Ethical Issues in Terminal Health Care

Part Three: Local Perpsectives on the Right-to-Die Debate

by Ed Newman

After exchanging goodbyes, he brought his wife a cup of coffee laced with secobarbital and codeine. She drank, and he waited. If the drugs failed, or made her uncomfortable, he was prepared to smother her with pillows.

This is the scene Derek Humphry recounts for the world in the book Jean's Way, the story of how he helped his wife commit suicide at age 42 during the last stages of her battle with breast cancer. Five years later, with co-author and second wife Ann Wickett, Humphry founded the National Hemlock Society, an organization dedicated to the cause of legalizing doctor assisted suicide for the terminally ill.

Humphry's latest book, Final Exit, goes further than advocacy for a cause. It is a how-to primer for terminally ill people who are considering "rational suicide." More than half a million copies of this Hemlock Society book have been purchased since its introduction last year.
The Hemlock Society is one of the leading proponents of active euthanasia and doctor assisted suicide for those who are dying slow, painful deaths. Its battle cry is for mercy, as in mercy killing. (The word euthanasia is an ancient Greek word meaning "good death.") This battle cry is evidently being heard. A survey in Parade Magazine asked if in the case of fatal illness, a doctor should be allowed to help that person end his or her life. 49 percent of its 2203 respondents said yes.

How do health care professionals here in the Northland feel? This article attempts to present a measure of this debate.

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For many people, the issue of doctor assisted suicide is very disturbing. As ethicist Carolyn Schmidt puts it, "The whole concept of doctor assisted suicide is a sad commentary on where we are societally. My personal viewpoint is that the whole concept is a total distortion of the basic commitment of the physician to support and help life. I cannot see how a physician can legitamize bringing about death."

Nevertheless, this is not a universal consensus. More than one person has suggested that Dr. Kervorkian -- a Michigan physician whose "suicide machine" has been used by three patients -- has brought attention to an important problem, even though he is "the wrong spokesman for the right issue."

David Mayo, Ph.D. and professor of philosophy at UMD and member of The Hemlock Society, put it this way. "I'm sympathetic to what Kervorkian is doing, but I'm unsympathetic to his modus operandi. I think he's a bit of a loose cannon, to be perfectly honest. A loose cannon who loves publicity." Dr. Mayo stated that he prefers Derek Humphry as the spokesman for this issue.

Derek Humphry and other proponents of doctor assisted suicide usually build their case around two main arguments. Those two arguments, according to Dr. Mayo, are the mercy argument -- the notion of sparing someone unnecessary suffering -- and the self-determination argument, the right to determine one's own fate or level of care while dying.

"Against that," Dr. Mayo adds, "the primary argument is the 'very slippery slope' argument. What will this lead to?"

Dr. William Portilla, a physician active on both state and local ethics committees, expressed this same concern. "Is this all scary? Yes. You talk to people who are well versed in Nazi Germany. Euthanasia was a very early step in all of that. So it is scary territory," Dr. Portilla said, "and those words, 'euthanasia' and 'suicide,' scare people, too."

A recent column in Newsweek shows that such fears are not unfounded. In a My Turn essay called "A Gentle Way to Die", March 2, writer Katie Letcher Lyle relates how she put her 16 year old cat to sleep, then goes on to advocate a similar solution for the troubles of a severely retarded 40 year old man named Henry who exhibits violent behavior patterns. This "gentle death" for Henry -- that is, a lethal injection -- is labeled humane. "Is a gentle death for human beings always the worst answer?" writes Ms. Lyle. "...I find it disgraceful, as well as ironic, that we cannot bring ourselves to treat our fellow humans as humanely as we treat our pets."

Interestingly enough, one of the most emphatic letters to Newsweek in opposition to this editorial came from Derek Humphry of the Hemlock Society. "We at the Hemlock Society," Humphry wrote, "were appalled to see that an advocate on behalf of the handicapped was hinting that a mentally disturbed man should be euthanized. Euthanasia should be lawfully available for the terminally ill adult who requests death because of unbearable suffering. To kill Henry, even out of mercy, would be murder in the worst degree."

WHERE DO WE DRAW THE LINE?
What is evident, then, is the problem of where to draw the lines. There is a wide range of opinions as to what is acceptable and unacceptable here. Many of the doctors interviewed by The Senior Reporter seemed to place that line between passive and active euthanasia. Do Not Resuscitate Orders might be considered a form of passive euthanasia.

Several doctors refered to the concept of "futile treatment", wherein a doctor is not obligated to use extraordinary intervention when its ultimate effect is obviously going to be futile. Carolyn Schmidt, who opposes both doctor assisted suicide and active euthanasia, strongly supports the non-use or withdrawal of extraordinary means of treatment such as respirators. "I don't feel morally we are required to use these," she said. "But there is a big difference between withdrawing or not using a technology and developing a technology of killing."

Identifying and clarifying these terms and developing rational standards for making difficult decisions has been a major role of the hospitals' medical ethics committees. [see Sidebar on Definitions]

The Hemlock Society proposes that the patient must be terminally ill and expected to die within six months. But others, it appears, wish to push the line back still further. None of the patients whom Michigan's Dr. Jack Kervorkian helped put to death by means of his suicide machine fell into the Hemlock Society's criteria for what is acceptable. Although all three requested and produced their own deaths with the aid of his machine, none would have been dead within six months. (Dr. Kervorkian's cause has not been helped by remarks such as, "To hell with the ethicists. I'm a real doctor.")


Historically, the accepted code of ethical conduct for doctors has been the Hippocratic Oath. Hippocrates was a Greek physician in the fourth century B.C. who taught that diseases have natural causes and can therefore be studied and often cured. As a result of his writings and teaching, he is called by many "the father of medicine." The most famous document attributed to Hippocrates is called the Hippocratic Oath. The Hippocratic Oath has served as a model of professional conduct and for the ethical practice of medicine. One portion of the oath reads: "I will neither give a deadly drug to anybody if asked for it, nor will I make a suggestion to this effect."

Dr. Camenga, a neurologist with the Duluth Clinic, affirmed the role this set of guidelines has tradionally played for physicians who are addressing end of life issues. "Certainly we are all having to think these things through a little more, but I have some fairly firm opinions. They come from such sources as the Hippocratic Oath and the notion that doctors should do no harm. That one should not be involved in suicide is very much a part of the ethic of medicine as I understand it." Dr. Camenga went on to say, "I am far more comfortable with using technical means to prolong life than I am with using technical means to abbreviate life."

An October 6,1989 article in the Journal of the American Medical Association by Ethics and Health Policy Counsel David Orentlicher, MD, JD, argues that allowing phsycians to assist in the suicide of hopelessly ill patients will violate the nature of the patient-physician relationship. "Indeed, from the time of Hippocrates, the principles of medical ethics have instructed physicians to refuse their patients' requests for death-causing treatments."

It is apparent from recent surveys that this Hippocratic tradition is eroding, even among doctors. Dr. Orentlicher concludes, "Suicide by the hopelessly ill may someday be sanctioned. However, much more thought needs to be given before involving physicians in the process and compromising their essential role as healers."

IF NOT HIPPOCRATES, WHAT THEN?
At bottom in all these matters is the question, How do we go about determining what is right and wrong in a given situation? What are the components of an ethical decision? How can physicians, patients and their families -- or courts -- decide?

Ethics has to do with decisions that involve making a distinction between right and wrong. In its simplest form, an ethical determination is an assessment of a moral act based on (1) what we do, (2) how we do it, (3) when we do it, and (4) our motivation for doing it, or why we do it.

But behind these criteria are also underlying assumptions about the meaning and value of life. Is human life inherently sacred? Or is value determined by one's current contributions to society as a whole? This latter utilitarian view comes dangerously close to resembling the social engineering of physicians and geneticists under Hitler's Germany of the thirties.

In the Twin Ports, much work is being done to address the dilemmas raised by prolonged suffering among the terminally ill. Advocacy for the right-to-die in the local health care community appears minimal. However, because a growing number of states -- more than a half dozen at this time -- is currently discussing legislation that pertains to this issue, it is not unlikely that the debate will eventually reach Minnesota lawmakers as well.

The issues are immensely complex and there is much at stake. On the state and national levels, it is hoped that proposed legal and ethical changes in health care policies will receive a thorough examination before such policies are revised. Ideas which have immediate surface appeal often have unseen consequences.

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Any information in this article pertaining to legal or medical matters is not to be construed as professional advice. Copyrights remain the property of the authors.

Original versions of these articles originally appeared in The Senior Reporter in the spring of 1992.

contact: ennyman@northlc.com

Part One: Issues and Their Implications
Part Two: Ethics Committees
Part Three: Local Perpsectives on the Right-to-Die Debate
Part Four: Patients Have Rights, But Doctors Have Rights, Too
Part Five:
The Pros and Cons of Physician Assisted Suicide

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