November of the Soul

by George Howe Colt

  Physician-assisted suicide is mistakenly understood as only a personal matter of self-determination, the control of our own bodies, not to be forbidden since it is only a small step beyond our no longer forbidding suicide. But unlike unassisted suicide, an act carried out solely by the person, physician-assisted suicide should be understood as a social act. It requires the assistance of someone else. Legalizing physician-assisted suicide would also provide an important social sanction for suicide, tacitly legitimizing it, and affecting many aspects of our society beyond the immediate relief of individual suffering. It would in effect say that suicide is a legitimate and reasonable way of coping with suffering, acceptable to the law and sanctioned by medicine. Suicide is now understood to be a tragic situation, no longer forbidden by the law but hardly anywhere understood as the ideal outcome of a life filled with suffering. That delicate balance would be lost and a new message delivered: Suicide is morally, medically, legally, and socially acceptable.

  In Biathanatos, John Donne defended voluntary euthanasia as a form of suicide. Nevertheless, he refrained from proposing guidelines or laws because “the limits are obscure, and steepy, and slippery, and narrow, and every errour deadly.” Donne was articulating an argument known as the slippery slope, which cautions against taking a certain action—even if the act is morally permissible in itself—for fear that it will lead to other actions that are impermissible. (This argument is also called the thin edge of the wedge, the domino theory, or, more colorfully, the camel’s nose under the tent.) Opponents of euthanasia believe that to permit a single instance of it will inevitably lead us down a slippery slope of abuse, at the bottom of which lies Nazi-style mass murder. In his oft-quoted 1949 essay, “Medical Science Under Dictatorship,” psychiatrist Leo Alexander, an American consultant at the Nuremberg trials, traced Nazi atrocities committed under the banner of “euthanasia” on the rapid journey down that slope. It started with a campaign to promote a utilitarian attitude toward the chronically ill. Propaganda included films such as I Accuse, in which a woman suffering from multiple sclerosis was killed by her doctor husband “to the accompaniment of soft piano music rendered by a sympathetic colleague in an adjoining room.” A popular high school mathematics textbook included problems detailing the cost of caring for the disabled and chronically ill. One question asked students to calculate how many housing units could be built and how many loans could be made to newlyweds with the amount of money spent by the state on “the crippled, the criminal, and the insane.” Alexander wrote:

  The beginnings at first were merely a subtle shift in emphasis in the basic attitude of the physicians. It started with the acceptance of the attitude, basic in the euthanasia movement, that there is such a thing as life not worthy to be lived. This attitude in its early stages concerned itself merely with the severely and chronically sick. Gradually the sphere of those to be included in this category was enlarged to encompass the socially unproductive, the ideologically unwanted, the racially unwanted and finally all non-Germans. But it is important to realize that the infinitely small wedged-in lever from which this entire trend of mind received its impetus was the attitude toward the non-rehabilitable sick.

  Although few suggest that right-to-die advocates have a hidden agenda of Nazi-style euthanasia, for many people the specter of the Third Reich is sufficient to justify opposing any change. They point to recent polls and court decisions favorable to the right to die, to the activities of Jack Kevorkian, to the legalization of euthanasia in the Netherlands, and to the passage of Oregon’s Death with Dignity Act as weigh stations along the slippery slope. “I think there is no way in which the right to die isn’t going to very soon become the duty to die,” warned Dame Cicely Saunders, founder of the hospice movement, in a discussion of right-to-die groups. “If you had an illness which made you fairly dependent upon other people, and somebody gave you the possibility to have a quick way out, would you really feel you could go on asking for that care? Human nature being what it is, euthanasia wouldn’t be voluntary for very long.” In The Right to Live, the Right to Die, former surgeon general C. Everett Koop warned that acceptance of euthanasia will invite deception and abuse; people will use it as a loophole to hasten the death of burdensome elderly relatives or to get at a legacy more quickly. “Once any group of human beings is considered fair game in the arena of the right to life,” wrote Koop, “where does it stop?” Yale Kamisar, a professor of law at the University of Michigan, opposes changes in the law because the benefit to a few might be outweighed by the danger to many. “Miss Voluntary Euthanasia is not likely to be going it alone for very long,” he has written. “Many of her admirers . . . would be neither surprised nor distressed to see her joined by Miss Euthanatize the Congenital Idiots and Miss Euthanatize the Permanently Insane and Miss Euthanatize the Senile Dementia.” The German physician Auer has said, “I have seen the true wish for death among my patients . . . one must be able to say to them, ‘I have listened—but the consequences for humanity are such that though I could open the door and let you out, others may then be thrown out.’”

  Derek Humphry admits that the slippery slope hypothesis is the strongest argument against euthanasia. But he points to Oregon’s Death with Dignity Act as an example of how safeguards protecting against abuse can be written into legislation. “What happened in Nazi Germany was a lesson to mankind, but that was in a brutal, murderous dictatorship, whereas we live in a democracy under the rule of law,” he says. “I believe we can design laws that draw the line at mature, competent terminally ill people.” In any case Humphry maintains that the possibility of abuse is not sufficient reason to abridge the rights of suffering individuals. “Where is the sense . . . in telling a person dying of throat cancer that euthanasia cannot be made available because Nazi Germany murdered thousands of people in the 1940s using a method labeled ‘euthanasia’?” he asks in The Right to Die. “The lessons of history are there to be learned, and the Nazi experience has taught society how not to let government slip into the hands of an irresponsible minority.” Despite Humphry’s confidence in our ability to avoid the slippery slope, one doesn’t have to look far for slippage. The Hemlock Society itself underwent a rapid evolution in its attitude toward divulging information on lethal drugs, from restricting the purchase of Let Me Die Before I Wake to members, to making it available to the public, to printing up a handy one-page list of lethal doses, to describing and evaluating more than a dozen ways to kill oneself in Final Exit, to offering “personal support and assistance in dying” to terminally ill members—an evolution apparently based less on firm ethical conviction than on calculating what society had become willing to accept.

  In the Netherlands, where assisted suicide and euthanasia have been practiced since 1973, a 1990 government-sponsored study, largely replicated five years later, found no evidence that physicians “are moving down a slippery slope.” Critics, on the other hand, suggest that the Dutch slippery slope has been more of a slippery crevasse. Poring over these reports, they conclude that safeguards intended to protect against abuse have been “routinely ignored.” Although physicians are required to report cases of assisted suicide and euthanasia to the government, only 41 percent of Dutch physicians complied in 1995—an improvement over the 18 percent who did so in 1990, yet still distressingly high, particularly given that 30 percent of the doctors who didn’t report their cases admitted that their reason for not doing so was that they had failed to observe the requirements for permissible euthanasia. Although patients seeking assisted suicide and euthanasia must be experiencing “intolerable suffering,” in one-quarter of all cases fear of future suffering or loss of dignity was cited as the impetus for seeking assisted suicide. Although assisted suicide and euthanasia were originally intended as a last resort, in 17 percent of cases the assisting physicians admitted that alternative treatments were available. (In almost all these cases, the patients refused the alternative treatments, and euthanasia was performed.) Although the patient seeking assistance
must make a voluntary, well-considered, persistent request to the physician, more than half of Dutch physicians considered it appropriate to bring up the subject of euthanasia with their patients. (They worried that the patients might be inhibited about introducing the subject themselves—yet didn’t seem to worry that suggesting it might suggest to the patients that their situations were hopeless.) Although consultation is required in all cases, it was procured in only about half. Even then, it frequently seemed to be pro forma; in 12 percent of cases in which there was consultation, the “consultant” never actually met the patient. Indeed, the most important reasons given by doctors for consulting a particular physician were that physician’s views on life-ending decisions and how nearby he lived. Perhaps that’s why consulting doctors disagreed in only 7 percent of the cases.

  The studies’ most alarming finding was that 25 percent of Dutch physicians admitted to practicing “termination of the patient without explicit request”—the report’s way of saying that in about a thousand cases each year, physicians had performed euthanasia without the patient’s clear directive. In about 13 percent of such cases, the doctors justified their actions by pointing out that they had previously discussed the subject with their patient. In other instances, physicians explained that their patients were incompetent and unable to give informed consent. Yet the 1990 study indicated that 37 percent of individuals terminated “without explicit request” were competent. (In 1995, the figure dropped to 21 percent.) In 15 percent of the cases in which there was no discussion even though the patient was competent, the doctor didn’t bring up the subject because he thought that euthanasia was clearly in the patient’s best interest. Among the reasons given by physicians for performing nonvoluntary euthanasia were the patient’s “low quality of life” and “relatives’ inability to cope.” (Defenders of the practice point out that a recent study suggests that the Netherlands, in fact, has a lower rate of ending life without the explicit request of the patient than several European countries in which euthanasia is illegal.) In recent years, the phrase “termination of the patient without explicit request” has been replaced by “life-ending acts without the explicit request of the patient,” a slightly less businesslike euphemism.

  “Virtually every guideline set up by the Dutch to regulate euthanasia has been modified or violated with impunity,” writes Herbert Hendin, one of three foreign observers to have studied firsthand the practice of assisted suicide and euthanasia in the Netherlands. During the five years he spent on the project, Hendin made four lengthy visits to the Netherlands to interview euthanasia’s practitioners. “I think they believed that the more I heard and saw, the more I would approve of what they were doing,” Hendin told me. In fact, the more Hendin heard and saw, the more horrified he became. “Assisted suicide and euthanasia were supposed to be for extreme suffering, but it had become a routine solution,” he says. He was alarmed at how frequently alternatives went unexplored, and at how uninformed some of the physicians were about pain relief. “Palliative care in the Netherlands was even worse than it was here—and palliative care in the United States was awful—and in part it was worse because doctors had this easy option, so they didn’t need to make it any better.” He was dismayed at how often doctors told him they sought consultations merely to meet the legal requirements. He worried that with only 3 percent of patients seeking assisted suicide or euthanasia referred for psychiatric consultation, psychological or emotional complexities might be overlooked. He was surprised that there were only three hospices in the entire country. (Dutch aid-in-dying advocates point out that the majority of their palliative care takes place in the hospital or in the home.)

  While its advocates argue that legalizing assisted suicide and euthanasia will give patients greater autonomy, Hendin found that in the Netherlands, the reverse was true. “In numerous cases, assisted suicide and euthanasia were usually the result of an interaction in which the needs and character of family, friends, and doctor play as big and often bigger role than those of the patient,” writes Hendin, pointing out that in a study of Dutch hospitals, doctors and nurses reported that more requests for euthanasia came from the patients’ families than from the patients themselves. Hendin cites the case described in a Dutch medical journal of a wife who no longer wished to take care of her ailing, elderly husband; she gave him a choice between euthanasia and admission to a home for the chronically ill. “The man, afraid of being left to the mercy of strangers in an unfamiliar place, chose to have his life ended,” writes Hendin. “The doctor, although aware of the coercion, ended the man’s life.” In another case, the life of a Dutch woman hospitalized with terminal breast cancer who had said she did not want euthanasia was ended because, in the physician’s words, “It could have taken another week before she died. I just needed this bed.”

  Because of cases like these, says British ethicist John Keown, a lecturer at Cambridge University known for his pro-life stance, many elderly Dutch are afraid to go to the hospital; some carry wallet-size cards that say if the signer is admitted, “no treatment be administered with the intention to terminate life.” The cards are distributed by the Dutch Patients Association, which will, for a modest fee, writes Keown, “watch over the patient so that euthanasia will not be administered without the patient’s consent.” Intending to illustrate why it was sometimes necessary for physicians to end the lives of competent patients without their consent, the attorney for the Dutch Voluntary Euthanasia Society described to Hendin the case of a nun whose physician, several days before she would have died, gave her a lethal injection because her religion didn’t permit her to ask for death, no matter how excruciating her pain. “If, as its proponents suggest, physician-assisted suicide and euthanasia are about giving patients autonomy,” says Hendin, “why wasn’t this woman entitled to make her own choice that the pain was less important to her than her feelings about not wanting euthanasia?” When I asked Hendin what he had concluded from such cases, he told me, “After a while, doctors in the Netherlands came to believe that they knew best who should live and who should die. Doctors—particularly young doctors—often think, ‘If I were in that situation, I wouldn’t want to live.’”

  Hendin was particularly concerned when a Dutch court ruled in 1993 that a psychiatrist was justified in having assisted the suicide of a physically healthy but severely depressed fifty-year-old social worker. Two months after the death of her twenty-year-old son to lung cancer, the woman had approached the psychiatrist, saying she could not get over the loss of her son and wanted death, not treatment. (Another son had fatally shot himself seven years earlier.) Telling her that he couldn’t make such a decision until he knew her better, the psychiatrist saw the woman for a number of sessions over two months, at which point she told him she would stop therapy if he did not help her die. The psychiatrist sent a written description of the case to seven consultants; five agreed that the woman’s situation was hopeless and that he should comply with her request. None felt it was necessary to see the patient. About two months after he first met the patient, four months after her younger son had died, the psychiatrist brought a lethal dose of drugs to the woman’s home and stayed with her while she swallowed them. The psychiatrist later told Hendin that his patient had said that if he didn’t help her, she would kill herself on her own. “He responded to a kind of emotional blackmail, the kind of thing that suicidal patients do all the time,” says Hendin. “And he ignored the fact that over time, even without treatment, people do tend to get over the death of a loved one, at least enough so that they can go on. He was annoyed when I suggested that he could have told the patient, ‘If you still feel this way in a year and a half, I will do it then.’” Hendin felt the psychiatrist’s concern for the patient may have been complicated by other motivations. “His career was going no place. He was looking for a case, so he went to the euthanasia society. I think he wanted to make a name for himself.” In 1994, the Dutch Royal Court, while finding the psychiatrist guilty of failing to have the
patient seen by a consultant, upheld the lower court’s ruling, affirming that mental suffering alone could justify performing assisted suicide and euthanasia. No punishment was imposed.

  According to the 1995 report, the woman’s case, while rare, is not unique. An estimated 320 psychiatric patients request suicide each year, two to five of whom are ultimately assisted to complete the act. In a recent survey, 6 percent of Dutch psychiatrists surveyed admitted that they had helped a person with a psychiatric disorder to die. (In some cases, the patient also had a terminal illness.) While agreeing that treatment was preferable, two-thirds said that assisted suicide was acceptable in cases of severe mental disorder.

  Hendin says that the slippery slope in the Netherlands may be leveling off. A third government study, in 2001, found more physicians reporting their cases, fewer physicians performing “life-ending acts without the explicit request of the patient,” and no further increase in the total number of physician-assisted suicide and euthanasia cases. Says Hendin, “Although the Dutch don’t concede that they are doing anything wrong, they have responded to criticism in ways I find very hopeful.” In the past several years, six centers for the development of palliative care have been established at hospitals in major cities, and more than a hundred new hospices have opened.