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‘Only a physician can commit homicide with impunity,’ said Pliny the
Elder. If only that were true, say a growing number of Americans. Over the
past year the campaign to legalise euthanasia in the US has suddenly gained
momentum. A controversial case history detailing how a doctor helped a patient
commit suicide appeared in the New England Journal of Medicine in March
1991; and the following November the State of Washington held a referendum
on a bill to legalise physician-assisted suicide. The issue has also taken
on some bizarre twists: the introduction of a controversial ‘suicide machine’
by a retired pathologist in Michigan, and the publication of what is surely
the strangest self-help book of recent years – Derek Humphrey’s Final Exit,
a best seller on how to commit suicide.

These developments reflect a growing distrust of the American health
care system, with its reputation for using formidable technology to prolong
the lives of dying patients, often against the wishes of relatives. Indeed,
it is partly because of this distrust that the termination of life-sustaining
treatment – so-called ‘passive euthanasia’ – has become morally acceptable.
Medical ethicists and the public alike accept that a mentally competent
adult who is terminally ill or in intractable pain has the right to choose
to be removed from a ventilator or to refuse tube feedings and hydration
– a view which American courts have so far upheld.

By contrast, medical ethicists remain divided about active euthanasia,
in which a physician ends a patient’s life intentionally and directly: for
example, by means of a lethal injection. Many believe that active euthanasia
should be legal for patients who have made a rational decision to end their
lives. They argue that active euthanasia falls within a person’s rights
of control over his or her body, and that legalising active euthanasia would
reduce pain and suffering. Others fear dire social consequences, arguing
that it would cast doctors in the role of executioners.

The way in which euthanasia divides medical ethicists is revealing.
Medical ethicists come from a diversity of backgrounds – law, theology,
history and literature, as well as from philosophy and medicine. But it
is from the latter two fields that the most vocal participants in the debate
over active euthanasia have come: philosophers in favour, and physicians
opposed.

EARLY CONTROVERSY

Many of the most influential and controversial early arguments in favour
of active euthanasia came from philosophers, such as Joseph Fletcher of
the University of Virginia, who was also an Episcopal priest. As early as
1954 Fletcher argued in his book Morals and Medicine that active euthanasia
should be legalised. Many philosophers today seem ready to accept active
euthanasia – if not as social policy, at least as a morally justifiable
option in exceptional circumstances.

Physicians, on the other hand, seem reluctant. Medical bodies such as
the American Medical Association have long opposed active euthanasia; the
Washington State Medical Association’s governing body opposed Washington’s
bill to legalise physician-assisted suicide by 114 votes to 22. Many of
the most articulate academic opponents of active euthanasia today are doctors,
such as Mark Siegler and Leon Kass of the University of Chicago, and Grant
Gillett of the University of Otago in New Zealand.

The split over active euthanasia may merely reflect the political sympathies
of doctors and philosophers, who tend to make their ideological homes on
opposite ends of the political landscape: physicians on the right, philosophers
on the left. But the reasons run deeper than that. Doctors are educated
to absorb and apply a received body of knowledge. To learn philosophy, on
the other hand, is to learn a method of thought and analysis. By habit philosophers
are much more inclined than doctors are to challenge the status quo, to
look for the reasons behind a particular belief or activity.

Philosophers argue that there is little difference between stopping
a patient’s ventilator and administering a lethal injection, if both acts
will lead to the patient’s death. And stopping the ventilator, most people
agree, is morally acceptable in many circumstances. Opponents of active
euthanasia reply that there is a difference between killing a patient and
letting a patient die. It is morally acceptable to allow a patient’s disease
to run its natural course, if this is what the patient wishes; it is another
matter entirely to administer the lethal drug. Administering a lethal injection
is a positive ‘act’; stopping a ventilator is merely an ‘omission’: a failure
to act. Acting, in this case, is wrong, but refraining from acting is acceptable.

Nonsense, say the defenders of euthanasia. Certainly there are differences
between acts and omissions, but morally these differences are irrelevant.
What matters are the doctor’s reasons for acting (or not acting), and whether
the doctor has acted intentionally. So administering a lethal injection
and stopping a ventilator are, morally speaking, the same. In both cases
the doctor has acted intentionally and his or her reasons for acting are
morally defensible – the patient’s wishes are being respected.

Philosophers build conceptual arguments, and this is a conceptual argument
at its most persuasive. If A is morally acceptable, then so is B, if morally
there is no difference between A and B. On the other hand, the most resilient
arguments against active euthanasia have not been conceptual ones, and
they have generally not come from philosophers. These are empirical arguments
against euthanasia based on its possible social consequences: the so-called
‘slippery slope’.

Slippery slope arguments contend that by sanctioning active euthanasia,
we will break a general moral prohibition against killing, and take the
first step towards pushing euthanasia beyond acceptable limits. Once onto
the slope, our moral balance will be lost and we will plummet towards the
bottom. First, active euthanasia for those who request it, then euthanasia
for those who are unable to request it: the comatose or disabled infants
in intractable pain. From there it is only a short step to the mentally
disabled and the mentally ill: the senile elderly, the mentally retarded,
chronic schizophrenics, patients with Alzheimer’s disease. Opponents of
euthanasia argue that we have had too long a history of mistreating society’s
‘undesirables’ to proceed confidently with a social policy with such potential
for abuse.

CONCEPTUAL BARRIER

Philosophers are not inclined to take slippery slope arguments very
seriously in the absence of overwhelming evidence that the slope is indeed
slippery, and as long as there is a conceptual barrier to keep one from
sliding down it. The conceptual barrier in this instance is the patient’s
consent. As long as a patient must request euthanasia before he or she received
it, many believe there is little danger of social abuse.

Erasing the line between the termination of treatment and active euthanasia
gives a much tidier conceptual system. But medicine is guided not so much
by conceptually tidy theories as it is by case histories: real examples
of pathology and treatment which, more often than not, refuse to conform
to theory. The question for doctors is usually ‘what will work in this case?’
– not, ‘how will this fit into a conceptual theory?’.

There is little doubt that the changes which have made it morally acceptable
to stop near-futile treatment – to allow dying patients to die less painfully
– have relieved the suffering of many patients. There is also little doubt
that active euthanasia would relieve the suffering of the small number of
patients who wish to die, but are physically unable to take their own lives.
Yet several troubling characteristics of contemporary medicine may make
active euthanasia a dangerous policy.

The first is the ‘technology imperative’: as new technologies and treatments
have emerged, so doctors feel obliged to use them. As a result, they have
become more uncomfortable with the softer, more time-consuming aspects of
caring for dying patients, such as listening to their fears and controlling
their pain. If active euthanasia became a genuine option for doctors, the
same kind of technology-centred attitude might prevail, and pressure to
perform euthanasia might grow.

A second danger comes from the pressure of health care systems which
spend an ever-increasing amount of money on the dying and the elderly. With
mounting financial pressure may come social pressure for less expensive
ways of treating these patients. These pressures appear threatening to those
who fear that legalised active euthanasia may make the elderly, disabled
and terminally ill feel obliged to die.

The most subtle danger of active euthanasia, however, may come from
the increasingly impersonal setting in which medicine is practised. Gone
are the days when physicians and families developed a relationship which
spanned gen-erations. Increasingly, the encounter between doctor and patient
is one between strangers, and takes place far from the traditional family
doctor’s office: in casualty units and hospital wards.

Most proponents of euthanasia envisage the lethal injection being administered
by a caring family doctor. Perhaps this ideal relationship is not necessary
for the act to be compassionate. On the other hand, as history has shown,
those situations with the most potential for moral abuse are often those
in which the players are strangers.

Carl Elliott has degrees in medicine and philosophy and is currently
based at the University of Natal in South Africa

* * *

The US warms as Europe wrestles

While public opinion about active euthanasia remains divided in Europe,
Americans appear to be growing more sympathetic to the idea. In March 1991
the New England Journal of Medicine published a controversial testimonial
in which Timothy Quill, a physician, told of Diane, a patient with acute
leukaemia who decided not to undergo the course of chemotherapy Quill had
recommended. Convinced that Diane was making a rational decision, Quill
eventually prescribed the barbiturates that Diane used to take her life.
In July a jury refused to indict Quill for assisting Diane’s suicide.

Initiative 119, Washington State’s referendum bill, is further evidence
of the growing support for active euthanasia in the US. If it had passed
in 1991, the bill would have legalised what it called ‘aid-in-dying’. One
problem with the bill, however, was its ambiguous language. It was unclear
whether the law would have permitted active euthanasia or a slightly less
controversial step, physician-assisted suicide. Here the physician prescribes
– but does not administer – the lethal dose.

Despite the problems with the Washington bill, nearly 40 per cent of
Washington voters cast their ballots in favour of it. Most public opinion
polls show that an even higher percentage of Americans favour the idea of
active euthanasia. In a 1988 poll, 58 per cent of those surveyed were in
favour of a physician being allowed to end a terminally ill patient’s life
at that patient’s request and only 27 per cent were opposed.

Two events suggest that Americans are willing to take matters into their
own hands. A retired pathologist, Jack Kevorkian, made headlines in 1990
when he helped Janet Adkins, a woman with Alzheimer’s disease, to commit
suicide in Michigan with his ‘suicide machine’, an intravenous line by which
Adkins administered lethal drugs to herself. In September 1991 Kevorkian
helped two more patients commit suicide – again in Michigan, which does
not have laws that explicitly prohibit physician-assisted suicide.

Also, in April 1991, the Hemlock Society published Derek Humphrey’s
book, Final Exit, which details the specifics of suicide – which pills to
take, and how many. The book soon became the best seller in the advice category
on the New York Times list.

Its proponents have praised it as a valuable tool for the terminally
ill, especially people with AIDS, who may be afraid of losing control of
how they die. Detractors fear that the book will aid and encourage suicide
by the mentally ill.

Though doctors generally seem much more reluctant to endorse active
euthanasia and assisted suicide than does the public, there are changes
in the medical community as well. In 1989 the New England Journal of Medicine
published a special article entitled ‘The Physician’s Responsibility Toward
Hopelessly Ill Patients: A Second Look’, by 12 prominent physicians. The
article discussed active euthanasia sympathetically, and 10 of the authors
endorsed physician-assisted suicide.

The notion of active euthanasia may be gaining support in Britain as
well. In 1988 a British Medical Association working party recommended that
it remain a crime; but a policy statement published in The Lancet in 1990
by London’s Institute of Medical Ethics argued that active euthanasia is
justifiable in some circumstances.

In Germany, by contrast, public opinion swings in the opposite direction,
occasionally with unhappy results. In 1990 pressure from groups opposed
to the public discussion of active euthanasia caused the cancellation of
several lectures due to be given by Peter Singer, an Australian philosopher
in favour of euthanasia.

And the 1991 meeting of the European Society of Philosophy and Medicine
was moved from Germany to the Netherlands because the organisers could not
guarantee the participant’s safety. In Austria, similar fears prompted the
cancellation of the International Ludwig Wittgenstein Symposium, whose theme
was to be applied ethics.