November of the Soul

by George Howe Colt

  Derek Humphry killed his wife;

  Now he wants your granny’s life.

  If your granny’s old don’t keep her;

  They say euthanasia’s cheaper.

  Hemlock Society you can’t hide,

  We still hang Nazis for genocide.

  Euthanasia is a crime.

  At least it was in Hitler’s time.

  Take ’em to Nuremberg and hang ’em high.

  There’s no such thing as the right to die.

  The protesters were members of the Club of Life, a radical right-wing organization that, over the years, had staged numerous demonstrations against the Hemlock Society. On the first morning of the conference in Santa Monica, as Hemlock members settled back into their seats at the end of a coffee break for a panel discussion of “Ethical Dilemmas in Euthanasia,” a young man walked up to the podium and announced, “I’m here to indict Derek Humphry and Gerald Larue for murder.” There was a moment of stunned silence before Humphry and Larue wrestled the microphone from the man and escorted him gently but firmly from the podium. At that moment a dozen other Club of Life members who had sneaked in during the coffee break to sit in the back of the room began to chant, “Let him speak! Let him speak!”

  It was a curious scene: the protesters, mostly young, well-scrubbed, clean-cut men and women, chanting stolidly, staring straight ahead, while an angry flock of neatly dressed gray-haired women circled around them, half-shouting, half-pleading, “Get out, get out.” “Did you pay?” an elderly lady in a red sweater asked one of the protesters, who ignored her. The elderly lady began to beg, “Please let us have our conference.” A young woman in a raincoat the color of a robin’s egg, her face pinched with passion, whirled around and shouted, “Why don’t you commit voluntary euthanasia? It’s what you’re all about!” It soon became a rhetorical free-for-all, the demonstrators hurling slogans, Hemlock members trying to reason with them. “Never again!” shouted a balding young man with glasses at a white-haired woman who implored, “Please leave. Just please leave.” Some Hemlock members wept in frustration because the protesters refused to budge or even to discuss their beliefs. A middle-aged man with a trim brown beard tried to talk quietly to a young man about the dignity of choice, but the young man refused to meet his gaze. “You’re killing your grandmother,” he suddenly shouted at the bearded man, who replied earnestly, “I love my grandmother.” Meanwhile, reporters waded into the crowd to ask the protesters sensible questions about their philosophical stance. (“We’re against euthanasia and genocide” was their standard response.) Hotel security men finally escorted the protesters out, still shouting, leaving behind a ring of dazed, angry, elderly people.

  Whether a suicide is completed by an elderly person in failing health or by a terminally ill person with or without assistance, a wealth of passionate arguments condemns the act. Christian fundamentalists say that suicide is a sin—a violation, as Augustine maintained, of the Sixth Commandment, “Thou shalt not kill.” Right-to-die advocates point out that exceptions have been made for self-defense and capital punishment, and that the Church itself has often supported killing in battle. John Donne wondered “whether it was logical to conscript a young man and subject him to risk of torture and mutilation in war and probable death, and refuse an old man escape from an agonizing end.” According to Albert Schweitzer, even Mahatma Gandhi, who literally wouldn’t hurt a fly, saw fit to go beyond his proscription against killing. Moved by the prolonged agony of a dying calf, Gandhi gave it poison to end its suffering. (His act is doubly significant because cows are held in special veneration by the Hindu religion.) Ethicist Joseph Fletcher, who told the story in Morals and Medicine, commented, “It seems unimaginable that either Schweitzer or Gandhi would deny to a human being what they would render, with however heavy a heart, to a calf.”

  Right-to-die advocates also contend that suicide is not murder because one’s body belongs to oneself. “Their argument turns on the proposition that since my life is my own, I can take it without committing murder in the same way that I can take my own money without being a thief,” wrote the Russian émigré philosopher Nicholas Berdyaev in his 1962 “Essay on Suicide.” “But this argument is false and superficial. My life is not solely my own, it does not belong to me absolutely, it belongs to God first. He is the absolute owner; my life also belongs to my friends, to my family, to society, and finally to the entire world which has need of me.”

  Berdyaev has summarized what some ethicists call the property arguments. Those who believe we are God’s property insist that in completing suicide or performing euthanasia we are “playing God.” Some right-to-die advocates argue that if shortening our lives interferes with God’s will, so too does lengthening them with life-support equipment. “If it is for God alone to decide when we shall live and when we shall die,” wrote philosopher James Rachels, paraphrasing David Hume, “then we ‘play God’ just as much when we cure people as when we kill them.” As one elderly woman says, “When I can’t digest my food, when I can’t breathe on my own, when my heart can’t beat on its own, it could just be that God is trying to tell me something.”

  In response to those who, like Aristotle, hold that our lives belong to society as a whole, right-to-die advocates question how useful to the state a terminally ill person can be. “Human life consists in mutual service,” wrote the author and socialist Charlotte Perkins Gilman in her 1935 suicide note. “No grief, no pain, no misfortune or ‘broken heart’ is excuse for cutting off one’s life while any power of service remains. But when all usefulness is over, when one is assured of an imminent and unavoidable death, it is the simplest of human rights to choose a quick and easy death in place of a slow and horrible one.” Gilman worked in the labor and women’s suffrage movements until the age of seventy-five when, suffering from cancer, she ended her life. “The time is approaching when we shall consider it abhorrent to our civilization to allow a human being to lie in prolonged agony which we should mercifully end in any other creature,” she wrote. “Believing this choice to be of social service in promoting wider views on this question, I have preferred chloroform to cancer.” The following morning the headline in the New York Times read, “Charlotte Gilman Dies to Avoid Pain.”

  Many antisuicide authors have argued that to shorten or avoid suffering is cowardly. In 1642, Sir Thomas Browne observed, “When life is more terrible than death, it is the truest valor to live.” According to Christian teaching, there is intrinsic value in suffering—especially during the last moments of life—because in doing so one emulates the suffering of Christ on the cross. Terminal illness is thus an opportunity for spiritual enrichment. “The final stage of an incurable illness can be a wasteland, but it need not be,” wrote British lawyer Norman St. John-Stevas, a longtime foe of euthanasia. “It can be a vital period in a person’s life, reconciling him to life and to death and giving him an interior peace.” Fletcher, however, pointed out that if suffering were truly ennobling, we would be bound to withhold all anesthetics and medical relief. While some may find the last stages of terminal illness spiritually rewarding, ethicists question whether it is a person’s duty to stay alive because others insist that pain is good for him.

  Some maintain that to choose death is wrong because a cure might be “just around the corner.” While there is life, they say, there’s hope. Responding to this argument, Seneca wrote, “Even if this is true, life is not to be bought at all costs.” With the biomedical advances of the last century, however, the odds of that hope being rewarded have improved. In 1921, physician George R. Minot was told that he had severe diabetes, for which there was no cure. For two years Minot fought a losing battle against the disease. In 1923, insulin was discovered, and he was saved. Eleven years later Minot won the 1934 Nobel Prize for Medicine for research that led to a cure for pernicious anemia. And there are instances in which apparently “hopeless” cases have recovered. In the spring of 1986, a forty-four-year-old Maryland woman suffered a cerebral hemorrhage and fell
into what doctors called a persistent vegetative state, not unlike that suffered by Terri Schiavo. The woman had often told her husband that if she ever became comatose, she wanted him to pull the plug. After forty-one days, her husband, a Presbyterian minister, went to court to stop treatment. The judge refused. Six days later, the woman woke up, smiled, and kissed her husband. Three months later she was able to get around with the help of a walker, and her memory was returning. “Miracles can and do occur,” said her husband. “I guess we’ve muddied the waters surrounding the question of a person’s right to die.” (Clinicians usually wait several months before considering withdrawing life-support equipment; beyond that time, they say, someone in a persistent vegetative state has virtually no chance of recovery.)

  For physicians, patients who choose death may present an agonizing ethical challenge. Many doctors categorically reject physician-assisted death, be it assisted suicide or voluntary euthanasia, as a violation of medical ethics and an abuse of the doctor-patient relationship. Says one oncologist, “How could my patients’ trust in me survive if they could never be quite sure whenever I approached their bed that I hadn’t come to deliver the coup de grâce?” Radiation oncologist Kenneth Stevens, president of Physicians for Compassionate Care, a group opposed to physician-assisted suicide, says that while people have a right to choose death, they don’t have the right to a doctor’s help. “People say they want the right to die, but what they’re really saying is ‘I want someone to kill me,’ “ he has observed. Other physicians, like Timothy Quill, contend that helping a patient to die may be a rare but organic part of a healthy doctor-patient relationship. Sherwin Nuland, the surgeon whose 1993 book How We Die graphically demonstrated that dying is rather more painful and messy than peaceful and neat, believes that a small number of terminally ill patients—“perhaps only a couple in a physician’s career”—will remain unresponsive to even the best palliative care. If those patients are persistent in requesting physician-assisted suicide, and all possible relief measures have been tried, he believes that it is the physician’s responsibility to relieve his patient’s suffering, even if it means knowingly causing his death. “I consider it an issue of morality,” says Nuland, who, twice in his own career, has helped suffering, terminally ill patients to die by injecting a lethal dose of narcotic. “Just as others would consider me immoral for considering helping a patient die, I believe it would be immoral to turn my back on the patient.”

  One of the main justifications for suicide prevention among the young is that their problems are usually temporary and their assessment of them often skewed by depression. For the older person considering suicide, however, depression may be temporary, but loss of movement, vision, hearing, friends, and career is often irreversible. In 1919, German psychiatrist Alfred Hoche introduced the notion of Bilanz-Selbstmord, or balance-sheet suicide. He suggested that it was possible for clear-thinking, competent individuals to weigh the pros and cons of living and to decide in favor of death. More recently, the philosopher Richard Brandt compared the choice of rational suicide to the decision of a firm’s board of directors to declare bankruptcy.

  But at an annual conference of the American Association of Suicidology, during a panel discussion of suicide manuals, a Minnesota counselor and stepmother of a girl who had killed herself stood up. “Rational suicide is a contradiction in terms,” she said. “I don’t care how paternalistic it is, I think suicide ought to be against the law for everyone. I think life is all there is.” The woman was expressing a common belief that suicide, even in terminal illness, is per se irrational. “There’s a tendency in the medical profession to think that anyone who doesn’t want to prolong life even a tiny bit longer must be incompetent and therefore cannot refuse treatment,” Curt Garbesi, former legal counsel for the Hemlock Society, has said. Some believe that terminal illness itself makes people irrational; as one doctor was heard to comment in bioethics rounds, “No dying patient is sane.” Certainly, older people are capable of impulsiveness and flawed judgment: more than a few right-to-die cases are complicated by depression, anger, and hostility. One study holds that those who prefer suicide tend to be not only elderly and terminally ill but also depressed. Some psychiatrists suggest that some of the people who carry out so-called rational suicides may be death-oriented men and women waiting for an excuse to take their lives. Lending credence to this notion is a study that found that more people take their own lives because they wrongly believe themselves to be suffering from cancer than do those who actually have cancer. In fact, the suicide rate among terminally ill cancer patients is low: “They tend to cling to what life they have left,” says psychiatrist Calvin Frederick. Clearly, a plea for “rational suicide” cannot always be taken at face value. In the New England Journal of Medicine, David Jackson and Stuart Youngner described six cases in which right-to-die issues masked feelings of depression and abandonment.

  University of Chicago philosopher Leon Kass suggests that the very nature of terminal illness renders patients virtually incapable of true autonomy.

  How free or informed is a choice made under debilitated conditions? . . . Truth to tell, the ideal of rational autonomy, so beloved of bioethicists and legal theorists, rarely obtains in actual medical practice. Illness invariably means dependence, and dependence means relying for advice on physician and family. This is especially true of those who are seriously or terminally ill, where there is frequently also depression or diminished mental capacity that clouds one’s judgment or weakens one’s resolve.

  Kass is among those who worry that patients in such a state are not only incapable of true autonomy but susceptible to manipulation. “With patients thus reduced—helpless in action and ambivalent about life—someone who might benefit from their death need not proceed by overt coercion,” he writes. “Rather, requests for assisted suicide can and will be subtly engineered.” Mental health professionals point out that motives in mercy killings are often mixed—showing “mercy” as much for the killer, who may find caring for an incapacitated person an oppressive responsibility, as for the victim—and that suicide pacts are rarely as mutual as they seem. A study of uncompleted suicide pacts found that one partner—apt to be the male—is usually the aggressor, conceiving the idea and then pressuring the other to go along. After the double suicide of Arthur and Cynthia Koestler, several writers pointed out that the eerie decorousness of the death scene camouflaged a more complex psychological scenario. They suggested that Cynthia had been emotionally coerced into joining her husband in death. (“I’m going to kill myself, aren’t we?” is how Edwin Shneidman mocked Koestler’s message.) Cynthia had been dominated by Koestler since the beginning of their relationship, when she was a shy young secretary and he a famous author twice her age. She called herself his “slavey.” “She was his appendix,” wrote a Koestler friend. “That was her role in life. She was content with that role.” Her suicide was an obvious and perhaps inevitable extension of their thirty-three-year relationship. “It is hardly an exaggeration to say that his life became hers, that she lived his life,” wrote Harold Harris, editor of Stranger on the Square, the Koestlers’ joint autobiography. “And when the time came for him to leave it, her life too was at an end.”

  Right-to-die groups often hold up Greek heroes or terminally ill patients in excruciating pain as examples when arguing their case. Prevention experts usually cite the depressed, impulsive teenage suicide when rejecting the right to die. The majority of suicides, however, lie somewhere between these extremes. “Some writers opposed to suicide in general would have us believe that all euthanetic suicides are . . . acts of cowardice and fear,” University of Utah philosopher Margaret Pabst Battin has written. “I think this is false, but I think it is equally wrong to assume that all suicide in the face of terminal illness is a rational, composed, self-dignifying affirmation of one’s own highest life-ideal.” Whether they call it “aid-in-dying,” “hastened death,” “assisted dying,” or “the final freedom,” right-to-die advocates
go to considerable semantic lengths to avoid the dreaded s-word. Indeed, under Oregon’s Death with Dignity Act, the death certificate must state the cause of death as the underlying illness, rather than suicide, not only to ensure that life insurance claims can’t be denied under a suicide clause, but to avoid suicide’s association with mental illness and violence. “Activists draw an obsessively careful distinction between ‘rational’ and all other suicides,” writes Andrew Solomon, who, along with his brother and his father, helped his fifty-nine-year-old mother, suffering from ovarian cancer, die by an overdose of Seconal, an event he eloquently describes in The Noonday Demon.

  In fact a suicide is a suicide—overdetermined, sad, toxic in some measure to everyone it touches. The worst and the best kind lie at either end of a continuum; they differ more in degree than in essential quality. . . . When we speak of a rational suicide and distinguish it from an irrational one, we are sketching out the details of our own or our society’s prejudices. Someone who killed himself because he didn’t like his arthritis would seem suicidal; someone who killed herself because she couldn’t bear the prospect of a painful and undignified death from cancer seems perhaps quite rational. . . . What is rational for one person is irrational for another, and all suicide is calamitous.

  Many mental health professionals and suicide prevention experts are sympathetic to the idea of suicide in the face of terminal illness on an individual basis—especially for themselves—but refuse to condone right-to-die groups and legislative changes for fear that they will invite abuse and encourage people to minimize the importance of life. “From an intellectual standpoint I can appreciate the importance of liberty and freedom in a truly democratic society,” writes Richard Seiden. “On a deeper emotional level . . . I wonder whether the advocacy of suicidal deliverance does not act as an end of hope for those depressed persons fighting a psychological battle of life and death, a struggle to be or not to be.” At Hemlock conferences I attended, each member had a compelling personal story that seemed to clinch the case for legalizing assisted suicide or voluntary euthanasia, yet many seemed unaware that the changes they proposed had implications beyond their own circumstances. They were, in fact, seeking to alter sanctions that have existed for four thousand years. “You are pioneers in the modern advocacy of suicide,” Joseph Piccione, a policy analyst at the Child and Family Protection Institute, reminded his audience at a Hemlock Society national conference. “You are sociologically important. And I ask you to consider the risks in the possible and unintended outcomes of your work. Suicide is one of the last taboos. Will the destruction of that taboo open it up to other persons who are not terminally ill but are liable to persuasion? I feel that it is the maintenance of the taboo that may be one way to protect them.” Daniel Callahan, director of the Hastings Center, a think tank for biomedical ethics, writes: