Throughout the nation, Americans are engaged in an earnest and profound debate about the morality, legality, and practicality of physician-assisted suicide. Our holding permits this to continue, as it should in a democratic society.

--Chief Justice William Rehnquist

In retrospect, you have to wonder what we expected the Supreme Court would accomplish in its June 1997 ruling on physician-assisted death. Had the justices ruled for or against, half of the nation would have mourned that pronouncement. Instead, Rehnquist and his black-robed colleagues have returned the question to us and our neighbors. That debate will not be ended anytime soon, nor will the battle lines always be clearly drawn. (Polls indicate, for example, that evangelical Christians are far more ambivalent about this issue than they are about abortion.) Indeed, as the number of aging and infirm Americans continues to increase, the conflict will intensify.

But how does a nation conduct a debate when there is no consensus about the basis for ethical decisions?

Love beneath a hemlock

In a society obsessed with individual "rights" and personal autonomy, it is not surprising that the debate over physician-assisted suicide has centered on the "right to die." The emphasis on autonomy is, in fact, relatively modern in medical ethics. For many years, the first principle of doctor-patient relationship was that of beneficence—generosity of the healer toward one's fellow beings. But physician beneficence was not an adequate safeguard for Jews in Nazi Germany. Subsequently, the Geneva Convention and the Nuremberg Code supplanted the Hippocratic tradition and shifted to an emphasis on the rights of individuals.

Stephen Jamison's Final Acts of Love is a work that is firmly rooted in the primacy of such autonomy. He appeals to love as the ultimate standard, but it is up to the individual to decide what constitutes the loving action in any given situation. (Yes, those are the echoes of Joseph Fletcher's Situational Ethics you are hearing.)

Like outspoken Derek Humphrey, founder of the Hemlock Society, the soft-spoken Jamison believes in the right to end one's life. Jamison asks readers to decide whether they have the right to be in control or believe that only God can give and take life. Jamison does not expect a unanimous consensus, but he believes that those who wish to choose suicide have the right to assistance to carry out their resolution. For Jamison, the scope of this right extends well beyond the limits of the laws that the Supreme Court was asked to review. He broadens the definition of suffering to give equal weight to "mental anguish" as justifying the decision to end one's life.

Recognizing the potential for abuse if assisted death is legalized, Jamison proposes a safety net of social workers, counselors, and hospice staff. Unfortunately, his vision does not encompass the ways in which health-care reform has already undermined the very remedies he proposes. In too many community hospitals today, managed care has alchemized compassionate social workers into keepers of the revolving front door, especially where the elderly are concerned.

Even more worrisome is the coercion that patients experience once they have raised the possibility of assisted suicide. Dr. Herbert Hendin, executive director of the American Suicide Foundation, quotes one woman who was referred by her neurologist to a group called "Compassion in Dying" that champions assisted death. "I'm not afraid," said Louise about death. "I just feel as if everyone is ganging up on me, pressuring me … . I just want some time."1 Hendin also points to the double suicide of Derek Humphrey's elderly parents-in-law as an example of potential abuses of legalized euthanasia. The psychiatrist has seen too many wives coerced by their depressed husbands to join them in their free-fall toward death.

Although Jamison's focus is on friends and family members as assistants, he is well aware of the need to have the cooperation of the medical profession. But Jamison, who is not a physician, assumes mistakenly that a doctor's economic interests run counter to assisted suicide, encouraging physicians to keep patients alive as long as possible. In fact, "gatekeepers" now stand to make more money if their patients die before consuming further costly treatment. Under managed care, even palliative measures bear a high price. Recent Medicare reviewers grumbled about hospice patients who outlived their physicians' six-month estimate of life expectancy. The merchants of managed death focused on how much those elderly patients cost the system rather than noting that hospice-type care can greatly ease the pain and disorientation of the dying and give their last days a human context.

The anatomy of a Teshuvah

In stark contrast to the love-is-the-only-law morality of Final Acts is the story of a people whose ethic is posited within religious law. As readers of the Responsa of Rav Moshe Feinstein, we are privileged, over-the-shoulder observers of a scholar and prophet whose job it is to interpret God's law for his faith community. For Feinstein, any ethic of love must start with love for the law and what it teaches.

It was in early childhood that Rabbi Moshe Feinstein began his love affair with the law. In this book, edited by his son-in-law and successor, Moshe Tendler, a wise man thinks out loud about his most difficult cases for the sake of the whole community. To Feinstein, this is a teshuvah—an act of repentance, and thus undertaken with humility.

Feinstein believes that the sanctity of human life is superseded only by the imperative to sanctify God's name. To assume the responsibility for your death would be the most egregious act of idolatry. In the quest to honor that sanctified human life, the rabbi uncovers other wise ones who sanctify the name.

There are bonuses in this book, such as Tendler's encounter with former surgeon general C. Everett Koop during the doctor's tenure at Children's Hospital of Philadelphia. He quotes Koop as the latter addresses impatient colleagues: "The ethics and morals involved in this decision are too complex for me. I believe they are too complex for you as well. Therefore I referred it to an old rabbi on the Lower East Side of New York. He is a great scholar, a saintly individual. He knows how to answer such questions. When he tells me, I too will know."

When Rav Feinstein died in 1986, 75,000 gathered for his funeral in New York, and 250,000 mourned together in Jerusalem. In his teshuvah he never once uttered the word "autonomy."

The ethic of covenant

Whereas Jamison gives voice to the claims of self-determination and Feinstein to vigorous law, William F. May presents a model where the ethics of the patient and the professional, autonomy and beneficence, intersect. Testing the Medical Covenant: Active Euthanasia and Health Care Reform builds on May's prior works, The Physician's Covenant and The Patient's Ordeal. May extends his covenantal model beyond biblical thinkers to all members of a democratic society.

Citing Tocqueville's notion of a secular covenant that unites citizens who feel subject to the same weakness and the same dangers, May hopes that our fragmented society can recover the force that covenant carries in its religious sources and its deeper setting in the virtues of gratitude and hope.

May regards active euthanasia largely as a misguided response to the problem of a runaway medical culture in which technology has become an end in itself. But he is not an absolutist on this issue. May tells us that he can imagine exceptions, cases of suffering so horrendous that he would hope that he himself would have the courage to kill for mercy. He describes a wounded soldier in Vietnam who lost all four limbs from a land mine and was reduced "to a trunk attached to a face transfixed in horror."

Realizing that relativists would seize upon such an exception as a reason to dissolve the principle, May adds: "Who ever said the moral life is easy?" Indeed, it's not an easy task when you've got the right-to-die movement making lunch-meat out of exceptions. Rather than seeking legal protection in advance of assisting, May imagines that he would proceed as best he could and hope for a merciful court.

While I respect May's candor as well as his compassion, I part company with him on his willingness to endorse euthanasia in such "exceptional" cases. Army Maj. Maury Cralle recalls his own response, somewhat similar to May's, when one of his soldiers sustained injuries very close to May's hypothetical case: "I remember distinctly saying, 'Geez, it's a shame he wasn't just killed.'"2

The wounded soldier, Max Cleland, survived Vietnam. On his first trip outside Walter Reed Army Hospital, Cleland recalls falling out of his wheelchair into the gutter. When he looked up, Cleland saw "horrified faces of onlookers frozen in shock." He looked like a "fish flopping on a riverbank."

The Black Stork: The Death of "Defective" Babies in American Medicine and Motion Pictures Since 1915

By Martin S. Pernick

Oxford University Press

295 pp.; $39.95

Final Acts of Love: Families, Friends and Assisted Death

By Stephen Jamison

Putnam

278 pp.; $13.95, paper

Testing the Medical Covenant: Active Euthanasia and Health Care Reform

By William F. May

Eerdmans

143 pp.; $14, paper

Responsa of Rav Moshe Feinstein, Volume 1: Care of the Critically Ill

Edited by Moshe Tendler

KTAV Publishing House

213 pp.; $22.95

Denial of the Soul: Spiritual and Medical Perspectives on Euthanasia and Mortality

By M. Scott Peck

Harmony/Crown

242 pp.; $23

Seduced by Death: Doctors, Patients and the Dutch Cure

By Herbert Hendin

Norton

256 pp.; $27.50

None of his shocked onlookers took his life in the name of mercy. At age 26, Max Cleland became the youngest state senator ever elected in Georgia. Under President Carter he served as chief of the Veterans Administration, where he vigorously advocated for rights of the disabled. This year Cleland celebrated his twenty-ninth annual "Alive Day" with old comrades. "I thought you were dead," admitted Major Cralle to the man he once thought would have been better off that way. They stood together under a banner that proclaimed: WE'RE GLAD YOU'RE ALIVE.

The ethic of access

To Jamison's credit, Final Acts offers and encourages a wide range of options to support a choice to continue living. But May notes that the libertarian spirit (I should be totally free to choose how I die) may have contributed to the fear of any change in the health-care system (I should be totally free to choose my doctor). Our two demands for choice are now at odds with one another.

Availability of choice does not necessarily stimulate a balance between options. In the Netherlands, where assisted suicide is tolerated, Herbert Hendin observes a momentum that often takes over once a patient has indicated even the most preliminary interest in such a choice. The participation of intimates and caregivers shifts from solidarity with the patient to that of manager of an event.

Jamison expresses legitimate concerns about society's failure to provide adequate assistance for the final stages of living. Here, William May agrees. He worries that, given the option of assisted suicide and in the absence of an adequate system of palliative care, some patients would pursue death in an attempt to unburden individual caregivers—often family members strained to the limit.

But it is one thing to draw attention to lack of access to adequate palliative care and another altogether to use this lack as a justification for assisted death. Whether in the sprawling outback of Australia or population-dense Holland, within the buffer of Canada's universal health insurance or the leaky sieve of American health care, access in the absence of unlimited resources is always a relative concept.

The Dutch cure

Hendin's Seduced by Death is full of warnings of what lies ahead for us if we cross boundaries that have long been taboo. A recent Dutch governmental review revealed that 45 percent of hospital-based assisted deaths occurred without patient or family consent despite legal exclusions of surrogate decisions, including deaths of children.

Wherever family and friends are concerned, the issue of surrogate opinions is a serious consideration. I can attest from my own practice that some parents of children with cancer are already requesting assistance. In many of these cases, the families were already in possession of adequate pharmacological resources to accomplish the task. More than a recipe, these parents sought from their children's physicians the moral sanction for what they contemplated.

While academic ethicists are pondering the issue of death by surrogate decision, parents are routinely being asked to consent to life-threatening toxic treatment in hopes of curing their children. If their surrogacy is deemed adequate in these matters of consent, who is to tell them that their opinion on behalf of their children is not adequate in matters of "mercy"?

Historical discussions of involuntary euthanasia frequently invoke the Nazi experience or what Hendin calls the "Dutch cure" but rarely point to American experiments in euthanasia earlier in this century. Standing apart from the ethical discussions of assisted death is a fascinating piece of medical history that provides a macabre footnote to the entire subject. In The Black Stork: Eugenics and the Death of "Defective" Babies in American Medicine and Motion Pictures Since 1915, Martin Pernick traces the bizarre career of a Chicago surgeon who "delivered" handicapped babies from their afflictions. The question, then, is not "can it happen here?" It has happened here. It is happening here.

Rediscovering the soul?

When the Northern Territory of Australia passed legislation in May 1996 to permit physician-assisted death, doctors, lawyers, religious, and Aboriginal leaders raised an outcry against the world's first law permitting euthanasia. The first Northern Territory resident to claim this new right was Robert Dent, a former Christian missionary who converted to Buddhism shortly after his diagnosis with prostate cancer. Three assisted suicides later, Dr. Philip Nitschke said, "Every time it gets easier as the path gets better trod."3 So easy, in fact, that all three Northern Territory patients who exercised this new right downloaded from the Internet Nitschke's "Deliverance" software for a computer-activated barbiturate-delivery system.

Supporters and opponents of the Northern Territory law agreed on one point: there is inadequate access to hospice services for the nearly 100,000 residents who live on a land mass twice the size of Texas, where doctors make their rounds by airplane.

Ironically, the son of the first man to take his life under the law was a leader in the successful campaign for the law's repeal in March 1997. No longer an advocate of the right to die, Rod Dent says that the law "denigrate[s] the medical profession and the doctors down to the level of the gutter." Dent now calls for a national uniform law in Australia for patients' rights to palliative care. "I feel that had [my father] had access to the optimum palliative care in the Northern Territory, I believe he would have made a slightly different decision."4

On narrow legal grounds, the U.S. Supreme Court's June 1997 ruling threw the issue of assisted death back to the states. Here the Court's finding was analogous to its ruling on the death penalty rather than on abortion. In upholding a state's right to ban physician-assisted death, the Court also upheld a state's right to approve it. Justice John Paul Stevens opined that "Just as our conclusion that capital punishment is not always unconstitutional did not preclude later decisions holding that it is sometimes impermissibly cruel, so is it equally clear that a decision upholding a general statutory prohibition of assisted suicide does not mean that every possible application of the statute would be valid."5

And so the "debate" will go on. Will it consist mostly of arguments that, based on utterly incompatible assumptions, yield nothing more than fuss and bluster and a steady flow of op-ed pieces? Or is it conceivable that some good may come from it?

One who hopes so is M. Scott Peck, whose book Denial of the Soul: Spiritual and Medical Perspectives on Euthanasia and Morality concludes with a chapter boldly titled "The Hope of the Euthanasia Debate." It is Peck's hope that this issue will force many Americans to acknowledge for the first time where the denial of the soul inevitably must lead. In circumstances that seem to call for the ferocity of Dostoevsky or Flannery O'Connor, Peck himself inclines to wistful sentiments ("If many are willing to think deeply about the issues of the [euthanasia] debate, then many will encounter their own souls, often for the first time"), but we may fervently join him in that hope.

Diane Komp is professor of pediatrics at Yale University School of Medicine. Her essay, "The Changing Face of Death in Children," appears in Facing Death (Yale University Press), edited by Howard M. Spiro, Mary G. McCrea Curnen, and Lee Palmer Wandel.

1. Hendin, Seduced by Death, p. 39.

2. Laura Blumenfeld, "Max Cleland Had a Dream: No Nightmare Could End It," Washington Post, April 9, 1997.

3. "Australia's Doctor Death to Take Time Out," Deutsche Presse-Agentur, January 15, 1997, Wednesday, BC Cycle.

4. Jane Nelson, "Euthanasia Man's Son Backs Move to Overturn Law," Reuters World Service, December 3, 1996.

5. Linda Greenhouse, "Justices Uphold Laws Banning Assisted Suicide," New York Times, June 26, 1997.

Copyright(c) 1997 by the author or Christianity Today, Inc./Books & Culture Magazine. For reprint information call 630-260-6200 or e-mail bceditor@booksandculture.com.

Nov/Dec 1997, Vol. 3, No. 6, Page 33