Chapter 2. Euthanasia

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Chapter 2

Euthanasia

General Comments

When introducing the issue of euthanasia, I stress very strongly the way in which modern medical technology has increasingly made euthanasia an issue that we all must face—whether in regard to ourselves or to those we care about. While modern medicine does not offer unending life, it does demand more and more that we decide when to stop trying to extend life. For many of the undergraduate student in class, this is a decision that their families have been faced with in regard to grandparents.

Comments on the ABC Video

This video centers around the 1992 trial of Dr. Kevorkian. (He was acquitted on this charge and in at least two subsequent trials.) It has several video clips, including one from Yale Kamisar, on the permissibility and desirability of physician-assisted suicide in general.

Video Transcript

Euthanasia

ABC NEWS: Nightline, December 13, 1993

ANNOUNCER: December 13th, 1993.

COKIE ROBERTS: [voice-over] He’s been on a prison hunger strike for the past 14 days, but today a judge laid down a stunning decision in the case of one who’s terminally ill, quote: ‘Such a person has a constitutionally protected right to commit suicide.’

PAUL ROTHSTEIN, Georgetown University Law School: Whatever happens to Doctor Kevorkian in this case, the public will never view this issue of suicide the same way again.

ROBERTS: [voice-over] Tonight, Dr. Kevorkian’s victory.

ANNOUNCER: This is ABC News Nightline. Substituting for Ted Koppel and reporting from Washington, Cokie Roberts.

ROBERTS: For years he’s been standing in the spotlight, conducting his macabre crusade for the right to commit suicide and have a doctor help you in the act. Today a judge in Wayne County, Michigan agreed with Dr. Jack Kevorkian. It was a big win for the man known as ‘Dr. Death,’ even though it was only one county judge declaring the constitutional right to suicide, and Kevorkian’s still in custody in another county, jailed for breaking the Michigan law outlawing assisted suicide. Kevorkian has now hastened 20 people to their deaths, and started arguments in state houses and households across the country. He’s provoked a national debate about whether a person has a right to death as well as life, and what role a doctor should play in those life and death decisions. It’s a subject that makes most of us uncomfortable at best, and Dr. Kevorkian’s tactics have added to that discomfort, but, as the ruling today shows, in the end, the doctor’s likely to succeed in changing the laws banning assisted suicide. Here’s Nightline correspondent Dave Marash.

DAVE MARASH, ABC News: [voice-over] Last Friday, when Dr. Jack Kevorkian appeared in a Michigan courtroom, the notorious ‘Dr. Death’ seemed to be close to ending his own life. The 65-year-old campaigner for physician-assisted suicide clearly showed the effects of two weeks in jail and a diet of nothing but juice, water and vitamins. On Sunday Kevorkian was rushed to a hospital, complaining of chest pains. Today doctors told him he had not suffered a heart attack, and a Wayne County, Michigan judge had even better news for him.

Judge RICHARD KAUFMAN, Wayne County, Michigan: This court has come to the conclusion that the Michigan statute banning all forms of assisted suicide is unconstitutional.

MARASH: [voice-over] Judge Kaufman said the legality of the suicide is determined by the health and the rationality of the victim, and ordered a hearing tomorrow on the particulars of the death of cancer patient Donald O’Keefe, whose suicide Kevorkian assisted. Outside the courtroom, Kevorkian’s lawyer demanded-

JEFFREY FIEGER, Kevorkian’s Lawyer: Dr. Kevorkian should be out of jail. Then the medical profession should come forward and say, ‘Look, we’re going to take this issue.’

MARASH: [voice-over] University of Michigan law professor Yale Kamisar says he doubts that Judge Kaufman’s decision will free Kevorkian, but he worries the decision could free other people, not necessarily doctors, to start assisting other would-be suicides.

YALE KAMISAR: One can certainly argue that why not medically trained people who are not doctors, and why not a spouse? I mean, why not- why not conclude that prohibiting a spouse from helping a husband or wife commit suicide would place an undue burden on the person who wants to commit rational suicide?

MARASH: [voice-over] The Kevorkian case goes to the heart of America’s moral and religious traditions. At Catholic University in Washington, assistant dean Father Robert Friday says the Catholic Church has always answered no on suicide.

Rev. ROBERT FRIDAY: The wrongness that is seen in it is really that the individual who takes his or her own life is really usurping, in a sense, the power of God or the right of God over life and death. Assisted suicide, for me to participate in helping someone else to commit suicide, is seen as cooperation in their evil act.

MARASH: [voice-over] Complicating that moral choice is modern medical technology. In deciding the case of comatose car crash victim Nancy Cruzan, the Supreme Court found that there can be legal grounds for ending extraordinary efforts to keep someone alive, for letting doctors pull the plug.

PAUL ROTHSTEIN, Georgetown University Law School: That’s considered not to be assisting suicide. That’s considered to be letting natural forces take their course, and it is nature that’s killing the person. Contrasted with that is the situation where affirmative steps would be taken that hasten nature along or change the course of nature. That is usually considered culpable, blameworthy.

MARASH: [voice-over] This is a distinction Derek Humphry rejects.

DEREK HUMPHRY, Founder, Hemlock Society: I think that pulling the plug on a comatose person and giving an overdose to a dying person who requests it are morally and philosophically the same thing.

MARASH: [voice-over] Humphry, who wrote the book Final Exit, which gives explicit instructions on how to commit suicide, says the media are clouding the real issue of a patient’s right to die.

Mr. HUMPHRY: When you look at their stories and listen to what they’ve said, it’s extremely painful, and you can see the justification for it. We want less emphasis on Kevorkian and more on the poor people that went to him.

MARASH: [voice-over] Meanwhile, Dr. Kevorkian has gone back from the hospital to jail tonight. He awaits Judge Kaufman’s hearing tomorrow and eventually a ruling by the Michigan Court of Appeals. Dr. Kevorkian’s cases are almost certain to wind up at the U.S. Supreme Court, where one expert predicts the right to die will be expanded.

Prof. ROTHSTEIN: Whatever happens to Dr. Kevorkian in this case, the public will never view this issue of suicide the same way again. He has succeeded, if his purpose was to stimulate public debate and, I venture to say, there will be changes in the law because of what he’s doing.

MARASH: [voice-over] As Dr. Kevorkian headed back to jail, he threatened to continue his hunger strike, even if it costs him his life.

[on camera] Prosecutor Richard Thompson isn’t fazed by that prospect, saying with a smile, quote, ‘I believe in free choice.’ In other words, Dr. Kevorkian is free to hurt or even kill himself, but no one else, even if they beg for his intervention. I’m Dave Marash for Nightline, in Washington.

ROBERTS: Is doctor-assisted suicide ever a rational option? We’ll discuss that question with three people who’ve given careful thought to the issue, a doctor and a woman who have each assisted in a suicide, and a bioethicist who opposes it. We’ll be back in a moment.

Introductory Writing Exercise

Ask students to read, "It’s Over, Debbie." Then ask them to imagine that they are members of a jury that must decide on the case of the resident who assisted in Debbie’s death. How would they vote? Why?

Comments on Specific Readings

Would you or your students like to comment on the readings—and to read what others are saying? Visit the "Comment" section of Ethics Updates at:

http://ethics.sandiego.edu/comment.html

Anonymous, "It’s Over, Debbie." and Timothy Quill, "Death and Dignity," provide an interesting contrast. Both are by physicians, but the relationship between physician and patient is vastly different. In the Debbie case, the resident knew little about the patient. There is nothing resembling informed consent. The Debbie article, when it appeared in JAMA, created a furor, and the local district attorney even tried to bring criminal charges against its author. In the Quill article, there is an on-going doctor-patient relationship, indeed a relationship between Quill and the patient’s family as well. Diane’s decision was well thought out, and was not made in isolation from those close to her. This is about as good as it gets in terms of the decision-making process.

Kenneth Vaux, "The Theologic Ethics of Euthanasia." Vaux begins by discussing the Debbie case, and then proceeds to argue for a double-effect principle. (For more on the principle of the double effect, see me introduction to abortion on Contemporary Moral Issues, p. 43.) This is an interesting piece in many ways, including the fact that as a Christian he sees active euthanasia as justified in "exceptional cases" such as the final stages of Lou Gehrig’s disease, cystic fibrosis, etc.

James Rachels, "Active and Passive Euthanasia." This is a now classic piece, originally published in The New England Journal of Medicine and directed toward a medical audience. He questions the moral significance of the distinction between actively killing and passively letting die. (This issue recurs in Chapter Nine in the discussion of world hunger and starvation.)

Richard Doerflinger, "Assisted Suicide: Pro-Choice or Anti-Life?" Doerflinger’s piece is a good example of a standard Catholic (and many Christian) position. He is particularly strong in seeing the slipperiness of the slope here.

Gregory S. Kavka, "Banning Euthanasia." This is the only previously unpublished piece in the anthology. It was written about two years before the author’s untimely death at the age of forty-six; he had been fighting cancer for ten years before he died. It’s a crisp and very nicely done argument against banning euthanasia that ultimately appeals to the moral principle that it is very wrong to prevent someone from rescuing someone else from great suffering (in a manner in which the latter person wishes to be rescued).

Daniel Callahan, "Pursuing a Peaceful Death." Etymologically, "euthanasia" refers to "dying well." Callahan’s article is a powerful and insightful discussion of dying well and what counts as a peaceful death. It is not principally about the narrow sense of euthanasia, but is an excellent discussion of the larger context of how we die.

Ethics Updates: World Wide Web Resources on Euthanasia and
End-of-Life Decisions
http://ethics.sandiego.edu/euthanasia.html

Court Decisions

US Ninth Circuit Court of Appeals. Compassion in Dying v. State of Washington. 1995. Opinion by Judge John Noonan. •Compassion in Dying v. State of Washington, 1996.

US Ninth Circuit Court of Appeals. Compassion in Dying v. State of Washington. 1996. Majority Opinion by Judge Stephen Reinhart. Recent ruling affirming a person's right to die and the right to physician-assisted euthanasia. •US Ninth Circuit Court of Appeals. Compassion in Dying v. State of Washington. 1996. Dissenting opinion by Judge Robert R. Beezer

Quill v. Vacco. Supreme Court Decision plus:

Second Circuit Court of Appeals. Argued: September 1, 1995 Decided: April 2, 1996
•Quill v. Vacco. Opinon by Judge Minor •Concurring opinion by Judge Calabresi •Amicus Brief filed before Second Cricuit of Appeals by the American Geriatrics Society
•Appeal of Compassion in Dying v. State of Washington and Quill v. Vacco to Supreme Court
•Amicus Brief. "Assisted Suicide: The Philosophers’ Brief" by Ronald Dworkin, Thomas Nagel, Robert Nozick, John Rawls, Thomas Scanlon, and Judith Jarvis Thomson.

Join a discussion of "Assisted Suicide: The Brief by Dworkin et al.," in Ethics Forums.
Read an exchange between Ronald Dworkin and Michael McConnell in Slate's Dispatches and Dialogues on the Brief by Dworkin et al.

Amicus Brief before the Supreme Court filed by the Project on Death in America, Open Society Institute.
Amicus Brief by Bioethics Professors George Annas et al.
Amicus Brief of Not Dead Yet and American Disabled •Amicus Brief of Choice in Dying
Amicus Brief of ACLU et al.
Amicus Brief of National Hospice Organization

Cruzon v. Director, Missouri Department of Health. U. S. Supreme Court, 1990.

Majoirty opinion by Justice William H. Rehnquist.
Dissenting opinion by Justice Stevens.

RealAudio recording of arguments before the court from Oyez Oyez Oyez. William H. Colby argued the cause for Cruzan. Robert L. Presson argued the cause for Missouri. Solicitor General Kenneth Starr argued the cause for the United States as amicus curiae urging affirmance.

Legislative Information

The Oregon Death with Dignity Act

The Patient Self-Determination Act. Maintained at the University of Chicago.

Other Basic Documents Relating to Euthanasia

On the Value and Inviolability of Human Life, a papal encyclical dealing with a number of issues of life and death, including euthanasia.

Declaration on Euthanasia. Sacred Congregation of the Faith. May 5, 1980.

When Death Is Sought. The New York State Report on Euthanasia and Physician Assisted Suicide. May, 1994
Transcripts of Hearings and the Final Report (June, 1995) of the Senate Special Committee on Euthanasia and Assisted Suicide. This is maintained on the DeathNET site.
Position of The American Dietetic Association: Legal and ethical issues in feeding permanantly unconcious patients.

Statistical Information

•What do Americans think about euthanasia? Click here to read a very interesting longitudinal study by Michael C. Kearl of Trinity Univesity.

Web Sites Relating to Euthanasia

Resources on End-of-Life Issues from the MacLean Center for Clinical Medical Ethics.

Euthanasia.com. Information on euthanasia, right-to-die, mercy killing, living wills, etc. "On this Web site we will provide information on the issue of euthanasia in the modern world. We are committed to the fundamental belief that the direct killing of another person is wrong. We have deep sympathy for those people who are suffering."

Compassion in Dying. Website of the organization that "brought two landmark legal challenges to achieve Constitutional protection for personal liberty and dignity at the end of life." Includes extensive links to materials on both the Washington case and the Quill case.

CURE -- Citizens United Resisting Euthanasia a grassroots advocacy network that defends the rights of patients to receive medical treatment, particularly when care is critical.

ERGO! Information Center, The Euthanasia Research and Guidance Organization maintains a site with extensive bibliography, court decisions, and links. ERGO!'s Euthanasia World Directory includes links, bibliography, and estensive coverage of recent news articles.

DeathNET, which has an adults-only rating.

LifeNET, which contains extensive links for both anti-abortion and anti-euthanasia sites.

Kara's Corner, a site devoted to right to life and healing

The Ohio Right to Life Page on Euthanasia

"Euthanasia: The Debate Continues", a philosophical debate between Bob Lane and Richard Dunstan on the morality of euthanasia

Scottish Voluntary Euthanasia Society Homepage. Voluntary Euthanasia Society of Scotland. Excellent set of resources.

The WEBster: Death and Dying. An extensive list of resources related to death, dying, and grief.

Links to "Talk of the Nation" Shows

Physician-Assisted Suicide Debate. Host: Ray Suarez. Guests: Dr. Ira Bylock, Director, Robert Wood Johnson Foundation National Program to improve end of life care, Director, Palliative Care Service, Missoula, Montana, Research Professor, Dept of Philosophy, University of Montana; Professor Margaret Battin, Department of Philosophy, University of Utah. Date: March 10, 1997.

Physician-Assisted Suicide. Host: Ray Suarez. Guest: Dr. Herbert Hendin, Author of Seduced by Death: Doctors, Patients, and the Dutch Cure (Norton, 1996) Executive Director of the American Suicide Foundation, Professor of Psychiatry, New York Medical College. Date: January 8, 1997.

Euthanasia. Host: Ray Suarez. Guest: Dr. Stephen Jamison, Author: Final Acts of Love: Families, Friends, and Assisted Dying (San Francisco, CA: Tarcher, 1995). Date: February 21, 1996.

"Before I Die: Medical Care and Personal Choices." An on-line version of the PBS documentary—an excellent resource for students.

Real Life Stories: •Mickey: Learning from Death •Joyce & Charles: The Hospice Alternative •Sabina & Perry: A Patient’s Wish •Jonathan: A Planned Death •Mary & Warren: Coping with a Long-Term Illness •Claire & Don: One Family’s Struggle

The Issues: •Medical Schools Respond •Do I Have to Die in Pain? •Breaking the Ice •When the Physician Is a Patient •What Is Hospice? •Hospice Facts & Figures •Byron’s & Frank’s Hospice Experience •Documenting Your Wishes •What Are Advance Directives? •Are Living Wills Honored? •Talking about Illness & Loss: The St. Francis Grief Communication Program •The Physician-Assisted Suicide Debate in the Courts •Paying for Long-Term Care How Much Do We Spend on End-of-Life Care?
Viewpoints: •Are physicians listening to patients’ wishes about dying? •Is it appropriate for a doctor to help someone to die? •Should physician-assisted suicide be legalized? •Should I be afraid to die in an intensive care unit?

Essays: •How do you decide when to give up the fight and focus on making the time you have left meaningful? •What role can nurses play in improving care of the dying? How can clergy play a larger role in caring for the dying in American hospitals?

Frontline: The Kevorkian Verdict. Another excellent on-line resource.

•Background material on Dr. Kevorkian, including his paintings.
Overview of the law on assisted suicide
Interviews with Timothy Quill and Arthur Caplan on physician assisted suicide, plus 1996 New England Journal of Medicine survey on the attitudes of doctors and the public in Michigan. And, a survey on the attitudes and practices of physicians in Oregon.

Time-line of events relating to Dr. Kevorkian

RealAudio recordings with Sherry Miller, Marjorie Wantz, and Thomas Hyde before their deaths as assisted by Dr. Kevorkian.
Interview with Dr. Timothy Quill about these cases.
Interview with Professor Arthur Caplan about these cases.

CD-ROM Interactive Software

A Right To Die The Dax Cowart Case : An Interactive Guide to the Right to Die Issue. This is a link to information about an extremely interesting CD-ROM program dealing with one of the most difficult right to die cases in recent times.

The Dying Rooms Controversy

'Return to the Dying Rooms'. The full transcript from the very powerful television documentary, including photographs.
Death by Default - A Policy of Fatal Neglect in China's State Orphanages. Summary and recommendations of the Human Rights Watch/Asia report, giving concrete evidence backing up the allegations that unwanted children were deliberately left to die in Chinese orphanages. A short summary is available in the Press Release, 7 January 1996, prepared by Human Rights Watch.
OneWorld OnLineNews Service presents a Special Report on the debate surrounding China's treatment of its children and of its family planning policy in general. This includes the perspectives of the Chinese Government, the documentary makers and charities - all of whom claim to be working in the interests of China's children.
Opinion from the Director of Human Rights Watch.. Originally printed by The New York Times, January 11, 1996, this article was written by Holly Burkhalter, who herself has adopted a Chinese child.

Suggested Paper Topics

Insurance Companies and Sustaining Life

Imagine that you are a vice-president of a major health insurance group. You are asked to develop a policy detailing the point at which your insurance company will cease to support efforts to keep a patient alive. Specify the rationale for your decisions.

Physicians’ Special Responsibilities

Some who are faced with terminal illnesses turn to physicians for assistance in dying. What special responsibilities do physicians have in this regard? Do they have any special obligation to their own patients simply because they are their own patients? Do they have any special obligations as physicians not to do anything that would end life?

Participation of Medical Personnel in Letting a Patient Die

Discuss the position of medical personnel (including doctors and nurses) in hospitals who have moral reservations about procedures (such as abortion) and decisions (such as letting die) at the hospital. What are the moral obligations of the hospital? the medical personnel?