Death is the inevitable fate of all humans but how we die is an issue of great concern for many of us. Fear of pain, loss of control and being a burden to our loved ones are common issues surrounding death and dying. But, to what degree should individuals be allowed to control the circumstances of their death — even to the point of involving a physician?

The proposed legalization of physician-assisted suicide (and to some degree euthanasia) is a topic of debate in state legislatures, medical journals and family gatherings, raising many questions along the way: Should personal autonomy in medical decision-making extend to having a physician assisted you in suicide? If so, should this “right” be limited to terminally ill patients or also extended to those who are chronically ill? What about depression and adequate pain relief to lessen the patient’s desire to die? And, what impact would legalizing physician-assisted suicide have on the doctor-patient relationship?

Q. Is there an example of assisted suicide in the Bible?

A. There is an account of reported voluntary euthanasia (in which one person asks another to kill them, ostensibly in order to alleviate the first person’s suffering) involving King Saul and an Amalekite (2 Samuel 1:1-16). The unnamed Amalekite tells King David that he killed Saul at Saul’s request, as Saul was wounded in battle. David’s response is to kill the Amalekite for touching God’s anointed. If euthanasia were a beneficial practice, David would have rewarded the Amalekite, not sentenced him to death.

Q. How should Christians respond to the fear (or reality) of pain and suffering?

A. Deuteronomy 31:6,8 “Be strong and courageous, do not be afraid or tremble..., for the Lord your God is the one who goes with you. He will not fail you or forsake you.... And the Lord is the one who goes ahead of you.... Do not fear, or be dismayed.”

Romans 8:32, 35,37 “He who did not spare His own son, but delivered Him up for us all, how will He not also with Him freely give us all things?... Who shall separate us from the love of Christ? Shall tribulation, or distress, or persecution, or famine, or nakedness, or peril, or sword?... But in all these things we overwhelmingly conquer through Him who loved us.”

Psalm 23:4 “Even though I walk through the valley of the shadow of death, I fear no evil; for Thou art with me ...”

Q. How should Christians respond to personal challenges, disabilities and infirmities?

A. Luke 1:38 “... Behold the bondslave of the Lord; be it done to me according to your word.”

2 Corinthians 12:9 “And He said to me, ‘My grace is sufficient for you, for my power is perfected in weakness.’”

Philippians 4:11,13,19 “... for I have learned to be content in whatever circumstances I am...I can do all things through Him who strengthens me.... And my God shall supply all your needs according to His riches in glory in Christ Jesus.”

Q. Job experienced physical, spiritual and psychological suffering. How did he respond?

A. Job 1:20-21, 2:10 “Then Job arose and tore his robe and shaved his head, and he fell to the ground and worshipped. And he said, ‘Naked I came from my mother’s womb, and naked I shall return there. The Lord gave the Lord has taken away. Blessed be the name of the Lord.’ Through all this Job did not sin nor did he blame God.” “... Shall we indeed accept good from God and not accept adversity?”

Q. Does suffering have spiritual value? Can God be glorified in how we respond to suffering?

A. Philippians 3:10 “That I may know Him, and the power of His resurrection and the fellowship of His suffering, being conformed to His death; in order that I may attain to the resurrection from the dead.”

2 Corinthians 4:7 “But we have this treasure in earthen vessels, that the surpassing greatness of the power may be of God and not from ourselves.”

2 Corinthians 4:16-18 “Therefore we do not lose heart, but though our outer man is decaying, yet our inner man is being renewed day by day. For momentary, light affliction is producing for us an eternal weight of glory far beyond all comparison, while we look not at the things which are seen, but at the things which are not seen; for the things which are seen are temporal, but the things which are not seen are eternal.”

Q. But, it’s my body. Don’t I have a right to choose when I die?

A. 1 Corinthians 3:16,17 “Do you not know that you are a temple of God, and that the Spirit of God dwells in you? If any man destroys the temple of God, God will destroy him, for the temple of God is holy and that is what you are.”

1 Corinthians 6:19,20 “Or do you not know that your body is a temple of the Holy Spirit who is in you, whom you have from God and that you are not your own? For you have been bought with a price: therefore glorify God in your body.”

Q. Is it acceptable for a Christian, who is terminally ill, to refuse available technology in order to let nature take its course and bring about a natural death?

A. Yes.

Ecclesiastes 3:1,2 “There is an appointed time for everything. And there is a time for every event under heaven — a time to give birth, and a time to die.”

Psalm 116:15 “Precious in the sight of the Lord is the death of His godly ones.”

Psalm 139:16 “And in Thy book they were all written, the days that were ordained for me.”

Q. Do the acts of assisted suicide and euthanasia deny God the opportunity to demonstrate His healing power?

A. Yes.

Matthew 8:16 “And when evening had come, they brought to Him (Jesus) many who were demon-possessed; and he cast out the spirits with a word, and healed all who were ill.”

James 5:16 “Therefore, confess your sins to one another, and pray for one another, so that you may be healed. The effective prayer of a righteous man can accomplish much.”

Carrie Gordon Earll is the Senior Policy Analyst for Bioethics at Focus on the Family and a fellow with the Center for Bioethics and Human Dignity.

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>>Physician-Assisted Suicide and Euthanasia (Focus on the Family, 010301)

Should physicians be granted the power to intentionally end the lives of their patients? Recent proposals to legalize physician-assisted suicide have raised this question and triggered intense legal, medical and social debate. For some individuals, the debate is fueled by their fear that medical technology may someday keep them alive past the time of natural death. However, this concern is unfounded for mentally competent adults who have a legal right to refuse or stop any medical treatment. It is also important to recognize that today’s health care climate lends itself more to undertreatment than overtreatment.

However, the present debate is not about refusing treatment or taking extraordinary measures. The issue is whether physicians should be allowed to intentionally kill their patients, either by providing the means of death or ending the patient’s life by the doctor’s hands. There is a tremendous distinction between allowing someone to die naturally when medical technology cannot stop the dying process and causing someone to die through assisted suicide or euthanasia. The question is one of intent: Is the intention to cause the death of the patient?

The terms “physician-assisted suicide” and “euthanasia” are often used interchangeably. However, the distinctions are significant. The act of physician-assisted suicide involves a medical doctor who provides a patient the means to kill him or herself, usually by an overdose of prescription medication.

Meanwhile, euthanasia involves the intentional killing of a patient by the direct intervention of a physician or another party, ostensibly for the good of the patient or others. The most common form of euthanasia is lethal injection. Euthanasia can be voluntary (at the patient’s request), nonvoluntary (without the knowledge or consent of the patient) or involuntary (against his or her wishes).

Legal Status

Euthanasia is illegal in the United States. Physician-assisted suicide is illegal by statute or common law in most states. Oregon is the only state where physician-assisted suicide is legal.

In 1997, the U.S. Supreme Court ruled that there is no federal constitutional right to physician-assisted suicide. However, the decision does not address individual state constitutions, which could be interpreted by other courts to include a state right to physician-assisted suicide.

Many state legislatures have tackled this issue in recent years, with more than 25 rejecting bills to legalize physician-assisted suicide and nearly a dozen states adopting new laws to ban it. No state legislature has voted to legalize physician-assisted suicide.

Oregon approved a ballot initiative to legalize physician-assisted suicide in 1994 and reaffirmed the vote in 1997. Five other attempts to legalize physician-assisted suicide (or euthanasia) through ballot initiative (California in 1988 and 1992, Washington State in 1991, Michigan in 1998, and Maine in 2000) all failed.

Stories Behind the Issue

Supporters often use emotional stories of terminally ill patients suffering in the final days of life to justify legalizing physician-assisted suicide. These stories communicate that an early, premeditated death is the best, and perhaps the only, option for the patient. However, a growing number of medical professionals who work with dying patients are speaking out to dispute this perception. Consider the following statements:

If we treat their depression and we treat their pain, I’ve never had a patient who wanted to die.

William Wood, M.D., clinical director of the Winship Cancer Center at Emory University in Atlanta, as published in Time, April 15, 1996, p. 82.

I simply have never seen a case nor heard of a colleague’s case where it (physician-assisted suicide) was necessary. If there is such a request, it is always dropped when quality care is rendered.

Linda Emanuel, M.D., Ph.D., director of the American Medical Association’s Institute on Ethics, as published in “The New Pro-Lifers,” The New York Times Magazine, July 21, 1996.

In my clinical practice, I have been asked by suffering patients to aid them in death because of severe pain. I have had the opportunity to see these requests for aid in death fade with adequate pain control, psychological support, provision of family support, and with the promise that their symptoms would be controlled throughout the dying process.

Kathleen Foley, M.D., chief of pain service at Memorial Sloan-Kettering Cancer Center in New York City, as part of her testimony before the House Judiciary Subcommittee on the Constitution, Washington D.C., April, 1996.

Reasons to Oppose Physician-Assisted Suicide

There are many reasons for opposing attempts to legalize such actions. Here are a few:

* Acceptance of physician-assisted suicide sends the message that some lives are not worth living.

Social acceptance of physician-assisted suicide tells elderly, disabled and dependent citizens that their lives are not valuable. Doctors who list death by assisted suicide among the medical options for a terminally or chronically ill patient communicate hopelessness, not compassion.

* The practice of physician-assisted suicide creates a duty to die.

Escalating health-care costs, coupled with a growing elderly population, set the stage for an American culture eager to embrace alternatives to expensive, long-term medical care. The so-called “right to die” may soon become the “duty to die” as our senior, disabled and depressed family members are pressured or coerced into ending their lives. Death may become a reasonable substitute to treatment and care as medical costs continue to rise.

* There are better medical alternatives.

Terminally ill patients do not need to suffer a painful death. Today’s pain management techniques can provide relief for up to 95 percent of patients, thus offering true death with dignity.1, 2, 3 In addition, these same techniques can lessen pain and other symptoms for all patients. Another alternative is palliative care through hospice, which addresses the physical, emotional and spiritual needs of dying patients and their families.

* Physician-assisted suicide ignores what may be a legitimate cry for help.

Suicidal thoughts often indicate the presence of severe depression. A study of terminally ill hospice patients found only those diagnosed with depression considered suicide or wished death would come early. Patients who were not depressed did not want to die.4 Depression can and should be treated.

* Physician-assisted suicide gives too much power to doctors.

Assisted suicide does not give the patient autonomy. It gives the power to the doctor. The doctor essentially decides if you live or die, and doctors can make mistakes. Consider a survey of Oregon physicians published in the February 1, 1996, issue of New England Journal of Medicine. Researchers found one half of the physicians responding were not confident they could predict that a patient had less than six months to live. One third were not certain they could recognize depression in a patient asking for a lethal dose of medication. Yet, these are the same doctors who, under Oregon’s law legalizing physician-assisted suicide, are allowed to assist in a patient’s death if they can recognize depression and predict patient death within six months.

* The practice of physician-assisted suicide threatens to destroy the delicate trust relationship between doctor and patient.

Every day patients demonstrate their faith in the medical profession by taking medications and agreeing to treatment on the advice of their physicians. Patients trust that the physicians’ actions are in their best interest with the goal of protecting life. Physician-assisted suicide endangers this trust relationship.

* Physician-assisted suicide opens the door to euthanasia abuses.

Allowing physicians to cross the line into killing does not stop with willing patients who request it. A case in point is in The Netherlands where doctors have practiced physician-assisted suicide and euthanasia for more than a decade. Two Dutch government reports, conducted in 1990 and 1995, found that, on average, 26 percent of euthanasia deaths in Holland were “without the explicit consent of the patient.” In 1995, 21 percent of the patients who were killed without consent were competent.5, 6

Dutch physicians have also extended the practice of euthanasia to include comatose patients, handicapped infants and healthy but depressed adults. In 1996, a Dutch court found a physician guilty of euthanizing a comatose patient at the request of the patient’s family. Although the court determined the patient was not suffering and did not ask to die, the doctor was not punished.7

In 1995, Dutch physician Henk Prins was convicted of giving a lethal injection to a baby born with a partly formed brain and Spina bifida. The court refused to punish Prins.8 Likewise, though psychiatrist Boudewijn Chabot was found guilty in 1994 of prescribing a fatal dose of sleeping pills for a woman who was suffering from depression, Chabot was not penalized.9 That same year, the Dutch Supreme Court ruled that physician-assisted suicide might be acceptable for patients with unbearable suffering but no physical illness. A 1996 survey of Dutch psychiatrists found 64 percent of those responding “thought physician-assisted suicide for psychiatric patients could be acceptable.”10

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Carrie Gordon Earll is the Senior Policy Analyst for Bioethics at Focus on the Family and a fellow with the Center for Bioethics and Human Dignity.

1K.M. Foley, “The Treatment of Cancer Pain,” The New England Journal of Medicine (1985): 313, pp. 84-95.

2I.R. Byock, “Kevorkian: Right Problem, Wrong Solution” [Letter to the Editor], The Washington Post, January 1994, p. A23.

3D. Colburn, “Assisted Suicide: Doctors, Ethicists Examine the Issues of Pain Control, Comfort Care and Ending Life,” The Washington Post, 14 September 1993, p. Z7.

4S. Barakat, J.H. Brown, P. Henteleff, C.J. Rowe, “Is It Normal for Terminally Ill Patients to Desire Death?” American Journal of Psychiatry (1986): 143:2, pp. 208-211.

5P.J. Van Der Maas, J.J.M. Van Delden, L. Pijenborg, Euthanasia and Other Medical Decisions Concerning the End of Life (Amsterdam: Elsevier Science Publishers, 1992), pp. 73, 75, 181-182.

6P.J. Van Der Maas, G. Van Der Wal, I. Haverkate, et al. “Euthanasia, Physician Assisted Suicide, and Other Medical Practices Involving the End of Life in the Netherlands, 1990-1995,” New England Journal of Medicine (1996): 335, pp. 1699-1705.

7”The Dutch Guidelines,” Newsday, 1997, p. A6.

8”Doctor Freed in ‘Justified’ Mercy Killing,” Chicago Tribune, 27 April 1995, p. N21; “Murder Charge Proved Against Euthanasia Doctor, but Case Dismissed,” Associated Press, 27 April 1995.

9”Doctor Unpunished for Dutch Suicide,” New York Times, 22 June 1994, p. 10A.

10J.H. Groenewoud, P.J. Van der Maas, G. Van Der Wal, et al., “Physician-Assisted Death in Psychiatric Practice in the Netherlands,” New England Journal of Medicine (1997): 336, p.1796.

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>>Euthanasia: The Stories Behind the Issue (Focus on the Family, 980227)

Supporters of physician-assisted suicide often tell emotive stories of terminally ill patients who ask a doctor to help them die. These stories communicate that an early, premeditated death is the best, and perhaps the only option for the patient. However, a growing number of medical professionals who work with dying patients are speaking out to dispute this perception that early death is the best solution. Consider these statements:

“If we treat their depression and we treat their pain, I’ve never had a patient who wanted to die.”

—Dr. William Wood, clinical director of the Winship Cancer Center at Emory University in Atlanta, Time April 15, 1996 pg. 82

“In my clinical practice, I have been asked by suffering patients to aid them in death because of severe pain. I have had the opportunity to see these requests for aid in death fade with adequate pain control, psychological support, provision of family support, and with the promise that their symptoms would be controlled throughout the dying process.”

—Kathleen Foley, MD serves as Chief of the Pain Service at Memorial Sloan-Kettering Cancer Center in New York City and as director of the World Health Organization Collaborating Center for Cancer Pain Research and Education. In April of 1996, Dr. Foley made the preceding statement before the Judiciary Subcommittee on the Constitution in Washington D.C., a Congressional subcommittee investigating physician-assisted suicide.

“There is a legacy that reverberates beyond a last breath, depending on how, one way or another, those last days were faced. I treated a young man with AIDS who begged for me to help him die. His religiously fundamentalist family was appalled with him. So much was unspoken, unsettled. Gradually the hospice team was able to bring them together, and to see that father gently bathing his son was nothing short of a miracle. Just think about that for a moment. It’s all right there, the moment of truth. This man died in peace, and his family will always know they had loved him, something that wouldn’t have happened if I or some other doctor had listened to his request to die.”

—Montana hospice physician Ira Byock as published in The New York Times Magazine, July 21, 1996

“We already know enough now to manage virtually all cases of malignant pain successfully. The widely held belief that pain can be relieved only by doses of morphine so high as to render the patient a zombie is a pernicious myth.”

—Eric Chevlen, MD, Director of Palliative Care at St. Elizabeth Health Center, Youngstown, Ohio. Excerpted from Chevlen’s article entitled “Mock Medicine, Mock Law” published in First Things, June/July 1996 p. 17

“I’ve taken care of 2,000 people who’ve died in my care. I only had two patients out of that whole group who, in a system of good care, where they could count on their nurses and doctors, still wanted to have that option.”

—Gerontologist Dr. Joanne Lynn during a panel discussion in WETA-TV’s “Who Plays God?” broadcast, May 3, 1996.

“A few years ago, a young professional in his early 30’s who had acute myelocytic leukemia was referred to me for consultation. With medical treatment, he was given a 25 percent chance of survival; without it, he was told, he would die in a few months.

“His immediate reaction was a desperate preoccupation with suicide and a request for support in carrying it out. he was worried about becoming dependent and feared both the symptoms of his disease and the side effects of treatment. His anxieties about the painful circumstances that would surround his death were not irrational, but all his fears about dying amplified them.

“Many patients and physicians displace anxieties about death onto the circumstances of dying - pain, dependence, loss of dignity, the unpleasant side effects resulting from medical treatment. Once the young man and I could talk about the possibility or likelihood of his dying - what separation from his family and the destruction of his body meant to him - his desperation subsided. He accepted medical treatment and used the remaining months of his life to become closer to his wife and parents. Two days before he died, he talked about what he would have missed without the opportunity for a loving parting.”

—Psychiatrist Dr. Herbert Hendin, Executive Director of the American Suicide Foundation. This statement is an excerpt from Lifesavers, a quarterly newsletter of the American Suicide Foundation, Spring 1995.

Carrie Gordon Earll is the Senior Policy Analyst for Bioethics at Focus on the Family and a fellow with the Center for Bioethics and Human Dignity.

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>>A “Painless” Death? (Weekly Standard, 031112)

Michael Schiavo insists that dehydration is “the most natural way to die.” It’s more like torture.

MANY WHO SUPPORT Terri Schiavo’s threatened dehydration assert that removing a feeding tube from a profoundly cognitively disabled person results in a painless and gentle ending. But is this really true? After all, it would be agonizing if you or I were locked in a room for two weeks and deprived of all food and water. So, why should we believe that cognitively disabled patients experience the deprivation differently simply because they receive nourishment through a feeding tube instead of by mouth?

An accurate discussion of this sensitive issue requires the making of proper and nuanced distinctions about the consequences of removing nourishment from incapacitated patients. This generally becomes an issue in one of the following two diametrically differing circumstances:

(1) Depriving food and water from profoundly cognitively disabled persons like Terri who are not otherwise dying, a process that causes death by dehydration over a period of 10-14 days. As I will illustrate below, this may cause great suffering.

(2) Not forcing food and water upon patients who have stopped eating and drinking as part of the natural dying process. This typically occurs, for example, at the end stages of cancer when patients often refuse nourishment because the disease has distorted their senses of hunger and thirst. In these situations, being deprived of unwanted food and water when the body is already shutting down does not cause a painful death.

Advocates who argue that it is appropriate to dehydrate cognitively disabled people often sow confusion about the suffering such patients may experience by inadvertently, or perhaps intentionally, blurring the difference between these two distinct situations. For example, when Michael Schiavo, Terri’s husband, and his attorney, George Felos, appeared on the October 27, 2003 edition of “Larry King Live” the following exchange occurred:

KING: When a feeding tube is removed, as it was planned [for Terri], is that a terrible death?

SCHIAVO: No. It’s painless and probably the most natural way to die.

FELOS: When someone’s terminally ill, let’s say a cancer patient, they lose interest in eating. And literally, they--by choice--they stop eating.

SCHIAVO: Cancer patients, they stop eating for two to three weeks. Do we force them to eat? No, we don’t. That’s their choice.

Later in the interview, Schiavo reiterated the assertion in a response to a telephoned question:

CALLER: Does it bother you that the death is so slow?

SCHIAVO: Removing somebody’s feeding tube is very painless. It is a very easy way to die. Probably the second best way to die, the first being an aneurysm.

Yes, it is true that when people are actively dying from terminal disease, they often refuse food and water. The disease makes the food and water repulsive to them. In such circumstances, it is medically inappropriate to force food and water into a person who is actively rejecting it. Indeed, doing so could cause suffering.

But this isn’t what is happening to Terri. She isn’t dying of cancer. Her body isn’t shutting down as part of the natural dying process. Indeed, she is not dying at all--unless her food and water is taken away.

WHAT HAPPENS to non-terminally ill people with cognitive disabilities whose feeding tubes are removed? Do they suffer from the process?

When I conducted research on this question in preparation for writing my book “Forced Exit,” I asked St. Louis neurologist William Burke these very questions. Here is what he told me:

A conscious [cognitively disabled] person would feel it just as you or I would. They will go into seizures. Their skin cracks, their tongue cracks, their lips crack. They may have nosebleeds because of the drying of the mucus membranes, and heaving and vomiting might ensue because of the drying out of the stomach lining. They feel the pangs of hunger and thirst. Imagine going one day without a glass of water! Death by dehydration takes ten to fourteen days. It is an extremely agonizing death.

Dr. Burke opposes removing feeding tubes from cognitively disabled people and so some might dismiss his opinion as biased. But Minnesota neurologist Ronald Cranford’s pro-dehydration testimony in the Robert Wendland case--Cranford also testified that Terri’s feeding tube should be removed--supports much of what Dr. Burke asserted. While Cranford called seizures “rare,” his detailed description of the dehydration process reveals its gruesome reality:

After seven to nine days [from commencing dehydration] they begin to lose all fluids in the body, a lot of fluids in the body. And their blood pressure starts to go down. When their blood pressure goes down, their heart rate goes up. . . . Their respiration may increase and then . . . the blood is shunted to the central part of the body from the periphery of the body. So, that usually two to three days prior to death, sometimes four days, the hands and the feet become extremely cold. They become mottled. That is you look at the hands and they have a bluish appearance. And the mouth dries a great deal, and the eyes dry a great deal and other parts of the body become mottled. And that is because the blood is now so low in the system it’s shunted to the heart and other visceral organs and away from the periphery of the body . . .

MOST OF THE TIME, we never know for sure what a starved or dehydrated person experiences. But in at least one case--that of a young woman who had her feeding tube removed for eight days and lived to tell the tale--we have direct evidence of the agony that forced dehydration may cause.

At age 33, Kate Adamson collapsed from a devastating and incapacitating stroke. She was utterly unresponsive and was diagnosed as being in a persistent vegetative state (PVS). At the urging of doctors, who believed she would never get better, her nourishment was stopped. But midway through the dehydration process, she began to show subtle signs of comprehension, so her food and water were restored.

Adamson eventually recovered sufficiently to author “Kate’s Journey: Triumph Over Adversity,” in which she tells the terrifying tale. Rather than being unconscious with no chance of recovery as her doctors believed, she was actually awake and aware but unable to move any part of her body voluntarily. (This is known as a “locked-in state.”) When she appeared recently on “The O’Reilly Factor,” host Bill O’Reilly asked Adamson about the dehydration experience:

O’REILLY: When they took the feeding tube out, what went through your mind?

ADAMSON: When the feeding tube was turned off for eight days, I thought I was going insane. I was screaming out in my mind, “Don’t you know I need to eat?” And even up until that point, I had been having a bagful of Ensure as my nourishment that was going through the feeding tube. At that point, it sounded pretty good. I just wanted something. The fact that I had nothing, the hunger pains overrode every thought I had.

O’REILLY: So you were feeling pain when they removed your tube?

ADAMSON: Yes. Oh, absolutely. Absolutely. To say that--especially when Michael [Schiavo] on national TV mentioned last week that it’s a pretty painless thing to have the feeding tube removed--it is the exact opposite. It was sheer torture, Bill.

O’REILLY: It’s just amazing.

ADAMSON: Sheer torture . . .

In preparation for this article, I contacted Adamson for more details about the torture she experienced while being dehydrated. She told me about having been operated upon (to have her feeding tube inserted in her abdomen) with inadequate anesthesia when doctors believed she was unconscious. Unbelievably, she described being deprived of food and water as “far worse” than experiencing the pain of abdominal surgery, telling me:

The agony of going without food was a constant pain that lasted not several hours like my operation did, but several days. You have to endure the physical pain and on top of that you have to endure the emotional pain. Your whole body cries out, “Feed me. I am alive and a person, don’t let me die, for God’s Sake! Somebody feed me.”

But what about the thirst, I asked:

I craved anything to drink. Anything. I obsessively visualized drinking from a huge bottle of orange Gatorade. And I hate orange Gatorade. I did receive lemon flavored mouth swabs to alleviate dryness but they did nothing to slack my desperate thirst.

Apologists for dehydrating patients like Terri might respond that Terri is not conscious and locked-in as Adamson was but in a persistent vegetative state and thus would feel nothing. Yet, the PVS diagnosis is often mistaken--as indeed it was in Adamson’s case. And while the courts have all ruled that Terri is unconscious based on medical testimony, this is strongly disputed by other medical experts and Terri’s family who insist that she is interactive with them. Moreover, it is undisputed that whatever her actual level of awareness, Terri does react to painful stimuli. Intriguingly, her doctor testified he prescribes pain medication for her every month during the course of her menstrual period.

BEYOND THE TERRI SCHIAVO CASE, it is undisputed that conscious cognitively disabled patients are dehydrated in nursing homes and hospitals throughout the country almost as a matter of routine. Dr. Cranford, for example, openly admitted in his Wendland testimony that he removes feeding tubes from conscious patients. Thus, many other people may also have experienced the agony described by Adamson and worse, given that dehydrating to death goes on for about a week longer than she experienced.

AT THIS POINT, defenders of removing feeding tubes from people with profound cognitive disabilities might claim that whatever painful sensations dehydration may cause, these patients receive palliating drugs to ensure that their deaths are peaceful. But note: Adamson either did not receive such medications, or if she did, they didn’t work. Moreover, because these disabled people usually can’t communicate, it is impossible to know precisely what they experience. Thus, when asked in a deposition what he would do to prevent Robert Wendland from suffering during his dehydration, Dr. Cranford responded that he would give morphine but that the dose would be “arbitrary” because “you don’t know how much he’s suffering, you don’t know how much aware he is . . . You’re guessing at the dose.” At trial, Cranford suggested he might have to put Wendland into a coma, a bitter irony considering that he had struggled over many months to regain consciousness.

The time has come to face the gut wrenching possibility that conscious cognitively disabled people whose feeding tubes are removed--as opposed to patients who are actively dying and choose to stop eating--may die agonizing deaths. This, of course, has tremendous relevance in the Terri Schiavo case and many others like it. Indeed, the last thing anyone wants is for people to die slowly and agonizingly of thirst, desperately craving a refreshing drink of orange Gatorade they know will never come.

Wesley J. Smith is a senior fellow at the Discovery Institute and an attorney and consultant for the International Task Force on Euthanasia and Assisted Suicide. His current book is the revised and updated “Forced Exit: The Slippery Slope From Assisted Suicide to Legalized Murder.”

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What the Bible says about suicide?

The Bible contains a number of references to men seeking suicide, either

by taking direct action or

by begging God to kill them on the spot.

The Christian church has traditionally considered suicide to be a great moral sin. Some denominations have even refused to bury people who have committed suicide.

The New King James translation is quoted here:

Numbers 11:12-15 Moses was in despair because of the complaints of the Israelites whom he was leading. The burden of leadership was too heavy for him to bear. He asked God “If You treat me like this, please kill me here and now...”

Judges 9:52-54: The warrior-king of Israel, Abimelech, was attacking a tower in Thebez, hoping to exterminate large numbers of unarmed civilians as he had just done in Shechem. As he attempted to burn the door to the tower, a woman dropped a piece of a millstone on Abimelech’s head. He felt that he was morally wounded. The king’s contempt for women was so great that he quickly asked his armor bearer to kill him with his sword, in order that people not say that he had been killed by a woman.

Judges 16:29-30 Samson had been chained to the two middle pillars of a temple. He pushed them apart. thereby knowingly causing the collapse of the building, his own suicide and the death of a few thousand people inside. The death toll exceeded the number of people that he had killed during the rest of his life -which was considerable. And by causing his own death, he had a chance to destroy many of the enemy.

1 Samuel 31:4-6 In a war against the Philistines, Saul’s sons Johnathan, Abinadab and Malchishua were killed, and Saul himself was seriously wounded. He asked his armor bearer to kill him, but his assistant refused. So he took a sword and fell on it. The armor bearer then also fell on his sword. Both committed suicide. These precise events are also described in 1 Chronicles 10:3-7. Saul’s justification for committing suicide was that because of his injuries, if the Philistines arrived, he would be abused and killed by uncircumcised men. 2 Samuel 1:2-17 describes that Saul was killed by an Amalekite. The explanation is that either the Amalekite lied or Saul’s action did not succeed in killing himself.

2 Samuel 17:1-29 Ahithophel recommended that he be allowed to choose 12,000 men, to pursue King David immediately, and kill him. When his advice was not accepted, he became so depressed that he returned to his city, “put his household in order, and hanged himself, and died...”

1 King 16:15-20 Zimri, king of Tirzah, saw his city besieged and taken. He was distressed at the sins that he had committed. He “went into the citadel of the king’s house and burned the king’s house down upon himself with fire, and died...”

I King 18:40 and 19:4 In an act of vicious religious intolerance, Elijah ordered 400 priests of Baal executed. Ahab went to Jezebel, telling her that Elijah had “executed all the prophets with the sword.” She swore to kill Elijah within the next 24 hours. Elijah fled for this life to Beersheba, went into the wilderness, and “prayed that he might die.” He said, “It is enough! Now, LORD, take my life, for I am no better than my fathers!”

Jonah 4:1-11 God had threatened the destruction of the Nineveh, a city of 120,000 people. But the king and people of the city listened to Jonah, repented of their sins, and fasted. God changed his mind and did not destroy the city. Jonah was so angry at God’s display of mercy that he asked God to kill him, “for it is better for me to die than to live!” He repeated the same request to God on the next day.

Matthew 27:5 After Judas had betrayed Jesus in return for 30 pieces of silver, he hanged himself.

1 Corinthians 3:17: “If anyone defiles the temple of God, God will destroy him. For the temple of God is holy, which temple you are.”

Philippians 1:20-26 Paul is contemplating whether it is better to live or die. He is hard pressed to decide between the two, “having a desire to depart and be with Christ, which is far better. Nevertheless to remain in the flesh is more needful for you...yet what I shall choose I cannot tell.”

Revelation 9:1-10 An angel is described as opening the bottomless pit to release clouds of locusts. These insects had a body like a horse, hair like a woman’s, a face of a man, and teeth like a lion. They were instructed to attack those people who “did not have the seal of God on their foreheads.” The locusts were to torment people for five months but not to kill them. They had stingers in their tails like those of scorpions. Verse 6 says: “In those days men will seek death and will not find it; they will desire to die, and death will flee from them.” i.e. they will attempt to commit suicide to end the torment, but for some reason, will be unable to achieve it.

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When dad asked to die (Christian American, 960300)

A family struggles with the pain and suffering of a terminal illness.

“I know if that time ever came, you would be the one I could count on to do it.”

The speaker was a close relative. The year was 1989. The subject was terminal illness. The “it” was assisted suicide. My relative believed that I loved her enough and was courageous enough to help her end her life if she, ill beyond hope, were incapable of doing it.

I didn’t tell her then that I wouldn’t do it. Not that I couldn’t do it, but that I wouldn’t do it.

I love her enough to risk the consequences of a legal system that calls assisted suicide murder. I love her enough to suffer the awesome psychological ramifications of ending a loved one’s life. I love her enough to consider her desperate wishes to end her life above my own selfish wishes to prolong it.

But I love her way too much to let the world’s well-meaning logic prevail in such a critical situation. For it’s not a question of ending a loved one’s suffering in the present. It’s a question of protecting that loved one in eternity.

I understand it all far better now.

My father, who was diagnosed with esophageal cancer in 1990, entered a nursing home in September 1994 for hospice care - care designed to ease pain, not extend life.

My dad was a proud, beautiful man. He was intelligent, kind and generous, with a dry sense of humor. The fellows I’ve brought home since my high school days all have loved my parents, but particularly my dad.

“He was a man’s man,” a good friend recently said. It was true. You could sit down with my dad and know him immediately. He could talk about anything, and he made everyone who met him feel instantly at ease. He was a negotiator by profession, and he neutralized potential conflict wherever he went by looking for the best in people and accepting them for who they were.

I loved him so much. He wasn’t perfect, but he was a man whom few could match in integrity, humor and intelligence.

Since entering the nursing home, he was not the man he had been.

My dad, who stood 6 feet, 4 inches tall, had lost 100 pounds. The cancer had spread to his lungs. He was confined to bed and fed through a food tube in his stomach. He couldn’t swallow water without regurgitating it. Even sucking ice chips caused his stomach to react violently. He couldn’t get out of bed because he was plagued with severe arthritis and, later, numerous bed sores. Soon, as his body weakened further, he became incontinent.

My sister, brother-in-law, mom and I visited him daily. Our main efforts were directed toward making him comfortable... a leg shifted one way, a pillow moved another, his bed adjusted up or down just so. One day, while I was combing his hair, I reminded him that when I was six years old or so he used to pay me a nickel every time I’d comb his hair for him, which I’d done often. The next day, he pointed to a nickel he’d had a nurse find for him to give to me. He started to cry.

I often read the Bible to him when I visited, but my dad would listen only occasionally. More often than not, he would shoo me away. He had been a good man, and he did not think he needed a savior in order to receive peace and sanction from God in any kind of afterlife.

“If good works would get you into heaven, Dad, you’d be going,” I’d tell him. “But not even the best of us will make it there unless we understand our need for Jesus Christ. The bottom line, according to the Bible, is humility, Dad. The need to realize we can’t be righteous on our own. “Professional negotiators understand bottom lines, don’t they?” I would ask. “Or maybe you know of some other heaven cited in some other book - one that doesn’t even mention or require some savior named Jesus.”

Dad would roll his eyes at me, and I’d call him a grouch, kiss him and leave for a while.

“Kill me”

(God, not man, needs to be the final arbiter of that time when our spirit leaves our body.)

In the early weeks of his nursing home stay, Dad talked of our need to consider getting hold of Jack Kevorkian or some other assisted-suicide specialist. He didn’t want to “live like this.” Later, his lungs were filling up with fluid and he barely could talk. He was in such pain that he couldn’t bear to have his throat aspirated of phlegm anymore. He cried out, “Kill me!” It devastated us emotionally.

But we didn’t call Jack Kevorkian. We didn’t smother my dad with a pillow or end his life through some other seemingly humane means. What we did, in my view, took more courage. The hardest, most terrible thing in the world is to watch someone you love suffer.

Our strength came in our knowledge of a personal God. We know that He loves us, and that even in the 11th hour of our lives we can come to Him, and He will forgive us. God, not man, needs to be the final arbiter of that time when our spirit leaves our body. He just may have a plan to more fully reveal Himself to a believer or bring a skeptic into last-hour communion with Himself.

Peace amidst the suffering

After the nursing home called us at 4 a.m. on Dec. 11, 1994, to tell us that Dad’s vital signs were ebbing away, my family and I increased our prayers that God soften my dad’s hard heart. We prayed over him. We read the Bible constantly. We had other people lay hands on him. The nursing home chaplain prayed with him. My dad kept saying, “I don’t know what to do” in the midst of our prayers. Doubtless, his indecision helped him hang onto life, to the doctor’s surprise.

He lived throughout the night and the next day. The prayers continued. And then, late that night, a nurse called my sister and told her that my dad, in a lucid state, had received Christ as his savior.

It was Dec. 12, his birthday - now the date of his spiritual rebirth.

The room was filled with a holy peace in the midst of my dad’s suffering that next day. And my sister and I prayed that God would take him that very day if my dad indeed had been saved and if God had finished dealing with him.

My dad died at 11:45 p.m. that evening.

There was no choking from the fluid in his lungs, no struggle, no horrified terror, no gasps, no expression of fear. My dad was breathing softly, then ever so lightly, and then, a minute later, he was gone. His beautiful hands, scarred and bloody from sores and needle marks, were folded in prayer. The room was silent and peaceful. My dad was free; thank God, my dad was free.

We wept in thanks for God’s mercy, a mercy that allowed my dad to suffer, yes to suffer, and to live those few extra days so that a greater good could be achieved.

My dad is with Christ now, not en route to an uncertain destination.

In those final hours, I am certain God revealed to him Christ’s purpose in dying on the cross.

Christ was no martyr, but willingly came to die for a humanity utterly unable to meet God’s standards of righteousness. God has a covering for that failure for all who are broken enough to ask for it. That covering is the blood of Jesus Christ.

“If that time ever came, you would be the one I could count on to do it,” my relative told me several years ago. I know that if “that time” ever comes again for a loved one, and it will, I will remember my beloved dad.

I now know without a doubt what it means to love with a heart that sees beyond the present to eternity. The pain is subsiding, bit by bit, as I dwell upon the hope we have in Christ. Someday we’ll all be together again.

See you in heaven, Dad.

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Jack Kevorkian’s Frightening World (from Christian American, 960300)

No one seems capable of stopping his killing sprees, and experts say he’s paving the way for much worst.

Judith Curren thought she wanted to die. On that, there is no dispute. But far from providing the answers she was seeking, Judith Curren’s Aug. 15 death open a medical library’s worth of new questions about the controversial suicide attendant Jack Kevorkian.

Kevorkian admits that Curren was on Percocet, Xanax, Tylenol 4 (Codeine), and Nifedipine. In high doses taken over a long of time, the drugs can impair a patient’s ability to think and can cause mood swings and depression.

But Kevorkian insists he did not know that Curren’s husband, who was at her side when she died, received a restraining order in 1993, in which his wife alleged a long history of emotional and physical abuse. Further complicating the case, Kevorkian argues that Curren suffered from chronic fatigue syndrome, autoimmune disorder, fevers, an enlarged spleen and other non-fatal ailments. Her relative youth - she was 42 - and the non-fatal aspect of her illness injected new controversy into Kevorkian’s now almost routine practice.

“Jack Kevorkian has made those who acted with previously outrageous behavior seem moderate,” said Rita Marker, executive director of the International Anti-Euthanasia Task Force. “What was previously unthinkable is topped by even more outrageous behavior and the boundaries are moved. The previously unthinkable has become the moderate middle.”

The 68-year-old Kevorkian has been tried - and acquitted - by Michigan courts on three separate occasions. He has now attended the suicides of 40 people, two of which occurred on the same day, one week after Curren’s death.

The fact that fellow citizens refuse to convict him and the reality that his actions no longer shock most people proves that Kevorkian has already accomplished much. Pro-life advocates worry that his actions are paving the way to a frightening world, one in which the value of human life is weighed against comfort and cost rather than respected as valuable and worth cherishing to its natural end.

Medical pariah

The medical establishment has an uneasy relationship with Kevorkian. In a strongly worded letter sent last year to Michigan Attorney General Frank Kelley, American Medical Association (AMA) General Counsel Kirk Johnson wrote that “no civilized society should condone assisted suicide as it is practiced by Jack Kevorkian.” In the letter, Johnson called Kevorkian “a reckless instrument of death” and “a great threat to the public.”

Yet three juries have disagreed with the AMA’s assessment. Richard Thompson became the first Oakland County, Mich., incumbent prosecutor in 24 years to lose his seat after his opponent in the Republican primary, David Gorcyca, challenged Thompson’s repeated prosecution of Kevorkian as a waste of taxpayer dollars.

The Michigan state legislature passed a law specifically aimed at stopping Kevorkian’s attended suicides, but Thompson was unsuccessful in prosecuting Kevorkian under that law. He also failed to convict Kevorkian under common law (Kevorkian was also acquitted by a Wayne County, Mich., jury). Gorcyca argued that Thompson should have realized he was trying to enforce an unenforceable law.

The real issue, according to Marker, is not that the law is unenforceable, but that “the prosecutors couldn’t hold a candle to [Geoffrey] Fieger [Kevorkian’s attorney] in emotion. They had the facts, but facts buried in boring rhetoric will not necessarily persuade a jury.”

“He has taken the things that frighten people the most -- pain and the fear of abandonment -- but he has given us a solution that is far worst than the problem.” -- Rita Marker

Kevorkian and Fieger make a strong presentation in court. Kevorkian wears a sweater and appears as a kindly, retired physician offering free services. He doesn’t charge any money for assisting with a suicide, the argument goes, so how could his motives be anything other than benevolent?

But if financial gain is not Kevorkian’s goal, then what is?

Fieger refused to return several calls from Christian American, but Dr. Diane Komp, a professor at the Yale University School of Medicine, believes that Kevorkian and other “right to die” proponents have another agenda. That agenda, according to Komp, would place emotional pain on the same plane as physical pain when determining eligibility for assisted suicide.

“Most of the discussion of assisted death in medical literature would exclude depression from any cause,” Komp said, and that is precisely why Curren’s death sparked new controversy. Curren had no life-threatening illness; she simply was depressed and thought she wanted to die.

None of Curren’s physical ailments were any more imminently life-threatening than her obesity (at 5 feet 1 inch tall, Curren weighed 260 pounds).

“Chronic fatigue syndrome and auto-immune disorder are real problem diagnoses for this discussion,” Komp said. “They may or may not exist, the patients may or may not have them if they exist. And of course an autopsy would be useless to determine their extent.”

Kevorkian’s primary defense has been that his actions are a more merciful response to unending pain than allowing people to suffer.

Komp warns that the pro-life community should not take this argument too lightly. “The truth is, not all pain is properly managed medically,” she said. “Christians cannot in the name of pro-life guarantee that pain will be dealt with effectively. This is due in part to the physician’s lack of knowledge or competence, or at times to the patient’s refusal of medications that dull mentation [the ability to think cogently].”

The bigger picture

Another danger posed by Kevorkian’s agenda is the problem raised by the increasing influence of managed care programs.

“Some managed care programs give physicians cash incentives for not treating patients,” Marker said. “Within that context, do we want to give doctors the power to prescribe the ultimate prescription, the one which is least expensive for the bottom line of managed care?

“Patients who are dead are not expensive to the managed care program.”

Komp adds another wrinkle to that dilemma.

“If physician-assisted death is supported by the Supreme Court, an insurer might contract preferentially with hospices whose caregivers agree to offer this ‘service.’ How is a patient to know the basis upon which his insurer contracts for hospice?”

Doctors who recommend assisted death may be favored by insurers, while doctors who will not participate because of conscience or ethics may be excluded from participation.

Furthermore, since insurance companies may legally restrict their coverage to certain hospices, it is feasible that in the future a patient who wants to use a hospice that does not use physician-assisted suicide may be forced to pay for the hospice out of his or her own pocket.

The issues are similar to those raised by abortion. Just as legalized abortion is threatening to force education programs for gynecologists and family practitioners to include abortion instruction, so the legalization of physician-assisted death may create similar pressures on physicians and nurses who care for the elderly and patients with cancer, AIDS and neurological diseases.

“Groups of physicians whose palliative care skills bring them into contact with larger numbers of dying patients will be under increased demand to provide assistance in suicide,” Komp explained. “The education programs to train these specialists may face requirements to provide training in this area.”

The effects of physician-assisted suicide, once legalized, will have a profound and pervasive effect on the nursing profession, Komp said.

“If state statutes for physician-assisted suicide are passed, and the Supreme Court upholds them, a patient may ask to exercise this legal right on an oncology ward, bone marrow transplantation unit, or even in a hospice,” she added. “A nurse whose conscience does not permit her to cooperate with abortion can avoid that ethical and moral conflict by not seeking employment in an abortion clinic or operating room where her assistance would be required.”

But what protection or alternative will exist for a nurse who wants to work with the dying? None.

The battle already has been lost in three Michigan trial courts, but for now it can perhaps be best waged in what Marker calls “the court of public opinion.”

“We have to help friends and relatives realize that Jack Kevorkian’s world is a terrifying world,” she said. “He has taken the things that frighten people the most - pain and the fear of abandonment - but he has given us a solution that is far worse than the problem.”

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Health Law: ‘Assisted Suicide’ Heads to Supreme Court (New York Law Journal, 961203)

By Francis J. Serbaroli

THE UNITED STATES Supreme Court will hear oral arguments in January on the controversial issue of whether there is a constitutional “right” to physician-assisted suicide. Earlier this year, two United States Courts of Appeals issued sweeping decisions striking down state laws banning assisted suicide. The courts’ rulings differed markedly in their reasoning, with the Ninth Circuit citing Due Process and the Second Circuit relying upon an Equal Protection theory. Both decisions have been roundly and justifiably criticized for the weaknesses and inconsistencies in their legal reasoning.

Ninth Circuit

When the Ninth Circuit Court of Appeals handed down its en banc decision last March in Compassion in Dying v. Washington,1 no other appellate court -- federal or state -- had ever recognized assisted suicide as a protected Fourteenth Amendment “liberty.” Wandering far afield from the customary sources of constitutional judgment, the Ninth Circuit, in an opinion authored by Circuit Judge Stephen Reinhardt, actually relied in part upon societal attitudes to bolster its unprecedented conclusion.

There can be little doubt that the Ninth Circuit judges were aware that a solid majority of the states have statutes banning assisted suicide. These laws, enacted by popularly elected state legislatures, would seem to present a compelling view of the public’s attitude toward the issue. Nevertheless, the Ninth Circuit came to the rather remarkable conclusion that such laws were not the relevant measure of the public’s view.

The court decided that these laws did not “necessarily indicate societal disapproval” of assisted suicide, and it added: “That is especially true when such laws are seldom, if ever enforced.” Of course, one can make the same point about laws prohibiting adultery: They too may be seldom, if ever, enforced. Nevertheless, their continued existence clearly conveys society’s desire as a matter of law to condemn the practice, and as needed, to recognize it as a legal basis for granting a divorce.

More disturbing than the “lack of enforcement” argument was the court’s reliance on public opinion polls to establish that “liberty” as used in the Fourteenth Amendment, includes the liberty to choose the timing and manner of one’s death. According to the Ninth Circuit, public opinion polls now may be used as evidence of the public’s considered thinking on a particular matter, and courts may rely on such data as opposed to the considered opinion of their directly elected representatives in state legislatures.

Public opinion polls, however, are far from the best evidence of the public’s opinion on a matter. If a court wished to consider more persuasive evidence of how Americans generally regard physician-assisted suicide, it would need to look no further than how the electorate in three states voted on referenda to legalize that practice. In California and Washington, referenda to legalize assisted suicide were defeated, and in Oregon it was approved by only a razor-thin margin. Founding a constitutional right even in part on public opinion polls is a remarkably misguided and dangerous exercise.

When the Ninth Circuit fell back on a more conventional source for constitutional authority, i.e., Supreme Court precedent, it relied on two decisions of relatively recent vintage: Planned Parenthood v. Casey 2 and Cruzan v. Director, Missouri Department of Health.3 Neither of these decisions really supports a broad constitutional “right” to die.

The Ninth Circuit repeatedly attempted to draw parallels between an individual’s decision to end her life and a woman’s decision to terminate an unwanted pregnancy. At one point, the court’s opinion called the following language the “fundamental message” of Casey:

These matters, involving the most intimate and personal choices a person may make in a lifetime, choices central to personal dignity and autonomy, are central to the liberty protected by the Fourteenth Amendment.4

Later on in the opinion, after repeating this “these matters” language, the Ninth Circuit went on to declare that such language applied with as much, if not more, force in the case of “hastening death” (at least in the case of the terminally ill) as in the case of abortion:

Like the decision of whether or not to have an abortion, the decision how and when to die is one of “the most intimate and personal choices a person may make in a lifetime,” a choice “central to personal dignity and autonomy.” A competent terminally ill adult, having lived nearly the full measure of his life, has a strong liberty interest in choosing a dignified and humane death rather than being reduced at the end of his existence to a childlike state of helplessness, diapered, sedated, incontinent. How a person dies not only determines the nature of the final period of his existence, but in many cases, the enduring memories held by those who love him.

Prohibiting a terminally ill patient from hastening his death may have an even more profound impact on that person’s life than forcing a woman to carry a pregnancy to term ....5

There are, of course, numerous practices that we would not conceive of as constitutional rights that would fall within the capacious “these matters” prose from Casey. An adult’s decision to engage in consensual sexual relations with her adult brother, for example, could be characterized as one of the most intimate and personal choices that that individual may make in her lifetime; it could even be deemed a choice central to her personal dignity and autonomy. Yet, would anyone, much less any court, so much as entertain the suggestion that adult consensual incest was constitutionally protected? No more, one thinks, than the Supreme Court will affirm the existence of a Fourteenth Amendment liberty to choose the time and manner of one’s death. The Ninth Circuit’s reasoning is particularly hollow in this respect.

Overlooked Roles

Part of the reason the Ninth Circuit erred was that it mistook the role that the doctrine of stare decisis played in Casey as a mere “influence” on the case.6 Moreover, the Ninth Circuit seems to have paid no heed to Casey’s signifi-cant discussion of the role of the federal judiciary, and above all, the role of the Supreme Court, in the constitutional scheme. Consequently, the Ninth Circuit’s opinion overstated the implications of Casey as a springboard for the further expansion of substantive due process rights, rather than recognizing that Casey was not really the sort of precedent the Ninth Circuit wanted it to be.7

Refusal v. Right

The Ninth Circuit’s reading of Cruzan is scarcely more accurate than its reading of Casey. The court stated:

... Cruzan, by recognizing a liberty interest that includes the refusal of artificial provision of life-sustaining food and water, necessarily recognizes a liberty interest in hastening one’s own death.8

Technically speaking, the majority opinion in Cruzan, authored by Chief Justice Rehnquist, only assumed the existence of a Fourteenth Amendment liberty interest in refusing unwanted medical treatment, including artificial nutrition and hydration. The accepted wisdom about Cruzan, however, is that Justice O’Connor’s concurrence in that case should be read along with the opinions of the dissenters as establishing a right to refuse unwanted medical treatment. Even if Cruzan did recognize such a narrow liberty interest, that interest should not be confused, as the court did, with a broad “right to die.”

One cannot claim Cruzan as authority for the proposition that there is a constitutional liberty interest in hastening one’s own death without considering the reasons that led the Cruzan Court to find a liberty interest in refusing lifesaving medical treatment. The Ninth Circuit in Compassion in Dying did no such thing.

In Cruzan, the Supreme Court correctly observed that the right to informed consent, the “logical corollary” of the right to refuse unwanted medical treatment, had long been recognized at common law. Because the liberty interest in hastening one’s own death, broadly defined, has no such common law pedigree, it was a mistake for the Ninth Circuit simply to assume that one form of “hastening death” is like all others.

Second Circuit

Following quickly on the heels of the Ninth Circuit ruling, a three-judge panel of the Second Circuit issued an opinion in Quill v. Vacco,9 written by Circuit Judge Roger Miner. In Quill, the Second Circuit flatly rejected the substantive due process rationale that had formed part of the basis of the Ninth Circuit’s decision in Compassion in Dying. The Quill court, however, then went on to find that New York State’s assisted-suicide ban violated the Fourteenth Amendment’s equal protection clause.

The Second Circuit’s equal protection theory rested on two controversial and debatable findings. First, the Second Circuit held that competent persons in the final stages of terminal illness who wish to hasten their deaths are “similarly situated,” whether they wish to die by refusing lifesaving medical treatment or by self-administering physician-prescribed medications intended to end life. Then, the Second Circuit’s opinion held that New York’s law banning assisted suicide lacked any rational relationship to a legitimate governmental interest that would justify the unequal treatment of the otherwise “similarly situated” terminally ill.

The Second Circuit’s finding, that all terminally ill individuals in the final stages of their disease are “similarly situated” with respect to hastening death, flows from the court’s refusal to acknowledge that there is any constitutionally cognizable difference between refusing life-sustaining medical treatment and committing physician-assisted suicide.

To the Second Circuit judges in Quill, this looked like a simple syllogism. Because both (a) the decision to refuse lifesaving medical treatment and (b) the decision to commit physician-assisted suicide amount to (c) the “conscious decision to hasten one’s death,” the terminally ill who would (a) make the decision to refuse lifesaving medical treatment must be “similarly situated” to those terminally ill individuals who would (b) make the decision to commit physician-assisted suicide. The syllogism, while of some interest in academic debate, simply does not square with our common law experience.10

If all this were not troublesome enough, there is also the troublesome reason the Second Circuit gave when it held that New York’s law against assisted suicide bore no rational relationship to a legitimate state interest. According to the Second Circuit, the State’s interest in preserving and protecting the lives of the terminally ill is not even a legitimate one. The court explained:

“But what interest can the state possibly have in requiring the prolongation of a life that is all but ended? Surely the state’s interest lessens as the potential for life diminishes.”11

The court’s question is a deeply disturbing one, and the answer it provides is even more so. It has always been our understanding that the terminally ill are still fully alive and not merely beings with “the potential for life.” Indeed, one would have thought that the proponents of physician-assisted suicide would have thought so too, since they are quick to observe that the terminally ill, if they had a right to physician-assisted suicide, would have to commit the last, death-causing act themselves.

The thrust of the Second Circuit’s opinion in the Quill opinion is that there is no good reason (and no constitutionally adequate one) for a state legislature to draw a line between permitting patients to refuse unwanted but lifesaving medical treatment and a total ban on physician-assisted suicide. Yet nothing in the Constitution, constitutional precedents or our common law heritage supports such a broad conclusion.

Conclusion

The gossamer legal basis for the creation of a new constitutional right to physician-assisted suicide by both the Ninth and Second Circuits should remind us once again how fragile such court-created rights are. As the dissent in the Ninth Circuit pointed out:

“That a question is important does not imply that it is constitutional. The Founding Fathers did not establish the United States as a democratic republic so that elected officials would decide trivia, while all great questions would be decided by the judiciary .... That an issue is important does not mean that the people, through their democratically elected representatives, do not have the power to decide it.”12

The Supreme Court would do well to restore the resolution of the issue of physician-assisted suicide to its rightful place in the normal democratic processes.

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Hospice Care (Focus on the Family, 980303)

by Carrie Gordon Earll

What is Hospice Care?

Hospice provides support and care for persons in the last phases of incurable diseases so that they may live as fully and comfortably as possible. Recognizing death as part of the normal process of living, hospice focuses on maintaining the quality of remaining life, neither hastening nor postponing the inevitable. Hospice exists in the hope and belief that through appropriate care--and the promotion of a caring community sensitive to their needs--patients and their families may be free to attain a degree of mental and spiritual preparation for death that is satisfactory to them.

A hospice program provides comforting care to terminally-ill patients and supportive services to patients, their families, and significant others 24 hours a day, seven days a week, in both home and facility settings. Physical, social, emotional, and spiritual care are provided during the last stages of illness, the dying process, and bereavement by a medically directed interdisciplinary team consisting of patients, families, professionals, and volunteers.

When a family member or caregiver contacts a hospice, the director of the center will call the patient’s doctor to verify his condition. If all information is accurate, the hospice will proceed with care for the patient. In any case, patients must have a terminal diagnosis to receive hospice care. In some instances, an individual who has no family will desire hospice care. In this situation, the hospice has two options:

* If the patient is able-bodied and independent, the hospice will treat the patient in the home.

* If the patient is bed-ridden, the hospice will send them to a hospice-operated, in-patient facility, or work with a nearby nursing home or hospital on a contractual basis to care for the patient. When home care is unavailable, hospices try to provide as close to a home-like setting as possible for the patient.

The Hospice Care Approach

The primary goal of hospice care is to manage or control pain and alleviate the fears most commonly associated for a person with a terminal illness. In fact, the patient is involved in the decision-making process for choosing how they would like to be treated for their pain. In the majority of cases, most medication is given orally to avoid the discomfort injections would cause the patients. Some of the fears hospice care addresses include:

* Fear of pain related to the illness

* Fear of becoming a burden to the family

* Fear of financing the cost of a terminal illness

The hospice team of doctors, nurses, psychologists, spiritual counselors, and volunteers provide such everyday support services as administering medication, lending equipment, shopping, cleaning, and running errands for the patient. The hospice staff can be reached 24 hours a day and will visit a patient when needed, whether night or day.

Availability of Hospice Care

Those seeking hospice care for a friend or relative can find a listing in their local telephone directory’s yellow pages. However, most people find out about a particular hospice through a friend, neighbor, or family member who has experienced hospice care. Other ways to obtain information about hospice care is through a pastor, a physician’s referral (which is the only way Canadian residents may obtain hospice care), newspaper advertisements, and community club presentations (i.e., Kiwanas, Rotary, local library, and others).

There are more than 200 hospices in the United Kingdom and Ireland, and 2,000 hospice programs in the United States with more than 33,500 full-time staff members. Great Britain is now the leading country for palliative care training and treatment.

How Hospice Prepares the Family

Hospice care does not only care for the individual, but for the family, as well. Here are some of the ways hospices help the families care for patients in the homes:

* The hospice staff walks through the realistic needs of the patient, such as a hospital bed, commode chair, or walker. The hospice also tries to fulfill the heartfelt needs of the patient, no matter how big or small.

* Hospice nurses serve as go-betweens for the patient and his or her doctor. The hospice also teaches the family how to administer pain medications. Patients aren’t required to make office visits.

* The hospice instructs the family that taking care of the patient must be a team effort among all family members.

* The hospice team encourages the family to surround themselves with a network of support from friends and church members.

* The hospice encourages the family to reminisce and take time out for light-hearted moments with the patient. The family is also urged to express their true feelings about what is happening.

* The hospice doctor instructs the family how to react (i.e., who to call first) when the person passes away, as well as what the patient will look like. This training with the family leaves the family with a sense of empowerment. · Volunteers work with the family to give them breaks and to run errands for the family or the patient. Volunteers also offer companionship to the patient, especially if they are in a facility.

* The hospice also helps the family plan the funeral (which volunteers and staff members often attend), sends cards and letters, and offers continuing psychological and spiritual counsel to the family for as long as needed.

The Cost of Hospice Care

Hospice care is the most cost-effective way of caring for a terminally-ill person. In the U.S., the approximate estimated cost for hospital care is $1,756 per day, $284 per day at nursing facilities, and averages about $100 per day for at-home hospice care and $200 per day in a private facility. Hospice care is covered under Medicare, Medicaid (in some states), most private-insurance groups, and HMOs. Families may be asked to meet some uncovered costs. However, hospices rarely, if ever, turn down patients for financial reasons. Public and community support through donations, grants, memorial gifts and fund-raising events assist to help cover the cost of care.

How You Can Get Involved

Volunteers are a hospice’s life-blood and keep the facility running in an efficient, caring manner. To become involved with hospice care:

* Contact your local hospice and find out how you can become a volunteer. Volunteers are fully trained by the hospice.

* Or, if you know a patient in your church, business, or neighborhood, you can assist the patient and their family on your own.

Other Practical Suggestions:

* Listen

* Pray

* Write letters or thank you notes for the patient

* Bake cookies for visitors

* Prepare a basket of teas and coffees

* Buy and/or wrap Christmas and birthday gifts

* Run errands

* Do the laundry and dishes

* Clean or vacuum the house

* Provide a meal

* Help take care of the lawn and weed flower beds

* Help write the patient’s memoirs

* Send flowers

* Read to the patient

* Visit the patient to relieve care-giver

Carrie Gordon Earll is the Senior Policy Analyst for Bioethics at Focus on the Family and a fellow with the Center for Bioethics and Human Dignity.

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Book: Physician Assisted Suicide: Expanding the Debate (New England Journal of Medicine, 981119)

Volume 339, Number 21

(Reflective Bioethics.) Edited by Margaret P. Battin, Rosamond Rhodes, and Anita Silvers. 454pp. New York, Routledge, 1998. $21.99. ISBN 0-415-92003-5

In the current debate about physician-assisted suicide, proponents argue that legalization would respect contemporary values of patient autonomy and that the practice, if legalized, would be limited in application. Opponents maintain that physician-assisted suicide would violate contemporary values because it would be applied both coercively and extensively. Most of the essays in this collection acknowledge that physician-assisted suicide would indeed constitute a change in contemporary values and that the practice might become widespread; nonetheless, they convincingly show that these propositions are not in themselves sufficient ground either to support or to oppose its legalization. These essays, most by philosophers, thus move the current debate to a new level of interest and sophistication.

The opening chapter, by Patricia Mann, sets the tone for the entire volume. Mann states that the way the value of autonomy is currently invoked to justify assisted suicide “ignores the fabric of relationships, good and bad, within which our actions necessarily occur” and that if physician-assisted suicide is legalized, “our cultural expectations [about dying] will be transformed” and “may become a ubiquitous form of death within the next quarter of a century.” She concludes, “That may be a good thing, or it may not.” Most of the other essays take up Mann’s challenge, and whether they support or oppose legalization (and the collection is evenly balanced on this score), they examine the issues from this enlarged perspective with clarity and analytic rigor.

Margaret Battin envisions the prospect that legalized physician-assisted suicide would represent a fundamental shift in our cultural ideal of death and that assisted suicide would not be a rare event: “dying,” she says, “no longer [would be] something that happens to you but something you do.” Frances Kamm carefully dissects the current arguments advanced for physician-assisted suicide, rejecting the proposition that there are no moral differences between respecting a person’s wish to refuse life-prolonging treatment and his or her wish for hastened death, but advocating legalized physician-assisted suicide on the ground that death can be rationally and morally chosen as “a lesser evil” in many specific circumstances. Don Marquis acknowledges that decisions to proceed with assisted suicide are not necessarily a product of clinical depression or misinformation but can be “rational choices made in accordance with an individual’s fundamental values”; he nonetheless argues frankly for paternalistic restriction on this choice, because legalization “will make many of those in need of care worse off” and because laws can justifiably restrict the right to self-determination in order to protect people against “fundamental loss of well-being” (just as participation in the Social Security system is mandatory). John Arras maintains that individual morality is not the proper perspective for evaluating claims for or against legalized physician-assisted suicide but that predictable social harms require its rejection and, in any event, whichever policy is chosen will inevitably and tragically harm someone. The essays conclude with four chapters by theologians with different views about the moral evaluation of physician-assisted suicide that follow from the tenets of their various religions.

Not all the essays address the most fundamental questions raised by legalized physician-assisted suicide. Michael Teitelman, for example, maintains more narrowly that even if physician-assisted suicide is legalized, it should not be available in hospitals because its public character there would be likely to intensify the dangers of assisted suicide, which would be more controllable in other, noninstitutional settings. Bernard Gert, Charles Culver, and K. Danner Clouser make a case for legalizing the assisted suicide of competent, terminally ill patients by facilitating their refusal of food and water, as a preferred alternative to more extensive legalization of physician-assisted suicide. These essays too are distinguished by the clarity and care of their arguments.

The summaries in this review cannot convey the subtleties of argument and the refreshing lack of cant in these essays. This excellent collection, in short, accomplishes the goal proclaimed by the subtitle of the book: it succeeds in expanding the debate about legalizing physician-assisted suicide well beyond its current narrow framework.

Robert A. Burt, J.D.

Yale Law School

New Haven, CT 06520

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Euthanasia in the Netherlands - down the slippery slope? (Journal of Medical Ethics, 990200)

Editorial by Gillon, Raanan

Vol. 25 Issue 1, p3, 2p

In this issue of the journal two staunch opponents of euthanasia take a searching look at the results of a survey into euthanasia in the Netherlands and conclude that “the practice of voluntary euthanasia remains beyond effective control”. Among other criticisms, Drs Henk Jochemsen and John Keown point out that in the survey doctors admitted to intentionally shortening patients’ lives in the absence of the patient’s explicit request in twenty per cent of the 4,500 cases reported of intentional and active shortening of life, despite the fact that an explicit request from the patient is one of the preconditions of legal acceptance of euthanasia in the Netherlands.(n1) In a commentary Dr Hans van Delden, a Dutch physician and bioethicist who accepts the need for euthanasia as a measure of last resort, also accepts that the criticisms may have some validity, though he cautions that interpretations of empirical findings depend crucially on the moral stance of the interpreter.(n2) In a third paper Dr Cuperus-Bosma and other medico-legal social scientists find that in the legal assessment of those cases of euthanasia that are reported to the public prosecution service in the Netherlands -- assessments which determine whether or not doctors will be prosecuted for murder -- doctors are likely to be subject to quite variable assessments, more or less “lenient”, depending on the particular assessor.(n3) For instance two of the 47 legal assessors surveyed would have dismissed from further investigation nine of the twelve hypothetical cases presented to them, while at the other end of the spectrum two other assessors would have recommended a summons in six of the twelve cases. Despite one of the basic requirements of the euthanasia code of practice being an explicit request from the patient, as many as five of the 47 prosecution service assessors were ready to dismiss one or more cases of euthanasia in the absence of an explicit request from the patient.

The three papers repay careful attention. Jochemsen and Keown are concerned about the various ways in which doctors in the Netherlands who in the survey admitted to intentionally shortening the lives of some of their patients did so outside the agreed criteria. Thus first, in 17 per cent of 3,600 cases of euthanasia or assisted suicide doctors stated that alternative palliative treatment options existed but in almost all these cases the patients did not want them. Yet, argue Jochemsen and Keown, the euthanasia guidelines and a Dutch Supreme Court decision forbid euthanasia when the alternative of palliative treatment is available. It should be noted that the issue here turns crucially on what is meant by “available” -- it could be reasonably argued that a treatment rejected by a patient is not “available” -- at any rate not to the doctor, who of course cannot treat a competent patient without that patient’s consent. As Van Delden points out, this finding may simply be reflecting a shift towards recognising the importance of patients’ own attitudes and decisions about the available treatment options and an acceptance that patients faced with the prospect of inevitable suffering, loss of dignity and decline, for example after a major stroke, should be given the option of choosing euthanasia rather than continuing down that path. And as Van Delden also points out, moral evaluation of this development will depend on one’s moral views. Whether or not this represents, as Jochemsen and Keown assert it does, a slide down the slippery slope, or whether it represents a valuable extension of a patient’s right to choose -- and a doctor’s right to assist in the decision -- not to undergo the suffering (including the indignities) associated with certain incurable diseases, is not determined by the empirical finding.

The same recognition of a patient’s right to choose does not, however, seem to underlie the survey’s finding that 900 patients -- twenty per cent of the 4,500 patients whose lives the doctors had said they had actively and intentionally helped to end by euthanasia or assisted suicide -- had had their lives ended without their explicit request. In a third of the 900 cases although there had been a previous discussion about possible termination of life, and although some fifty per cent of these patients were competent at the time of their death, their lives had been ended without their explicit request.

Jochemsen and Keown also point to cases where doctors admitted to administering palliative drugs at least partly with the intention of shortening life but without discussing it with patients, despite the fact that some of these patients were competent and able to have such discussion. In addition, of the many cases of withdrawal or withholding of life-sustaining treatment a small number were both explicitly intended to shorten life and did not involve discussion with patients who were admitted to be competent to have such discussion. And in 41 per cent of 1,000 deaths in the first year of life, life-prolonging treatment had been withheld or withdrawn with the explicit intention of shortening the baby’s life. Where this had been done because the doctor thought the baby’s life was unbearable, in 20 per cent of cases there had been no discussion with the parents. Finally, Jochemsen and Keown point out that many doctors, according to the survey, were failing to consult with colleagues as required by the euthanasia guidelines before carrying out euthanasia or assisting with suicide; and that almost 60 per cent of all cases of euthanasia and assisted suicide were not reported to the legally appointed authorities.

As Van Delden points out, these figures do not necessarily point to any slippery slope -- they are not much different from the previous survey in 1990, and before that time we simply do not know how much euthanasia of various sorts was carried out in Holland any more than we know how much was -- and is -- carried out in other countries. Certainly it is reasonable to infer that very much more voluntary euthanasia is being reported to the authorities in the Netherlands than in most other countries. And it might be added, the sorts of cases in the non-voluntary euthanasia vignettes offered by Dr Cuperus-Bosma and colleagues indicate that if there is a slippery slope in the Netherlands it does not have Nazi-like atrocities at its foot.

None the less what is shown by the empirical findings is that restrictions on euthanasia that legal controls in the Netherlands were supposed to have implemented are being extensively ignored and from that point of view it is surely justifiable to conclude, as Jochemsen and Keown do conclude, that the practice of euthanasia in the Netherlands is in poor control; and in particular, that as well as voluntary euthanasia, which is explicitly legally acceptable there, involuntary and non-voluntary euthanasia are also being carried out, despite their remaining illegal and officially uncondoned. On the other hand as Van Delden points out, this may always have been the case for we simply have no reliable evidence about its extent in the past any more than we have reliable evidence of its extent in most other countries. The culture of relative openness that has developed in the Netherlands is surely to be welcomed. In most of the rest of the world euthanasia is not legally accepted but almost certainly is surreptitiously practised.

More empirical studies of euthanasia would surely be useful, both in the Netherlands and in other countries. Such investigations would be particularly useful if the attitudes to euthanasia of the researchers could be rigorously prevented from affecting the design, performance and interpretation of their studies. One possible way of achieving such an objective might be for a multinational, multidisciplinary, multiattitudinal research project to be funded in the forthcoming round of European Union Biomed bioethics research projects. Among the social questions worth asking in such a project would be: what, in different countries, are people’s real fears about what lies at the bottom of a slippery slope if euthanasia is legalised, and how much, if at all, are such fears being realised in the Netherlands? For example, one of the common worries in the UK about the legalisation of voluntary euthanasia is that people will feel pressured into “volunteering”, either to avoid being a burden on the state, and/or to avoid being a burden on their families. It would be of great benefit to discover how much, if at all, this is occurring in the Netherlands. And so far as non-voluntary and involuntary euthanasia are concerned one obvious and major fear is that people will be killed without their consent in circumstances where they would otherwise have continued to live a life they considered worth living. Is that happening in the Netherlands? Were it possible to design studies that could offer some reliable answers to such questions, both in the Netherlands and in countries where euthanasia is illegal, then perhaps we could obtain information useful for policy-making about whether or not the Dutch social experiment with legalised euthanasia is or is not descending a socially dangerous slippery slope.

References

(n1) Jochemsen H, Keown J. Voluntary euthanasia under control?: further empirical evidence from the Netherlands. Journal of Medical Ethics 1999; 25:16-21.

(n2) Delden van JM. Slippery slopes in fiat countries -- a response to Jochemsen and Keown. Journal of Medical Ethics 1999;25:22-24.

(n3) Cuperus-Bosma J, van der Wal G, Looman C, van der Maas P. Assessment of physician-assisted death by members of the public prosecution in the Netherlands. Journal of Medical Ethics 1999; 25:8-15.

~~~~~~~~

By Raanan Gillon, Imperial College School of Medicine, University of London

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Voluntary euthanasia under control? Further empirical evidence from the Netherlands (Journal of Medical Ethics, 990200)

Jochemsen, Henk and Keown, John

Vol. 25 Issue 1, p16, 6p

Abstract

Nineteen ninety-six saw the publication of a major Dutch survey into euthanasia in the Netherlands. This paper outlines the main statistical findings of this survey and considers whether it shows that voluntary euthanasia is under effective control in the Netherlands. The paper concludes that although there has been some improvement in compliance with procedural requirements, the practice of voluntary euthanasia remains beyond effective control. (Journal of Medical Ethics 1999;25:16 21)

Keywords: Euthanasia; the Netherlands; regulation; slippery slope

Introduction

Worldwide, the euthanasia debate continues to intensify. In 1997, the Australian parliament voted to repeal euthanasia legislation in the Northern Territory and the US Supreme Court upheld the constitutionality of legislation prohibiting “physician-assisted suicide”.(n1) In deciding whether euthanasia or assisted suicide should be permitted in principle, and whether they can be controlled in practice, the experience of the Netherlands, where they have been officially tolerated and widely practised for well over a decade, is clearly of profound importance.

Nineteen ninety-one saw the publication of the results of an important survey, by Professor PJ van der Maas, into end-of-life decision making by Dutch doctors in the year 1990.(n2) Despite claims to the contrary by supporters of Dutch euthanasia, this survey helped to cast serious doubt on Dutch claims that their guidelines were sufficiently strict effectively to control the practice of voluntary euthanasia (the intentional termination of patients’ lives at their request) and to prevent non-voluntary euthanasia (the intentional termination of the lives of patients incapable of making a request).

The survey disclosed the widespread practice of non-voluntary euthanasia; the use of euthanasia even when doctors thought that palliative care was a viable alternative, and the common practice by doctors of illegally certifying euthanasia deaths as deaths by “natural causes” instead of reporting them, as required by the guidelines, to the authorities.(n3)

In 1996, Van der Maas and Van der Wal published the results of an extensive survey into end-of-life decisions by Dutch doctors in the year 1995.(n4) Do the results of this survey show any improvement in the degree of control over euthanasia?

I The survey

The survey sought particularly to ascertain the incidence of intentional life-shortening by doctors; the extent to which they complied with their duty to report such cases (in accordance with a procedure dating from late 1990 which was given statutory force in June 1994), and the quality of their reporting. The main purpose of the reporting procedure is to provide for possible scrutiny of the intentional termination of life by doctors and to promote careful decision making in such cases.(n5) The most important quantitative data generated by the survey are reproduced in table 1.

Before the figures are analysed, it is important to note that the only objectively verifiable figures are those concerning the total number of deaths and the total number of cases reported. All the other figures are based on the responses of the physicians concerning cases in which they said they had recently been involved.

It is no less important to stress that this paper does not question the methodology used by the researchers to obtain their data, namely, interviews with 405 physicians and postal questionnaires mailed to physicians who had attended 6,060 deaths identified from death certificates. We use the researchers’ own data and standardly cite their “best estimate” (though in some cases numbers have been arrived at on the basis of percentages and numbers used in the survey and, in such cases, we have rounded off the number arrived at). In other words, our paper does not take issue with the researchers’ methodology but with their interpretation of the statistics it generated.

A final preliminary point is that the Dutch adopt a particularly narrow definition of “euthanasia” as the intentional shortening of a patient’s life at the patient’s explicit request. In other words, “euthanasia” in the Netherlands means “active, voluntary euthanasia” and does not include intentional life-shortening by omission (“passive euthanasia”) or euthanasia without the patient’s request (whether non-voluntary if the patient is incompetent or involuntary if the patient is competent.) For ease of exposition, the Dutch definition is followed here unless the contrary is apparent.

1. EUTHANASIA AND ASSISTED SUICIDE

Between 1990 and 1995 the number of requests for euthanasia increased, as did the number of requests granted.(n6) Cases of euthanasia and assisted suicide rose from 2,700 cases in 1990 to 3,600 in 1995, or from 2.1% to 2.7% of all deaths.

According to the attending physicians, there were treatment alternatives in 17% of these cases but in almost all the patients did not want them.(n7) However, in 1994, the Dutch Supreme Court held that doctors should not hasten death whenever the alternative of palliative treatment was available, at least in cases of mental suffering(n8) and the ministers of justice and health,(n9) and the Royal Dutch Medical Association (KNMG),(n10) have decided that the same restriction should apply in cases of somatic suffering. The above cases appear, therefore, to have breached this guideline.

Life was shortened by one to four weeks in 31% of euthanasia cases and 45% of assisted suicides and by more than a month in 7% of cases of euthanasia and in 30% of assisted suicides.(n11)

Physicians stated that the main reason why patients requested euthanasia was “intolerable suffering without prospect of improvement” (74%),(n12) which has become the standard terminology to describe the seriousness of the condition required by the law. But the next most common reasons were “to prevent loss of dignity” (56%) and “to prevent further suffering” (47%). It must surely be doubted whether either of these reasons, by itself, satisfies the requirement of unbearable suffering.

Interestingly, one of the most important reasons for rejecting a request for euthanasia (cited by 35% of physicians) was the physician’s opinion that the patient’s suffering was not intolerable.(n13) This suggests that, despite the emphasis placed by the advocates of euthanasia on patient autonomy, the application of euthanasia is more a function of the physican’s judgment about the quality of the patient’s life than of respect for the patient’s autonomy. This suggestion is fortified by the evidence about the extent to which Dutch doctors continue to terminate the lives of patients without an explicit request.

2. LIFE-TERMINATING ACTIONS WITHOUT EXPLICIT REQUEST

The survey confirms that the intentional shortening of patients’ lives without explicit request remains far from uncommon. Nine hundred patients had their lives ended without explicit request in 1995, representing 0.7% of all deaths, only a slight decrease on the 0.8% so terminated in 1990.(n14) In other words, of the 4,500 (3,200+ 400 + 900) cases in which doctors admitted they actively and intentionally terminated life, one in five involved no explicit request.

The main reason for not discussing the issue with the patient was stated to be the patient’s incompetence (due, for example, to dementia). But not all patients whose lives were terminated without an explicit request were incompetent. In 15% of cases where no discussion took place but could have, the doctor did not discuss the termination of life because the doctor thought that the termination of the patient’s life was clearly in the patient’s best interests.(n15)

Furthermore, in a third of the 900 cases, there had been a discussion with the patient about the possible termination of life, and some 50% of these patients were fully competent, yet their lives were terminated without an explicit request.(n16)

Moreover, in 17% of the 900 cases, treatment alternatives were thought to be available by the attending physician.(n17)

The physicians thought that life was shortened by one to four weeks in 3% of cases but by more than a month in 6%.(n18) Finally, physicians had not discussed their action with a colleague in 40% of cases, with a close relative in 30% of cases, and with anyone at all in 5%.(n19)

3. INTENSIFICATION OF PAIN AND SYMPTOM TREATMENT

In 20,000 cases (according to the physician interviews) or 25,800 cases (according to the death certificate survey), palliative drugs were administered in doses which almost certainly shortened life. In some 2,000 of these cases the doctor explicitly intended, and in a further 2,850 cases, partly intended, to shorten life. The researchers estimate that the grey area between intending to alleviate pain and symptoms and intending to shorten life is about 2% of all deaths, the same as in 1990.(n21)

Where doctors administered palliative drugs partly in order to shorten life, they had discussed it with the patient in just over half of the cases (52%) and in only 36% of the cases was there an explicit request for life-shortening doses by the patient. The physicians stated that 86 patients (3%) with whom they had not discussed this treatment were fully competent.(n22) Moreover, in only 36% of the cases had the doctors consulted a colleague. Life was shortened by an estimated one to four weeks in 7% of cases but by more than a month in 1%.(n23)

4. WITHHOLDING/WITHDRAWING TREATMENT

In some 27,300 cases a treatment was withheld or withdrawn (in 5,200 cases at the patient’s explicit request) taking into account a probable shortening of life.

However, in 18,000 of these cases (14,200of which involved no explicit request by the patient) it was the physician’s explicit intention to shorten life (though the survey does not state in how many cases the treatment was disproportionate, in which case doctors could, had they wished, have properly withdrawn it for that reason and without intending to shorten life.(n24))

In the majority of cases in which no discussion with the patient had taken place, the physicians stated that the patient was either incompetent or only partly competent. However, in 1% of these cases (140 patients) the physician considered the patient fully competent.(n25)

In cases where treatment was withheld or withdrawn with the explicit intent to shorten life, the physician estimated that life was shortened by one to seven days in 34% of cases, by one to four weeks in 18% and by more than a month in 9%.(n26)

5. NEONATES

The survey reports that over 1,000 newborns die in the Netherlands before their first birthday and estimates that the lives of about 15 are actively and intentionally terminated by doctors.(n27) The figure of 15 seems, however, a significant underestimate.

The survey shows that in ten cases (1%) doctors administered a drug with the explicit intention of shortening life. But it also reveals a further 80 cases in which, also with the explicit intention of shortening life, doctors administered a drug and withdrew or withheld a life-prolonging treatment.(n28) In total, therefore, it appears to have been the explicit intention of doctors to shorten the lives of 90 neonates, not 15.(n29)

Moreover, in no fewer than 41% of the 1,000 cases, treatment was withdrawn or withheld with the explicit intention of shortening life. In a significant proportion of these cases, life was terminated because the babies’ lives were not thought bearable. Forty-five per cent of these babies were expected to live more than four weeks, and some of them more than half a year.(n30)

In around a fifth of cases in which doctors intentionally withheld or withdrew treatment with the explicit purpose of shortening life because the baby’s life was thought unbearable, there had been no discussion with the parents.(n31) Doctors said that in most cases this was because the situation was so clear that discussion was unnecessary or because there was no time, though these reasons are not elaborated.

Finally, doctors reported hardly any cases of the intentional shortening of neonatal life to the authorities.

6. ASSISTED SUICIDE OF PSYCHIATRIC PATIENTS

Based on the replies of psychiatrists in respect of the year 1995, the survey estimates that although some 320 psychiatric patients explicitly request assistance in suicide annually, only two to five are assisted to commit suicide by psychiatrists. Among psychiatrists who would never grant a request for assisted suicide on the basis of mental suffering (almost 1/3 of the respondents) “professional opinion” was cited by 88% as the most important reason. Only 2% of psychiatrists had ever assisted suicide.(n32)

This relatively restrictive approach of psychiatrists may owe not a little to the controversy generated by the case of Dr Chabot, a psychiatrist criticised by a medical disciplinary court for assisting in the suicide of a 50-year-old woman who suffered grief after the loss of her two sons.(n33)

Disclosing statistics which support a restrictive approach, the survey also indicates that of those patients not assisted in suicide, 16% committed suicide without assistance by a physician and that, of those patients still living, 35% no longer wished for death and that the death wish in a further 10% had diminished.

7. CONSULTATION

The guidelines for permissible euthanasia and assisted suicide require the doctor, before agreeing to either, to engage in a formal consultation (consultatie), and not merely an informal discussion (overleg), with a colleague.

In cases of euthanasia and assisted suicide 92% of doctors had, according to the survey, discussed the case with a colleague.(n34) In 13% of these cases, however, the discussion did not amount to a formal consultation. Consultation took place, therefore, in 79% of cases. However, other figures in the survey suggest that consultation occurred in a significantly smaller percentage of cases. For the survey indicates that consultation occurred in 99% of reported cases but in only 18% of unreported cases(n35) and that almost 60% of all cases of euthanasia and assisted suicide were not reported,(n36) from which it seems that consultation occurred in only around half of all cases.(n37)

In the cases of life-termination without explicit request, a discussion occurred in 43% of cases but in 40% this did not amount to consultation. Consequently, there was no consultation in 97% of such cases.

Moreover, even when consultation did take place, it was usually with a physician living locally and the most important reasons given for consulting such a physician were his views on life-ending decisions and his living nearby: expertise in palliative care was hardly mentioned. Further, in the overwhelming majority of cases, the first doctor had made his mind up before consulting and the doctor consulted disagreed in only 7% of cases.(n38) In short, the requirement of consultation, even when it is satisfied, hardly operates as a rigorous check on decision making.

8. REPORTING

In 1995 41% of cases of euthanasia and assisted suicide were reported to the local medical examiner, as required by the reporting procedure. While this is an improvement on the figure of 18% reported in 1990, it means that a clear majority of cases, almost 60%, still go unreported. Moreover, the survey confirms that the legal requirements are breached more frequently in unreported cases, in which there is less often a written request by the patient, a written record by the doctor, or consultation by the doctor.(n39)

The most important reasons given by doctors for failing to report in 1995 were (as in 1990), the wish to avoid the inconvenience (for the doctor and/or the relatives) of an investigation by the authorities, and to avoid the risk of prosecution (though, as the consistently tiny number of prosecutions indicates, this risk is negligible). Thirty per cent of doctors stated that they did not report because they had failed to observe the requirements for permissible euthanasia and 12% because they considered euthanasia was a private matter between doctor and patient.(n40)

II Discussion

The second survey confirms at least three disturbing findings of the first survey.

1. INCIDENCE OF INTENTIONAL LIFE-SHORTENING WITH AND WITHOUT EXPLICIT REQUEST

Like the first survey, the second indicates a sizeable incidence of intentional life-shortening by Dutch doctors. Even adopting the unusually narrow Dutch definition of euthanasia as active, voluntary euthanasia there were no fewer than 3,200 cases in 1995 (2.4% of all deaths), an increase of almost a thousand on the 1990 total of 2,300 (1.8% of all deaths).

But if all cases in which doctors explicitly intended to shorten life (whether by act or omission, and whether with or without the patient’s request) are included, the total rises steeply. Adding the cases of assisted suicide (400); life-termination without explicit request (900) and the intensification of pain and symptom treatment with the explicit intent to shorten life (2,000), the total more than doubles from 3,200 to 6,500.

And if to this number are added the cases of withholding or withdrawing treatment with the explicit intent to shorten life (18,000(n41)); cases in which neonates were intentionally terminated (90 cases) and psychiatric patients assisted in suicide (two to five cases), the total rises to over 24,500 cases.

2. EUTHANASIA AS AN ALTERNATIVE TO PALLIATIVE CARE

The survey’s comment that “the quality of medical treatment near the end of life has improved”(n42) might not unreasonably be thought to display a certain complacency, particularly in a country which has some way to go in the provision of adequate palliative care. The high incidence of intentional life-shortening disclosed by the survey and the relative weakness of the reasons for euthanasia given in many cases by the doctors tend to suggest that euthanasia is not confined to cases of “last resort” and is at least sometimes used as an alternative to palliative care. The case of Dr Chabot, in which the defendant doctor assisted a grieving woman, whom he did not consider to be physically or mentally ill, to kill herself, and in which the Supreme Court held that such suffering could indeed justify assisted suicide, illustrates the elasticity of the requirement of “unbearable suffering”.

The survey confirms that, even when doctors believe that treatment alternatives are available, they not infrequently resort to euthanasia. The opinion of the Supreme Court, the ministers of justice and health, and the KNMG, that euthanasia is impermissible when treatment alternatives are available, even if the patient refuses them, has clearly not prevented its administration in such circumstances. In a move that would make the prospect of prosecution even more remote, the then minister of justice appeared to reverse her earlier position and instructed the attorneys general that the refusal by the patient of available treatment alternatives does not render euthanasia unlawful.(n43)

3. WIDESPREAD BREACH OF THE REQUIREMENT TO REPORT

Although 41% of cases (1,466) were reported in 1995 as opposed to 18% (486) in 1990, it remains true that in both years, as in every year in between, a clear majority of cases has gone unreported. There was, in short, no official control whatever over the majority of cases of euthanasia, assisted suicide or the termination of life without explicit request.

Nor should the alleged increase in reporting be accepted uncritically. First, the second survey records an increase in cases of euthanasia between 1990 and 1995 (900 cases) almost as large as the increase in cases reported (980 cases). Secondly, if the total of 6,500 cases of active, intentional life-shortening is used, then the proportion of unreported cases rises from 59% to 77%. On the total of 24,500 cases, the proportion unreported reaches 94%.

It will be recalled that the purpose of the reporting procedure is to allow for scrutiny of the intentional termination of life by doctors and to promote observance of the legal and professional requirements for euthanasia. The undisputed fact that a clear majority of cases (59% according to the survey, at least 77% on our calculations) still goes unreported, serves only to reinforce doubts about the ability of the procedure to fulfil its purpose and to undermine Dutch claims of effective regulation, scrutiny and control. Further, even those cases which are reported are reported by the doctor, and one may wonder whether the doctor’s report is any more likely to disclose evidence of wrongdoing than is a tax return to disclose evidence of undeclared earnings.

Conclusions

With the publication of the first Van der Maas survey in 1991 it became clear that the so-called “strict safeguards” laid down in 1984 by the courts and the Royal Dutch Medical Association had largely failed. The survey cast doubt on central assurances which had been given by the advocates of voluntary euthanasia: that euthanasia would be performed only at the patient’s explicit request and that doctors terminating life without request would be prosecuted for murder; that euthanasia would be used only in cases of “last resort” and not as an alternative to palliative care; and that cases would be openly reported and duly scrutinised. The Dutch reaction to the survey’s findings was also revealing: the cases of non-voluntary euthananasia it disclosed, far from being criticised, were largely condoned. In short, the survey indicated that, in less than a decade, the Dutch had slid down the slippery slope.

It is therefore surprising that an American commentator should observe that the similarity between the findings in respect of 1990 and 1995 shows that the Dutch are apparently not descending a slippery slope.(n44) This observation quite overlooks the fact that the first survey showed that the descent had already occurred by 1990: the second survey, far from showing that there has been no descent from 1984 to 1995 shows merely that there has been no significant ascent from 1990 to 1995.

The second survey is little more reassuring than the first. Dutch proponents of voluntary euthanasia claimed that tolerating voluntary euthanasia, subject to “safeguards”, would allow it to be “brought into the open” and effectively controlled. As the valuable surveys by Van der Maas and Van der Wal disclose, and as several expert commentators have now concluded,(n45) the reality is that a clear majority of cases of euthanasia, both with and without request, go unreported and unchecked.(n46) In the face of the undisputed fact that in a clear majority of cases there is not even an opportunity for official scrutiny, Dutch claims of effective regulation ring hollow.

Table 1 End-of-life decisions by doctors in the Netherlands 1990-1995

	1990	1995
Deaths in the Netherlands	129000 (100%)	135500 (100%)
Requests for euthanasia	8900(7%)	9700 (7.1%)
Euthanasia	2300 (1.8%)	3200 (2.4%)
Assisted suicide	400 (0.3%)	400 (0.3%)
Life-terminating acts without explicit request	1000 (0.8%)	900 (0.7%)
Intensification of pain and symptom treatment	22500 (17.5%)	20000 (14.8%)
a. Explicitly intended to shorten life	1350(1%)	2000 (1.5%)
b. Partly intended to shorten life	6750 (5.2%)	2850 (2.1%)
c. Taking into account the probability that life will be shortened	14400 (11.3%)	15150 (11.1%)
Withdrawal/withholding treatment (incl tube-feeding)	22500 (17.5%)	27300 (20.1%)
a. At the explicit request of the patient	5800 (4.5%)	5200 (3.8%)
b. Without the explicit request of the patient
b1. Explicitly intended to shorten life	2670 (2.1%)	14200 (10.5%)
b2. Partly intended to shorten life	3170 (2.5%)	--
b3. Taking into account the probability that life will be shortened	10850 (8.4%)	7900 (5.8%)
Intentional termination of neonates	--
a. Without withholding/withdrawing treatment	--	10
b. Withholding/withdrawing treatment plus administration of medication explicitly to shorten life	--	80
Assisted suicide of psychiatric patients	--	2-5

References and notes

(n1) Washington v Glucksberg (1997) 117 S Ct 2258; Vacco v Quill (1997) 117 S Ct 2293.

(n2) Maas PJ van der et al. Medische beslissingen rond het levenseinde. ‘s-Gravenhage: SDU Uitgeverij Plantijnstraat, 1991 (published in translation as Euthanasia and other medical decisions concerning the end of life. Amsterdam: Elsevier, 1992).

(n3) See for example Jochemsen H. Euthanasia in Holland: an ethical critique of the new law. Journal of Medical Ethics 1994;20:212; Keown J. Euthanasia in the Netherlands: sliding down the slippery slope? In: Keown J, ed. Euthanasia examined. Cambridge: Cambridge University Press, 1995: ch 16.

(n4) Wal G van der, Maas PJ van der. Euthanasie en andere medische beslissingen rond het levenseinde. De praktijk en de meldingsprocedure. (Euthanasia and other medical decisions concerning the end of life. Practice and reporting procedure.) Den Haag: SDU uitgevers, 1996. For summaries of the research in English see Maas PJ van der. Euthanasia, physician-assisted suicide, and other medical practices involving the end of life in the Netherlands, 1990-1995. New England Journal of Medicine 1996;335:1699; van der Wal G. Evaluation of the notification procedure for physician-assisted death in the Netherlands. New England Journal of Medicine 1996;335:1706.

(n5) See reference 4: 25.

(n6) See reference 4: tables 5.3; 6.2; 9.1.

(n7) See reference 4: table 5.5.

(n8) Nederlands Juristenblad 1994; 69 nr26: 895ff. See also Jochemsen H. The Netherlands experiment. In: Kilner JF et al, eds. Dignity and dying. Grand Rapids: Eerdmans, 1996: ch 12; Hendin H. Seduced by death: doctors, patients and the Dutch cure. New York: WW Norton, 1997: ch 2.

(n9) Sorgdrager W, Borst-Eilers E. Euthanasie -- De stand van zaken. Medisch Contact 1995;12:381-4.

(n10) Kastelijn WR. Standpunt hoofdbestuur KNMG inzake euthanasie. Utrecht: KNMG, August 1995.

(n11) See reference 4: table 5.4.

(n12) See reference 4: table 5.6.

(n13) See reference 4: table 5.12.

(n14) See reference 4: table 6.2; 92.

(n15) See reference 4: table 6.5.

(n16) This suggests a disturbing incidence not only of non-voluntary euthanasia but also of involuntary euthanasia.

(n17) See reference 4: table 6.4.

(n18) See reference 4: table 6.3.

(n19) See reference 4: table 6.6.

(n20) See reference 4: table 7.2.

This figure is calculated from the researchers’ percentages and estimates at pages 92-93. In fact the figure of 2,000 is conservative as it is derived from the total number of 20,000 cases yielded by the physician-interviews rather than from the larger total of 25,800 in the death certificate study. “Explicit” is the researchers’ translation of the word “uitdrukkelijk”. We think a more accurate translation would be “primary” as a purpose can be explicit yet secondary or primary yet implicit.

(n21) See reference 4: 93.

(n22) See reference 4: table 7.4.

(n23) See reference 4: tables 7.3; 7.5.

(n24) See reference 4: tables 8.1; 8.3; 84.

(n25) See reference 4: tables 8.1; 8.3.

(n26) See reference 4: table 8.2.

(n27) See reference 4: 189.

(n28) See reference 4: table 17.2.

(n29) The researchers’ estimate of 15 cases may be traced to their observation that in 17% of cases in which drugs were administered with the explicit intent to shorten life (totalling 15 cases), one of the drugs administered paralysed muscles and therefore caused death almost immediately whereas in a majority of cases in which drugs were administered in combination with the withdrawal of treatment, the treatment withdrawn was artificial ventilation and the medication may have been administered to prevent suffocation.

(n30) See reference 4: table 17.3.

(n31) See reference 4: table 17.5.

(n32) See reference 4: table 18.1.

(n33) See reference 8: Hendin: ch 2.

(n34) See reference 4: table 10.1.

(n35) See reference 4: table 10.2.

(n36) See text on page 19 immediately preceding reference 39.

(n37) The reason for the discrepancy between the two totals might be a certain bias in the physicians’ responses. The authors of the survey suggest that some of the physicians interviewed, when asked to discuss their most recent case of euthanasia, in fact discussed a recent case which had a stronger impact, probably because it was reported. See reference 4:113. 38 See reference. 4: 102-7.

(n39) See reference 4: table 11.6.

(n40) See reference 4: table 11.8; 225.

(n41) 14,200 of these cases involved no explicit request from the patient. In cases where the patient had refused treatment, the doctors could properly, had they wished, have omitted treatment for this reason and without intent to shorten life. Similarly, as was mentioned above, it is unclear in how many cases of non-treatment the treatment was in fact disproportionate and could properly have been withdrawn for that reason without the doctors resorting to an intention to shorten life.

(n42) See reference 4: 240.

(n43) See reference 4: 144-5.

(n44) See for example Angell M. Euthanasia in the Netherlands -- good news or bad? New England Journal of Medicine 1996;335: 1677.

(n45) See for example Gomez C. Regulating death. New York: Free Press, 1991; see reference 8: Hendin; see reference 3: Jochemsen; see reference 3: Keown.

(n46) While acknowledging this fact, Dr Angell suggests that doctors fail to report because they find the reporting procedure “burdensome” and “daunting”. See reference 44:1677. But it is difficult to see how the procedure -- the filing of a report with the local medical examiner (another doctor) in the sure knowledge that if the guidelines have been followed there is no prospect of prosecution -- can realistically be so described. Indeed, many doctors admit that they omit to report simply because they do not want the inconvenience of an investigation either for themselves or the family (see text at page 19 immediately preceding reference 40).

~~~~~~~~

By Henk Jochemsen and John Keown

Henk Jochemsen, PhD, is Director of the Lindeboom Institute for Medical Ethics. John Keown, DPhil, is University Lecturer in the Law and Ethics of Medicine in the Faculty of Law, University of Cambridge.

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Tale of two laws (Ottawa Citizen, 990408)

Two events with a great deal in common were recently resolved: Retired pathologist Jack Kevorkian was convicted of second-degree murder because he killed a patient by lethal injection in full view of millions of TV viewers and Dr. Nancy Morrison received a mild reprimand from the Nova Scotia College of Physicians and Surgeons for administering a similar lethal injection to one of her patients who was dying of cancer.

There is a striking similarity between the cases. In both situations, a medically trained person knowingly injected their patient with potassium chloride, a substance commonly used in the United States to execute prisoners. Dr. Morrison denied doing it and her lawyers argued that her patient had died of natural causes.

In both cases, the professed excuse for “hastening death” was that they were acting to end another person’s suffering. Dr. Morrison’s case did not go to trial and, as a result, no serious efforts were ever made to determine whether or not her patient had actually been receiving proper pain control, either before or after, he was removed from the respirator. Potassium chloride is never used for pain relief. There is no other reason to inject such a dosage except to cause death.

There are also significant differences between these cases. Dr. Kevorkian’s killing was recorded for TV viewers but Dr. Morrison killed her patient in the antiseptic privacy of a tertiary hospital’s critical-care unit.

Another difference is the way the courts approached these killing acts. Dr. Kevorkian was convicted of second degree murder and awaits sentencing. Dr. Nancy Morrison had the charge of second degree murder quashed by a judge who accepted her lawyers’ claim that death was due to natural causes and so he ruled that there was insufficient evidence to go to trial. On appeal, a second judge inexplicably upheld the first judge’s ruling even though she had stated that “a reasonable and properly instructed jury could very well have returned a verdict of manslaughter or even first degree murder.”

Dr. Morrison’s punishment was a mild reprimand from the Nova Scotia College of Physicians and Surgeons. This same rap on the knuckles was issued to surgeon Claudio de la Rocha by the Ontario College of Physicians and Surgeons after he killed one of his patients in Timmins in October 1991 with an injection of potassium chloride.

In the U.S., the message is that killing of patients by doctors will not be tolerated in law. In Canada, the message is that the worst outcome for a physician for intentionally killing his or her patient is the possibility of a reprimand to the effect that injecting their patient with a lethal substance is “inappropriate and outside the bounds of currently acceptable medical practice.”

Physicians are not being warned that they are not to take the life of their patients for any reason. Instead, the message is that if they do kill their patients, Canadian doctors should be careful to do so in a manner which does not run counter to what the medical and legal establishments consider “appropriate.”

For all Canadians who are handicapped, chronically ill, terminally ill or taking too long to die, this is a disturbing trend in medical ethics.

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Doctors should heal, not ‘kill’ (National Post, 000524)

Background:

· In October 1993, the Supreme Court of Canada upheld the “sanctity of life” over “the right to die” and prohibited assisted suicide. In June 1995, a Senate committee recommended against euthanasia after lengthy public hearings.

BY Susan Martinuk

“Back in the Greco-Roman days, the whole Hippocratic tradition arose because physicians said, ‘We are different from other people. Somebody out there may give hemlock to that old man so he will die quickly tonight. Someone over here will bash that defective baby’s head against a rock so she will die. But a physician will not do those things.’ “ Dr. C. Everett Koop, former surgeon general of the United States.

In the days before the Hippocratic oath (which requires physicians to “first do no harm”), it was just as common that “health-care professionals” would kill a patient as heal him.

The sick were subjected to a plethora of potions and cures by various doctors, mystics and witch doctors and, unfortunately, whether they were cured or killed frequently depended on which relative was paying the bill -- and what he requested the “physician” to do.

Such practices seem barbaric in our modern age where we put our trust in doctors to save lives, not take them. Yet, ironically, it now appears our “progressive” health-care practices are leading us back to a time when doctors routinely betray their patient’s trust.

In recent weeks, there have been persistent allegations that doctors in Britain’s public hospitals are practising involuntary euthanasia (where death is induced without the consent of the patient). No attempts are being made to revive seriously ill, older patients and life-saving treatments are being withheld from disabled children and young people. Even more frightening is that doctors are making judgments about who lives and dies without consulting patients or their families -- a practice that runs contrary to the guidelines of the British Medical Association.

Jill Baker, a 67-year-old cancer patient, was shocked to find a note on her medical chart stating that “resuscitation would be inappropriate” in the event of a cardiac arrest or stroke. In other words, the doctors had planned to let her die if complications ensued.

There had been no discussion about this drastic measure with Baker or her husband, and she had never even met the doctor who wrote the order to let her die. The hospital has since admitted that the order was inappropriate and, nine months later, Baker is very much alive and living a full life.

Baker’s story is one of more than 100 cases currently alleging discriminatory medical practices against the elderly in Britain. A growing number of complaints also allege that doctors commonly issue Do Not Resuscitate (DNR) orders for seriously disabled children and young people without the knowledge or consent of parents. Still others allege doctors are coercing parents into agreeing to withhold life-saving treatment from their disabled children.

The allegations have sparked a major health-care scandal and, if true, paint a chilling picture of the future of health care.

Some health-care advocates claim inadequate funding and a high demand for scarce hospital beds have forced doctors to ration treatment and placed them in a position where they must determine which patient is more deserving of care.

A recent article in the British Medical Journal states that all “doctors have stereotypes of who is not worth saving” and that British doctors aren’t the only ones who may be making discriminatory determinations that have deadly consequences. Not surprisingly, American studies show DNR orders in U.S. hospitals are more commonly placed on blacks, non-English speaking patients, alcohol abusers and those who are HIV-positive.

If such practices are common in Britain and the United States, it isn’t difficult to presume similar scenarios are occurring in Canada.

After all, we have increasingly asked physicians to abandon their medical principles to solve our social problems. We have asked them to kill the unborn for reasons of our convenience. More recently, we have publicly debated giving doctors the legal right to “euthanize” the sick and the disabled, and we have cheered doctors and others who are willing to assist the sick in leaving this world behind. We have selfishly asked our doctors to take on the role of “killing” -- just so our lives can be lived with greater convenience and so we can pride ourselves in protecting a very confused notion of “human dignity.”

So we shouldn’t pretend to be shocked when physicians start to view the lives of the sick, the old and the disabled through the lens of convenience and make determinations about the value of life from a strictly utilitarian perspective.

These events are simply the next logical step in the moral devolution of a society that has already embraced death at the expense of life.

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Terminally misguided (National Post, 001130)

After years of tolerating euthanasia on an unofficial basis, Holland is set to become the first country in the world to legalize the practice. The move will set a frightening precedent, and one which Canadians would be wrong to applaud.

Advocates of the Dutch law insist the practice will remain rare and limited. The law requires, for instance, that the patient must be enduring “unbearable suffering”; he or she must make his or her request on a “voluntary, well-considered and sustained” basis; and there must be “no reasonable alternative” that is acceptable to the patient.

Such guidelines are obviously well-intentioned, but they will likely escape enforcement. A February, 1999, study published in the Journal of Medical Ethics found that, despite “strict guidelines” circulated among Dutch doctors, almost two-thirds of all cases of voluntary euthanasia and physician-assisted suicide in 1995 went unreported. Nearly 20% of deaths took place without the patient’s express request; in 17% of cases, alternative treatments were necessary; in 56% of cases, the justification for killing was not “unbearable suffering” but “loss of dignity.” Advocates for euthanasia often argue that a person’s right to self-determination includes the right to decide the manner and time of his or her death. Yet the facts show that decision-making over euthanasia often gets left to someone other than the person requesting it.

Not only are the guidelines likely to be breached, they may be loosened as well. In Oregon, where euthanasia is legal and subject to similar controls, there has been pressure to ease the rules. A fundraising letter for the Compassion in Dying Federation in America declares: “We have expanded our mission [in Oregon] to include not only terminally ill individuals, but also persons with incurable illnesses which will eventually lead to a terminal diagnosis.” That definition covers myriad conditions, including early stage cancer and heart disease. Kathryn Tucker, the Federation’s legal-affairs director, argues some of the “protective guidelines” in Oregon’s euthanasia law should be scrapped. One of the most crucial of these protections is the mandatory waiting period between the request for death and the issuance of the lethal prescription. Oregon’s law requires a 15-day wait; Ms. Tucker claims that this is “overly restrictive” and “unduly burdensome.”

All of the above argues for caution on euthanasia, but it is beside the main point. Even if guidelines could be devised to protect the vulnerable from the unscrupulous, there still exists a more profound objection to mercy killing: Euthanasia involves one person, generally a member of the healing professions, extinguishing the life of another. According to our Criminal Code and our shared sense of morality, that is a crime.

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Dead Wrong, but Still Kicking: The physician-assisted suicide movement loses again (Weekly Standard, 001218)

Maine voters’ rejection on November 7 of an initiative to legalize physician-assisted suicide was only the latest in a string of defeats for the American euthanasia movement. Granted, the margin was narrow—51.5 percent to 48.5 percent. And with the Netherlands finally in the process of formally legalizing assisted suicide, no one should infer that this tenacious international movement is dead. Still, its advocates in this country have failed to move the ball since 1994, when Oregon voters passed a legalization initiative. The latest setback should spur the media to give less coverage to killing as “medical treatment” and more to the underreported subject of truly compassionate assistance to the dying, such as pain control, symptom management, and hospice care.

If the assisted-suicide movement was rebuffed in Maine, it was not for lack of investment in the campaign. Euthanasia activists from around the nation had carefully selected Maine as the most promising site for a breakthrough. “Maine is a small state with a small media market, and proponents believed that they could carefully control the message,” explains Rita Marker, executive director of the International Anti-Euthanasia Task Force. “More importantly, some of the most vulnerable groups who oppose the assisted-suicide agenda nationally—disability rights activists, minorities, advocates for the poor—are not as numerous in Maine as they are elsewhere in the country, and thus assisted-suicide activists had substantial reasons to be optimistic about their chances of prevailing.”

The practice in Maine of allowing an initiative’s proponents to determine the wording that appears on the ballot also favored the measure. Euthanasia activists couched Question 1 in soothing language: “Should a terminally ill adult who is of sound mind be allowed to ask for and receive a doctor’s help to die?” And to mobilize support for it, they mounted a national full-court press. Euthanasia organizations from all over the country urged their members to donate time and money to the campaign, with much success. More than 90 percent of the financing for the “Yes on Question 1” campaign came from outside Maine. Many of the nation’s best-known assisted-suicide proponents—including Oregon governor John Kitzhaber—strove to persuade Maine voters to make it legal for doctors to write lethal prescriptions.

Initially, public support for the measure was high—70 percent, according to the Bangor Daily News of February 17, 2000. But as the campaign progressed and voters considered assisted suicide in the context of HMO cost-cutting, the potential for abuse and coercion, and the problems reported in Oregon despite the secrecy surrounding the practice there, public support steadily waned. When the final tally was made, the initiative lost by almost 20,000 votes.

The same pattern of early support for assisted-suicide initiatives, dwindling to eventual defeat at the polls, occurred in Washington state (1991), California (1992), and Michigan (1998). Even in Oregon, where the initiative passed, support shrank from nearly 70 percent at the beginning of the campaign to just 51 percent in the final tally.

The euthanasia movement, moreover, has also been stymied in the courts and legislatures. In 1997, its advocates failed to persuade the U.S. Supreme Court to issue an assisted-suicide Roe v. Wade. The vote in Washington v. Glucksberg was unanimous, a rare achievement for our often divided high court. Only a few months later, the Florida Supreme Court refused to rule that assisted suicide was a right under the privacy guarantee in the Florida Constitution.

And in 1999, a court in Michigan sentenced euthanasia’s most notorious practitioner, Jack “Dr. Death” Kevorkian, to 10 to 25 years in prison for the murder of Thomas Youk. Thus ended a macabre career that had helped eliminate some 130 people and made kidneys removed from one disabled victim available to the public on a “first come, first served” basis. Kevorkian had outworn the patience of law enforcement by arrogantly providing a videotape of his crime for airing on the program 60 Minutes.

As for the legislative arena, not one of the many euthanasia bills introduced at the state level has had a realistic chance of passage. A robust coalition came together to fight these bills. In addition to the constituencies mentioned by Rita Marker, this alliance includes hospice professionals, religious organizations, pro-lifers, and medical associations, all of them willing to set aside their differences on other controversial issues in order to unite against the proposition that doctors should have license to kill their patients.

The only prospect euthanasia advocates have for gains in the immediate future is in Alaska, where a lawyer for the misnamed Compassion in Dying Federation has sued under the privacy guarantee of the state constitution to overturn the state ban on assisted suicide. The suit failed in the trial court and was recently argued before the Alaska Supreme Court, where the justices noted the Florida high court’s refusal to legislate from the bench. The Alaska decision is expected next year.

Whatever happens in Alaska, assisted suicide won’t soon be widely legalized in the United States. Thus, the time has come to look beyond a movement that actively harms the dying and disabled people it purports to help. Not only does it disparage the value of their lives, but it diverts media and popular attention from all that medicine can do to make people’s dying days worth living.

It is high time that the issue of end-of-life care be given serious and concentrated consideration. For example, it is a national scandal that only 29 percent of Americans who died in 1999 received hospice services, and those who did often did so for only weeks or days. By contrast, in England the figure is 65 percent, and most hospice patients receive care for many months. For 30 years, the British have been educating the public about care for the dying, making hospice a household word. Nor do they place policy impediments between dying patients and hospice care—as we do in the United States, where patients are required to refuse all further curative treatment in order to receive hospice relief. According to Dame Cecily Saunders, the creator of the modern hospice movement, this irrational American rule makes patients, families, and physicians far less likely to turn to a hospice, which is seen as the end of all hope.

In an era when the media are addicted to scandal, assisted suicide makes for juicier copy than hospice care and pain control. But the stalling of the euthanasia movement can and should change that. The big story should be the challenge of creating a medical environment in which no American dies alone or in pain.

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Going Dutch: We ignore the Netherlands at our own peril (National Review, 001218)

By Wesley J. Smith, an attorney for the International Anti-Euthanasia Task Force. His latest book, Culture of Death: The Assault on Medical Ethics in America

The Netherlands is about to become the first nation in modern times to formally legalize euthanasia. The mainstream media stories about legalization frequently assert with a straight face that euthanasia will be governed by strict guidelines to prevent abuse. Well we’ve been hearing that little ditty for decades about Dutch euthanasia, and as Ira Gershwin once put it, “It ain’t necessarily so.” Indeed, the vaunted guidelines do not even rise to the level of paper tigers.

The newly enacted killing regulations are virtually identical to those that have governed Dutch euthanasia for many years under which euthanasia remained technically illegal but was not prosecuted so long as doctors followed the guidelines. (The only substantial difference between the former decriminalized regime and legalized euthanasia is that doctors will no longer have to notify coroners after they kill a patient.) Not only have the guidelines failed to protect vulnerable and devalued patients but they have been violated so often that they might as well not exist at all.

Here are the guidelines followed by a brief recitation describing how each has been violated in actual practice over the last 27 years:

When ending a life a physician must be convinced that the patient’s request was voluntary, well-considered, and lasting. Study after study of Dutch euthanasia practice have shown that Dutch doctors routinely kill patients who have not asked to be poisoned. (The favored method of killing in the Netherlands is an overdose of barbiturates followed by a lethal dose of curare.) In the Netherlands this practice is known as “termination without request or consent,” and is not even formally considered euthanasia in the statistics compiled by the government.

The evidence of decades demonstrates that such involuntary euthanasia is rampant. Indeed, in its 1997 ruling refusing to create a constitutional right to assisted suicide (Washington v. Glucksberg) the United States Supreme Court quoted a 1991 Dutch government study finding that in 1990 doctors committed “more than 1000 cases of euthanasia without an explicit request” and “an additional 4,941 cases where physicians administered lethal morphine overdoses without the patients’ explicit consent.” That means in 1990, nearly 6,000 of approximately 130,000 people who died in the Netherlands that year were involuntarily euthanized — approximately 4 percent of all Dutch deaths. So much for “choice.”

The physician must be convinced the patient was facing unremitting and unbearable suffering. Notice that this guideline does not require that the patient be dying or, for that matter, even be actually ill. Indeed, there have been several documented cases of euthanasia based on depression or suicidal ideation. For example, a Dutch documentary reported on the euthanasia of a young woman in remission from anorexia. Worried that her eating disorder would return, she asked her doctor to kill her. He did and the authorities refused to prosecute.

The most infamous case of this sort involved a physically healthy woman who had become obsessed about being buried between her two dead children. She bought a cemetery plot, had her children buried one on each side of her planned grave, and then asked a psychiatrist named Boutdewijn Chabot to assist her suicide. He met with her four times over approximately five weeks and never attempted treatment. He then assisted her suicide. The Dutch Supreme Court refused to punish him, ruling that suffering is suffering and it does not matter whether it is physical or emotional, to justify euthanasia.

Another documented euthanasia that violated this and other guidelines was depicted in a Dutch documentary played in this country in the PBS program the Health Quarterly, in 1993. Henk Dykma had asymptomatic HIV infection. Fearing future afflictions that might befall him, Henk asked his doctor to kill him. The film shows the doctor telling Henk that he might live for years at his current state of seemingly healthful living. When Henk still proclaims a desire to die, the doctor speaks with a colleague but never consults a psychiatrist or psychologist. He then helps kill Henk on July 28, a date, we are told, which had symbolic importance for the patient.

This killing, like those of the anorexic young woman and the bereaved mother, was clearly not a matter of last resort, as the guidelines claim to require. Henk and his doctor did not explore all other options available to him before ending his life. Indeed, psychiatric treatment, which might have alleviated Henk’s obvious anxiety about being HIV-positive, was never even discussed or attempted. Nor was Henk advised of the steps that could be taken to alleviate his suffering should he fall ill. The doctor didn’t even wait until Henk had actual symptoms of AIDS. There is a word for that level of care — abandonment — and it demonstrates the utter hollowness of the Dutch protective guidelines.

The physician must have informed the patient about their situation and prospects. This guideline presumes that the physicians involved will have sufficient expertise to adequately inform the patient about their condition and options for treatment or palliation. But the Dutch medical system is unlike ours. It is primarily made up of general practitioners, rather than specialists, who may not have the training, expertise, or desire to know the many treatment alternatives that may be available. Moreover, there are few hospices in the Netherlands, meaning that the many compassionate and dignified methods of alleviating suffering in the dying may never be discussed with patients who ask to be killed.

A good example of this phenomenon is illustrated in the memoir Dancing with Mr. D, written by a Dutch nursing-home doctor named Bert Keizer. Keizer writes about a patient who had been tentatively diagnosed with lung cancer. A relative tells Keizer that the man wants to be given a lethal injection, a request later confirmed by the patient. Keizer quickly agrees to perform the killing. Demonstrating the utter uselessness of “protective guidelines,” Keizer never tells his patient about treatment options that may be available or how the pain and other symptoms of cancer can be palliated effectively. He never checks to see if the man has been pressured into wanting a hastened death or is depressed. Indeed, Keizer doesn’t even take the time to confirm the diagnosis with certainty or to prepare a prognosis about the expected course of the disease. When a colleague asks, why rush, and points out that the man isn’t suffering terribly, Keizer snaps:

Is it for us to answer this question? All I know is that he wants to die more or less upright and that he doesn’t want to crawl to his grave the way a dog crawls howling to the side walk after he’s been hit by a car.

The next day, he lethally injects his patient, telling his colleagues as he walks to the man’s room to do the deed, “If anyone so much as whispers cortisone [a palliative agent] or ‘uncertain diagnosis,’ I’ll hit him.”

The physician must have reached the firm conclusion with the patient that there was no other reasonable alternative solution. The cases already described illustrate the hollowness of this guideline. Another prime example of its uselessness is the killing by Dr. Henk Prins of a three-day old infant born with spina bifida and limb anomalies. (Yes, euthanasia has entered Dutch pediatric wards. A 1997 study in the British medical journal, The Lancet, revealed that about 8 percent of all infants who die in the Netherlands are killed by doctors.)

Spina bifida is a condition in which there is an opening at the spine that may cause disability or death. Prins — a gynecologist, not a pediatrician or expert in spina bifida — killed the child at the request of her parents, because, he later testified, the baby screamed in agony when touched. No wonder the baby was in pain! Prins never closed the wound in her back. In other words, the doctor killed his patient without first attempting proper medical treatment. Yet, rather than punishing Prins, the trial judge praised him for his “integrity and courage,” wishing him well in any further legal proceedings he might face.

The physician must have consulted at least one independent physician, who has examined the patient and formed a judgment about the above points. The idea of independent physicians acting as a check and balance to prevent abuses sounds good. But in practice, it offers little actual protection. Proof of this is found in a Dutch euthanasia documentary — played in the USA on the ABC television program Prime Time Live. It is the euthanasia of Cees van Wendel, a patient disabled by ALS (Lou Gehrig’s disease). As depicted in the film, the driving force behind the euthanasia appears to be the man’s wife, Antoinette, who does all of the talking for her husband (who is able to communicate). This also proves true during the second opinion consultation, which is cursory and perfunctory. Suicide expert, the New York psychiatrist Dr. Herbert Hendin, in his book about Dutch euthanasia Seduced by Death, describes the “consultation,” such as it was:

The consultant, who practices on the same block as the doctor, also makes no attempt to communicate with Cees alone, and he too permits the wife to answer all the questions put to Cees. When the consultant asks the pro forma question if Cees is sure he wants to go ahead, Antoinette answers for him. The consultant seems uncomfortable, asks a few more questions, and leaves. The consultation takes practically no time at all.

Dutch euthanasia is a human-rights disaster. Not only does the practice devalue the lives of the most defenseless people, but once killing became an acceptable answer to one problem, it soon became a solution to one hundred. Indeed, in their nearly 30 years of euthanasia practice, Dutch doctors have gone from killing terminally ill patients who ask for it, to chronically ill patients who ask for it, to disabled patients who ask for it, to depressed patients who ask for it, to babies who cannot by definition ask for it, to thousands of patients without request or consent. Now, the last slight remaining impediment to killing by doctors — its technically illegal status — has been dismantled. And as an additional plum to depravity, teenagers beginning at the age of 16 will be able to receive euthanasia without parental consent.

The theologian and philosopher, Richard John Neuhaus, was once asked “Do you believe there is a euthanasia “slippery slope?” His answer hit the mark: “Yes, like I believe that there is a Hudson River.” We ignore the lessons of the Netherlands at our own peril. [Kwing Hung: It is not imagination; it is reality.]

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Culture of Death Angels: Nothing isolated about it (National Review, 010306)

By Wesley J. Smith, an attorney for the Task Force on Euthanasia and Assisted Suicide. His latest book, Culture of Death: The Assault on Medical Ethics in America, was published recently by Encounter Books.

They call them “death angels” — doctors or other medical professionals who stalk hospital and nursing-home corridors searching quietly for the sickest and most defenseless patients to secretly dispatch. The term is most unfortunate, carrying with it the implication that these premeditated killers of sick, disabled, and dying people are somehow doing their victims a favor by “ending their suffering.” In fact, there is nothing angelic about presuming the right to decide that the time has come for another human being to die.

Lately, the United States has been experiencing something of a boom in so-called angels of death:

In Los Angeles, former respiratory therapist Efren Saldivar has pleaded not guilty to charges that he murdered six elderly patients at Glendale Adventist Medical Center between December 1996 and August 1997. Salvidar told the police that he killed more than 50 patients, a confession he has since recanted. Twenty former patients’ bodies were exhumed, providing the evidence upon which to charge Salvidar with murder. The alleged serial killer is behind bars awaiting trial.

In September 2000, in Uniondale, New York, former physician Michael Swango pleaded guilty to killing three patients at a Long Island Veterans hospital with injections that stopped their hearts. Before allegedly killing his victims, he had placed Do Not Resuscitate (DNR) orders on their medical charts to prevent medical personnel from performing CPR. Swango received a life sentence.

In Oakland County, Michigan, where Jack Kevorkian used to play, hospice nurse Anne Nicolai, after “finding God,” wrote an e-mail to her boyfriend confessing to having overdosed three of her elderly hospice patients with morphine. The body of one of her alleged victims, a woman who had Alzheimer’s disease, was exhumed and the Oakland County Medical Examiner ruled the death a homicide. As of this writing, Oakland County Prosecutor Dave Gorcyca — who was elected on a plank of not prosecuting Kevorkian but who ultimately bagged Dr. Death after 60 Minutes aired a video of Kevorkian murdering Thomas Youk — has not decided whether to prosecute.

In September 2000, Utah, a jury convicted psychiatrist Robert Allen Weitzel of two counts of second-degree felony manslaughter and three counts of negligent homicide, for the morphine overdoses patients at a geriatric/psychiatric unit Weitzel ran at the Davis Hospital and Medical Center in Layton. Weitzel’s conviction was later overturned and he is free on bail awaiting a new trial.

In Springfield, Massachusetts nurse Kristen H. Gilbert is charged with murdering four of her patients and attempting to murder three others at the Veterans Affairs Medical Center in Northampton. Gilbert is accused of injecting her patients with adrenalin to make their hearts race fatally out of control. As these words are written, the jury is deliberating Gilbert’s fate.

The seeming increase in the number of medical professionals accused of killing their patients in recent years may be a mere coincidence. Then again, it may be the beginning of a trend. This isn’t idle speculation. The sanctity of human life is under as intense attack in this country as we have seen since those bad old days when the likes of Sen. John C. Calhoun promoted slavery as a positive good. Indeed, our country is currently steeped in a “culture of death” in which dying — and even killing — are promoted by bioethicists and assisted-suicide advocates as acceptable answers to the individual difficulties associated with serious illness and disability, the emotional and financial hardships sometimes generated by family care-giving responsibilities, and the “crisis” in health-care resources. We have actually gotten to the point where the predominate opinion in bioethics holds that people with a “lower” quality of life have less moral value than “normal adults.”

These death-culture attitudes lead to actual medical policies that hurt real people. Most famously, Oregon has legalized assisted suicide where studies show that most who swallow prescribed poison do so in order not to “burden” their families. Meanwhile, beneath the media’s radar, “futile care” protocols are being quietly implemented in hospitals across the country that arrogantly give doctors and ethics committees the right to refuse wanted life-extending treatment unilaterally if the doctor believes the patient’s quality of life is insufficient to justify the cost of care. At the same time, cognitively disabled patients — both conscious and unconscious — are made to die slow deaths by dehydration in all 50 states by having their tube-supplied food and water withheld or withdrawn on the basis that their lives are no longer worth living. In such a cultural milieu, is it really surprising that some medical professionals would take the extra step of “mercy” killing dying, elderly, and disabled patients or that a few evil psychopaths would use “compassion” as a front for the fulfillment of their homicidal obsessions?

We need only look to the Netherlands for proof that widespread acceptance of the culture of death leads inexorably to non-voluntary euthanasia. The Netherlands has permitted doctors to kill patients who volunteer to die since a court decision essentially decriminalized the practice in 1973. Since then, Dutch doctors have skied down the steepest of slippery slopes, normalizing medicalized killing in the process. Today, Dutch doctors lethally inject dying people who ask for it; chronically ill people who ask for it; disabled people who ask for it; depressed people who ask for it; and, disabled babies whose parents ask for it.

More to the point of this essay, killing by Dutch doctors has not been limited to voluntary cases. Study after study of Dutch euthanasia have repeatedly demonstrated that more than one thousand people who have not asked to be killed receive lethal injections by their doctors each year. The practice is so common that the ever-rational Dutch have given non-voluntary killing a name: “termination without request or consent.” The murders of tens of thousands of Dutch patients killed in the last 30 years without request or consent (for that is what such killings are considered technically under Dutch law) have led to only a handful of prosecutions, and no doctors have been jailed for the practice.

A case reported just last week in the British Medical Journal News illustrates vividly the license that country has given Dutch doctors to kill catastrophically ill and disabled patient — even if they have not asked for euthanasia. Dr. Wilfred van Oijen, a Dutch general practitioner, was recently found guilty of murdering a dying 84-year-old patient despite her statements that she did not wish to die. The doctor said he killed the comatose woman because she had bed sores and was soaked in urine. But bed sores can be mostly prevented through regular turning and a catheter will prevent an incontinent patient from soiling her linens. Despite this, Oijen was not penalized, because the Amsterdam court ruled that he had merely made an “error of judgment” while acting “honorably and according to his conscience” when he ended his patient’s life. (So much for “choice.”)

We have not yet become so accustomed to medicalized killing in the United States that we are willing to countenance murder in our hospital wards. But we are moving in that general direction. Unless we begin to reassert the sanctity and inherent value of all human lives — most especially of those among us who are dying, disabled, and elderly — we may soon find that patients who need our protection the most will find themselves increasingly in danger of being hustled into an early grave by the very professionals they counted upon to do them no harm.

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Dying for an Injunction: The debate over Oregon (NRO, 011119)

By Carla T. Main, an attorney and an associate editor/legal at The National Law Journal.

The Oregon law that legalized assisted suicide, the so-called Death with Dignity Act, may be having its own death throes now. On November 6, 2001, Attorney General Ashcroft advised the DEA that dispensing controlled substances for purposes of assisting a suicide was not a “legitimate medical purpose” within the meaning of the Controlled Substances Act (CSA), the federal law that regulates the sale and dispensing of narcotics. Ashcroft gave the DEA the green light to revoke a physician’s DEA registration if he writes a prescription for a massive dose of narcotics with the intent of helping a person commit suicide, even if such conduct is permitted under state law.

Hardy Myers, the attorney general of Oregon, wasted no time in bringing a lawsuit to have the directive declared unconstitutional. Additional plaintiffs have intervened, including a doctor, a pharmacist, and three people who may want to kill themselves with a doctor’s help. The state swiftly got an injunction from the federal district court in Oregon, temporarily enjoining the federal government from enforcing Ashcroft’s interpretation of the CSA. The parties agreed in a court conference on November 15 to continue the temporary order until the court rules on the underlying preliminary injunction motion. A hearing is set for November 20th.

Oregon’s challenge to Ashcroft’s directive poses a dicey dilemma for conservatives. Most would like to see an end to state-sanctioned mercy killing. The American Medical Association, the American Psychiatric Association, religious groups, and advocates for the disabled, which have spoken out in opposition to euthanasia, would agree. The vast majority of states have laws prohibiting assisted suicide. However, Oregon claims that Ashcroft’s directive unconstitutionally treads on states’ rights, raising federalism questions under the Commerce Clause and the 10th Amendment.

The state’s federalism position may not hold up once the case gets to the Supreme Court, where it is likely headed. Oregon argues that “the CSA, and its implementing regulations, do not define what medical purposes are ‘legitimate.’ Traditionally, that determination has been left to the States,” and that such authority goes beyond Congress’s intent in enacting the CSA. The state takes the position that if Congress authorized the federal government to decide what constitutes a legitimate medical purpose in enforcing the CSA, then Congress overstepped its bounds and the CSA itself is unconstitutional.

The inquiry into “traditional state’s authority” according to Michael Greve, the John G. Searle Scholar and director of the Federalism Project at the American Enterprise Institute, “doesn’t answer the federalism question — ever.” Just because Congress didn’t regulate an area in the past, “doesn’t mean they couldn’t ever do it. The real question,” he says, “is does Congress have the authority, yes or no, under the Commerce Clause.” It has long been clear that medical practice impacts interstate commerce and therefore may be regulated by the federal government (as the CSA already does in part), although primary regulation of medicine has been left largely to the states. However, Oregon maintains that when a physician prescribes a controlled substance for a patient to use in committing suicide, that act is so limited and intimate that it is not a part of interstate commerce, and therefore not subject to federal regulation. Oregon compares it to the question of gun possession in United States v. Lopez. In Lopez, the high court struck down a law making it a federal crime to carry a gun within 100 yards of a school, finding the law beyond the scope of the Commerce Clause, which does not regulate “things” alone. But assisted suicide involves prescribing and dispensing a drug from a pharmacy, quite arguably a commercial transaction within the meaning of the Commerce Clause.

Anxiety is already running high. Will Ashcroft’s directive have an unintended chilling effect on palliative care given by doctors to dying patients all over the country? The directive expressly states there is to be no change in enforcement policies outside of Oregon, and even within Oregon only with respect to assisted suicide, not palliative care. Some maintain, though, that it is a fine line between giving morphine to a dying patient — without the intent to kill — and assisted suicide. To nip this kind of hysteria in the bud requires brutal honesty about the Oregon law. It allows doctors to prescribe a lethal dose (e.g., 50 or 60 pills), to be taken all at once (outside of a doctor’s presence) by a patient who may yet have six months to live. The pills can result in convulsions, vomiting, and a coma. Websites on assisted suicide suggest having a plastic bag on hand, large enough for asphyxiation, to finish the job. The death is obvious, but where’s the dignity? When the Supreme Court parses this out, one hopes it keeps in mind the words of a 1963 case: “[W]hile the Constitution protects against invasions of individual rights, it is not a suicide pact.”

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Euthanasia Sets Sail: An interview with Philip Nitschke, the other “Dr. Death.” (NRO, 010605)

Viewpoint of a pro-death doctor.

By Kathryn Jean Lopez, NR associate editor

Philip Nitschke is president of the Voluntary Euthanasia Research Foundation in Australia. He is currently in the planning stages of a “euthanasia boat” — in the model of the “ abortion boat” that sails international waters to provide abortion to those women who live in countries where the procedure is illegal.

Kathryn Jean Lopez: You have long been prominent in the pro-euthanasia movement in Australia. What drives you?

Philip Nitschke: I was caught up in the issue. I watched with dismay as the Australian Medical Association did all it could to wreck the world’s first law legalizing voluntary euthanasia — the Northern Territory Rights of the Terminally Ill Act, which came into operation on July 1966. Although the initiative was popular with the people of the Northern Territory, the attitude of the AMA was that they knew what was best for the people: a breathtakingly arrogant position, which grated with my idea of the role of the profession. And I became involved in getting together a small group of doctors who took an opposing position to the AMA. While the law was in operation I had the unique opportunity to compare the situation with and without such legislation. There was no comparison.

Since the legislation was overturned by the federal Australian government, we have been once again plunged back into a jungle where people with powerful friends, people with contacts, [and] people with mates who are doctors, have no trouble getting help to peacefully end their lives at the time of their choosing. But for the rest, many people who have never broken a law in their lives find themselves having to sneak around and expose those they care about to significant legal risk. Without the existence of voluntary euthanasia legislation, it is inequitable and unjust [toward] the losers on the bottom of the socio-economic spectrum. There is an uncanny parallel with the abortion issue of 25 years ago, where women with contacts and money never had to take risks getting access to safe terminations. It is the inequity and injustice of the current situation that those seeking help to obtain a peaceful death that upsets me and drives me.

Lopez: How many deaths have you assisted?

Nitschke: The number depends a little on one’s definition of “assistance.” Nevertheless, to “assist” in the eyes of the law is now a crime, since the territory’s law has been overturned. It would be accurate to say that there have been about 20 deaths that I have been intimately associated with. Four of those were legal and took place when the euthanasia legislation was in place.

Lopez: You’ve also developed a computer program, haven’t you, that instructs people on how to give themselves lethal injections? Does it worry you that anyone can get their hands on this? You could be helping anyone die?

Nitschke: The computer program referred to was part of the “deliverance machine,” a piece of equipment I developed to allow those people who had qualified to use the Northern Territory’s Rights of the Terminally Ill Act to control the process themselves. Although it would have been legally possible for me to come to the bedside of my four patients that used the law, and give them a lethal injection, I preferred to have them initiate the process. The laptop computer displayed three questions which the person wanting to die needed to answer in the affirmative. They were deliberately blunt. The final one said, “If you press this button, you will receive a lethal injection and die in 15 seconds — Do you wish to proceed?” The deliverance machine made it clear that in each of the cases where people used the law, it was not an instance of a doctor giving an unwilling or moribund patient an involuntary needle. The machine also allowed me to leave the immediate personal space of the patient, so that the family could enter and be closest to the patient when the button was pushed.

The machine has been acquired by and is currently on display in the British Science Museum in Kensington, London.

Lopez: How big a role does the Internet play in the your pro-death movement?

Nitschke: As in many embryonic political and social movements, the pro-voluntary-euthanasia movement makes a great deal of use of the Internet. The Internet provides a means of spreading the information that empowers those wishing to exercise control at the time of death. As many supporters of voluntary euthanasia become increasingly disenchanted with the progress toward a legislative solution, a rapidly growing subset of the movement is developing and disseminating the information that will effectively make legislation irrelevant. This is information about the archetypal “peaceful pill,” the substance/method, etc., that will allow anyone access to a peaceful death at anytime, irrespective of the legislative framework in which they find themselves. Considerable work is going on in developing such solutions and the Internet is an integral and necessary part of that development.

Lopez: Do you object to the “pro-death” label?

Nitschke: The labels come with the territory, as they say. I don’t enjoy being referred to as another “Dr. Death” or having people attempt to make links between my name and the Nazis (the Nitschke’s came to Australia from Germany in the 1860s to avoid persecution), but it would be a little precious to complain every time someone called you a name you didn’t appreciate. And at some level, one can even derive some encouragement from it: People only start calling you names if and when you become effective.

Lopez: You’re looking to take your crusade to the sea. Why?

Nitschke: The concept of a vessel operating in international waters and thus freeing those traveling from the constraints of the repressive legislative regimes from where they’ve come has been around for some time. When it was first looked at, our Foundation came to the conclusion that the idea had no legal merit--one would still be bound by the laws of the country of registration of the vessel. The recent news that the Dutch have now passed laws making them the first country with voluntary-euthanasia legislation seemed to affect the legal situation. We have not been able to establish — and our foundation is now working to clarify this — what the exact legal situation would be with a Dutch-registered vessel engaging in international travel between countries. There are people prepared to back such a proposal, but only if it could be shown that there are no legal difficulties with the project. The recent comments by Dutch health minister Els Burst — that the government in the Netherlands would move to pass legislation to thwart such an initiative — is of great concern to us.

Questions about “restrictions” and “who could be served” are the questions that we are seeking answers to from those with knowledge of international law.

Lopez: Would there be any restrictions on who could be served on your boat? Do you see any restrictions that should be placed on euthanasia generally? If I am depressed, do I qualify? If an elderly woman’s husband dies and she says she no longer has anything to live for, would you help her kill herself? What about a troubled teen? Who qualifies? Who decides if a life is worth living?

Nitschke: This difficult question I will answer in two parts. My personal position is that if we believe that there is a right to life, then we must accept that people have a right to dispose of that life whenever they want. (In the same way as the right to freedom of religion has implicit the right to be an atheist, and the right to freedom of speech involves the right to remain silent). I do not believe that telling people they have a right to life while denying them the means, manner, or information necessary for them to give this life away has any ethical consistency. So all people qualify, not just those with the training, knowledge, or resources to find out how to “give away” their life. And someone needs to provide this knowledge, training, or recourse necessary to anyone who wants it, including the depressed, the elderly bereaved, [and] the troubled teen. If we are to remain consistent and we believe that the individual has the right to dispose of their life, we should not erect artificial barriers in the way of sub-groups who don’t meet our criteria.

This would mean that the so-called “peaceful pill” should be available in the supermarket so that those old enough to understand death could obtain death peacefully at the time of their choosing. It’s hard to imagine how such a development would affect society, but I believe the impact would not be as great as people fear. One group to clearly benefit from such a development would be those terminally ill patients who would derive immense comfort from knowing that they now have such control in their hands. We have a great deal of anecdotal evidence from the clinics I run in all Australian states, that the acquisition of such substances or drugs takes away a great deal of uncertainty associated with the feeling of loss of control. Perhaps it is a paradox, but we see it time and time again, that the acquisition of lethal substances that would guarantee a peaceful death enables those suffering to keep on going, living longer, and getting more out of the remaining part of their life. So empowering the entire population in this way could result in a net increase in the integrated total of human life, something I’m sure that many of the detractors of voluntary euthanasia would support.

Any position other than this leads to considerable debate about where exactly the cut-off point should be. All the legislative models in existence (Oregon, the Netherlands, and the past law in the Northern Territory of Australia) have attempted to do just that--define this eligible sub-group — i.e., terminally ill, not depressed, over 18, articulate, and lucid, etc., etc., and laws that attempt to do this produce a great deal of confusion in the gray areas of the cut-off. What about psychic suffering from mental illness? What about teenagers with terminal cancer; why should they have to wait till they’re 18? What about the 95-year-old who is “tired of life” but not clinically depressed?

We acknowledge that suicide is a legal act, but try to preserve laws that prevent “advising, counseling, or assisting” those who would [commit] suicide except in these very select groups. I would argue that if suicide is legal, then advising, counseling, or assisting people to carry out this legal act should also be legal.

The final question that needs to be answered though is, “Whom do I want to help?” While acknowledging that all have the “right” to receive assistance without fear of legal consequence, I do not personally want to involve myself in helping those who can manage the act themselves. The purpose of the deliverance machine referred to above was to allow the individual to initiate the process and to take the responsibility for their actions. My guidelines for those whom I am prepared to assist are of course arbitrary. In this country, without protective legislation, I could do what I liked, or rather, what I could get away with. However, I choose to restrict myself to that group identified in the overturned legislation. I involve myself with terminally ill adults who are articulate, lucid, and not suffering from clinically treatable depression.

Lopez: Do you know Jack Kevorkian? What do you think of him and his assisted suicides? About his jail time?

Nitschke: I have only had indirect contact with Jack Kevorkian, and greatly admire his courage. His actions moved the work forward on this issue and I agree totally with the editorialist from the British Medical Journal who referred to him as a rare example of a true medical hero. I know of no one who looked at the 60 Minutes film of the death of Thomas Youk and believed that the actions of Jack Kevorkian constituted willful murder. As Judge Cooper sentenced him, she claimed that Jack had flouted the rule of law, and that it was the rule of law that made the nation great, but she seemed to overlook that years earlier, it was the actions of heroes prepared to “flout the rule of law” that had won for her the vote, [much less] the chance to sit on the judicial bench. Kevorkian has paid a very steep price for his courage: His incarceration shames us all.

Lopez: What do you say to those who would argue that doctors who assist patients in killing themselves are violating the Hippocratic Oath to “do no harm”? That they are aiding in a murder of a human life?

Nitschke: Over time the Hippocratic Oath has been modified on a number of occasions as some of its tenets became less and less acceptable. References to women not studying medicine and doctors not breaking the skin have been deleted. The much-quoted reference to “do no harm” is also in need of explanation. Does not doing harm mean that we should prolong a life that the patient sees as a painful burden? Surely, the “harm” in this instance is done when we prolong the life, and “doing no harm” means that we should help the patient die. Killing the patient — technically, yes. Is it a good thing — sometimes, yes. Is it consistent with good medical end-of-life care: absolutely yes.

Lopez: What do you say to those who believe that human life is sacred? Do you believe that it is?

Nitschke: Many people I meet and argue with believe that human life is sacred. I do not. I believe the so-called “sacredness” of human life has been responsible for most of the wars, genocidal crimes, and global environmental and ecological disasters that we as a species have experienced. If you believe that your body belongs to God and that to cut short a life is a crime against God then you will clearly not agree with my thoughts on this issue. I do not mind people holding these beliefs and suffering as much as they wish as they die. For them, redemptive suffering may well pry open heaven’s door that little bit wider, and if that is their belief they are welcome to it, but I strongly object to having those views shoved down my neck. I want my belief — that human life is not sacred — accorded the same respect.

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Australia’s Dr. Death: Spreading the assisted-suicide gospel (NRO, 021126)

By Wesley J. Smith

There is an old folk wisdom: “You are known by the company you keep.” As is true of most folk wisdom, the saying has much to recommend it. To use an extreme example, if you hung out with and financially supported a known terrorist, most people would reasonably think that you were a terrorist too.

Which brings to mind the Hemlock Society of the United States, perhaps the world’s largest assisted-suicide advocacy group. No, they are not terrorists. But the organization’s close association with and financial support for Australian suicide fanatic Dr. Philip Nitschke exposes how radical Hemlock really is.

For those who haven’t heard of him, Nitschke is the Australian Jack Kevorkian. (The murderer Kevorkian is another Hemlock favorite despite his oft-stated goal of using assisted suicide to open the doors to “obitiatry,” e.g., medical experimentation on people being euthanized.) While Nitschke doesn’t publicly assist suicides and dump the bodies of victims at local hospitals the way Kevorkian did, he does travel Australia and New Zealand giving well publicized how-to-commit-suicide classes. He also manufactures plastic suicide bags — “the Exit Bag” — for distribution to members of an Australian euthanasia advocacy group. Nitschke also hopes to purchase a suicide death ship to take past the Great Barrier Reef into international waters where he would engage in the mass euthanasia of sick and disabled people who wanted to die.

As surreal and macabre as all of this may sound, it is actually pretty conventional assisted-suicide-advocacy fare. What makes Nitschke stand out from the pack is his desire to give troubled teenagers access to a suicide concoction — the so-called “peaceful pill” — that Nitschke is formulating from generally available household products.

Nitschke’s promotion of suicide for troubled teens first came to light in a 2001 interview on National Review Online. At one point, NRO’s Kathryn Jean Lopez asked Nitschke who would qualify for access to his suicide pill. His response was as chilling in its candor as it was for its utter disregard for the value of human life:

This difficult question I will answer in two parts. My personal position is that if we believe that there is a right to life, and then we must accept that people have a right to dispose of that life whenever they want…. I do not believe that telling people they have a right to life while denying them the means, manner, or information necessary for them to give this life away has any ethical consistency. So all people qualify, not just those with the training, knowledge, or resources to find out how to ‘give away’ their life. And someone needs to provide this knowledge, training, or resource necessary to anyone who wants it, including the depressed, the elderly bereaved, the troubled teen. If we are to remain consistent and we believe that the individual has the right to dispose of their life, we should not erect artificial barriers in the way of subgroups that don’t meet our criteria.

In other words, assisted suicide should not be restricted to one “subgroup” of people with terminal illnesses.

“This would mean,” Nitschke continued, that the so-called peaceful pill should be available in the supermarkets so that those old enough to understand death could obtain death peacefully at the time of their choosing.” (Emphasis added.)

Does Nitschke really believe this? Surely, some might say, he misspoke under the pressure of a microphone-in-the-face style interview.

But that excuse won’t fly. This particular Q&A was done via e-mail — so Nitschke had all the time he needed to write and edit his responses to NRO’s questions. Nitschke wrote those words because he deeply believes them.

Nitschke’s actions match his advocacy. He is currently hip deep in a heated controversy surrounding the suicide of an Australian woman named Nancy Crick. Crick became famous in Australia when she announced publicly that she was under the care of Nitschke and was planning her suicide, because, she and Nitschke said, she was dying from terminal cancer. That put the Australian media into an American-style feeding frenzy, which became white-hot, when, after months of equivocating, she finally killed herself in front of a group of awestruck euthanasia advocates who actually applauded when she took the pills. (Nitschke, fearing jail, left Crick’s side before she did the deed.)

Then came the autopsy. Oops. It turned out that Crick was not dying from cancer. Moreover, Nitschke soon admitted that he and Crick both knew that she wasn’t terminally ill. However, rather than being repentant or embarrassed that he had supported Crick’s suicide desire even though he knew she wasn’t dying, Nitschke argued that her non-terminal condition was “irrelevant” because she was “hopelessly ill” with a painful digestive problem. Only later did he halfheartedly apologize for lying to the media.

How is Hemlock involved in this madness? The organization has paid Nitschke tens of thousands of dollars to develop the “peaceful pill.” Moreover, despite his outspoken advocacy for making the peaceful pill available to troubled teens and in supermarkets, Hemlock recently invited Nitschke to present “What’s New in Hastening the Dying Process” at their January National Convention in San Diego, Calif.

Clearly, the Hemlock Society likes Philip Nitschke.

This did not surprise those of us who pay close attention to Hemlock Society advocacy. In recent years, the organization’s publicly stated beliefs have become increasingly Nitschke-like. For example, little noticed by the media, the Hemlock Society of the United States recently announced that it no longer wants to restrict the legalization of assisted suicide to people with terminal illnesses. Rather, it now urges that assisted suicide be available legally to people who are not dying, specifically to the “hopelessly ill,” that is, to people like Nancy Crick.

Hemlock’s leaders have privately expressed such beliefs for years. Thus, in 1998, Dr. Richard McDonald, Hemlock’s medical director, joined Nitschke and other assisted-suicide physician ideologues in signing the “Zurich Declaration on Assisted Dying.” Meant more for private rather than public consumption, the Zurich Declaration called for the legalization of assisted suicide “for all competent adults suffering severe and enduring distress.” This comes very close to Nitschke’s death-on-demand philosophy. No wonder Hemlock loves Nitschke.

Yes, we are known by the company we keep. Through their moral and financial support of the odious Philip Nitschke, the Hemlock Society has revealed its true colors. Society should judge the organization and its advocacy, accordingly.

— Wesley J. Smith, is an author and an attorney for the International Task Force on Euthanasia and Assisted Suicide and a senior fellow at the Discovery Institute.

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Connecting the Dots: Sanctity of life threatened on many fronts (NRO, 030124)

Jack Kevorkian shocked consciences and turned stomachs a few years ago when he advocated using assisted-suicide victims as subjects of medical experimentation, a process he planned to call “obitiatry.” Even though Kevorkian is now in prison in Michigan, it appears that his idea of medically experimenting on the bodies of dying people is gaining adherents in the bioethics and medical research communities. Indeed, if a story in the January 19 Pittsburgh Gazette is true, it appears that such research is already being conducted.

Gazette science editor Byron Spice’s story primarily concerned the recent use by medical researchers of the bodies of persons who had been declared “brain dead.” Many may be shocked at the idea, but assuming a proper diagnosis, a “brain dead” person is as dead as someone whose heart and lungs have permanently ceased functioning. However, unlike other cadavers, the body of a person declared dead by neurological criteria — meaning the whole brain and each of its constituent parts have permanently ceased all brain function — is kept functioning temporarily, usually to permit time to procure organs for transplantation. Since these are the bodies of the dead and not the living, assuming proper regulation, it would seem this research would be as appropriate as that using other corpses.

The real bombshell in Spice’s story concerned the potential that catastrophically ill or injured people are also being used in research, the “very sick people whose life support or drug therapy is about to be withdrawn.” Indeed, according to Spice, the bodies of “nearly dead patients” have already been used in researching a new cancer drug. But nearly dead isn’t dead. Someone who is very sick, whose life support is about to be withdrawn, isn’t dead — he’s living.

To understand the full import of this story we need to connect some important dots by considering the context in which it arises. Unbeknownst to many, the sanctity-of-human-life ethic is under sustained attack. Indeed, the predominant view of contemporary bioethics rejects the view that life is sacrosanct simply and merely because it is human. Rather, what matters morally is whether a life — be it animal, human, space alien, or machine — is a “person,” a status that must be earned by possessing relevant cognitive capacities.

This subjective view of life — as opposed to the objective approach contained in the sanctity-of-life ethic — strips some humans of their moral equality and threatens to transform them into the moral equivalent of a lab animal or a natural resource. This was the very point made by Georgetown University bioethicist Tom L. Beauchamp in the December 1999 Kennedy Institute of Ethics Journal, one of the most influential bioethics publications in the world. Since “many humans lack properties of personhood or are less than full persons,” Beauchamp wrote, they are “equal or inferior in moral standing” to some animals. As a consequence, such “unlucky humans” might be available for use in the same ways as are “relevantly similar nonhumans. For example, they might be aggressively used as human research subjects and sources of organs.”

In a similar vein, philosopher and bioethicist R. G. Frey, of Bowling Green University, has explicitly asserted that, for humans as well as animals, the “value of life is a function of its quality.” This the so-called quality-of-life ethic leads to very dark conclusions. “Because some human lives fare drastically below the quality of life of normal (adult) human life,” Frey writes, “we must face the prospect that the lives of some perfectly healthy animals have a higher quality and greater value than the lives of some humans. And we must face this prospect, with all the implications it may have for the use of these unfortunate humans by others” including “the use of defective humans in [medical] research.”

This kind of thinking is even more common in the organ-transplant community. In order to increase the number of vital organs available for transplantation, some bioethicists and transplant professionals want to redefine death to include a diagnosis of permanent coma or unconsciousness. If that were done, the thousands of people in comas at any given time could have their organs procured. Pending such a redefinition, some have suggested that non-vital tissues and organs be procured, such as corneas and single kidneys.

Meanwhile, Norman Fost, director of the Program in Medical Ethics at the University of Wisconsin at Madison, has opined that we should be able to take vital organs from the living, even if doing so would kill them: “My contention is that that there is ample precedent in the law and good moral justification for removing [vital] organs from persons who are not legally dead,” Fost wrote. Such procurement would not be limited to the unconscious — it could also include conscious people who are terminally ill, whose organ harvesting before dying would be considered “part of their terminal care.”

These same attitudes drive much of the thinking of bioethicists and medical researchers in the embryonic-stem-cell and human-cloning debates. Since embryos are not sentient, the thinking goes, the fact that they are human is not morally relevant. Indeed, it is their very membership in the human species that makes them so attractive for use in medical research and as a source of what could be a very profitable commodity: human embryonic stem cells.

The desire to harvest embryonic stem cells has led bioethicists, patient groups, ill and disabled movie stars, and politicians to seek the legalization of human cloning for biomedical research. At present, most of these cloning advocates would require all human clones to be destroyed while still in the embryonic stage of development. But this seems primarily a political expedient rather than a never-to-be-violated moral boundary. Indeed, to the applause of the biomedical research community and cloning advocates, the New Jersey state senate recently passed S. 1909, a radical human-cloning-for-biomedical-research legalization bill.

Tellingly, S. 1909 would not prohibit the implantation of cloned embryos into women’s wombs. It would not outlaw their gestation into fetuses. In fact, it only requires human clones to be killed before they reach the “newborn” stage of life, meaning that New Jersey is, quite literally, on the verge of permitting the creation of — and experimentation upon — cloned human babies through the ninth month of pregnancy.

Throughout life’s spectrum — from the beginning to the end — the value of human life is increasingly being measured through a distorting, utilitarian prism. This is happening a little bit here, and a little bit there, by small steps. But just as a roaring river is created by the coming together of many streams, our current piecemeal deconstruction of the sanctity-of-life ethic is leading toward an explicit hierarchy of human life that would permit some to be exploited and destroyed for the benefit of others deemed to have superior moral worth. Seen in this light, research on the near-dead as if they were already corpses is but one short chapter in a much longer book.

— Wesley J. Smith is a senior fellow at the Discovery Institute. He is the author of Culture of Death: The Assault on Medical Ethics in America.

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Study At Odds With Assisted Suicide Data, Experts Say (LifeNews, 030716)

New York, NY (LifeNews.com) -- A recent study published in Archives of Internal Medicine on palliative care and how doctors treat patients is at odds with research published about the assisted suicide decisions made by resident of Oregon, pro-life experts on end-of-life care say.

The study, directed by Dr. Diane Meier of the Center to Advance Palliative Care at the Mount Sinai School of Medicine in New York City, indicated that patients who seek help from their doctors to hasten death are in significant physical pain and discomfort.

Not so say pro-life experts on end-of-life issues.

Brian Johnston, the author of “Death as a Salesman: What’s Wrong With Assisted Suicide,” says euthanasia advocates are normally the ones touting uncontrollable pain as the reason why some patients seek assisted suicide.

That is the “standard boilerplate incantation of the euthanasia movement, but has already been disproved in Oregon and elsewhere where reports indicate that physical pain is rarely the reason for killing the patient,” Johnston said in an interview with LifeNews.com.

Jerome R. Wernow, Ph.D., the Executive Director of the Northwest Center for Bioethics in Portland, agreed. He said the study’s conclusion is “an inaccurate assessment of the reason behind Oregon’s assisted suicide practice.”

In fact, the 2002 report on assisted suicide in Oregon, published in the New England Journal of Medicine, found that the three most commonly cited end-of-life concerns were loss of autonomy, a decreasing ability to take part in enjoyable activities, and loss of control over bodily functions.

Wernow told LifeNews.com that “the majority of those choosing assisted suicide did based on a perceived violation of their personal autonomy and ‘right to choose.’” He said the study further legitimatizes the myth that uncontrollable pain is the prime reason for seeking an assisted suicide.

Johnston agreed with Meier’s study that adequate resources are already available to alleviate pain and eliminate that as a reason for assisted suicide.

John Henry Crosby of the Family Research Council’s Center for Human Life and Bioethics, said he was surprised that the study showed 49 percent of those asking for assisted suicide were depressed.

“My hunch is that the numbers are actually much higher and that certain forms of depression won’t necessarily be detectable,” Crosby told LifeNews.com.

Johnston also said the study revealed that patients made the request for assisted suicide along with family. He said doctors need to not acquiesce to familial pressure to assist a suicide.

“One thing the study does not address is the question of how many people requested assisted suicide because they considered themselves burdensome to their families,” Crosby said

Johnston said that, as a self-reporting study, it is “drawing its sweeping conclusions from reports where the actual agent of the act is serving as their own monitor.”

“How many of these accommodating physicians would unnecessarily volunteer, ‘There was no medically indicated reason, it just was an easy way to wrap things up and get the family off my back.’ As in the Netherlands and in Oregon, there is no way to check for misrepresentation or misapplication,” Johnson concluded.

Crosby was surprised that doctors outside of Oregon would admit to performing an assisted suicide, since the practice is illegal in the forty-nine other states.

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Saving Terri Schiavo: The Florida state legislature steps in to save a woman whose husband is trying to kill her (Weekly Standard, 031021)

WHEN TERRI SCHIAVO collapsed in 1990, causes unknown, she could have had no idea that 13 years later people the world over would know her name and care very much about whether she lived or died. Yet what began as a private tragedy--a vivacious young woman stricken in the very prime of her life with a brain injury that left her profoundly disabled--has become a story heard round the world.

In case you are one of the few people who still do not know about the controversy, Terri’s husband Michael requested--and received from Judge George Greer of the 6th Circuit Court in Clearwater, Florida--the right to dehydrate Terri to death by removing her feeding tube. This despite open and notorious financial and personal conflicts of interest and acts taken in disregard of Terri’s welfare that should have caused Michael to be removed as her guardian. These conflicts include his engagement to a woman with whom he has one baby with another on the way and his refusal to allow efforts at rehabilitation that might allow her to eat without the feeding tube--all despite promises to a medical malpractice jury that he would attempt to rehabilitate her. Instead, once the jury award was received, Michael refused all rehabilitation, forcing Terri to simply lie in a bed for 10 years.

Terri’s parents, Bob and Mary Schindler, have fought for their daughter’s life tenaciously, spending virtually every dime they have. But over five years, the courts, one-by-one-by-one, turned their backs. And despite testimony by credible medical experts that Terri might still relearn to eat by mouth, Judge Greer refused to even allow her that opportunity. Terri’s feeding tube was pulled, per Judge Greer’s order, on October 15, 2003.

In most cases, that would have been that. But the Schiavo case is no normal case. While the story was virtually ignored by the mainstream media--perhaps because the case illustrates vividly the dangers of the so-called “right to die”--talk radio once again rose to the fore and generated a firestorm of opposition to the dehydration. Led by nationally syndicated radio host Glenn Beck, and including other conservative and Christian talk radio hosts such as Janet Parshall, Sean Hannity, Jane Chastain, and Janet Folger, and promoted vigorously by the nation’s politically liberal disability rights community as well as by numerous Catholic bloggers, a grass-roots movement in the last few months has produced tens of thousands of emails, phone calls, and letters to Governor Jeb Bush’s office begging him to intervene to save Terri’s life.

BUSH WAS CLEARLY MOVED BY TERRI’S PLIGHT. He wanted to do the right thing but hesitated, doubting he had the legal authority to order Terri’s food and water restored. First, he wrote a letter to Judge Greer asking him to reconsider and appoint a guardian ad litem for Terri. But there had already been a guardian ad litem appointed in this case who had recommended that Terri not be dehydrated. Judge Greer ignored the recommendation, and now Terri no longer has a guardian ad litem. True to form, Greer also ignored the governor.

Then, when Schindler attorney Patricia Anderson filed a federal civil rights lawsuit seeking an injunction against the court order, Governor Bush filed an amicus brief in support of the Schindlers’ request. There is “a critical distinction between removing life support and the deliberate killing of a human being by starvation and dehydration,” Bush asserted. The first is protected by Florida’s right to privacy, he advised the court. But, he stated, “the removal of the feeding tube without first determining by medically accepted means whether the plaintiff can ingest food and water on her own, with or without rehabilitative therapy, constitutes the deprivation of her life without due process of law.” This was a remarkable event: a governor asking a federal court to overturn a state judge’s ruling, for which Bush deserves great appreciation.

WHEN THAT SUIT FAILED, thousands continued to pressure Governor Bush, demanding that he intervene. Bush demurred, claiming he had no legal authority. But now, six days into the dehydration, a breakthrough has arrived for those desperately striving to save Terri’s life. The Florida Legislature is in special session, and at the urging of Governor Bush and the speaker of the Florida House Johnnie Byrd, “Terri’s Bill” has been added to the agenda to give Bush the power to issue an executive order suspending dehydrations that are contested by families for fifteen days. The idea is to permit the legislature to take the time to sort this whole dehydration business out.

Late last night, the House passed Terri’s Bill. The Senate will take it up this morning. If it passes, Jeb Bush is expected to quickly issue an executive order restoring Terri’s food and water.

Will Terri live or die? That can’t be known. But this much is clear: The Schiavo case has changed everything. Our government leaders have been put on notice that tremendous numbers of people in this country are determined to halt the erosion of the sanctity/equality of life ethic in the practice of medicine. The routine practice of dehydrating the cognitively disabled who need a feeding tube--which occurs to the conscious and unconscious alike in all 50 states--is going to receive a badly needed review. The bioethics movement, which has been leading us down this treacherous slope, can no longer expect to pontificate from on high in medical matters of life and death and expect the people to just meekly go along.

In a sense, the Schiavo case is a miracle. Because so many people around the country and the world have come to love her, root for her, and yes, pray for her, our country has been given a rare opportunity to look at where we are heading as a culture and reinvigorate a simple moral maxim: When in doubt, choose life.

Wesley J. Smith is a senior fellow at the Discovery Institute and an attorney for the International Task Force on Euthanasia and Assisted Suicide. He is the author of “Forced Exit: The Slippery Slope from Assisted Suicide to Legalized Murder.”

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The Battle for Terri (Weekly Standard, 031021)

Even after Terri’s Law was passed, Michael Schiavo fought to secure his wife’s death. Now that she’s still alive, he won’t allow her parents to visit her.

OCTOBER 21, 2003 may have been the most important day in 39-year-old Terri Schiavo’s life. She had been without any food or water for six days, per the order of Judge George Greer of the Sixth Judicial Circuit Court in Clearwater, Florida. Terri’s family believed she was holding up well. But her body could surely not take much more of being deprived of all fluids.

In Tallahassee, a furious political debate was raging. The previous night, Governor Jeb Bush and speaker of the Florida House Johnnie Byrd had pushed “Terri’s Bill” successfully through the House in an emergency session. The bill was now in the Florida Senate. If it passed, Bush, as governor, would be authorized to immediately issue an executive order restoring Terri’s tube-supplied food and water.

But although the bill was moving through the Senate at the political speed of light, for supporters of Terri’s life, it seemed a glacial pace. Every minute was one more minute Terri was drying out.

AS I LISTENED to the debate over the Internet, I could see the tug of war. On one side were many bioethicists, members of the medical intelligentsia, “right to die” advocates, Terri’s husband, Michael Schiavo, and his attorney, George Felos. On the other were disability rights advocates, right to lifers, Governor Jeb Bush, Terri’s parents and their stalwart lawyer, Patricia Anderson, and the tens of thousands of people from all over the country and the world whose months of insistent emails and telephone calls had resulted in such overwhelming political pressure that Florida’s government had felt compelled to act.

As the debate raged, some senators opposed the bill, believing that a husband should be permitted to make this tragic decision. But didn’t they know that this particular husband, Michael Schiavo, was engaged to be married and already had one child with his fiancé (with another on the way)? Didn’t they know he had denied Terri rehabilitation after promising a medical malpractice jury he would provide her with just such care? Didn’t they know he wouldn’t even let the nursing home personnel clean her teeth?

No, of course they didn’t. How could they? This terrible issue had been sprung on them unfairly on extremely short notice. But there had been no other way. Terri’s life had literally hung in the balance.

Others worried that the “process” was being violated. The courts had spoken. No matter what we might think, the legislature should stay out of it, they intoned.

But legislative actions to circumvent unpopular court rulings are part of our system of checks and balances. Few complained, for example, when Congress recently passed legislation to override the federal courts after two judges refused to permit the national telemarketing “do not call” list to go into effect.

Finally, Terri’s Bill passed by a huge margin in the Senate, and after a brief reconciliation with the House version, the bill became “Terri’s Law.” But if the supporters of Terri’s life thought that this meant Terri was ipso facto saved, they were being naive. In the legal and political battles over the culture of death, nothing is easy. Rehydrating Terri would be no exception.

THE STRUGGLE then moved to the hospice in which Terri has been living for three years. The administration was served with Executive Order 03-201, signed by Governor Bush stating in part:

“Effective immediately, all medical facilities and personnel providing medical care for Theresa Schiavo, and all those acting in concert or participation with them, are hereby directed to immediately provide nutrition and hydration to Theresa Schiavo by means of a gastronomy tube, or by any other method determined to be appropriate in the reasonable judgment of a licensed physician.”

Was the order being followed? Had the hospice hooked up an IV to begin the rehydration process? No one knew. Michael Schiavo is in complete control of Terri’s person and her parents are often kept in the dark about what is happening to her.

Late in the afternoon, members of the Florida Department of Law Enforcement arrived with an ambulance that whisked Terri away to a hospital, where it was expected, her feeding tube would be reimplanted. But then, the roller coaster that has been the Schiavo case took another sickening plunge. A court hearing had been scheduled. Michael’s lawyers were requesting an immediate restraining order preventing Terri from being treated. Even though Terri’s supporters had been told the rehydration had already begun, a doctor had actually refused the job. Despite Terri’s Law, Terri remained untreated, slowly dehydrating to death.

AT 8:30 P.M., JUDGE DOUGLAS BAIRD of the Florida Sixth Judicial Circuit began a hearing that would determine the immediate fate of Terri’s Law. Meanwhile, it became clear why doctors had refused to reconnect Terri’s feeding tube or even begin an IV line to provide her with desperately needed fluid: Deborah Bushnell, one of Michael’s lawyers, had faxed a letter to virtually every doctor in Pinellas County in which she threatened to sue any physician who reconnected Terri’s feeding tube or otherwise treated her. The chilling intent behind the letter worked. Even though Terri’s Law protected doctors from liability, the hospital felt compelled to seek legal advise.

Finally, at about 9:00 P.M., there came news: The doctors had inserted an IV. Terri was again receiving fluids. Moreover, Judge Baird had refused to issue an injunction. At least for now, Terri’s Law was protecting Terri Schiavo’s life.

IS THE TUG OF WAR OVER? Far from it. There will probably be many more days like this one, days in which Terri’s life will hang in the balance. Michael remains Terri’s legal guardian and he still seeks her death. True to form, Michael immediately ordered the hospital to refuse visitation rights to her parents and siblings. Appeals against Terri’s Law are certain, the results unknowable. The bioethics movement is sure to howl in rage and mobilize to undo what Florida has done. But as an emotionally exhausted, yet elated Patricia Anderson told me, “Every day that Terri Schiavo is alive is a good day.” For those who believe in the sanctity and equality of human life, October 21, 2003, was a very good day indeed.

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The Consequences of Casual Conversations (Weekly Standard, 031027)

Michael Schiavo’s argument that his wife wants to die stems from an off-hand remark she made while watching a movie. It isn’t the first time this has happened.

ONE EVENING, during the second term of President Ronald Reagan, Terri Schiavo and her husband Michael decided to watch a television movie about Karen Ann Quinlan. Quinlan, as most readers know, had a tragic life. After overdosing on a combination of drugs and alcohol, she fell into unconsciousness and never awakened. Her parents won a lawsuit in the New Jersey Supreme Court allowing them to disconnect her ventilator. Karen didn’t die immediately--she lived on for 10 more years before finally expiring from pneumonia.

While discussing the movie, Michael claims that Terri stated she would not want to live hooked up to a “machine” (she’s not), or be a “burden” (her parents don’t consider her a burden and want to care for her). Michael’s brother, Scott, backs up his claim, while his sister-in-law, Joan, told the court that Terri had approved of pulling the life support from the dying baby of a mutual friend and said that if she ever wrote a “will” she would say that she didn’t want “tubes.”

Little did Terri know that these purported statements, uttered under very casual circumstances, would become the justification used by her husband in his six-year drive to remove her feeding tube and end her life. Indeed, based on these casual statements, Judge George Greer of the Sixth Judicial Circuit in Clearwater, Florida ruled that Michael had established “by clear and convincing evidence”--the highest evidentiary standard in civil law--that Terri would rather dehydrate to death over a period of 10-14 days than live on food and water supplied by a feeding tube.

THIS ASPECT of Terri’s case deserves far more attention that it is receiving. Most of us have undoubtedly made similar casual statements in response to the death of a relative or the emotions generated by a movie. But shouldn’t much more be required to justify the intentional ending of a human life? At the very least, shouldn’t we demand a well thought out, informed, and preferably written statement that not only indicates what is desired, but also shows that reasonable alternatives have been fully considered?

For example, if Terri did say she didn’t want tubes, did she know that it would include a feeding tube and that it could mean a dying process that involved seizures, heaving, nose bleeding, cracked lips, parched tongue, and the extremities becoming cold and mottled? If she did, would that have made a difference to her? And would her opinion have changed if she knew that the statements made to her husband and in-laws would be stretched by Judge Greer to refuse her parents’ reasonable request that before being dehydrated, she be allowed access to rehabilitation that many medical experts believe might permit her to be weaned from the feeding tube altogether?

And what does the statement, “I don’t want tubes,” mean anyway? Perhaps Terri was thinking about the stark atmosphere of a neonatal intensive care unit in which babies may be kept alive by battalions of beeping and buzzing medical machines. But she isn’t in that condition. Or, if she was thinking of Karen Quinlan’s circumstance, she might have conceived of herself spending years on a respirator, which was the treatment at issue in her case. But Terri isn’t on a respirator. The only life support she needs is food and water.

MANY DEHYDRATION CASES have involved such casual statements. The most disturbing of these was that of Marjorie Nighbert, which, ironically, also occurred in Florida. Marjorie was a successful Ohio businesswoman who was visiting her family in Alabama when she was felled by a stroke that left her disabled but not terminally ill. After being stabilized, she was moved to a nursing home in Florida where, it was hoped, she could be rehabilitated to relearn how to chew and swallow without danger of aspiration. To ensure she was nourished, she was provided a feeding tube.

This presented an excruciating quandary for her brother Maynard, who had a general power of attorney from Marjorie (not power of attorney for health care), as a consequence of which he became her surrogate medical decision-maker. Marjorie had once told her brother that she didn’t want a feeding tube if she were terminally ill. Despite the fact that she was not dying, however, Maynard believed that if she were unable to be weaned off the tube, she would have wanted to die rather than live using the tube for nourishment. When she did not improve, he ordered the tube removed.

As she was slowly dehydrating to death, Marjorie began to ask the staff for food and water. In response to her pleas, members of the nursing staff surreptitiously gave her small amounts. One distraught staffer eventually blew the whistle, leading to a state investigation and a temporary restraining order requiring that Marjorie be nourished.

Circuit Court Judge Jere Tolton received the case and appointed attorney William F. Stone to represent Nighbert and to conduct a 24-hour inquiry, the sole issue being whether Marjorie was competent to rescind her power of attorney and make her own decisions. After the rushed investigation, Stone was forced to report to the judge that she was not competent at that time. She had, after all been intentionally malnourished for several weeks. Stone particularly noted that he had been unable to determine whether she was competent when the dehydration commenced.

With Stone’s report in hand, the judge ruled that the dehydration should be completed, apparently on the theory that Marjorie did not have the competence to request the medical treatment of food and water. Before an appalled Stone could appeal, Nighbert died on April 6, 1995.

Society’s approach to the so-called “right to die” has become far too casual. None of us should be made to die because of statements made in casual conversations or due to misconstrued oral directives. The time has come for the best legal minds in the country to draft model legislation that will tighten existing laws so as to give every reasonable legal benefit of the doubt to life rather than, as too often happens now, to slow death by dehydration.

Author Wesley J. Smith is a senior fellow at the Discovery Institute and an attorney and consultant for the International Task Force on Euthanasia and Assisted Suicide. He is the author of “Forced Exit: The Slippery Slope from Assisted Suicide to Legalized Murder.”

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Life, Death, and Silence: Why the media elites won’t tell the full story on Terri’s prognosis and Michael Schiavo (Weekly Standard, 031031)

FOR MONTHS, as the Terri Schiavo case roiled much of the country, the establishment media all but ignored the story. But then, in the midst of her dying by dehydration, the Florida Legislature passed “Terri’s Law,” authorizing Governor Jeb Bush to place a moratorium on the dehydration deaths of certain cognitively disabled patients, including Terri. When that happened, the media blackout transformed into media frenzy.

It soon became quite clear, however, that increased media attention was not synonymous with increased dissemination of relevant facts. For despite carpet coverage of the controversy in establishment outlets, the full story still isn’t being told for the simple reason that most media refuse to report it.

What are these ignored facts?

(1) Michael Schiavo has lived with his fiancé for nearly eight years and has sired two children by her. In the years since Terri’s devastating disability, Schiavo has gone on with his life, fallen in love with another woman, and started a family. Few would hold this against him--if he would turn Terri’s care over to her parents. Instead, Schiavo insists that he should retain all the rights of a husband--including inheritance and retention of marital property--as he simultaneously enjoys connubial bliss and sweet domesticity with his fiancé.

By siring two children with another woman, Michael effectively estranged himself from his marriage. Surely, thinking people would want to know this fact. Yet Schiavo’s new family is consistently unmentioned. Instead, he is almost always depicted simply as a “husband” struggling against in-laws and right-to-lifers to fulfill his wife’s stated desire to die.

The entire episode is beginning to take on the feel of a conspiracy of silence. Consider the following very partial list:

Newsweek’s extensive report on the story (“Who Has the Right to Die” by Arian Campo-Flores, November 3, 2003) laudably mentioned both sides of many of the controversies in the case--indeed more than most other stories--but significantly omitted Schiavo’s new family.

Similarly, in the New York Times’s many recent articles, opinion columns, and in its editorial against Terri’s Law, Schiavo’s extracurricular activities were completely ignored. It’s October 23 editorial merely stated:

Michael Schiavo, her husband and legal guardian, went to court seeking to cut off the feeding tube that was keeping her alive. He testified that Ms. Schiavo, who did not have a living will, would not have wanted the feeding to continue.

Sounds reasonable. But imagine how different readers’ impression of the case would be if the editorial had included the total context, by stating, “Michael Schiavo, who remains legally married to Ms. Schiavo but has sired two children with his fiancé, went to court seeking to cut off the feeding tube.”

The Christian Science Monitor editorialized on October 29 that challenges to spousal decisions in these matters by other family members “could lead to chaos.” Would the editors have been able to express that opinion with a straight face if they had included the facts about Schiavo’s new life?

Could it be that the reporters and editors who are writing and editing these pieces don’t know Schiavo has established a new family? That’s hard to believe. Indeed, in at least in one case I know the reporter knew the story because I told it to him and he still failed to report it (or perhaps, the editor removed it from his final copy).

Manuel Roig-Franzia interviewed me for a story on Jeb Bush’s ordering Terri’s food and water restored. We spoke at some length during which I made a point of emphasizing Schiavo’s current domestic circumstances. Yet, when his front page story appeared (including a brief quote from me), there was no mention of these facts, despite their clear relevance to the following assertion:

Terri Schiavo left no written instructions, but her husband testified that she told him she would not want to live in a vegetative state. The courts have been clear, legal experts said, that spouses have the authority to make decisions in such cases.

But the real issue is whether estranged spouses have the authority. In this case, shouldn’t that be the pertinent point?

(2) Many medical experts believe Terri can be improved. Most media reports depict the medical prognosis for Terri as being settled fact. Thus, stories have described her as “comatose,” which she is not, and vegetative, which remains a matter of dispute despite courts ruling otherwise.

But it is a matter of court record that many doctors and medical therapists who specialize in rehabilitating people with profound cognitive disabilities have testified that Terri’s condition can possibly be improved. This includes board certified neurologists and reputable speech therapists, such as Sarah Green Mele from the world-renowned Rehabilitation Institute of Chicago. Indeed, Mele stated in an affidavit that Terri would, “within a reasonable degree of clinical probability, be able to improve her ability to interact with her environment, communicate with others, and control her environment if she were given appropriate therapy and training . . .”

But since the judge sided with Schiavo’s experts, the media has acted as if that settles the matter. But this isn’t akin to a situation of “he said / she said.” We don’t have to believe one side over the other. There is a simple way to find out for sure whether Terri can be improved: allow her to receive therapy for six months and then take another look. Too bad the media generally refuses to report that Judge George Greer of the Sixth Judicial Circuit Court in Clearwater, Florida, won’t permit that.

(3) Many opponents of dehydrating Terri are not “pro-life religious fundamentalists.” The establishment media’s consensus view is that the Schiavo controversy is being driven by religious, pro-life fundamentalists who have insinuated themselves into a family tragedy in order to further their own narrow sectarian purposes. Thus, when Operation Rescue founder Randall Terry briefly surfaced as a defender of Terri’s life, the New York Times happily splashed the story all over its front page warning darkly that religious conservatives intend to parlay the public interest generated by Terri’s case as a wedge to “chip away at court rulings allowing abortion and banning organized prayer in schools and the posting of the Ten Commandments in public schools, among other issues.” (The article was titled “Victory in Florida Feeding Case Emboldens the Religious Right.”)

It is true, of course, that many Christians--most of them conservative--have joined the fray, and good for them. But so too has Joe Lieberman, a top tier candidate for the Democrat presidential nomination. Lieberman, who is not Christian, not conservative, and not pro-life, courageously supported Jeb Bush’s efforts to save Terri’s life, telling the Associated Press, “where there is not a living will . . . we ought not to create a system where people are being deprived of nutrition and hydration in a way that ends their lives.”

The politically liberal disability rights movement has also committed itself to saving Terri’s life. Indeed, activists almost unanimously declare that dehydrating Terri would be an act of bigotry against her because of her cognitive disability. There was even an effort in Canada to obtain asylum for her on this score. This is why more than a dozen national disability rights groups signed the National Disability Groups Joint Statement in Support of Terri Schiavo, which reads in part:

In this matter of living as a disabled person, those of us who live with a disability are the experts--not husbands, not parents, not doctors, not ethicists. We know that life with a disability is worth living, and we know something we find appalling is the attitude of “better off dead”--an opinion that drives much of the thinking surrounding people like Terri-Schindler-Schiavo.

SO WHY IS THE ESTABLISHMENT MEDIA covering the Schiavo story as if it wants Michael to succeed in his campaign to end Terri’s life?

The establishment media usually reflects the attitudes of society’s elites, who do generally believe that people like Terri are better off dead. On the other hand, talk-radio and the Internet--what I call dissident media--generated the unprecedented outpouring of support for Terri’s life that culminated in Terri’s Law. Members of the establishment disdain dissident media and perceive it to be a threat.

Thus, the Schiavo case has, for the mainstream media, become a potent symbol both of the culture wars--pro-life versus pro-choice--and an acute challenge by dissident media to its hegemony over news dissemination.

Too bad for Bob and Mary Schindler, Terri’s folks: They aren’t trying to lead a crusade. They don’t want to undercut the cultural and media status quo. They just want to save their dear daughter’s life.

Wesley J. Smith is a senior fellow at the Discovery Institute and an attorney and consultant for the International Task Force on Euthanasia and Assisted Suicide. He is the author of “Forced Exit: The Slippery Slope from Assisted Suicide to Legalized Murder.”

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The Guardian of Terri Schiavo (Weekly Standard, 031104)

In 1998, Terri Schiavo’s first guardian ad litem filed a report on her case. It makes for interesting reading today

THE TERRI SCHIAVO CASE continues to take dramatic twists and turns. Even as Michael Schiavo attempts to have Terri’s Law declared unconstitutional, pursuant to the law’s requirements, a judge has appointed a guardian ad litem--Professor Jay Wolfson, of the College of Public Health at the University of South Florida in Tampa--to represent Terri’s interests.

There has been some confusion as to whether Wolfson replaces Terri’s quasi-estranged husband Michael Schiavo as guardian of Terri’s person. (I use the term “quasi-estranged” because Schiavo effectively shattered the sanctity their marriage years ago by entering a committed relationship with another woman and starting a family with her.) He does not. Wolfson’s sole responsibilities are to determine whether Terri should be allowed a swallow test, whether she should be provided rehabilitation, and to write a report with his recommendations about these matters--all within 30 days. In the meantime, Schiavo remains fully in control over Terri’ life and care (or the lack thereof)--with the exception that he cannot, for now, remove her tube-supplied food and water.

A little known but interesting facet of this case is that Wolfson is not the first guardian ad litem appointed to represent Terri’s interests. When Schiavo first petitioned the court for permission to dehydrate his wife in 1998, he properly admitted that he had two significant conflicts of interest: He was likely to want to remarry and if Terri died, he would inherit the more than $700,000 then on deposit in her trust account. (For those who have not followed this case, Terri received the money in a medical malpractice lawsuit.)

Because of these conflicts of interest, the Probate Court appointed Richard L. Pearse Jr. of Clearwater, Florida, as Terri’s guardian ad litem and instructed him to investigate the matter and report back with a recommendation. Pearse filed his report with the court on December 28, 1998 urging that the court deny the petition to remove Terri’s food and water.

Considering that the Pearse’s report was written long before the Schiavo case became an international cause celebre, it makes interesting reading. The guardian ad litem supported Schiavo’s position on some points and the Schindlers on others. The following are its pertinent portions:

*Pearse unambiguously accepted the diagnosis that Terri is in a persistent vegetative state (PVS) based on the opinions of two doctors, one who treated her and one who consulted on the case. This diagnoses was--and remains-- disputed by Terri’s parents, Bob and Mary Schindler. Indeed, subsequent to Pearse’s report, the Schindlers energetically attempted to garner evidence that she is conscious. To some degree, they have succeeded: Four board certified neurologists, two board certified internists, one neuro-psychologist, and two speech pathologists have testified in person or by affidavit that Terri is not PVS. These opinions were reinforced by the affidavits of three nurses who cared for Terri in the mid-1990s and who claim to have observed her being interactive. Moreover, millions have viewed videos of Terri and been shocked by the extent to which she appears to aware and awake. (The courts have ruled consistently that Terri is PVS.)

*Pearse claimed that Terri has muscle contractures despite receiving “regular physical therapy.” He may have assumed that she received such care--it is routine for bedridden patients, after all. Yet, according to Patricia Anderson, the Schindler’s attorney, there are no entries indicating that PT was ever performed in Terri’s chart after 1992. Indeed, in 1998, when a new doctor urged Schiavo to approve an evaluation of Terri so that a plan of physical therapy could be developed, he refused to permit it.

*Pearse confirmed the charge by the Schindlers that once the medical malpractice money was in the bank, Schiavo began to refuse medical treatment for Terri, writing:

After February 1993, Mr. Schiavo’s attitude concerning treatment for the ward apparently changed. Early in 1994, for example, he refused to consent to treat an infection from which the ward was then suffering and ordered that she not be resuscitated in the event of cardiac arrest. The nursing home where she resided at that time sought to intervene, which ultimately led the ward’s husband to reverse his decision and authorize antibiotic treatment.

Perhaps because of the intervention by the home, Schiavo soon moved Terri to a different nursing facility.

*Schiavo admitted to the guardian ad litem that he had at least “two romantic involvements” after Terri’s collapse. “It is apparent to me,” Pearse wrote the court, “that he has reached a point that he has no hope of the ward’s recovery and wants to get on with his own life.” (To say the least. At the time of Pearse’s investigation, Schiavo was already living with the woman who would become the mother of his children.)

*Contrary to Schiavo’s allegation on Larry King last week that the Schindlers “really basically didn’t have any care with Terri,” Pearse painted a vivid picture of parents worried deeply about the quality of care their daughter was receiving and profoundly committed to remaining involved in her life:

From the time of the ward’s accident, the ward’s parents have been vitally interested in her welfare . . . After the falling out between the ward’s parents and her husband, Mr. and Mrs. Schindler pursued removal litigation in an effort to have Mr. Schiavo removed as their daughter’s guardian and to have themselves appointed guardians of her person . . . They have also pursued litigation against him to gain access to medical and financial information concerning the ward which was withheld by the ward’s husband, with only partial success. They express extreme frustration with the current situation in which they have virtually no input into the decision making process concerning their own daughter. The ward’s parents visit her regularly but at times when they won’t have to confront Mr. Schiavo.

Moreover, rather than the Schindlers not being interested in seeing Terri, as was asserted on Larry King, Pearse noted that it was Schiavo who “has isolated the ward from her parents.”

*As of April 4, 1998, Terri’s trust fund held $713,828.85. “Thus,” wrote Pearse, “Mr. Schiavo will realize a substantial and fairly immediate financial gain if his application for withdrawal of life support [tube-supplied food and water] is granted.” (Schiavo now claims that there is only $50,000 left in the account, the bulk of the money having gone to pay his attorneys.)

*At the time of the report, only Schiavo claimed that Terri would not wish to be kept alive if severely incapacitated. “However,” Pearse opined, “his credibility is necessarily adversely affected by the obvious financial benefit to him of being the ward’s sole heir at law in the event of her death while still married to him. Her death also permits him to get on with his own life.” (Subsequent to the filing of the report, and perhaps in response to it, Schiavo’s brother and sister-in-law came forward to claim Terri made similar statements in their presence. In this regard it is worth noting that no member of Terri’s family, or any of her friends, recall her ever making any such statements to them.)

*Pearse concluded, “Given the inherent problems already mentioned, together with the fact that the ward has been maintained the life support measures sought to be withdrawn for the past 8 years, it is the recommendation of the guardian ad litem that the petition for removal be denied.”

UNFORTUNATELY, Pearse’s opinion held scant sway with the court. After filing his report, he requested further court instructions to authorize him to continue to represent Terri as guardian ad litem. Schiavo’s attorney, George Felos objected, and attempted to have Pearse removed for bias. This attempt failed but after his report was received, Pearse was discharged from participating any further in the case. And despite Schiavo’s continuing conflicts of interest--which only deepened on the personal level as he sired children--no other guardian ad litem was ever appointed to represent Terri during the years of litigation, proceedings that culminated in an October 15, 2003 court order requiring Terri Schiavo to be deprived of all water and food toward the end that she dehydrate to death.

Wesley J. Smith is a senior fellow at the Discovery Institute and an attorney for the International Task Force on Euthanasia and Assisted Suicide. His current book is the updated and revised “Forced Exit: The Slippery Slope from Assisted Suicide to Legalized Murder.”

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Information on Euthanasia (Kearl’s Ring of Death, 031111)

(http://www.trinity.edu/~mkearl/death.html)

So what is to be made of the 1990 merger between Concern for Dying and the Society for the Right to Die, the media attention given to Jack Kevorkian’s suicide machine, and Derek Humphry’s Final Exit reaching the top of the New York Times best-seller list in 1991 (and its video version appearing on Oregon television and in Amazon.com’s inventory in 2000)? Have we reached the point where dying has become another form of consumer resistance? Certainly one common theme underlying these developments is the failure of the contemporary death ritual for both the dying and the bereaved.

The loss of control experienced by institutionalized terminally ill patients is a central motif of much thanatological research. Dying patients’ basic human rights are seen to be violated when they lack the knowledge and power to make decisions which, in turn, diminishes dignity. Patients have the right to know their condition, to choose or to reject the treatment regimen, to choose or to reject attempts to prolong their life, and to decide fully as to the disposal of their remains. They also have the right to ritually vent their fears and frustrations. (Consider the findings of David Spiegel, whose study of women with metastic breast cancer found that those who belonged to a psychotherapy group survived almost twice as long on average as those who did not participate in a support group, and reported less depression, anxiety and pain.) For the moving story of John Graham’s death check out Soundprint’s “A Matter of Life and Death: Assisted Suicide in Australia” (Michael Lutsky, producer).

As is the case with any ending--whether it be music resolutions, the denouements of literature and drama, conclusion sections of research papers, the logic of desserts, or the completion of a human life--failure to culminate “correctly” jeopardizes the overall meaningfulness of the social product. Endings occasion special insight. Representing consummation and closure, endings reveal the connections between means and goals. They demand summations of the worthiness, coherence, and meaningfulness of their encounters with time. Further, the endings of role careers and lives can be the most individualizing of experiences: Individuals “in exit” no longer need to conform to trivialities of mass culture nor to the norms of the status hierarchy; one can say what one likes for there is nothing to lose. For these reasons, endings are highly ritualized.

From this perspective, the problem of our times is the apparent lack of cultural consensus over exactly how endings --whether from work, the family, or from life itself-- should be ideally conducted. It is for this reason that we now witness expanding political and legal involvements in status terminations. In 1997, the U.S. Supreme Court will decide if states can prosecute physicians for assisting in the suicides of their competent, terminally ill patients. We do know that “good” endings require personal control and the minimization of degradation. As a consequence, we’re witnessing the emergence of the death awareness movement that features the right-to-die, euthanasia, and hospice movements as well as the public’s receptivity to Kübler-Ross’s stages of the death process. This, in turn, is regenerating a life awareness movement. As Martin Luther King said on the eve of his assassination, no one is truly free to live until one is free to die.

Given the results of an eight-year clinical study of dying in America, (Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments, funded by the Robert Wood Johnson Foundation; William Knaus and Joanne Lynn principal investigators), revealing that one-half of conscious patients who died in hospitals reported moderate to severe pain at least one-half of the time, and given the survey results of 1,400 doctors and nurses at five major hospitals in different parts of the country (published in the January 1993 issue of the American Journal of Public Health) indicating that 81% agreed that “the most common form of narcotic abuse in caring for dying patients is undertreatment of pain” with nearly half of the attending physicians and nurses and 70% of resident physicians reporting having acted against their conscience by not aggressively treating terminally ill patients, perhaps we would not be faced with the euthanasia debate if adequate pain control had been administered. Check out the philosophy and resources at the Palliative Page.

PHYSICIAN-ASSISTED SUICIDE

There is a fine moral line between euthanasia and physician-assisted suicide. Physicians still, however, control the final passage as terminally ill patients’ ability to have legal access to lethal drugs is contingent on doctors’ approval. In the July 2000 edition of Reason magazine, Thomas Szasz speaks of “the galloping therapeutic state, where increasingly we are giving away our existential choices and responsibilities to doctors.” He notes that if one buys a rope to hang oneself we don’t refer to it as “merchant- assisted suicide.” And is accelerating the inevitable really “suicide”?

Thomas A. Bowden’s “Assisted Suicide: A Moral Right” produced by the Ayn Rand Institute’s MediaLink

KEVORKIAN’S BOX SCORE

At the center of this moral hurricane is Dr. Jack Kevorkian, a Michigan pathologist (whose business card reads “Jack Kevorkian, M.D. Bioethics and Obitiatry. Special Death Counseling”) who created suicide machines to allow terminally ill patients to kill themselves in supposedly humane and painless ways. In his 1991 book Prescription: Medicine--The Goodness of Planned Death, he speaks of the “Stone-Age ethics of space-age medicine” and of his personal crusade for physician- assisted suicide. His highly publicized activities have been viewed by others in a multitude of ways, from his being a godsend to a serial killer.

Kevorkian is not alone is his acceleration of the death process of the terminally ill. A 1996 study by David A. Asch of over 800 critical-care nurses, for instance, revealed nearly one in five admitting to hastening the deaths of terminally ill patients--16 percent by performing euthanasia or assisting in suicide, and another 4 percent by only pretending to live life- sustaining treatment ordered by physicians.

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“In Sickness”: The unfettered right to love, honor, and pull the plug (NRO, 031113)

Terri Schiavo is a married woman. Her husband, Michael, promised at their wedding to love her, to honor her, to comfort her, to keep her in sickness and in health, forsaking all others, and to be true to her as long as they both should live. After Terri was rendered severely brain-damaged due to hypoxia 13 years ago, Michael filed a medical-malpractice suit on her behalf. In his testimony for that lawsuit, Michael reaffirmed his devotion to his now-disabled wife: “I believe in the vows I took with my wife: through sickness and health, for richer or poor. I married my wife because I love her and I want to spend the rest of my life with her. I’m going to do that.” The sympathetic jury awarded Michael $640,000 for loss of consortium; Terry was awarded nearly $800,000 to be used for her rehabilitation and lifetime care. Because he is Terri’s husband, Michael has the authority to administer this fund and to make medical decisions regarding her care.

Less than a year after the money was in the bank Michael apparently suffered a little cognitive deficiency himself, because he seemed to forget all about his promises to his wife and to the jury. The plans for rehabilitative therapy that he presented to the jury were squelched. He had a do-not-resuscitate order placed on Terri’s chart. He repeatedly denied treatment for infections that Terri suffered. He began to date other women, and currently lives with a woman who had a child by him. They are expecting another and plan to marry when Terri dies.

Terri’s parents, Bob and Mary Schindler, objected to what they perceived as Michael’s neglect of Terri’s needs, so in 1993 they filed a petition to have him removed as Terri’s guardian. Thus began one of the ugliest family feuds of all time.

Michael demands that Terri not be fed or given water, claiming that she told him before she became disabled that she would rather die than be dependent on tubes. He declares that Terri has no significant mental function, so it is up to him as her loving husband to ensure that her desire to die be fulfilled. Terri’s parents say that they have known her a lot longer than Michael has, and they never heard her say any such thing. Furthermore, they claim that Terri is not a vegetable, and that she responds to their attention in a meaningful way. They want Terri to live, and they want her to be provided the rehabilitative care that was supposed to have been funded by the malpractice award.

Michael has prevailed in the courts. Even Michael can offer no evidence about Terri’s wishes but his word, he is her husband; therefore, the courts have agreed that he should have nearly absolute control over her fate, and her parents none at all.

Why did the courts accept such weak evidence as to whether Terri would want to be fed in her current condition? (If she did tell her husband what he claims she did, was it a well-thought-out opinion or just the sort of casual remark that healthy young people are prone to make?)

Michael wants to marry his current girlfriend but of course cannot as long as he is married to Terri. But if he simply divorces her he will no longer stand to inherit her property, including whatever remains of her medical fund (incredibly, the court allowed him to pay his legal fees from this fund, which was intended to provide care for his wife; he has already paid his lawyers nearly $400,000 from it in his efforts to end her life.)

It seems odd that a husband with such questionable motives should be granted so much power over his wife’s life. The case reminds one of the old view of marriage as the incorporation of the wife into the husband’s legal and social identity: Married women had no independent rights. Feminists have been challenging this idea for more than a hundred years. Where are they now? Feminists for Life is the only feminist group to object to Michael’s nearly total control over his wife’s destiny. Regardless of one’s opinion about what course of action is in Terri’s best interest, the courts’ given Michael such unfettered control ought to be a cause for concern.

The Florida legislature has given Terri a reprieve from her death by starvation, allowing for a little more time to sort out the wrenching issues illuminated by her predicament. I hope that Michael will divorce Terri and allow her parents to assume responsibility for her. They are convinced that with therapy, her condition can improve. Their belief is supported by recent research described in a recent New York Times Magazine article (“What if There Is Something Going On in There,” September 28, 2003). This research suggests that “even after an injury that leaves a brain badly damaged, even after months or years with little signs of consciousness, people may still be capable of complex mental activity,” and that “a vast number of people who might once have been considered vegetative actually have hidden reserves of mental activity.”

This year, a man named Terry Wallis woke up after 19 years in a coma. His wife never gave up on him. If Michael is successful in his efforts to give up on Terri, we’ll never know what surprises she might have for us.

— Rosemary Oelrich Bottcher, a former president of the Board of Feminists for Life of America, lives in Florida. She is a former columnist of the Tallahassee Democrat.

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Dutch (Holland/Netherlands) Euthanasia: The Dutch Disaster (Focus on the Family, 030922)

by Carrie Gordon Earll

Euthanasia advocates argue that strict guidelines will protect the dependent, disabled and elderly from family members or medical professionals who deem their lives are no longer worth living. These “right to die” supporters point to Holland, where physicians have practiced physician-assisted suicide and euthanasia for more than two decades. While euthanasia and assisted suicide remain illegal in Holland, doctors are free to engage in such practices without prosecution if they follow specific guidelines. Among others, these parameters require that the patient be competent, voluntarily repeating the request for death and experiencing unbearable suffering from an irreversible illness.1

However, two Dutch studies, conducted in 1990 and 1995 found that doctors in the Netherlands practiced euthanasia apart from these guidelines. These studies substantiate the suspicion that granting physicians the legal liberty to intentionally bring about the death of a patient could result in people being killed who did not ask to die.

The studies make a distinction between two forms of euthanasia: euthanasia -- the intentional killing of a patient by the direct intervention of a physician at the patient’s explicit request, and ending life without the explicit request of the patient -- the intentional killing of a patient by the direct intervention of a physician without the patient’s explicit request. An analysis of deaths in both categories reveals that 31 percent of cases in 1990, and 22.5 percent in 1995 involved patients who did not give their explicit consent to be killed.2

In April 1995, Dutch physician Henk Prins was convicted of giving a lethal injection to Rianne Quirine Kunst, a baby born with a partly formed brain and spina bifida. The court refused to punish Prins.4 Likewise, though psychiatrist Boudewijn Chabot was found guilty in 1994 of prescribing a fatal dose of sleeping pills for Hilly Bosscher, who was suffering from depression, Chabot was not penalized.5 That same year, the Dutch Supreme Court ruled physician-assisted suicide might be acceptable for patients with unbearable suffering but no physical illness. A 1996 survey of Dutch psychiatrists found 64 percent of those responding “thought physician-assisted suicide for psychiatric patients could be acceptable.”6

As the Dutch experience demonstrates, euthanasia does not remain limited to competent, terminally ill adults who choose to end their own lives. Furthermore, guidelines have proven to be no protection for Holland’s disabled, depressed or elderly citizens. In fact, involuntary euthanasia has become so prevalent that many Dutch citizens carry “Life Passports,” cards that state they do not want so-called “physician aid-in-dying” if they are hospitalized.7

Analysis of Dutch Euthanasia Studies

The studies were conducted in 1990 and 1995. Methods included surveys of and interviews with Dutch physicians as well as analysis of Dutch death certificates listing the cause of death. The 1990 study is often referred to as the Remmelink Report, named after the government representative who chaired a national commission formed to examine medical decisions at the end of life. In the Netherlands, physicians are able to engage in the practices of both euthanasia and physician-assisted suicide, generally without fear of prosecution. However, the two Dutch studies indicate that, on the average, euthanasia is practiced 10 times more frequently than physician-assisted suicide (PAS).

Table 1: Comparison of euthanasia and physician-assisted suicide deaths (% in total deaths Ý):

1990-- Euthanasia (1.8%), PAS (0.2%), Ratio 9:1 1995-- Euthanasia (2.4%), PAS (0.2%), Ratio 12:1 Average: 10.5

(Percentages used in this analysis are based on the total number of deaths in the Netherlands in the year: 128,786 deaths in 1990 and 135,546 deaths in 1995.)

The Dutch studies make a distinction between two forms of euthanasia: euthanasia -- the intentional killing of a patient by the direct intervention of a physician at the patient’s explicit request and ending life without the explicit request of the patient or ELWERP -- the intentional killing of a patient by the direct intervention of a physician without the patient’s explicit request. Based on these definitions, the studies document the following number of deaths:

Table 2: Analysis of euthanasia deaths with and without explicit request (% of total deaths Ý):

Method of death 1990 Euthanasia (with request) 2318 (1.8%) ELWERP (without request) 1030 (0.8%) TOTAL 3348

1995 Euthanasia (with request) 3253 (2.4%) ELWERP (without request) 948 (0.7%) TOTAL 4201

(Percentages used in this analysis are based on the total number of deaths in the Netherlands in the year: 128,786 deaths in 1990 and 135,546 deaths in 1995.) These numbers reveal that, of all euthanasia deaths (3348 and 4201, respectively), 30.76 percent in 1990 and 22.56 percent in 1995 involved patients who did not give their explicit consent to be killed.

Sources:

1990 study: van der Maas, P.J., van Delden, J.J.M., Pijenborg, L. (1992). Euthanasia and other medical decisions concerning the end of life: An investigation performed upon request of the Commission of Inquiry into the medical practice concerning euthanasia. Amsterdam: Elsevier Science Publishers. (p. 178, 181-182).

1995 study: van der Maas, P.J., van der Wal, G., Haverkate, I., et al. (1996). Euthanasia, physician-assisted suicide, and other medical practices involving the end of life in the Netherlands, 1990-1995. New England Journal of Medicine, 335, 1699-1705.

Carrie Gordon Earll is the Senior Policy Analyst for Bioethics at Focus on the Family and a fellow with the Center for Bioethics and Human Dignity.

1Carlos Gomez, Regulating Death, (New York: Free Press, 1991), p. 32; “The Dutch Guidelines: How a Nation Tolerates Euthanasia,” Newsday, January 6, 1997, p. A6

2P. J. van der Maas, J.J.M. van Delden and L. Pijenborg, Euthanasia and other Medical Decisions Concerning the End of Life: An Investigation Performed Upon Request of the Commission of Inquiry into the Medical Practice Concerning Euthanasia, (Amsterdam: Elsevier Science Publishers, 1992) p. 178-179, 181-182; P.J. van der Maas, G. van der Wal, I. Haverkate, C.L.M et al.,(1996). Euthanasia, physician-assisted suicide, and other medical practices involving the end of life in the Netherlands, 1990-1995. New England Journal of Medicine, 335, p. 1700-1701

3”The Dutch Guidelines,” Newsday, 1997, p. A6

4 “Doctor Freed in ‘Justified’ Mercy Killing,” Chicago Tribune, April 27, 1995, p. N21; “Murder Charge Proved Against Euthanasia Doctor, but Case Dismissed,” Associated Press, April 27, 1995

5 “Doctor Unpunished for Dutch Suicide,” New York Times, June 22, 1994, p. 10A

6 J.H. Groenewoud, P.J. van der Maas, G. van der Wal, et al., Physician-assisted death in psychiatric practice in the Netherlands. New England Journal of Medicine, 336, p. 1796

7 “Dutch Death,” Oregonian, January 8, 1995, p. 17A

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Continent Death: Euthanasia in Europe (NRO, 031223)

Too many people think with their hearts instead of their brains. Wanting the world to suit their desires, when faced with hard truths to the contrary, they refuse to face facts they don’t want to believe. This common human failing has a name: self-delusion.

Self-delusion is rampant in the euthanasia movement. Most proponents recognize that it is inherently dangerous to legalize killing. But they desperately want to believe that they can control the grim reaper. Thus, they continue to peddle the nonsense that “guidelines will protect against abuse” despite overwhelming empirical evidence to the contrary.

Euthanasia has been around long enough and practiced sufficiently enough for us to detect a pattern. Killing is sold to the public as a last resort justified only in cases where nothing else can be done to alleviate suffering. But once the reaper is allowed through the door, the categories of killable people expand steadily toward the acceptance of death on demand.

The classic example is the Netherlands, where doctors have been allowed to euthanize patients since 1973. Dutch death regulations require that euthanasia be strictly limited to the sickest patients, for whom nothing but extermination will alleviate overwhelming suffering — a concept in Dutch law known as force majeur. But once mercy killing was redefined as being good in a few cases rather than being bad in all circumstances, it didn’t take long for the protective guidelines to be viewed widely as impediments to be overcome instead of important protections to be obeyed.

Thus, supposedly ironclad protections against abuse — such as the doctrine of force mejeur and the stipulation that patient give multiple requests for euthanasia — quickly ceased meaningfully to constrain mercy killing. As a consequence, Dutch doctors now legally kill terminally ill people who ask for it, chronically ill people who ask for it, disabled people who ask for it, and depressed people who ask for it.

Euthanasia has also entered the pediatric wards, where eugenic infanticide has become common even though babies cannot ask to be killed. According to a 1997 study published in the British medical journal The Lancet, approximately 8 percent of all Dutch infant deaths result from lethal injections. The babies deemed killable are often disabled and thus are thought not to have a “livable life.” The practice has become so common that 45 percent of neonatologists and 31 percent of pediatricians who responded to Lancet surveys had killed babies.

It gets worse: Repeated studies sponsored by the Dutch government have found that doctors kill approximately 1,000 patients each year who have not asked for euthanasia. This is not only a violation of every guideline, but an act that Dutch law considers murder. Nonvoluntary euthanasia has become so common that it even has a name: “Termination without request or consent.”

Despite this carnage, Dutch doctors are very rarely prosecuted for such crimes, and the few that are brought to court are usually exonerated. Moreover, even if a doctor is found guilty, he or she is almost never punished in any meaningful way, nor does the murderer face discipline by the Dutch Medical Society. For example, in 2001, a doctor was convicted of murdering an 84-year-old patient who had not asked to be killed. Prosecutors demanded a nine-month suspended probation (!), yet even this brush — it can’t even be called a slap — on the wrist was rejected by the trial judge who refused to impose any punishment. Not to worry. The appellate court decided to get tough: It imposed a one-week suspended sentence on the doctor for murder.

Even such praising with faint damnation isn’t enough for the Dutch Medical Association. As a result of this and the handful of other non-punished murder convictions of doctors who engaged in termination without request or consent, the organization is lobbying to legalize non-voluntary euthanasia. Along these same lines — and demonstrating that the culture of death recognizes no limits — the day after the Dutch formally legalized euthanasia, the country’s minister of health advocated the provision of suicide pills to the elderly who do not qualify for killing under Dutch law.

Lest we think the Dutch experience is a fluke, let us now turn our attention to Belgium. Only one year ago the Belgians legalized Dutch-style euthanasia under “strict” guidelines. As with the Netherlands, once unfettered, the euthanasia culture quickly began to swallow Belgium whole. Moreover, the slide down the slope has occurred at a greatly accelerated pace. It took decades for the Dutch euthanasia to reach the current morass. But Belgian euthanasia went off the rails from day one: The very first reported killing — that of a man with multiple sclerosis — violated the legal guidelines (not that anything was done about it). Moreover, while 203 people were officially recognized as having been euthanized in Belgium during the first year of legal practice, most euthanasia deaths were not reported (a violation of the law). The actual toll is probably closer to 1,000.

And Belgian euthanasia advocates have already begun agitating to expand the categories of killable people. A just-completed forum attended by hundreds of Belgian doctors and euthanasia enthusiasts advocated that minors be allowed to request euthanasia, as well as people with degenerative conditions, such as Alzheimer’s, who are not imminently dying. Not only that, but the chairman of the conference wants to force doctors to participate in killing patients, even if they are morally opposed. If he gets his way, the law will soon require doctors who oppose euthanasia to refer patients who want to be killed to a colleague willing to do the deed. So much for choice.

The Swiss have also unleashed the culture of death into their midst. Rather than authorizing doctors to commit euthanasia, however, Swiss law instead permits private suicide facilitation. As a result, Switzerland has become a destination for “suicide tourists” who travel there not to ski, but to receive a poison cocktail.

A private group that goes by the name “Dignitas” facilitates most Swiss assisted suicides. Its founder, lawyer Ludwig Minelli, recently told the Swiss press that he will not restrict Dignitas’s dark work to providing services to the dying. Indeed, the report said Minelli believes that “severe depression can be irreversible and that he is justified” in helping “the mentally ill” to die. Along these lines, a Swiss doctor is being investigated for possible prosecution for the double suicide of French twins with schizophrenia. That may sound like a serious effort to crack down on abuse, but remember, once euthanasia is legitimized, such talk is often cheap. If the Dutch experience is any indication, even if the suicide doctor is convicted, he will not be meaningfully punished.

Despite this history, euthanasia advocates here and abroad still cling irrationally to the hubristic and foolish notion that they are competent to administer death. They remind one of Dr. Frankenstein, who, in the name of benefiting humankind, unleashed a terrible monster.

— Wesley J. Smith is an attorney and consultant for the International Task Force on Euthanasia and Assisted Suicide. His most recent book is the revised and updated Forced Exit: The Slippery Slope From Assisted Suicide to Legalized Murder.

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While I Was Sleeping (Christianity Today, 040130)

Why my husband finally refused to end my life during my two-month coma.

My blood ran cold as I watched the video of Terri Schiavo. I shivered at the news that this brain-injured woman was comatose or in a persistent vegetative state while the video seemed to show otherwise. The chill was more than just my journalistic intrigue. People everywhere were debating the right to “die with dignity” and wondering what it would be like to be in Schiavo’s place, but I didn’t exactly have to imagine.

One year before the day Schiavo’s feeding tube was pulled, I awoke briefly from a 47-day coma, only to go back under for several more weeks. Severe childbirth complications resulted in two emergency surgeries and the transfusion of 20 units of blood and blood products—about twice the blood volume of my body. I remained comatose and on life support in the ICU for two months.

My family expected my death repeatedly during my coma. I developed acute respiratory distress syndrome, which is often fatal, and it critically impaired my lungs. I had pneumonia, a toxic blood infection, blood clots, kidney failure, and life threateningly low blood pressure and oxygenation. My family was told I had anoxia—brain damage from oxygen deprivation. I lay hooked up to a ventilator and a feeding tube, receiving maximum doses of drugs to keep me alive. Heroic measures and life-and-death decisions were daily realities for my family.

My husband slept and ate little. Tim juggled his job with being constantly available to me, to doctors’ consultations, and to our family. He described our surreal journey in e-mail updates that were forwarded by many people around the world. He also undertook “Caroline therapy”: laying our mother-deprived newborn on my chest while I slept, so she would sleep too.

Tim learned to be an effective advocate for a critically ill patient by researching my diagnosis thoroughly and making the doctors make him understand. And on days when his faith was in shock and he was too numb to pray, the prayers of others and a Holy Spirit–inspired mind propelled him beyond his capacity. Yet the possibility of a brain-damaged wife, or the thought that he was about to be a single father of five, including our newborn baby, always hovered.

Our children took on responsibilities uncommon for their ages. Three birthdays and our 15-year-old Claire’s high-school homecoming came and went while I slept. The children discovered that profound sadness can coexist with moments of normalcy and surprising pockets of happiness. But in the dark, a brave front gave way to deep fears as 10-year-old Allison finally admitted to her father, “I’m so afraid of not having a mommy.”

We experienced the body of Christ in action as our local church and others completely ran our home and came in the middle of the night when I’d take a dive. My fellow members of the Advanced Writers and Speakers Association held a day of prayer and fasting, unaware that their prayers ascended on my worst day.

Three of my close friends took weeklong turns in our home caring for the baby and children. Our eldest daughter, Jacquelyn, decided to leave her freshman year in college to become the baby’s primary caregiver.

She also experienced a faith crisis. One night, in her car in the hospital parking lot, she pictured her life two ways—with God and without. Was her faith in God just her parents’ teaching to invoke good moral choices, or was it real, hers, and worth anything at all? She pondered that age-old question: How could God let something so terrible happen? She decided that as difficult as this was to get through with God, going it alone terrified her. Her faith became her own that night.

Our story is like a movie shown on two screens: my loved ones’ experience on one, my experience on another. Their story happened to me but I missed it, missed two months of my life and the greatest tragedy my family’s been through. My story shows me giving a happy birth, then having trouble, then going to sleep before the surgeries. I awaken from a drug-induced coma, thinking it was the next morning, and hear my husband say, “You’ve been here for 47 days.” Later that day, I slip back into the coma for several more weeks, then awake to the invasion of the body snatchers, unable to breathe or move on my own, my heart severed from my newborn.

When Schiavo’s story broke, I waded through the murky ground of what many felt but few voiced. Many prolife Christians agreed that what was being done to Schiavo was terribly wrong, but still deep questions swirled: Who would want to be in her position? Is there a morally acceptable line for relinquishing life support? Could sanctity and dignity of life walk hand in hand?

The In-Between

When Dr. James Dobson was a guest on Sean Hannity’s national talk-radio show discussing Schiavo, he recounted my story. Add me to the list of poster adults for not pulling the plug. Yet from my new perspective, the sanctity of life versus the dignity of life still seems complex.

Gradually I’ve begun to remember bits of my comatose state: The swimming-through-mud feeling of trying to surface to awareness. The frightening dreams. The intense and very real spiritual warfare, a battle as unto death. The fog of being strapped in a chair with daytime television on to “stimulate” me, vaguely registering that people were in my room, but unable to comprehend that, let alone communicate. It was like watching someone through opaque glass underwater, visible but obscure and unreachable. And the weeks of living in the shadowland between my coma and full awareness, with times of frustration beyond belief.

I remember Tim holding one of my hands, a neurologist the other, and telling me to squeeze their hands. Unable to do so or to speak, I felt my brain screaming, “Why can’t I do this? Maybe I’m dying.” Later, my inability to use the call button left me banging a spoon on the bedside table for an hour and a half. No one came. They thought it was the repetitive motor response of a brain-damaged woman.

These memories seeded a need for clarity in answers and—just as important—a passion to ask the right questions in life-and-death issues. William Temple, who was Archbishop of Canterbury in the 1940s, wrote that the “church must announce Christian principles and point out where the existing social order is in conflict with them.”

What then are the Christian principles at the heart of this argument? Two come to mind: “Thou shalt not murder” is a protective boundary whose removal would incite societal moral free-fall. And life is sacred and reflects God’s image, with innate value regardless of its quality or productivity.

But if God values us, whole or brain-damaged, and there’s value in being a loving caregiver to an incapacitated person, what about the seeming purposelessness of that patient’s existence? A second biblically derived principle sheds light here: if our chief end is to glorify God, then we can find purpose and meaning in a life that society deems a mere existence. God can be glorified even through our suffering.

But how do we apply this truth in the modern hospital, especially when science can seem to be extending suffering while extending life? When is it morally right for a Christian to remove or refuse medical treatment? How do we determine when or if we can remove life support from our loved ones? When is it okay to issue a Do Not Resuscitate (DNR) order? Can we request that we not be kept alive artificially without violating the Sixth Commandment?

My family lived these agonizing questions. Two weeks after the initial dance on the edge came a death vigil. As I lay dying, the respirator whirred, pumping air into my lifeless-looking body and then sucking it out. My chest rose and fell to the machine’s rhythm, yet my lungs failed to properly oxygenate my blood. Paralytic drugs immobilized me. Vasopressor drugs fought to keep my blood pressure up. My limbs were blue and as cold as refrigerated meat. It did not look like I had any upper-level brain function. I was expected to die before morning.

I later learned that 40 or more friends and relatives stood vigil in the waiting room. My friend Sue brought our son in to join his siblings for the grim task of saying goodbye. She said to my pastor, Brent, “So, this is it?” He nodded.

Sharon marveled at our Christian paradox through grief: “She may see the face of Jesus today.”

Susan, one of my best friends, looked at my gray, barely recognizable body and said, “Death is ugly, isn’t it?”

Kathy, my other best friend, said goodbye and left distraught with my baby.

My dad touched my feet and said, “I taught these feet how to walk.” He agreed with Tim as he made end-of-life decisions.

Tim said, “Even though we have hope, there is still pain. The difference with a Christian worldview is that the outcome is established. Even if we leave things unsaid, we’ll have an opportunity to talk again.”

Through the long night, Tim hammered out the heart-rending ethics and options. He cited the radical drugs I was receiving, which essentially cut off blood flow to my extremities so the body could concentrate circulation and pressure to the vital organs.

“Does this constitute heroic measures?” he asked.

“Yes,” answered the doctor.

“So would it be ethically acceptable and appropriate to limit this medicine?”

“It would be acceptable,” she said.

Tim anguished about the ghoulish side effects and the possible dire outcome. Torn by his pain in my suffering, he issued a DNR order under certain circumstances. Then he rescinded it. Then he issued it again. Then, again, he rescinded it. Removing the respirator and feeding tube was never an option. What he questioned continuing was the heroic measure of a drug so strong that doctors privately call it “leave ‘em dead.”

“She’s suffering and she’s not there,” Tim said.

“But we don’t know that,” Susan said.

“Tim, there’s a high likelihood she’s going to die tonight, so keep your fingerprints off of it,” counseled Brent.

Mama Goes North

Thankfully, God’s leading through the counsel of community left every lifesaving measure in place, including the “leave ‘em dead” drug. Tim’s was a model decision-making process: He researched my situation; he consulted with doctors; he considered the futility or burden over benefit of treatment; he remembered my wishes; he questioned his own motives. Most important, he prayed constantly and sought godly counsel.

I don’t remember waking up the second time. Weeks after I woke up I was still on a vent, unable to speak. I went into the hospital on August 30, 2002, and came home just before Christmas, still unable to walk or breathe on my own. But in February 2003, while still incapable of driving and doing most things, I did rewrites on a book I had turned in the week before the birth (ironically titled If Mama Goes South, We’re All Going with Her). Discovering I could still think and write was another miracle, since in the hospital I couldn’t read (coma can affect vision) or concentrate. I didn’t know if I’d ever be able to resume my work.

I sometimes hear comments that Lazarus could have heard. One of my Christian doctors said, “There’s no medical reason you are alive. You are a miracle at the hand of God.” Tim often reminds me, “Life is fragile, so leave nothing unsaid.” In spite of daily physical effects of the trauma, I’ve learned that radical obedience (in my case, having a baby at 40) is worth any cost, that prayer is inconceivably important, that miracles still happen, and that I have a faith worth dying for.

Would I want to live without cognitive awareness? Well, no. Wanting to avoid suffering is human. Even Christ asked if his suffering could be avoided. I believe there are times when it is acceptable and ethical to remove medical treatment from our loved ones. But in all cases, we should weigh our desire to be released from suffering against a greater desire to glorify God. If I had predetermined no life support (or only short-duration support), as some have in advance directives, I’d be dead. I’d also perhaps have missed the greatest opportunity of my life to bring God glory, because he can use us for his purposes in any bodily state—even while we’re sleeping.

Lindsey O’Connor is an author, speaker, and former news anchor. Her most recent book is If Mama Goes South, We’re All Going with Her (Revell, 2003).

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Compassionate or Callous? Assisted suicide undermines our essential humanity (NRO, 040617)

Compassion, literally defined, means, “to suffer with another.” That is why I have always found the monopolization of that word by proponents of euthanasia and assisted suicide so discordant. Euthanasia isn’t about suffering with anybody. It’s about using someone’s suffering — and the pity it evokes — as a justification to kill.

The Netherlands has allowed euthanasia for more than 30 years, supposedly under strict guidelines to protect the vulnerable from abuse. But the list of those “eligible” has steadily lengthened, to the point that it now includes depressed people without organic illnesses. And now, the Dutch government has opened the legal door to killing patients with Alzheimer’s disease. In doing so, the nation sent a powerful message to Alzheimer’s patients and their families: The lives of those with this dreaded disease are so burdensome and undignified that they are not worth maintaining or protecting.

Contrast this with the message Nancy Reagan and her family sent the world by lovingly caring for Ronald Reagan in his declining years. This is what true compassion looks like. Through their unwavering devotion — giving wholeheartedly to Reagan even when he had little to give back in return, and taking some of his suffering on their own shoulders for ten difficult years — the Reagan family provided a vivid demonstration of the power of unconditional love. Nothing that has been done to recognize the late president — the naming of an airport after him, the public outpouring of respect during the week of mourning, the burying of political hatchets — could have honored Ronald Reagan the man, husband, and father more appropriately.

Ronald Reagan understood clearly how crucial it is to value all people equally, regardless of their capacities or state of health. Writing in Human Life Review in 1983, in words that are especially poignant considering what befell him ten years later, he warned:

Regrettably, we live at a time when some persons do not value all human life. They want to pick and choose which individuals have value. Some have said that only those individuals with “consciousness of self” are human beings.

This dehumanization offended Reagan to his core. He warned that the philosophy established at the Founding of the United States that all are created equal, possessing an inalienable right to life, is subverted when some of us are seen as disposable. And he recognized that sanctioning their killing — even in a desire to alleviate suffering — undermines our essential humanity.

Of course, some would say that the reverse is true, that a life with Alzheimer’s isn’t really living. Better to put people out of their misery than allow them to die slowly, while losing their identities. Such an end is seen as especially burdensome for those who have lived robust lives of independence, intellectual rigor, achievement, and accomplishment — people who would be humiliated to see themselves having to depend so totally on others for their care.

But the life Reagan led in his declining years demonstrates how wrongheaded such views are. True, Reagan was no longer able to occupy the public stage. True, he was very ill. True, this caused him and his family tremendous anguish. But it is untrue that falling prey to catastrophic illness meant that he possessed less human dignity and moral worth than he did when telling Mikhail Gorbachev to “tear down this wall.” Indeed, what we have learned in the last week about Reagan’s gentle life in his final, private years demonstrates that there can be profound meaning even in the most difficult and trying circumstances.

Betsy Streisand’s “Memories of a Friend in the Park,” a first-person observation piece published in the June 21, 2004 U.S. News and World Report, was especially touching in this regard. Streisand recounts how, as Reagan’s Alzheimer’s forced him out of the public limelight in the late 1990s, he frequented a park in Beverly Hills. Reagan, accompanied by his nurse, liked to sit on a park bench and watch children at play. She recalled:

Reagan didn’t speak much to adults. It was our children he was interested in. Time and again these sticky little specimens encrusted with juice and sand would come up next to him as they made their way to the bags of snacks on the bench. And he would beckon them closer...And although he gradually stopped speaking to us — and our children — we never stopped speaking to him or having the kids play close by where he could watch.

As Reagan’s cognitive and verbal abilities collapsed, his human desire to love and be loved remained undiminished. Reagan’s son Michael spoke emotionally to this when he described his dad’s joy at hugging and being hugged. “As the years went by and he could no longer recognize me,” Michael said in a tribute to his father, “I began a process of hugging him whenever I would see him.” Most poignantly, the son recalled once forgetting to hug his father goodbye. As he was about to get into his car, Michael’s wife told him to turn around. There in the doorway was Ronald Reagan, arms outstretched, waiting for his hug. Tears in his eyes, Michael rushed back to his father and the two embraced.

Even at the very end, love triumphed over disease. Reagan loved his Nancy deeply and intensely, and as he was breathing his last breaths, somehow, some way, he dug deep within himself and found some final reserve of devotion. He opened his eyes, recognized her, and giving her one final look, he died. Nancy Reagan and the family called his final great communication a “wonderful gift.”

Now juxtapose this story of anguish — as well as love, grace, and devotion — with euthanasia in the Netherlands, which will now be applied to patients with Alzheimer’s. The best view of it is found in a book by a nursing-home doctor named Bert Keizer. In >Dancing with Mr. D. Keizer describes several euthanasia cases in which he provided lethal injections. In every case, he depicts the lives of frail and dying people under his care as pointless, useless, ugly, grotesque. Those with whom he interacts all seem to share these views, including his colleagues, family members of patients, and the patients themselves — allowing Keizer to kill patients without bad conscience.

One man he describes probably has lung cancer but the diagnosis is never certain. When a colleague asks, “Why rush?” while pointing out that the man isn’t suffering terribly, Keizer snaps, “Is it for us to answer this question? All I know is that he wants to die more or less upright and that he doesn’t want to crawl to his grave the way a dog crawls howling to the side walk after he’s been hit by a car.”

Keizer either doesn’t know or doesn’t care that with proper medical treatment, people with lung cancer don’t have to die in unmitigated agony. The next day, he lethally injects the patient, telling his colleagues as he walks to the man’s room, “If anyone so much as whispers cortisone [a palliative agent] or ‘uncertain diagnosis,’ I’ll hit him.”

Another patient Keizer kills is disabled by Parkinson’s disease. The patient requests euthanasia, but before the act can be carried out, he hesitates after receiving a letter from his religious brother who warns that God is against suicide. This upsets Keizer, who writes: “I don’t know what to do with such a wavering death wish. It’s getting on my nerves. Does he want to die or doesn’t he? I do hope we won’t have to go over the whole business again, right from the very start.”

Keizer decides to push the process along. He asks the nursing-home chaplain to assure the man that his euthanasia will not upset God. The man reconsiders and again decides he wants to die. Keizer is quick with the lethal injection, happy the man has “good veins.” The patient expires before his uncertainty can disturb his doctor’s mood again.

Where is the compassion in this? Caring, unlike killing, can be costly in time, money, and emotional anguish. But, as the near universal outpouring of admiration for Nancy Reagan as caregiver demonstrates, it also ennobles and liberates. Indeed, as Ronald Reagan wrote long before he knew the words would apply so personally:

My Administration is dedicated to the preservation of America as a free land, and there is no cause more important for preserving that freedom than affirming the transcendent right to life of all human beings, the right without which no other rights have any meaning.

— Wesley J. Smith is a senior fellow at the Discovery Institute, an attorney for the International Task Force on Euthanasia and Assisted Suicide, and a special consultant to the Center for Bioethics and Culture.

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Disabled activists oppose California assisted suicide bill (Scripps Howard News Service, 060210)

SACRAMENTO, Calif. — Lilibeth Navarro, a community activist in Los Angeles who became disabled after surviving polio as a child, remembers visiting her doctor after a near-fatal bout with pneumonia.

The physician, she recalls, urged her to sign a do-not-resuscitate order so that it could be on file the next time she was admitted to the hospital. To Navarro, 50, the doctor’s attitude appeared markedly different than the manner medical professionals seemed to display toward family members such as her 93-year-old grandmother.

Doctors presumed, she said, that her fully mobile grandmother would want them to use all medical technology at their disposal to extend her life.

“What’s the difference?” said Navarro, who uses a motorized wheelchair. “I wasn’t walking and she was walking. It’s scary. It’s very scary.”

Experiences such as Navarro’s are at the heart of the reason why many disability rights activists have opposed efforts to legalize assisted suicide in the past year, joining religious and conservative groups at protests outside the U.S. Supreme Court and the California Capitol.

The advocates say societal bias combined with an emphasis on cost-cutting in the health-care industry may pressure people with disabilities to request lethal prescriptions _ and their doctors to provide them _ when what they really need is more support for living.

The matter is heating up in California, where Assembly members Patty Berg, D-Eureka, and Lloyd Levine, D-Van Nuys, say they will hold hearings next month on Assembly Bill 651, a measure that would permit doctors to prescribe lethal drugs to terminally ill patients.

Berg and Levine tried unsuccessfully last year to pass another aid-in-dying measure, Assembly Bill 654. But they are more optimistic about their chances in the wake of a U.S. Supreme Court decision last month clearing the way for states to make their own laws on assisted suicide.

Meanwhile, the issue has become a flashpoint in a broader struggle for the civil rights of the disabled that is taking hold across the United States.

Some advocates say people who live a rich, full life of the mind are often consigned to nursing homes or other institutions because they cannot care for themselves physically.

Until society provides more support that allows people with disabilities to live independently in their communities, they say, people with potentially terminal diseases might choose suicide simply because they have don’t believe they have other options or don’t want to be a burden to their families.

Activists also say health-care institutions have a bias against spending money on expensive care, and that bias may lead doctors to be more likely to prescribe lethal drugs to disabled patients.

“We get reports from around the country that individuals with disabilities go into hospitals for some kind of treatment and hospital staff pressure them to sign (do not resuscitate) orders,” said Paul Longmore, a history professor at San Francisco State University and an expert on disability studies. “That’s really serious discrimination.”

To be sure, the issue is controversial even within the disability rights community.

Alan Toy, a Santa Monica, Calif., activist who is on the board of Autonomy, an organization of people with disabilities who support assisted dying for the terminally ill, says the disability rights movement is ill-served by joining this particular fight.

“To deny people who are capable of making decisions the power to make decisions for themselves is in direct opposition to what the independent living movement was designed to promote,” Toy said.

Supporters of assisted suicide say there is no link between their cause and the civil rights issues that people with disabilities face. Assembly Bill 651 even includes language condemning discrimination against the disabled in response to concerns raised by activists. It also specifies that lethal prescriptions can’t be issued solely because of a patient’s disability or advanced age.

“I certainly agree that the disability community has not always been treated fairly, and I have great respect for that,” Berg said. “However, there is a real difference between chronic illness and terminal illness.”

But others believe that bias against the disabled is so insidious that the two issues can’t be separated.

“There are the folks who see it as a right-to-life issue, and there are the folks who see it as a right-to-death issue,” said Teresa Favuzzi, director of the California Federation of Independent Living Centers, which opposes the bill. “And for the disability community, it’s about the right to live, to be seen as valuable.”

Longmore pointed to attempts by hospitals and government agencies to cut health-care costs and suggested that economics could play a role in some of the support for assisted suicide.

“People with disabilities are much more familiar than other Americans with how the health-care system works and for that reason, I think we can speak with authority on this subject,” he said. “We know that patients are denied the kind of care they have a right to, particularly with regard to things like pain management. . . . We understand the horrible experiences people have that can lead them to support assisted suicide.”

Disability rights activists opposing assisted suicide also say it can be hard to draw the line between a chronic disease and a terminal illness, regardless of whether safeguards are written into the law.

“It is the experience of disability that a lot of us have defied medical science,” Navarro said.

When she was diagnosed with polio at five months old, Navarro said, “my parents were told I might die in two weeks. Boy, that’s the longest two weeks of my life.”

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