Assisted suicide: The tip of the iceberg

Traditional medical ethics in the United States are crumbling before our very eyes. Where once physicians swore to "do no harm," today many doctors believe it is acceptable to kill a patient who asks to die. Doctors used to be taught that all patients have equal inherent moral worth (a value system known variously as the "equality of life" or "sanctity of life" ethic but which I call simply, "The Ethic")' and were thus entitled by simple virtue of their humanity to optimum medical care based on their individual health needs. Today, a growing utilitarian spirit threatens some elderly, disabled, and dying patients with virtual abandonment by doctors based on "quality of life" considerations. Doctors of yore believed that their patients deserved their sole allegiance: they would never permit business executives to make their medical decisions. Today, many physicians divide their loyalties between patients and managed health care business entities in which profits come from inducing physicians to reduce levels of care. Hippocrates must be turning over in his grave.

We did not enter this dark new world of medicine by chance but have been steered in this direction intentionally by an influential group of moral philosophers, academics, doctors, lawyers, and members of the medical intelligentsia-known generically as bioethicists-who, in the years following World War II, dominated public and professional discourse about medical ethics and the creation of health-care public policy.

Bioethics started out with the best of purposes: to ensure that the medical horrors associated with the Holocaust were never repeated. Later, bioethics helped fashion the means by which excruciating decisions about access to health care were made ethically, such as selecting which patients should have access to kidney dialysis when demand for that life-saving treatment far exceeded its availability.

But as the years passed the influence of bioethics grew, and it became both less benign and more ambitious. What began as a process of decisionmaking evolved over time into an orthodoxy-perhaps even an ideologypredominately utilitarian in outlook, radical in its notions of almost unfettered personal autonomy while, paradoxically, devaluing the individual moral worth of people-from infants to the elderly, the disabled and the otherwise "marginalized." Moreover, predominate bioethics-thinking explicitly rejects The Ethic, the Hippocratic tradition, and other fundamental mores of Western Civilization.

What went wrong with modern bioethics can be traced to one of its founding fathers, the late moral philosopher Joseph Fletcher. He is probably best known for his exposition of "situational ethics," a philosophical construct that denies the existence of absolutes such as right and wrong, good and bad, moral and immoral; it promotes behavioral "choices" based on intended or likely outcomes-better known as relativism. Fletcher was wildly radical and aimed to completely remake American culture. Perhaps recognizing that a society's overall moral outlook is influenced profoundly by its medical ethics, he wrote and lectured extensively throughout the 1970s and 1980s on bioethics. He became so influential that the predominate outlook of contemporary bioethics can be traced directly to his advocacy. Indeed, many of today's most prominent bioethicists are accurately described as "acorns off of the Fletcher oak tree."

Fletcher was a truly radical utilitarian. His goal was to maximize human happiness and minimize human suffering. That sounds good in the abstract, but-as Ross Perot often says-"the devil is in the details." Fletcher-style utilitarianism is paradoxically both anarchic and totalitarian. Thus, he willingly supported the wildest ideas in the name of human freedom, such as the manufacture of chimeras (part human, part animal) through genetic engineering.2 But individuals, in and of themselves, actually mattered little to Fletcher. Those lives which he perceived to interfere with the pursuit of the greater happiness were expendable, even subject to being killed.

Joseph Fletcher did not believe in universal human rights. What mattered to him was having a "personal life" earned by possessing certain relevant "indicators," such as "self awareness," "a sense of time," "the capability to relate to others," "and control of existence," among others. According to Fletcher, people who possess these qualities are "subjects," and those who do not are "objects." Being a subject is good. It means you have equal rights. Not so human objects, who not only possess no rights but who can be exploited for the greater good of human subjects.3

Fletcher was one of the primary instigators of what has come to be known as the "culture war." Richard John Neuhaus once described this ongoing struggle as "a conflict between those who believe that human beings possess `unalienable rights' that we are bound to respect and those who, in various ways, argue that rights in law and life are 'fictions' that we can more or less make up as we go along."4 This culture war is being waged on many fronts: politics, family life, education, art, entertainment, sports, but most especially in medicine-where the struggle is literally a matter of life and death. Indeed, some people have already died as a consequence of the slow devolution of medical ethics along the lines envisioned by Fletcher.

That is not to say that bioethics' influence has been entirely negative. Patients were once passive about their own medical care: today, thanks in large measure to bioethics, the doctrine of informed consent permits patients to accept or reject medical treatment. That means people are far less likely to be involuntarily "hooked up to machines," a medical abuse that led to the creation of the so-called "right to die" movement. Unfortunately, patient autonomy has been taken to an unhealthy extreme, as-for examplejustification for legalizing assisted suicide.

As worrisome as assisted suicide advocacy is, it is just the tip of the iceberg. Medical policies equally violative of The Ethic-only a few years ago mere gleams in many bioethicists' eyes-are being implemented in the clinical setting, directly threatening human lives. Meanwhile, new and even more radical proposals are published nearly every month in the nation's most influential medical and bioethics journals, pushing us ever-closer to a society created in Fletcher's image in which some of us are subjects and others of us are objects. This essay will offer a broad overview of these hottest issues in the bioethics debate.

Assisted Suicide

Assisted suicide presents the most immediate threat to contemporary medical morality and is quickly becoming one of the flash points of American politics. The debate entered a new phase recently, when Jack Kevorkian was convicted of second degree murder and sent to prison for ten to twentyfive years for lethally injecting 52-year-old Thomas Youk, an event witnessed by tens of millions of people on CBS' 60 Minutes (Nov. 22, 1998). Kevorkian's conviction was a great victory. But assisted suicide advocates quickly distanced themselves from him and said that now, with the Kevorkian distraction out of the way, they could focus their argument. Look for an increase in "real life cases" of the "compassion" of assisted suicide to replace reporting on Kevorkian in the immediate future.

This is what has happened in Oregon as that state completed its first year as the only place in the world in which assisted suicide is formally and officially legal. Because Oregon regulators shrouded the practice in mystery through rigid state-imposed secrecy, the little hard news reported in the media came directly from assisted-suicide advocacy groups. For example, Barbara Coombs Lee, the executive director of one such group, Compassion in Dying (CID), held a press conference to announce the country's first reported legal assisted suicide, that of a woman with breast cancer. CID attempted to put the best face on this killing. Even so, it was easy to detect the ugly truth that assisted suicide isn't so much about "choice" as about abandonment and ideology.

When the woman's own doctor refused to lethally prescribe, she asked a second doctor, who diagnosed her with depression and also refused to participate in her killing. She then went to CID, whose medical director blithely assured her that she wasn't depressed but "frustrated." He referred her to a death doctor willing to prescribe lethally. She died only 2 2 weeks after meeting the doctor who helped end her life. The woman clearly was not in unbearable pain or unremitting suffering. She claimed in an audio tape, played posthumously by Lee, that she wanted assisted suicide to alleviate her "stress."5 This was not how legalization was sold to the voters of Oregon.

Then, in March, 1999, the New England Journal of Medicine6 published a study, based upon interviews with legally-prescribing doctors, that purported to show that all is well with assisted suicide as a legal act. Much was made of the report that 15 people had killed themselves under the law with the help of a physician, and that none of the dead had done so because of financial worries or fear of pain. But a closer look at the study revealed many glaring problems that the media failed to address:

None of the assisted suicides was based on actual and unrelievable pain and suffering, the purported purpose for legalizing assisted suicide. Rather, doctors legally prescribed for patients concerned "about loss of autonomy or control of body functions."That represents a broadening of the purposes for which assisted suicide can be used. Indeed, if worries about needing help with bathing, toilet, and other activities of daily living constitute grounds for doctors to lethally prescribe, there are far more disabled and elderly people for whom assisted suicide should be permitted. This is the slippery slope in action.

Many of the patients who died had very short relationships-some as short as 15 days-with the doctors who helped kill them. This wasn't supposed to happen, either. Assisted-suicide advocates promised that it would be performed only by doctors with strong, long-term relationships with the patients.

Many, if not all, of the doctors who lethally prescribed were affiliated with CID or other assisted-suicide advocacy groups. The doctors interviewed for the study were asked if they were affiliated, but-in a telling omissionthe results were not published. It is thus likely that many of the assisted suicides were motivated primarily by ideology.

Investigators exhibited a shocking lack of curiosity. Physicians who had "treated" the dead patients were not interviewed for the study even though they were the most likely to provide the best information on their patients' health and state of mind. Nor were physicians interviewed who were asked, but refused, to commit assisted suicide: nor were the families of the dead patients.

No autopsies were performed to determine whether the dead patients were actually terminally ill when they were helped to kill themselves.

All in all, rather than alleviating fears, the study demonstrates that legalized assisted suicide will not be restricted to the rare case of medical urgency but that it will be practiced far more liberally, often by doctors the patients barely know. Thus, rather than being a carefully controlled and regulated practice, legal assisted suicide bears a striking resemblance to the rogue practice of Jack Kevorkian.8

This message will have to be forcefully and repeatedly made by opponets in the coming years, as proponents pepper the nation with legalization schemes. For example, in the wake of the Oregon study, legislation was introduced in California to legalize assisted suicide based on the Oregon statute where it was voted quickly if narrowly out of the Judiciary Committee by an 8-7 vote. As of this writing, its ultimate fate is uncertain but looks to be close. Legalization attempts are also underway in New Hampshire, Maine, Arizona, Louisiana, and Nebraska. A lawsuit has been filed in Alaska seeking to declare that state's law against assisted suicide a violation of the state's constitution. On the positive side, legislation has passed both houses in the Maryland legislature that would outlaw the practice. If the governor signs the bill, Maryland will become the sixth state to pass anti-assisted suicide legislation since Oregon legalized assisted suicide in 1994.

Dehydrating Cognitively Disabled People

It has been fewer than ten years since the United States Supreme Court accepted the contention that delivery of food and fluids by feeding tube is a form of "medical treatment" that can be withdrawn legally and ethically from people diagnosed to be in a permanent unconscious condition? Initially, bioethicists assured that dehydration would be restricted to people who were unconscious.

But the clinical reality is quite different: conscious cognitively-disabled people are intentionally dehydrated in nursing homes and hospitals all over the country, almost as a matter of medical routine. So long as the family approves, no questions are asked.

Now, there is a court case in California that seeks to allow intentional dehydration of people who are conscious-even when some family members object. The case involves Robert Wendland, who was severely injured in an auto accident. Wendland was comatose for 16 months. Then, in 1995, he awakened and improved, to the point where he could perform simple functions on request, such as removing and replacing colored pegs from a board and maneuvering an electric wheelchair down a hospital corridor. Despite Robert's achievement, his wife, Rose, asked doctors to remove his feeding tube: the ethics committee of the Lodi Memorial Hospital gave unanimous consent. But an anonymous nurse, appalled that Robert's life would be erased because of a "quality of life" judgment, blew the whistle to one of Robert's sisters. Soon, his mother Florence and a sister, Rebekah Vinson, sued to prevent the dehydration.

The litigation was bitter and prolonged. Robert's interests were supposed to be represented by San Joaquin County Deputy Public Defender, Doran Berg. But in a nasty twist, she quickly sided with the death decision and argued more vehemently and emotionally than Rose did for Robert's dehydration-this was perhaps the first time in the history of jurisprudence that a public defender has urged a judge to sentence a client to death. But Judge Bob McNatt reluctantly declined. Stating that he was making "the absolutely wrong decision, for all the right reasons," he ruled wisely that such a momentous change in law and ethics should be decided in the legislature or a court of appeals, not by a trial judge.

McNatt's decision may have only been a reprieve-not a "pardon"-for Robert. Berg and Rose quickly appealed.'o Judge McNatt agreed that up to $50,000 of San Joaquin County funds would be made available for Berg to retain a private attorney to pursue Robert's death in the appeals courts. Now, the power of the state and the money of taxpayers is being used to pursue the death of one of its citizens, whose only "crime" is to be brain damaged. If the Court of Appeals allows Robert to be dehydrated, a strong message will be sent that the lives of conscious, cognitively disabled people can be ended ethically, placing thousands of defenseless people all over the country at lethal risk.

Futile Care Theory

The media usually characterizes cases like Cruzan and Wendland as promoting patient autonomy and private medical decision-making. But that is only partially true. Increasingly, "choice" in medical cases involving the profoundly disabled and the actively dying is viewed by many bioethicists and doctors as a one-way street. If families insist that treatment such as tube feeding or ventilator-assisted breathing continue, these policy makers advocate that it be refused because "autonomy has its limits."

This concept, little known among the general public but all the rage in bioethics, is called Futile Care Theory.nI The idea behind it goes something like this: When a patient reaches a certain predefined stage of age, illness, or disability, any further treatment other than comfort care is "futile" and shall be withheld, regardless of the desires of the patient or family. This is a bit duplicitous. In futile-care cases, it is the patients, not the the treatment, these theorists see as futile. Treatment is stopped not because it has no physiological effect, but because it does.

Futile-care decisions are already being implemented in many of the nation's hospitals. Little-noticed by the mainstream media-but well documented in the medical literature-doctors and hospitals in Michigan, Massachusetts, Texas, Tennessee and California have already refused to provide desired medical treatment to profoundly disabled and dying patients. Futile-care theory is not simply about quickening their end: its purpose is to create a principle-that doctors can make bedside health-care decisions based not on what is good for the patient but on what is better for "society." This is nothing less than preparing the way for overt health care rationing.

Creating a "Duty to Die"

Taken together, assisted suicide and futile care sound suspiciously like the creation of a "duty to die." Indeed, some bioethicists are quite candid about the existence of such a moral duty. Perhaps the most famous advocate of this position is the former governor of Colorado, Richard Lamm, who is now a bioethicist at the University of Denver. He is best known for proclaiming that elderly people have a "duty to die and get out of the way" (a statement Lamm claims was taken out of context). He contends that there is a moral duty for society to withhold medical treatment from people diagnosed with permanent unconsciousness (as just one example), because the resources needed for their care are urgently needed by society elsewhere.l2

The most candid advocate for a "duty to die" comes from a bioethicist, John Hardwig, chairman of the Department of Philosophy at the University of East Tennessee. Hardwig's thesis is that dying, elderly, and disabled people should be ready to die when their lives are too much of a burden on family, community, or country. The "fundamental insight underlying the duty to die," he wrote, comes when "continuing to live will impose significant burdens emotional burdens, extensive care giving, destruction of life plans, and yes, financial hardship-on . . . family and loved ones."'3 Indeed, Hardwig writes, "to have reached the age of, say, seventy-five or eighty years without being ready to die is itself a moral failing, the sign of a life out of touch with life's basic realities."14

It is important to note that this is not the raving of a fringe character. Hardwig's essay was a cover story in the Hastings Center Report, one of the most influential bioethics journals in the world. His essays and others are being discussed actively within bioethics circles. This is how public policy in health care often begins-with philosophical debate. But as with dehydrating cognitively-disabled people, once "consensus" is reached among bioethicists, the policy is soon moved toward active implementation.

Organ Transplants

When Jack Kevorkian ripped the kidneys out of assisted-suicide victim Joseph Tushkowski, and offered them to the public ("first come, first served") one would have expected members of the organ-transplant community to be outraged. Chillingly, most were not. Oh, some were quoted as stating that the kidneys were unusable: an opinion based on practical problems such as proper preservation, tissue typing, and other pragmatic, rather than moral, considerations.l5 But few, if any, came forward to say that it is morally wrong to help kill someone and then harvest his organs.

Could it be that obtaining organs from an "assisted suicide" is no longer considered by many bioethicists as beyond the pale? Alas: yes. Kevorkian was once shunned for advocating organ harvesting from people being executed or committing assisted suicide. Indeed, his beliefs materially contributed to his failed medical career. Today, some of the most mainstream bioethicists and physicians involved in organ procurement and transplantation actively contemplate using organs from assisted-suicide victims as one way to increase the supply of organs for transplantation. "If active euthanasia . . . and assisted suicide are legally sanctioned," write Robert M. Arnold and Stuart J. Youngner, well-respected members of the professional organtransplant community, "patients could couple organ donation with their planned deaths; we would not have to depend only upon persons attached to life support [as organ sources]. This practice would yield not only more donors, but more types of organs as well, since the heart could now be removed from dying, not just dead patients."16

Some bioethicists also want to expand the definition of death in order to permit expanded organ procurement. These advocates claim that human life, in and of itself, is not morally meaningful. What matters is human rationality. Thus, they urge that patients who have been diagnosed as permanently unconscious be considered "dead," so that their organs can be procured for transplantation. Some of the world's most notable bioethicists favor redefining death in this way. One is Robert M. Veatch, the influential director of the Kennedy Institute of Ethics at Georgetown University, who has written that when the "organic and mental functions" of a human being are "irretrievably disjoined, then human life no longer exists."17 Similarly, a 1997 article in the British medical journal, The Lancet, argued that permanent unconsciousness for 12 months should be deemed "dead," after which it should be acceptable to end the body's functioning through "lethal injection, and then remove the organs needed for transplantation, subject to the usual criteria for consent."'8

Narrowing the Definition of Protectable Life

Most people know that it is wrong to kill babies. They understand that pigs are animals, not persons. They view the intentional killing of mentally incompetent people as murder.

Not Peter Singer. The Australian utilitarian philosopher, a founder of the animal rights movement, claims that infants have no moral right to live and views infanticide as an ethical act. (Singer believes parents should have 28 days within which to decide whether to keep or kill their newborn children.) He not only promotes legalizing voluntary euthanasia but advocates the involuntary killing of medically defenseless people, if it will enhance the happiness of family and society.19

If Singer was the subject of a movie, it would be called, "The Son of Fletcher." To him, membership in the human species is irrelevant to the right to life. Rather, what matters is whether a "being" is a "person," a status to be earned based on "relevant characteristics," such as the ability to be selfaware over time. To Singer, this means that some animals are persons: specifically pigs, elephants, dolphin, dogs, and many others, "perhaps including all mammals." Other forms of life-newborn infants, people with advanced Alzheimer's disease or other severe cognitive disabilities, along with fish and birds-are not persons. To Singer, a newborn infant is the moral equivalent of a mackerel; and an advanced Alzheimer's patient is comparable to a turkey.

Singer's ideas should make him an outcast. To illustrate how tenuous is our grasp of The Ethic, over the last 20 years Singer's vigorous advocacy of these Nazi-like policies have made him a darling among the bioethics set and with academic philosophers, many of whom share his views, or at least respect his intellectualism. Indeed, Singer is invited to present papers at seminars, symposia, and philosophy association conventions throughout the world. His 1979 book, Practical Ethics, which unabashedly advocates infanticide, euthanasia, and decries "discrimination" based on species (a bizarre notion Singer labels "speciesism"), has become a standard text in many college philosophy departments. Singer is now so mainstream that he even wrote the essay on ethics for the Encyclopedia Britannica.

Most disturbingly, beginning July 1999, Singer will become a permanent member of the Princeton University faculty, where he will be the Ira W. DeCamp Professor of Bioethics: a prestigious, tenured academic chair, at the university's Center for Human Values. For many years to come, Singer will repeatedly clone himself in the young minds he molds in university. Making matters worse, most of his students-to-be are destined to rise to the top of American life. They are the physicians, health-care executives, political office holders, bureaucratic policy-makers, foundation decision-makers, and the university and college professors of tomorrow. Which means that Singer's ideas are likely to eventually affect the everyday reality of American life.

Conclusion

It is ironic that as the United States prevailed in its half-century struggle against an international despotism that held The Ethic in open contempt, our own academics and medical intelligentsia have pushed us ever closer to an ethical cliff that will eventually threaten the lives and welfare of each and every one of us. Tragically, most Americans do not realize the depth to which our culture has fallen nor the importance of what is at stake in these and other emerging biomedical and ethical issues. But-ready or not-we are approaching the crucial crossroads. Two paths lie before us: a culture of death that devalues and even countenances the killing, death by neglect, and exploitation of infants, disabled, elderly, and dying people, or a culture of life that embraces the utter human equality of us all. Each path leads to a dramatically different future. The choice is ours. As will be the society we create for the twenty-first century.

Notes

1. Whether based on religious values or secular pragmatism, The Ethic is the moral backbone of Western Civilization. Without it, our millennial struggle to secure equal rights for all and our

belief in protecting the defenseless and downtrodden would soon cease to exist. Joseph Fletcher, Humanhood: Essays in Biomedical Ethics (1979, Prometheus Books, Buffalo, NY), p. 85. Id., p.16

Richard John Neuhaus, America Against Itself Moral Vision and the Public Order (1992, University of Notre Dame Press, Notre Dame, IN).

Hendin, Foley, and White, "Physician Assisted Suicide: Reflections on Oregon's First Case:' Issues in Law dE Medicine, Volume 14, No. 3, 1998.

Chin, Kedberg, Higginson, and Fleming, "Legalized Physician-Assisted Suicide in Oregon-The First Year's Experience," New England Journal of Medicine, Volume 340, No. 7, February 18,1999. Id.

8. See also, Smith, "Dependency or Death? Oregonians Make a Chilling Choice," Wall Street Journal, February 25,1999.

9. Cruzan v. Director, Missouri Department of Health, 110 Supreme Court, 2841. 10. In re Conservatorship of Wendland, California Court of Appeals, Third Appellate District, Case No. C 029439.

11. Wesley J. Smith, "Our Discardable People," Human Life Review, Summer 1998. 12. Richard Lamm, interview with Wesley J. Smith, November 19, 1998. 13. John Hardwig, "Is There a Duty to Die?," Hastings Center Report, March/April 1997, p. 38. 14. Id., p. 39.

15. David Goodman, "Kevorkian Gives Organs From Suicide," from the Associated Press appearing in the Washington Post, June 7, 1998.

16. Robert M. Arnold and Stuart J. Youngner, "The Dead Donor Rule: Should We Stretch It, Bend It, or Abandon It?", Kennedy Institute of Ethics Journal, June 1993, p. 271. 17. Robert M. Veatch, "Brain Death and Slippery Slopes," The Journal of Clinical Ethics, Volume 3, No. 3, Fall 1992, p. 185.

18. R. Hoffenberg, et al., for the International. Forum for Transplant Ethics, "Should Organs From Patients in Permanent Vegetative State Be Used For Transplantation," The Lancet, Volume 350, November 1, 1997, p.1321.

19. Peter Singer, Rethinking Life and Death: The Collapse of Our Traditional Ethics (1995, St. Martin's Press, New York, NY). fi

Wesley J. Smith is the author of Forced Exit: The Slippery Slope From Assisted Suicide to Legalized Murder. A new work dealing with bioethics, The Culture of Death, will be published next year.

Copyright Human Life Foundation, Incorporated Spring 1999
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