to die may be found in R. F. Weir,

	   Abating Treatment with Critically III Patients:  Ethical and

	   Legal Limits to the Medical Prolongation of Life (New York:

	   Oxford University Press, 1989), 228-32, 261-68; J. McMahan,

	   "Killing, Letting Die, and Withdrawing Aid," Ethics 103

	   (1993):  250-79; J. Feinberg, Harm to Others (New York:

	   Oxford University Press, 1984), 159-63, 171-86, 257-59n; P.

	   Foot, "Morality, Action and Outcome," in Morality and

	   Objectivity:  A Tribute to J L. Mackie, ed.  T. Hondreich

	   (London:  Routledge and Kegan Paul, 1985), 23-25.

     (117) Rachels, 106-28, 139-43; Rachels, "Active and Passive

	   Euthanasia," New England Journal of Medicine, 78-80.  See

	   also J. Fletcher, Humanhood:  Essays in Biomedical Ethics

	   (Buffalo:  Prometheus Press, 1979), 149-58.  Rachels

	   describes two cases:  Smith, who kills his 6-year-old cousin,

	   and Jones, who intentionally lets his cousin die, both in

	   order to gain an inheritance.  He argues that as both acts

	   are equally reprehensible, the "bare difference" between

	   killing and letting die is morally insignificant.  Others

	   have criticized such arguments as inconclusive at best.  Even

	   if the two cases in the example are equally objectionable,

	   the difference between killing and letting die is significant

	   in other cases.  For instance, a person is not morally

	   obligated to endanger his or her own health or spend a large

	   sum of money to save another person, but it would be morally

	   wrong for a person to kill someone actively in order to

	   safeguard his or her health or save that sum of money.

	   Beauchamp and Childress, 136-38; Feinberg, 167-68, citing H.

	   Maim, "Good Samaritan Laws and the Concept of Personal

	   Sovereignty," typescript, University of Arizona (1983), 11.

    CHAPTER 5 - THE ETHICAL DEBATE			      page 111

    the benefit of continued life, and violates the individual's rights.

    However, in appropriate cases of assisted suicide or voluntary

    euthanasia, the patient believes that continued life would not

    provide a benefit (and, with euthanasia, waives his or her right not

    to be killed).(118) Some patients decide to stop or withhold

    life-sustaining treatment because they perceive life as a burden and

    wish to die.  In these cases, assisted suicide or euthanasia would

    end the patient's life and suffering more quickly and effectively

    than withdrawing or withholding treatment.  As one philosopher


		    If one simply withholds treatment, it

	      may take the patient longer to die, and so he

	      may suffer more than he would if more direct

	      action were taken and a lethal injection

	      given.  This fact provides strong reason for

	      thinking that, once the initial decision not

	      to prolong his agony has been made, active

	      euthanasia is actually preferable to passive

	      euthanasia, rather than the reverse.(119)

	  Finally, proponents of assisted suicide and euthanasia point

    out that the potential for mistake or abuse exists for withdrawing

    and withholding treatment as well.  They argue that society has

    addressed this problem with appropriate safeguards, and could do the

    same for assisted suicide and euthanasia.

For the Distinction

	  Despite such claims, the distinction between killing and

    letting die, in general and in the context of medical decisions, is

    widely accepted and supported.  Many insist that the nature of the

    action in each case is different.  Decisions to withhold or withdraw

    treatment allow the natural course of the disease to continue.  The

    decision maker determines that certain treatments are not medically

    appropriate or morally obligatory, and the physician refrains from

    imposing interventions that legally would constitute battery.

    Moreover, forgoing treatment does not always result in a patient's

    immediate death; the patient may continue to live, as in cases of an

    inaccurate prognosis.  (120)


    (118)  Rachels, Fnd of Life, 39-59.

    (119) Rachels, "Active and Passive Euthanasia," 78-80.

    (120)  Beauchamp and Childress, 144; Weir, Abating Treatment,

	   316-18; Ramsey, 153.  See also G. R. Scofield "Privacy (or

	   Liberty) and Assisted Suicide," Journal of Pain and Symptom

	   Management 6 (1991):  283.

    page 112		      WHEN DEATH IS SOUGHT

	  This distinction in the nature of the acts of killing and

    allowing to die is accompanied by a difference in causation.  In one

    case, the decision maker seeks to cause death and employs direct

    means to achieve this result.  In the other, the decision maker

    accepts but does not cause the person's death, which is caused by

    the underlying illness or condition.  Paul Ramsey, for example,

    argues that forgoing treatment is not simply an indirect means of

    killing.  "In omission no human agent causes the patient's death,

    directly or indirectly.  He dies his own death from causes that it

    is no longer merciful or reasonable to fight by means of possible

    medical interventions."(121)

	  For many, the prohibition against actively and intentionally

    killing innocent persons represents a basic moral and social norm.

    Diverse philosophical and religious perspectives affirm this

    view.(122) Some also contend that the psychological effect on

    professionals and family are different in cases of killing and

    allowing to die.(123)

	  For others, the crucial distinction lies in the different

    consequences of policies of killing and of allowing to die.  A

    practice of accepted killing is more vulnerable to abuse in

    particular cases, and poses a greater risk of harm to others in

    society.  Some focus on the role of the distinction in the context

    of law and public policy.  As articulated by the President's

    Commission for the Study of Ethical Problems in Medicine and

    Biomedical and Behavioral Research, the prohibition of active

    killing is part of "an accommodation that adequately protects human

    life while not resulting in officious overtreatment of dying

    patients," and "helps to produce the correct decision in the great

    majority of cases."(124)


    (121)  Ramsey, 151.  See also Callahan, "When

	   Self-Determination Runs Amok," 53-54; McMahan, 263, 271. The

	   two types of cases also tend to be characterized by different

	   intentions.  See Weir, Abating Treatinent, 310-11; G.

	   Meilaender, "The Distinction Between Killing and Allowing to

	   Die," Theological Studies 37 (1976):  468-69.

    (122)  see pp. 88-91.

    (123)  This argument was put forward as early as 1884 in an

	   editorial in the Boston Medical and Surgical Journal:

	   "Perhaps logically it is difficult to justify a passive more

	   than an active attempt at euthanasia; but certainly it is

	   less abhorrent to our feelings.  To surrender to superior

	   forces is not the same thing as to lead the attack of the

	   enemy upon one's friends.  May there not come a time when it

	   is a duty in the interest of the survivors to stop a fight

	   which is only prolonging a useless and hopeless struggle?"

	   "Permissive Euthanasia," in Fye, 501-2.

    (124)  President's Commission, 70-73.

    CHAPTER 5 - THE ETHICAL DEBATE			      page 113

	  Some argue that the negative effects of active killing on

    those involved and on society are stronger, and the potential scope

    of abuse wider, than with allowing patients to die.(125)

    Additionally, patients have a strong moral and legal right to refuse

    treatment.  Respecting decisions to forgo treatment recognizes this

    right to be let alone and the moral obligation not to impose

    treatment coercively.  In contrast, people do not have the same

    basic right to active participation by others in achieving their

    death.  Society's refusal to allow another person to assist suicide

    or to cause death directly does not impose the same burden on the

    patient that would result from forced medical interventions.(126)


   (125)  See the discussion of risks posed by euthanasia throughout

	  this chapter and in chapter 6.

   (126)  See, e.g., Veatch, 67.

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