Medical Perspectives on Death and Dying
Several states have begun to consider legislation that would legalize active voluntary euthanasia. To address some of the ethical issues raised by such legislation, the Center for Applied Ethics sponsored a symposium entitled Legalizing Euthanasia: Ethical Perspectives on Medicine and Dying. Principal speakers were Derek Humphry, founder and president of the Hemlock Society, and author of the current best-seller, Final Exit, a suicide manual for the terminally ill; and Richard Gula, S.S., Ph.D., a professor of moral theology at St. Patrick's Seminary in Menlo Park, California. The symposium was funded in part by the California Council for the Humanities, a state program of the National Endowment for the Humanities. The following excerpts highlight the remarks of Mr. Humphry and Father Gula.
Let me explain how I became involved with the subject of euthanasia. In 1974 my first wife, Jean, was dying of bone cancer. Thrombosis had set in, her bones were cracking and she was losing control of her bowels. One day, after a very close brush with death, she sat up in her hospital bed and said to me, "Will you help me die?" That is when I first encountered the issue of euthanasia; from across my late wife's hospital bed.
After she made her request, I asked myself, "What if I were sitting in that hospital bed? What if I had had two years of pain and agony? What if I faced an imminent death? What if I was losing control of my bowels and my bones were cracking and so-forth?" I realized then that I would be asking her to help me to die. That, ladies and gentlemen, is my simple reason for what I did. It was an act of love.
Jean had been a good wife to me for 22 years. She stood by me in good times and bad. And when she was experiencing a bad time, I felt it was my duty to support her in her decision. I am not a Christian. I am an atheist. So, for me there was no question of consulting any god. It was a matter of situational ethics.
In 1980, five years after Jean's death, I helped to establish the Hemlock Society. This organization seeks to change certain laws regarding suicide. We want the government to decriminalize the actions taken by physicians in the assisted suicides of terminally ill patients.
We believe that a mentally competent adult who is dying should be able to submit a written request to their doctor that would state, "I've had all I can take. The pain and suffering are too much. I wish to die. Help me."
The physician, according to the Hemlock movement's prepared law, would have to obtain the opinion of a second doctor. They would both have to agree that the person is dying. The first doctor could then end the life of the patient with an oral or intravenous drug overdose, without the threat of prosecution or lawsuit. Our laws also state that the doctor could elect not to assist the patient with such an action.
There are those who agree with what the Hemlock movement is saying at the present time, but are fearful that such an ideology would result in a system of euthanasia similar to that used by Nazi forces. It is true that the Nazis introduced a program which they called euthanasia. They murdered about 100,000 people who were physically or mentally handicapped. No senior citizens or terminally ill people were allowed to voluntarily end their own lives.
But how can you say to a person who is dying of throat cancer today that they cannot have voluntary euthanasia because of what the Germans did in 1940 and 1942? I think that the person would respond, "It's not relevant. It's me. It's my body. It's my liberty. It's my life. And it's my death. Let me have control."
I would claim that this is the ultimate civil liberty. If we cannot go to our deaths in the manner of our own choosing, what liberty do we have?
Most of the focus on euthanasia so far has been dominated by what I'm going to call the paradigm of individual case analysis. My position is that euthanasia is not primarily an individual issue; it's a societal one. So discussion about euthanasia should not be governed primarily by individual case ethics, but by societal ethics.
The sanctity of life principle is probably the common ground principle. There are two extreme positions that can give sanctity of life as a principle a bad name. One extreme is what I call vitalism, and that is the extreme that tries to absolutize physical life making an idol out of biological existence. This principle says no cost is too great to keep this biological life going. The other extreme interpretation leads to what I'm calling a utilitarian perspective, which values life for its usefulness. This is the interpretation that says only the strongest and the fittest ought to survive. The danger here is the abuse of undertreatment.
I want to think about the sanctity of life from the middle position. This is the interpretation of the principle that recognizes we have limited dominion over life. It's the interpretation that says we are stewards of life, that we ought to care for life and promote it and enhance it in order to allow our lives to flourish and to achieve our potential. This is the interpretation that wants to respect life in all its forms and in all its stages. Interpreting sanctity of life in this way entails two obligations: a positive one--to nurture and support life„and a negative obligation not to harm life. Therefore, to appeal to sanctity of life in a discussion of euthanasia is to create a presumption in favor of life.
The second principle is the principle against the prohibition of killing. I want to look at three ways of interpreting this principle. The first says there is no moral difference between killing and allowing to die -- that once you decide that life no longer needs to be sustained, because the use of treatment would be futile, then it makes no difference whether you actively intervene or simply withhold or withdraw treatment.
The second interpretation is that there is a qualified moral difference. That qualified moral difference is that the distinction holds but gives way at a certain point. Some will say when the person has gone beyond the reach of human care, when there is no longer the capacity to receive love, or to receive comfort, then the distinction dissolves. Others will say when the person is in intractable pain and there's nothing more that can be done to relieve the pain, then the distinction between killing and allowing to die dissolves. Others would say when the patient is overtaken by the dying process -- that is to say, once you have decided that nothing more needs to be done, that life has reached its limits, then it makes no difference whether you withhold treatment or intervene, because in that condition, you are not usurping the dominion that is not yours. Then there's the third position that says the distinction holds all the way through.
The next principle is the principle of autonomy, which is probably going to be at the core of this discussion of whether euthanasia ought to be legalized. In our culture, we interpret autonomy as the right to self determination. The prevailing interpretation of autonomy in our culture is that autonomy is there to maximize self-interest. That means that we are able to pursue our own goals and life plans without external constraints. When we interpret autonomy this way, we answer the question "whose life is it anyway?" in favor of the one whose life is in question. This is solid ground for supporting euthanasia.
Can the principle of autonomy be used to challenge euthanasia? Some argue that the very interpretation of autonomy that says that you have the freedom to have another person intervene to take your life is a contradiction of what autonomy means -- that actually what you're doing is giving away your freedom. The other way of looking at it is to say that euthanasia is not primarily a private affair. It's a public or societal action that involves others, and therefore it is something that ought to be treated as a form of public action.
The third principle is the principle of the common good. To show that euthanasia ought to be sanctioned as a public practice, we need to be able to show that we can justify it in more than the individual case. This is the principle that says that when we establish a policy, we are sanctioning actions as a common practice. When we apply that principle to euthanasia, we need to ask, "how does the goal of my own private killing contribute towards making society the context in which human life can flourish?"
Now let's turn to the perspective of virtue. Virtue asks whether or not a policy on euthanasia creates the right kind of relationship between the physician and the patient, and would a policy on euthanasia create the right kind of community in which health care is delivered. The perspective of virtue asks that the physician deliver compassionate care within the limits of the physician's role. The trust that we extend to the medical profession to heal and protect life is something that we would want to sustain and the perspective of virtue asks whether that kind of trusting relationship would be enhanced or hindered if euthanasia became part of the options that are available to the physician. The perspective of virtue looks on ourselves as a community of interdependents in which we are partners to one another. It sustains the community of trust and care by promising not to abandon anyone, and it tries to be realistic about accepting the limits about what it means to be human. We recognize that life will not be free of suffering, that life will be burdensome, and there will be tragedy. The perspective of virtue tries to be realistic about accepting that. It encourages us to construct structures of support which will enable us to raise those who suffer into the network of the supportive, caring community.
Ultimately we cannot convert individual cases into public policy without having something remaining. The common good resists the temptation. How do the burdens to one individual compare to the burdens and the benefit on society as a whole? I think all of this ultimately is going to turn not on the basis of principles we argue with, but on the kind of people we are. Are we a virtuous people that creates a community of caring or are we going to compromise that in the way we allow euthanasia to become a practice in our healing society?
Videotapes of the symposium are available for $16.50 by writing to the Center for Applied Ethics, Santa Clara University, Santa Clara, CA 95053.
This article was originally published in Issues in Ethics - V. 5, N. 2 Fall 1991