Editorial: Euthanasia: Final Exit, Final Excuse

At year’s end, the eyes of the world turn again to an infant who is, so Christians believe, the revelation of God to man and of man to himself. In the words of John’s gospel, “In him was life, and the life was the light of man. The light shines in the darkness, and the darkness has not overcome it.” It is not for the lack of trying that the darkness has not overcome it.

This year, like all years, has witnessed myriad stratagems of the darkness. Readers can readily draw up their own list of events and trends that have contributed to the fading of the light in our public life. High on our list are the ominous advances made by the campaign for euthanasia. In the media and in state legislatures, it is called assisted suicide or aid in dying or the right to choose death with dignity. By whatever name, it is a further social permission to terminate life and extinguish the light.

Derek Humphry’s Final Exit became a best seller this year. The book is a “how to” manual for killing oneself and helping others to do likewise. Drugs are the lethal means of choice, but Mr. Humphry has helpful advice also for those whose taste may turn to guns, plastic bags, or asphyxiation by automobile exhaust. Putting out the light has never seemed easier. Perhaps it should not bear too strongly on our thinking, but Humphry, founder of the Hemlock Society, boasts of having helped “euthanize” his first wife, and he divorced his second after she was discovered to have cancer. In October of this year, she committed suicide. Humphry says he only wants to make death a “rational choice.” Rationality has seldom seemed so chilling.

Final Exit has reportedly sold over 300,000 copies. The book, the author, and the Hemlock Society are hardly marginal phenomena. They are driving forces in a number of initiatives to change state laws against homicide and assisted suicide in order to allow physicians to give drug overdoses or lethal injections to their patients. Proponents have orchestrated highly successful publicity blitzes around instances in which family members or physicians killed severely ill, sometimes terminally ill, persons or helped them to kill themselves. The euthanasia campaign is assuming the appearance of another juggernaut of Progress—an idea, as they say, whose time has come. In fact, the campaign is motored by a set of ideas that civilized people have long since consigned to a barbaric past. Final Exit is the final excuse for not caring for the burdensome. It is the renewal of a long-cancelled license to kill. All of civilization and all of religion, Peter Berger has written, is humanity waving its little flags of defiance in the face of death. Final Exit is the lowering of the flags.

Yet we must try to understand the enormous appeal of the euthanasia campaign. The campaign’s success is in large part the product of a naked and cruel exploitation of understandable fear. The National Conference of Catholic Bishops recently declared

Those who advocate euthanasia have capitalized on people’s confusion, ambivalence, and even fear about the use of modern life-prolonging technologies. Further, borrowing language from the abortion debate, they insist that the “right to choose” must prevail over all other considerations. Being able to choose the time and manner of one’s death, without regard to what is chosen, is presented as the ultimate freedom. A decision to take one’s life or to allow a physician to kill a suffering patient, however, is very different from a decision to refuse extraordinary or disproportionately burdensome treatment.

The understandable fear has to do with connections—being connected to burdensome technology and disconnected from a community of caring. With respect to the ending of life, the proponents of the license to kill typically present the extraordinary and most harrowing circumstance as the normal. The reality is that most Americans spend their last days in their own homes, in the company of family and friends, fully aware of their surroundings, often in control of their bodily functions, and without pain. About one-third actually die at home, while others transfer to a hospital a few days before dying. The National Institute on Aging studied 4,000 deaths of people over sixty-five years old. The day before they died, 51 percent had no difficulty with orientation or recognizing their families, 61 percent had no pain. 90 percent had no diarrhea, 87 percent had no nausea. Just over half, 52 percent, could breathe freely, and 69 percent needed no pain medication. Nine out of ten saw their family and friends within the last three days of life.

The point is not that death is easy. Death remains, in the words of Saint Paul, the last enemy. All the chatter about “death with dignity” ignores the fact that death is the final indignity of losing all that commanded respect in this life. In dying we know that, as Martin Luther put it in the last words he wrote, “We are all beggars, that is for sure.” The point, rather, is that, for the overwhelming majority of people, dying is not the medical-technological horror show routinely portrayed by the euthanasia enthusiasts in order to panic people, especially older people, into supporting the license to kill.

The purveyors of hemlock claim that the legal changes they propose are carefully crafted to address the hard cases of those who have been called “the biologically persistent”—those who go on living after they have lost their “quality of life” and are therefore, we are told, dead. We know from hard experience, however, that the license to kill, no matter how carefully crafted at first, cannot be contained. In law, in habits of mind, and in everyday behavior, killing is socially contagious. Also in the hard cases, there are alternatives to the legal injection or overdose. The chief alternative is a communal context in which caring is not contingent upon the qualities of those cared for. More specifically, the euthanasia campaign has deliberately and effectively distracted attention from a growing hospice movement that allows people to die at home or in some other caring environment, and without pain. The hospice approach carefully respects the fundamental rule of civilization that it is always wrong to directly intend to terminate an innocent human life. We have not understood the radicality of the current euthanasia campaign until we see that it is precisely that civilizational rule that is under attack.

All civilized societies sharply restrict the permissions given for one person to kill another. They do not recognize private agreements for one person to take the life of another in order to serve the interests of one party or both. In the law of our society, the license to kill is limited to four circumstances: self-defense or the protection of another life; killing in a just war; the punishment of those guilty of capital offenses: and, only in recent years, the killing of unborn children. Few dispute the first permission. Pacifists have always disputed the second. Most advanced societies have now banned capital punishment. In this society, the abortion license is, just maybe, in the process of being restricted or withdrawn. To the first two and apparently secure permissions to kill, the euthanasia campaign would add another. The permission is incoherent in its logic, unlimited in its scope, and almost certainly devastating in its social and moral consequences.

There is an analogy between life and freedom. In his essay On Liberty, John Stuart Mill wrote that societies cannot grant individuals a legal right to sell themselves into slavery, even though that limits their self-determination. “The principle of freedom,” he wrote, “cannot require that he should be free not to be free. It is not freedom to be allowed to alienate his freedom.” To that observation Daniel Callahan adds, “The absolute power that is put into the hands of another—the right to be a slaveholder—is not compatible with respect for our human dignity. Both the slaveholder and the enslaved are corrupted by the relationship, even if both have the good of the other as their motive.”

In a society obsessed as ours is by the self-determination of the autonomous and sovereign self, the “right to be killed” attacks the heart of secular liberal theory. Callahan writes,

A sovereignty that can legally and morally be given away is fragile and contingent, not sovereignty at all. To allow another person to kill us is the most radical relinquishment of sovereignty imaginable, not just one more way of exercising it. Our life belongs no longer to us, but to the person into whose power we give it. . . . No defender of civil liberties and the right of self-determination should want to see that possibility made available.

Or think about it this way: If the right to life itself can be surrendered in exchange for the “good” of death, why cannot other rights be exchanged for other goods? Rights then become fungible. They are no longer moral claims to be recognized by law but “things” to be traded in the marketplace. Rights, far from being trump (Ronald Dworkin), are reduced to the status of baseball cards.

There is a yet more radical incoherence in the proposal that one party can give to another the right to kill him. The right is presumably given in exchange for a benefit, namely death. But there can be no benefit without a beneficiary. Death eliminates the beneficiary. It may be objected that in the hard cases, when bodies are riddled by disease and racked with pain, surely the “owners” of such bodies, the “persons” in the bodies, can demand to be released. The redoubtable Leon Kass has considered that argument:

However sympathetically we listen to such requests, we must see them as incoherent. Such person-body dualism cannot be sustained. “Personhood” is manifest on earth only in living bodies; our highest mental functions are held up by, and are inseparable from, lowly metabolism, respiration, circulation, excretion. There may be blood without consciousness, but there is never consciousness without blood. Thus one who calls for death in the service of personhood is like a tree seeking to cut its roots for the sake of growing its highest fruit. No physician, devoted to the benefit of the sick, can serve the patient as person by denying and thwarting his personal embodiment. To say it plainly, to bring nothingness is incompatible with serving wholeness: one cannot heal—or comfort—by making nil. The healer cannot annihilate if he is to heal. The physician-euthanizer is a deadly self-contradiction.

In the biblical view, the person—or soul, if you will—continues to live beyond bodily death. In that view, it is also true, however, that a person does not “own” his body or his self. He is owned, body and soul, by God—or, in more biblical language, he is created by and destined for God. That tradition leaves no doubt that committing suicide or helping someone to commit suicide is prohibited. It is doubtfully the business of the state to entrench this biblical understanding in law. The state deals with temporal, not eternal, life; and in this life body and person are inseparable. The philosophy undergirding our constitutional order is incompatible with the notion of a right to be killed.

The inalienable rights to life and liberty cannot be alienated by a putatively free act that destroys life and liberty alike. A society whose overriding value is the freedom to choose, without reference to what is chosen, unravels the very reasons for protecting the freedom to choose. A person’s right to choose is respected because each person is endowed with the right to life, liberty, and the pursuit of happiness. A person does not have the right to choose to deprive himself of the rights that are the foundation of his right to choose. In other words, the arguments for the “right to death” have no grounding apart from the right to life, and are therefore self-contradictory. It is not true, as the euthanizers claim, that “death is a normal part of life.” In the terms appropriate to the temporal order, death is the end of life, death is the opposite of life.

This may seem like a painfully esoteric set of philosophical disputes, until we see that they drive to the heart of the moral and legal justifications of our constitutional order. The convoluted illogic of certain ways of thinking is evident in, for example, “wrongful life” suits that have been successfully prosecuted. Thus parents sue a doctor on behalf of a baby who, because of some abnormality, “should have been aborted.” Because the doctor did not do appropriate tests or did not advise abortion, the baby and the parents, it is claimed, are burdened with a wrongful life. Perhaps because of the manifest philosophical and legal problems posed by such reasoning, wrongful life litigation seems to have subsided in the last few years. But the same problems are inescapably present in the argument for the right to be killed.

Beyond the philosophical, it takes no great imagination to see the practical consequences of a legalization of the right to be killed. Measures currently being proposed place great emphasis upon the importance of free choice and voluntary request for euthanasia. The reality of the law in America, however, makes it certain that provisions for mercy killing will be challenged under the equal protection clause of the Fourteenth Amendment. Why should the comatose or demented be denied the benefit of deliverance from life through euthanasia? There is clear precedent for the court appointment of proxies and others who exercise “substituted judgment” in terminating treatment for those who cannot speak for themselves. There is exquisite irony in our present situation. In the case of the unborn, the right to life is deemed to depend upon the unborn’s ability to effectively assert that right. Which, of course, the unborn cannot do. When it comes to the right to death, however, people are allowed to assert that right on behalf of others. And, of course, it is not difficult to find people who are prepared to assert that other people would be better off dead.

Leon Kass writes:

Euthanasia, once legalized, will not remain confined to those who freely and knowingly elect it—and the most energetic hackers of euthanasia do not really want it thus restricted. Why? Because the vast majority of candidates who merit mercy killing cannot request it for themselves: adults with persistent vegetative state or severe depression or senility or aphasia or mental illness or Alzheimer’s disease; infants who are deformed; and children who are retarded or dying.

None of these is capable of requesting death and would therefore be denied “assistance in dying,” except that those who claim to have their best interests at heart will assuredly secure for them the equal protection of being killed. Ours is a society firmly opposed to discrimination against the handicapped, the aged, and the mentally ill. The law will see to it that death does not discriminate.

In addition to emphasizing free choice, measures currently proposed stress that mercy killing or assisted suicide will be limited to those who experience severe suffering. But this too cannot be controlled, in significant part because suffering cannot be defined. Suffering, as numerous medical authorities attest, is a subjective state. There are two people with identical medical indicators; one suffers severely and the other very little or not at all. It is generally acknowledged that there are no objective medical measurements of suffering. And what about psychological suffering? In the experience of the one suffering, the loss of a job, a broken marriage, a disappointed romance, or the death of a family member can produce suffering every bit as acute as the most fearful cancer. The law cannot discriminate between sufferings. The number of people who would be legally entitled to assistance in suicide would be very large indeed.

Experts in suicide prevention say that there are five million Americans alive today who at one time attempted suicide. Suicide is the second leading cause of death among teenagers. This is the situation when the law does not recognize a right to death and makes it a criminal offense to help someone else to commit suicide. The law has a powerful pedagogical effect. Until now, it has been weighted on the side of life. Again, it takes little imagination to recognize what would happen if the severely depressed knew that they had a right to kill themselves and obtain help in doing so. Today, if someone is really determined to commit suicide, he can almost certainly find a way. Bridges, guns, drugs, and a three-inch turn of the wheel that sends a speeding car over the cliff—these are readily available. Millions of people who have contemplated suicide or have halfheartedly attempted suicide are alive today because the voice of law reinforced the voice of conscience in favor of choosing life.

The advocates of mercy killing and assisted suicide typically focus on the cases of wonderfully competent and articulate people who have rationally decided that they want to control their deaths as they think they have controlled their lives. No doubt there are such people and, if they are set upon making a Final Exit, they will find a way to do so. Most people who think about ending their lives, however, are in a state of acute distress. Especially for older people, that distress includes the thought, perhaps confirmed by others, that their lives are useless and an inexcusable burden upon their families and upon the scarce medical resources of society. If being killed or getting help in killing themselves is viewed as a perfectly legal and morally acceptable option, that distress cannot help but be compounded.

Yale Kamisar puts the matter forcefully:

Is this the kind of choice, assuming that it can be made in a fixed and rational manner, that we want to offer a gravely ill person? Will we not sweep up, in the process, some who are not really tired of life, but think others are tired of them; some who do not really want to die, but who feel that they should not live on, because to do so when there looms the legal alternative of euthanasia is to do a selfish or cowardly act? Will not some feel an obligation to have themselves “eliminated” in order that funds allocated for their terminal care might be better used by their families or, financial worries aside, in order to relieve their families of the emotional strain involved?

Today when someone dies after a prolonged and painful illness, family and friends frequently say, “She is better off this way.” If the euthanasia campaign has its way, people will decide that she would be better off dead. And, at least in many cases, that would mean that we would be better off with her out of the way. The burden of proof would be on continued life. Once we have abandoned, in law and social habit, the presumption in favor of life itself, it is very difficult to make the case for sustaining burdensome lives. It takes no imagination at all to recognize the consequences of such a change, for we have at hand a valuable case study in the experience of the Netherlands.

On this question Regulating Death: The Case of the Netherlands (The Free Press) by Dr. Carlos Gomez is must reading. Unlike current proposals here, the Netherlands has not formally legalized euthanasia; it has simply decided not to prosecute doctors who kill their patients. Euthanasia or assisted suicide is protected by a notion of privacy and it is left to the medical profession to regulate itself. As might be expected, there is little regulation. The Dutch medical establishment estimates—and Gomez thinks it is an unrealistically low estimate—that 2,400 to 3,600 patients are “euthanized” by their physicians each year, many of them without their consent and against their will. In the United States that rate would mean 40,000 to 60,000 per year. Keep in mind that Holland is a democratic and generally humane society with universal health care and generous social services. There is no crisis of a medical system overloaded by excessive demands, and there is no “underclass” population of the socially nonfunctional.

Far from being progressive, the euthanasia campaign is a regression to a time when society had not devised protocols to check the human propensity to choose evil. Such a protocol is the Hippocratic Oath, dating from the fourth century B.C., and taken by physicians at the beginning of their practice. The oath imposes at least three limits on the physician: no breach of confidentiality; no sexual relations with patients; no dispensing of deadly drugs. Advocates of the license to kill argue that the Hippocratic Oath has in recent years been abandoned by many medical schools. Some argument. It is tantamount to saying that, since the protocols against the corruption of medicine have been abandoned, we are free to corrupt medicine further by endorsing the concept of the physician as healer-killer.

No one should dispute that this is the further and lethal corruption of medicine. Conscientious physicians have long lamented the fact that their vocation (to use a term that sounds increasingly quaint) is being turned from a profession into a mere technical skill. Technicians, as technicians, profess nothing. When their technique reaches the point where they can no longer cure, they have little reason to care. Indeed there is an understandable inclination to discard the lingering evidence of their “failure.” Nobody likes to fail, and administered death is a convenient closure of the unhappy reminder of one’s limitations. For the proponents of euthanasia, there is only a choice between healing and killing. This, too, is a regression, for in the long story of civilization it has been understood that our primary obligation to the suffering is simply to care for them. There is much chatter about new rules being required because of technological breakthroughs in medicine. The great change, however, is not in technique but in the hubris of the technical. It is the growing refusal of society and of medicine to recognize that, in a painfully unsatisfactory world, we are called to be the company of the caring—of which company physicians were once exemplars.

As appalling as this corruption must be for conscientious physicians, the consequence for the patient is at least as ominous. Kass again:

The patient’s trust in the doctor’s wholehearted devotion to the patient’s best interests will be hard to sustain once doctors are licensed to kill. Imagine the scene: you are old, poor, in failing health, and alone in the world; you are brought to the city hospital with fractured ribs and pneumonia. The nurse or intern enters late at night with a syringe full of yellow stuff for your intravenous drip. How soundly will you sleep? It will not matter that your doctor has never yet put anyone to death; that he is legally entitled to do so will make a world of difference.

The medicalizing of death cannot be responsibly discussed without reference to the class factor. The autonomous, rational, self-directed patients portrayed by the hemlock faction are not the chief candidates for mercy killing. Financially secure, well educated, and accustomed to exercising control, they may feel unthreatened by legalized euthanasia. Although they, too, deceive themselves about the actual circumstances in which they would be making the final decision, or will have it made for them. Those most directly threatened, however, are the very poor. Along with the comatose, the retarded, the radically handicapped, and the senile, most of them have no “quality of life” that a euthanizing society would have any interest in preserving.

Final Exit is the final excuse, and both are related to something that might be called the final solution. This is not alarmist, but it is rightly alarming. Of course the United States is not Nazi Germany. Of course there will not be, next year or ten years from now, the systematic elimination of millions of the socially burdensome. We say “of course” because of our confidence in this constitutional order, in the basic goodness and common sense of most Americans, and, above all, in God’s care for the American experiment in ordered liberty. But, if we accept the logic of the euthanasia campaign, there is no “of course” whatever. On the contrary, the logic of that campaign—like the eugenics ideology from which it emerged and with which it is closely associated—drives directly and relentlessly toward a brave new world of the rationalized elimination of the unfit. When the distinction between life and death is deliberately blurred, when death is declared to be a benefit bestowed, all but the morally comatose know that great evil is afoot.

In his distinguished study, The Nazi Doctors, Robert Jay Lifton wrote that it all began with the medicalizing of death. “At the heart of the Nazi enterprise,” wrote Lifton, “is the destruction of the boundary between healing and killing.” In the United States of America in the Year 1991, that boundary is being destroyed. And that is why, in this season celebrating the light, we are compelled to draw attention to the encroaching darkness.