The Question: Is There a Right to Death?

AT CHRISTMAS TIME, 1967, when my family went to visit my grandmother at the Boston University Medical Center, the doctors took my father aside and told him that she did not have much longer to live; the cancer for which they had just operated was spreading. About 20 operations and over five years of determined suffering later, she is still fighting the disease that should have killed her long ago.

Physicians in hospitals in Boston and Washington who have treated her are amazed that she has lived so long with the cancer engulfing almost all her internal organs, most of which have been wholly or partially removed. Throughout her bout with the disease, the doctors have maintained that she does not have much longer to live. But cancer, like other afflictions for which we have no cure, can be very unpredictable.

The question of precisely when a patient suffering from a so-called "terminal" disease is beyond hope of recovery is a highly subjective one and one with which doctors have a great deal of difficulty. It is, for this reason, one of the funademental problems involved in euthanasia.

EUTHANASIA--literally "good death"--involves either the direct mercy killing (active euthanasia) or the more common practice of withholding lifesaving drugs or treatment (passive euthanasia) from patients deemed to be in extreme suffering and without hope of recovery.

The questions raised by euthanasia, especially active euthanasia, are profound moral ones, and for the most part remain unanswered. One thing is for sure: To date most of the burden of decision remains in the hands of individual doctors. At this time there are no national or state guidelines to outline just how to handle cases which may involve some form of euthanasia, and few hospitals have advisory groups to help doctors resolve the ethical and legal problems they may face.

Mercy killing is illegal in most countries: in a recent trial in the Netherlands, for example, a famous physician was found guilty in the mercy killing of her terminally ill mother. This, however, brought forward a large number of doctors who admitted that they had induced painless death in patients who preferred to die rather than to continue suffering. Although most doctors in the United States say they will not perform actual mercy killings under any circumstances, some favor such a practice if the patient, family and attending physicians conclude that it is the most "humane" solution.

The frightening fact is that if mercy killings are performed--and undoubtedly some are--the incidents can easily remain a secret between the attending doctor and the family, or even just the secret of the doctor. The death of a patient already diagnosed as hopeless would neither surprise nor arouse suspicion in anyone.

All of the physicians and legal experts with whom I talked said that they were opposed to any use of active euthanasia, and for the most part they reflected the mood of doctors and legislators throughout the country. Mercy killings involve the basic moral question of whether anyone ever has the right to take another person's life. And the possibilities for abuse or extreme extension of the right to put people out of their misery, either by individuals or governments, are far too obvious for people living only 30 years after Hitler to accept. While the courts have dealt more lightly with mercy killers than with murderers, it is unlikely that active euthanasia will become accepted practice in this country in the near future.

PASSIVE EUTHANASIA is not considered murder by the U.S. legal system and in fact is practiced every day in hospitals all over the country. Usually it involves withholding drugs, treatments or heroic measures which, in the opinion of the doctor and the patient's family, merely prolong suffering and the patient's inevitable death.

A recent survey conducted by Louis Harris concluded that Americans are opposed by a 53 to 37 per cent margin to the practice whereby "a patient who is terminally ill" should have the option to "tell his doctor to put him out of his misery." Harris also said, however, that 62 per cent believe that a patient with a terminal disease "ought to be able to tell his doctor to let him die rather than extend his life when no cure is in sight."

The three main reasons cited by opponents of active euthanasia in Harris sampling were:

* "Death should be left to God or to nature and should not be controlled by man";

* Such a practice "puts too much of a burden" on the doctor involved in the case, forcing him "to play God"; and,

* Mercy killing is "just plain murder and that is wrong."

Those who favored mercy killings justified them mainly by reasoning that "it is the patient's life, and the choice should be left up to him." Others said that "anyone is entitled to put a halt to suffering that can only end in death anyway."

Since active euthanasia is illegal and not widely practiced in this country, most doctors are not faced with the dilemma of deciding whether or not to put someone out of his misery. Most of the controversy in this area currently centers around the question of whether or not the practice should be legalized.

Despite popular support, however, the issues and questions surrounding passive euthanasia have become far more acute and complicated for physicians, as a result of the tremendous gains in medical science's ability to significantly prolong the lives of many "terminal" patients. Today, more and more doctors must decide when it is no longer worthwhile to attempt to keep a patient alive by further treatment or heroic measures.

Most of the doctors attribute the fact that my grandmother is still alive today to her intense desire to survive. Had her will to live and endure the suffering been any less intense she might have convinced the doctors that further treatment was not worth the agony of prolonging her life by a month or two. But in each case over the last five years, the doctors' assessments that she could only live a short time longer with treatments has proven wrong.

Because pain and suffering are subjective elements, the question arises of who should say the patient is in too much agony to continue treatment. In how many cases, where a decision to withhold lifesaving treatments is based on the patient's assessment of pain, would the patient have been able to make an unpredicted recovery with treatment--regardless of the small odds given by doctors?

A doctor must decide in which cases he is willing to play the odds and in which he should do everything within reason to beat those odds. And he must further decide whether the patient has the right or the proper outlook to demand an end to his suffering. In some cases the agony is so severe and the prognosis so hopeless that there is little question that heroic measures to prolong the patient's life should not be employed. But many times the line between hope and hopelessness is a fuzzy one, and the problems of who is to draw it and on what basis remain unresolved.

THESE AND OTHER moral, judgmental and legal problems raised by passive euthanasia have concerned increasing numbers of medical and legal experts in the past few years.

Most of these experts do not think that these doubts should mean that no doctor may dare let a patient die without first doing everything humanly possible to prolong even the most hopeless cases. Instead they say that advisory groups and some general guidelines for doctors should be considered.

As a result of the famous case several years ago where a mongoloid child with an intestinal obstruction was allowed to dehydrate and die instead of being operated on, Johns Hopkins University Hospital in Baltimore, Md., established a review board to advise its medical staff. The board, which meets regularly to attempt to develop ethical guidelines, consists of a surgeon, a psychiatrist, a clergyman and a lawyer.

Dr. Alejandro Rodriguez, director of child psychiatry at Johns Hopkins and a member of the board, said that board members' expectations of outlining definite policy were too premature. "We just didn't know enough about so many questions," Rodriguez said. "We're trying to put together meaningful answers to ethical problems on which we can base some sort of guidelines for the handling of [passive] euthanasia." He added that until more thought goes into the matter, he is "terrified at the thought of individual doctors being faced with life and death situations and decisions."

THE JOSEPH P. KENNEDY Jr. Foundation in Washington sponsored a symposium on ethical problems of medicine in October 1971 which was attended by legal and medical experts from all over the country. The foundation has funded programs in medical ethics at several institutions, including Harvard's Interfaculty Program in Medical Ethics. Harvard's program is designed to examine the ethical behavior of physicians "at a time when reappraisal of the moral basis for the medical acts of society and physicians is occurring in a wide variety of issues," according to the foundation.

William J. Curran, Lee Professor of Legal Medicine at the School of Public Health and one of the joint directors of the program, said last month that the interfaculty group has already initiated several programs and courses in medical ethics, including one of the only undergraduate courses in medical ethics in the country, History of Science 141: "Problems in Medical Ethics."

Curran said that the whole question of euthanasia raises the basic "question of the quality of life." The undergraduate medical ethics program was created because the moral and legal problems of the question must be encountered before the student begins his internship and active involvement in the medical field, Curran says, adding: "There is a very, very strong drive to help patients on the part of most of those who intend to practice medicine, but they must develop moral and ethical standards early in their training."

Sissela Bok, who teaches History of Science 141 with Stanley J. Reiser, assistant professor of the History of Medicine, said recently that the medical ethics course deals with euthanasia and other similar problems by "examining cases which pose questions about the ethics of the subject and discussing the difficulties encountered by physicians and patients." She said that the improvements in medical techniques over the last few decades have been a problem to doctors who know that their patients are terminally ill.

"Something that laymen don't consider is the enormous pressure that the doctor is under," she said. Many doctors have done everything in their power to prolong a hopeless patient's life, she continued, because they are afraid of being accused of negligence in not trying everything possible to save someone's life. Bok added that this trend is becoming less of a problem as more and more patients opt against extraordinary means of prolonging life.

Still, each individual doctor who is faced with the problems of seriously ill or injured patients bears enormous burdens and the decisions to which he must come may have serious consequences. Recently, many doctors have suggested that national guidelines concerning the ethical extremes of euthanasia should be outlined. "The problem is a legal one as much as a medical one," says Dr. Irwin Kopin, chief of the Laboratory of Clinical Science at the National Institute of Health in Bethesda, Md. "And the ethical and legal elements simply haven't been explored enough."

Kopin said that the current situation, where doctors must go out on a limb and bear the legal burden of such an important and controversial question, must be improved. "Although I think that it's a long time before people say that mercy killing should be legalized," he said, "I do think that there are times when the withholding or termination of treatments is justified. However, the definition of such cases cannot be dealt with lightly; it must involve many people from many fields."

"Even then," Kopin continued, "the direction in which things go will depend so much on the integrity of everyone involved in resolving the important social questions on the subject."

EUTHANASIA SOCIETIES in America have long advocated clearcut policies in the area with an emphasis on attempting to clear up the burden of decision which faces relatives and physicians of dying patients. The Euthanasia Educational Fund, founded in New York City in 1967, has advocated the use of a "living will."

Over 40,000 people have signed the "living wills," which tell doctors that "if there is no expectation of my recovery from physical or mental disability, I request that I be allowed to die and not be kept alive by artificial or heroic measures." Although these wills help alleviate the burden of deciding exactly what the patient desires, physicians must still take it upon themselves to interpret the "expectation of recovery."

The Euthanasia Society of America, also located in New York City, even distributes a "living will" which is in the form of a dying patient's request for death by mercy killing. Although those requests are not likely to be met by most doctors because of the illegality of such action, supporters of the Society say they have received thousands of the applications.

The issue of euthanasia, when broached to many doctors, brings the same response that the topic of legal abortion brought several years ago. Many of them simply do not want to talk openly about the issues. The issue centers so much on individual beliefs, morals and judgments, and the merits of each individual situation that physicians are always going to come under fire from some group if they make the issue an open one. Many will candidly admit a vehement opposition to actual mercy killing, but say that they may no longer elect, for instance, to give penicillin to treat the pneumonia of a terminal cancer patient.

ALMOST ALL of the doctors I talked to felt very strongly that a patient has the right to request that doctors take steps to terminate their pain and that a doctor should accede to a patient's wish not to be kept alive by unnecessary or heroic means. Most agree that just as in the area of abortion, it is clear that it is no longer a matter of continuing without guidelines for doctors to base their decisions on. The ethical and legal considerations surrounding euthanasia are far too serious, and too little exploration of them has taken place to allow them to be placed solely in the not-always-so-knowing hands of individual doctors.

Despite popular support, the issues and questions surrounding euthanasia have become far more acute and complicated for physicians, as a result of the tremendous gains in medical science's ability to significantly prolong the lives of many "terminal" patients.