H E C FORUM, Vol 3, No. 2, pp. 95-98, 1991. Printed in the USA. All rights reserved.

MURDER

0956-2737/91 $3.00+.00 Copyright © 1991 Pergamon Press pie

OR MERCY?

THE DEBATE OVER EUTHANASIA HAS ONLY

ACTIVE JUST BEGUN

S T E V E H E I L I G , MiP.H.

It has become one of our most common and frightening personal and collective nightmares: To find oneself lying in a hospital bed, hooked up to any number of machines, unable to move or speak or otherwise communicate with anyone. Perhaps in this nightmare we are completely unconscious, in a comal alive only in body and by the cruel grace of modern medical technology - in other, cruder parlance, a "vegetable." Many people end up in this terrible situation suddenly and unpredictably - as victims of automobile accidents, for example. But more often, we have some advance notice of the possibility of losing control of our mind and body. For most of us, the spectre approaches with the inexorable march of time, through the aging process and a slow deterioration of health. But the risk if not limited to the elderly debilitating diseases such as cancer or AIDS can and does strike at any age. There are thousands of people in beds across the nation with little or no awareness o f who or where they are, their hearts kept beating and their lungs pumping by the often mixed blessing of artificial life support. Recently, Jack Kevorkian, M.D. of Michigan arrived on the scene with a proposed answer to many of these problems - a "suicide machine." After hooking up 54-year old Janet Adkins, who presumably no longer wished to face the terrible progression of her Alzheimer's disease, he watched as she pressed a button allowing the machine to first deliver a drug to render her unconscious, and then another drug to end her life (1). The pushing of that button also triggered a front-page uproar, with predictably confusing and conflicting results. Legal authorities have been far from unified in their responses - was this murder, suicide, or assisted suicide? The Hemlock Society praised Ms. Adkins and Dr. Kevorkian as "torchbearers" for the right to die (2). On the other side, in an unusual alliance, some medical and ethical experts quickly joined with self-proclaimed "right to life" activists in denouncing

95

96

S. Heilig

Dr. Kevorkian's actions (3). But medical and ethical figures, for the most part, are uniform in their opposition to how Ms. Adkins life was ended, and are not necessarily opposed to every type of "aid in dying" (4). The distinction between what Dr. Kevorkian did and how the same end might be achieved in a more appropriate manner is crucial, and one that HECs may well be called upon to face. What Doctors Think -

and Do

In early 1988, this author conducted a survey of San Francisco physicians regarding their views on "active" euthanasia - the taking of intentional actions to end a patient's life. "Passive" euthanasia turning off the life sustaining machines, or even disconnecting the tubes delivering artificial nutrition and hydration to comatose patients - is gradually becoming an accepted part of medical practice, when done in accordance with specific guidelines. Taking the next step and intentionally causing death is an entirely different matter, strictly prohibited both by laws and written and spoken codes of physicians. On the other hand, whispered stories abound about physicians actually helping patients to die in various ways. The San Francisco Medical Sdciety (SFMS) survey was designed to see how local physicians thought and felt about this situation (5)Of the 330+ physicians who answered the survey, 70% responded that active euthanasia should be a legal option for patients with terminal illnesses. Feelings were strong on both sides, with rationales ranging from a simple "This is murder" to "It is about time we became as kind to humans as we are to our pets when they are dying." But the striking thing about this survey's basic finding, and about the often very similar results in subsequent surveys of other physicians, was how closely physicians mirrored the general public in polls on this issue: Generally, about two-thirds of Americans are "pro-choice" not only concerning the beginning of life, but also concerning decisionmaking at the end of it as well (6) (7) (8). How does this silent-medical-majority view reconcile with the strong condemnation of active euthanasia by the American Medical Association and many medical ethicists? In some ways it is a matter of theory vs. practice - for many of the doctors who favor the concept of "aid-in-dying," actually doing it for patients may be another matter. In the SFMS survey, a significantly lower proportion (54%) indicated that they themselves might be willing to help patients die. While this represents over half of the respondents, it is possible that a still smaller proportion would agree that Dr. Kevorkian's "suicide device" is the best approach. Dr. Kevorkian acted largely in isolation, with a patient he hardly

Murder or Mercy?

97

knew, and with little or no input from his colleagues. Janet Adkins died in the back of a rusty Volkswagen van - hardly an ideal setting for the ultimate step in h u m a n existence. Patients and physicians confronting the many issues surrounding dying now have a wide range of resources to draw upon, from medical-legal documents specifying a patient's wishes to H E C s established to explore many options. Often, improvements in communication, therapy, and pain relief can lessen or eliminate the request to die. But not always. Rational suicide does exist. There are some kinds of pain not assuaged by medication, and levels of "living death" few of us would wish upon ourselves or our loved ones. For many of us, the fear of what becoming an artificially-sustained "vegetable" would do to our family and friends, both emotionally and financially, is enough to warrant our wanting to at least have more control over the ending of our own lives. Physicians can also be caught in a difficult position - forced to chose between what they may feel is best for their patient and what the law and various codes of medical ethics tell them is permissible. Many take refuge in the strict doctrines of tradition; others hedge their bets a little and do everything they can to relieve a patient's pain, perhaps hastening death in the process - but, they say, never intentionally doing so. Many physicians at some time face the slruggle between what is Hippocratical and what might be seen as hypocritical. I_x~oking to the Future Attempts to codify active euthanasia in California and other states have failed thus far, but for reasons having more to do with a lack of money and organization than of public support. The movement to legalize active euthanasia is in fact gathering public support, with planned attempts to introduce legislation or ballot initiatives spreading around the nation. Considering the tide of public opinion, it may be only a matter of time before some form of legalized active euthanasia becomes a reality in this country (9). Hopefully, any such legal option will be tightly controlled and monitored to avoid abuses and ensure that any instance of active euthanasia is fidly voluntaty on the part of all concerned. We might do well to look very closely and impartially at The Netherlands, where active euthanasia is not legal but is carried out by physicians under strict criteria and guidelines (10). The jury is still out on what is taking place there, with people on both sides of the debate using the same scant "evidence" in attempts to bolster their arguments. Much more information and education is warranted on the part of all concerned. As the Supreme Court's decision in Cntzan v. Directot,

98

S. Heilig

Missouri Dept. of Health, et al. underscores, the importance of prior discussion between patient and physician, with written legal documentation of the patient's wishes, is more important than ever (11). Like many other modern problems, the growing debate over "the righl to die" ironically is rooted in human progress, in this case in medicine's successes in prolonging life and the dying process. Dr. Kevorkian stated that he helped Janet Adkins kill herself in order to force more discussion of these issues. To that end he has certainly succeeded. Open discussion about active euthanasia is essential if we are to find our ethical way between extreme positions. A knee-jerk reaction for or against the practice is unhelpful, at best. At this point the situation is still far from ideal, and no o n e should ever find himself or herself in such desperate straits that he or she needs, however willingly, to crawl into an automobile to end his or her life. REFERENCES 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11.

As menlory and music faded, Oregon woman chose death. New York Times, June 7, 1990; A1. Janet Adkins: The torchbearer, l/em/ock Qt~arterly. 1990; 39:1. Adelman SI I. Doctor's role in patient suicide a thorny issue, American Medical News. August 3, 1990; 19. Orenllicher D. Physician participation in assisted suicide. Journal of the American MedicalAssz)ciatiotl. 1989; 262:1844-5. Heilig S. The San Francisco Medical Society euthanasia survey: Results and analysis. San Fralzcisco Medichze. 1988; 61:24-34. Kuhse H, Singer P. Doctors' practices and attitudes regarding voluntary euthanasia. Medical Journal o f Australia. 1988; 148:623-7. Somerville J. Survey finds support among Colorado MDs for euthanasia. Americal~ Medical AYws. 3uly 1, 1988; 17. Most California doctors favor new euthanasia law. ltemh)ck Quarterl),. 1988; 31:1-2. Sprung CL. Changing attitudes and practices in forgoing life-sustaining treatments. Journal of lhe An,erican Medical Association. 1990; 263:2211-5. de Wachter MAM. Active euthanasia in the Netherlands. Jourtzal of the Attzev'iealz Medical Association. 1990; 262:3316-9. Annas GJ. Nancy Cruzan and the right to die. New England Journal of Medicine. 1990; 323:670-2.