The Medicalization of Death

by MD G. Steven Suits

In 1879 the South Carolina Medical Association became the first American medical society to speak out on euthanasia: "In the present state of society, the practice of euthanasia is illegal and can only be regarded as the practice of murder."¹ The American Medical Association’s Council on Ethical and Judicial Affairs, in a more modern statement, wrote, "What is termed ‘active euthanasia’ is a euphemism for the intentional killing of a person; this is not part of the practice of medicine, with or without the consent of the patient . . . The intentional termination of the life of one human being by another (mercy killing) is contrary to public policy, medical tradition, and the most fundamental measures of human value and worth."²

Hippocrates of Cos, in the fourth or fifth century BC, broke with his Pythagorean contemporaries by issuing the oath that anthropologist Margaret Mead said marked one of the turning points in the history of man: "For the first time in our tradition there was a complete separation between killing and curing. Throughout the primitive world the doctor and the sorcerer tended to be the same person."³ In the oath of Hippocrates, the physician declares that he will give nothing to injure or kill his patient (even if asked), nor suggest such a plan.

This tradition was unchallenged orthodoxy until the twentieth century. Early proponents of euthanasia in Great Britain and continental Europe were silenced by the Nietzschean atrocities of the Nazi regime. Once again in the past two decades, proponents of the medicalization of death have become vocal, not only in the academic arena, but also (and more loudly) in the popular media. For most Americans the issue is being framed by sincere advocates attempting to legitimize their cause through politics, and by Dr. Jack Kevorkian. The purveyor of truth to so many, the public opinion survey, suggests that as many as 75 percent of Americans feel that physician-assisted death⁴ is a good thing.

Escalation of the Calls for Killing
Progress of the march toward physician-assisted death has been significant in the past twenty-five years. Ultimately the reasons for this are philosophical in nature. But the explosion of technology has contributed crucially as well. Withholding or withdrawing life-saving measures did not achieve existential significance until the development of advanced life-sustaining machines and drugs. The fear of being hooked up to such machines for a prolonged period of time did not become reality until they were in common use in hospitals throughout the land. The advancement of pharmacology makes possible pain-free death at the hands of a physician. The visions of the gas chambers of Hitler no longer impede the idea of a quiet, peaceful death, which can be brought about by the ingestion of pills or the injection of a quick-acting solution.

The more fundamental grounds for advancement of medicide are philosophical. Bioethicists and medical ethicists have emerged who advocate principles that formerly were unthinkable. Richard John Neuhaus, former director of the Rockford Institute Center on Religion and Society, describes them as "professionally guid[ing] the unthinkable on its passage through the debatable on its way to becoming the justifiable, until it is finally established as the unexceptional."⁵ These "professionals" have established centers, institutes and journals to increase the persuasiveness and credibility of their arguments. They overwhelm "traditionalists" on faculties and government councils.

The basis of their musings is actually anti-philosophy. It issues forth from the post-modern death of truth, an ancient story played out in real life. In the Egyptian story, Typhon and his co-conspirators took the virgin Truth and hewed her lovely form into a thousand pieces, scattering them to the four winds. Milton, relating the story in his Areopagitica, says, "from that time ever since, the sad friends of truth, such as durst appear, imitating the careful search that Isis made for the mangled body of Osiris, went up and down gathering up limb by limb still as they could find them. We have not yet found them all."⁶ Sadly, for so many today, the search is now abandoned as futile.

All is relative, there are no absolutes. Even a good reason for saying no holds no force in a culture that has lost any comprehension of the good. And so Neuhaus says, "Indeed, it is doubtful that we still have a significantly shared moral vocabulary even for debating what good answers might be."⁷ With no common or shared understanding of what is right, true, or good, so many today establish emotion or opinion as the beginning point of ethical discussion. But to do so is to abandon ethics altogether. For ethics implies permanence. It is derived from the Greek ethos, itself from the word for "a dwelling, or place of permanence." The things of ethics are first or primary things. Not so for the existential ethicist who derives his or her positions from life’s experiences alone.

The exploitation of the postmodernistic principle of radical autonomy drives the debate from a framework of right and wrong, good and bad, to one of what is best for a given individual, at a given time, given particular circumstances. This "absolutization of autonomy tends to eclipse moral reasoning, because ‘the sheer fact that a choice is the patient’s tends to be viewed as the right-making characteristic of the choice.’"⁸ Within this framework, no collective "we" can determine what is noble. The noble must be determined by the individual herself. More and more, personal nobility is determined hedonistically. Maximizing pleasure, and, perhaps more importantly, minimizing pain and suffering have replaced such time-honored virtues as equanimity and long-suffering. No loss is as great as the loss of the value of human life. The resulting concept of lebensunwertes Leben9 has introduced a new player to the ethical stage: the untermenschen.¹⁰ He is whoever fails to meet the maximum pleasure, minimum pain test. So, the life which can no longer seek pleasure is not worth living. The life which experiences pain and suffering is not worthy of life.

In order to advance medicide, the existential ethicist has jettisoned the principle of the sanctity of human life. In its place has come the nebulous, neo-sovereign principle of quality of life. Upon this principle the relativist defends all kinds of previously unthinkable positions. Curing has replaced caring as the primary social good. When curing is not possible, the courageous would cut their losses and kill. And they will do it in the name of caring for the quality of a person’s life. What they will not do is care for the person as a fellow human being. Humans are no longer beings, but rather a collection of qualities.

Rationale for Death
This is clearly illustrated in the new understanding of compassion.¹¹ Literally, compassion is the act of suffering or enduring together with another. To proponents of physician-assisted killing, compassion is a primary reason for advocating the acceptance of assisted killing. But to them compassion is putting an end to the person experiencing pain and suffering, not coming alongside them. At times it seems that these advocates are as concerned with their own discomfort with suffering as they are with the suffering patient.

Proponents of physician-assisted killing argue that patients with terminal illness who are suffering should be able to relieve themselves of their pain and discomfort. Besides ignoring the ethical principle of the sanctity of life, this false cry for compassion overlooks the ability to control virtually all such pain. As Dr. Douglas Heimbureger, Director of Clinical Nutrition at the University of Alabama at Birmingham opined, "It is ironic, in fact, that this call comes at a time when we have better means than ever for treating pain."¹² Even Dr. Pieter Admiraal, a pioneer of Dutch euthanasia, has stated repeatedly that essentially all pain can be controlled and that euthanasia for pain is unethical.¹³ Dr. Kathleen Foley, Chief of the Pain Center at Memorial Sloan-Kettering Cancer Center, says this about the very real fears of physicians and patients regarding pain and its control: "Those fears are purely myths and need to be changed by education." Explaining that untreated pain and symptoms can lead patients to feel that physician-assisted death is their only option, she added, "Adequate pain relief, control of symptoms, and treatment of psychological distress clearly alters patients’ requests to terminate life."¹⁴

Depression is responsible for much of the "desire" of the suffering to end their lives. It is estimated that from 90 to 100 percent of people who commit suicide are mentally ill. Many of those have treatable depression. This is particularly so among the elderly who commit suicide. It is estimated that in 75 percent of these the family physician failed to detect curable depression.¹⁵ For these, a professional skilled in treating psychiatric aspects of terminal illness can often alleviate the suffering that leads to the desire to end life.

The decision to seek death is often an indictment against those who treat the patient. There is a real threat that with the acceptance of physician-assisted killing will come a lessened concern for providing comfort care to the dying. This is seen currently in the Netherlands. "In England, where palliative care is emphasized, requests for euthanasia are rare. In Holland, on the other hand, where euthanasia is easy to obtain, palliative care is said to receive lower priority."¹⁶ Echoing this is a statement by two psychiatrists with extensive professional experience in treating suicidal patients:

If those advocating assisted suicide prevail, it will be a reflection that as a culture we are turning away from efforts to improve our care of the mentally ill, the infirm, and the elderly. Instead, we would be licensing the right to abuse and exploit the fears of the ill and depressed. We would be accepting the view of those who are depressed and suicidal that death is the preferred solution to the problems of illness, age and depression.¹⁷

The medical profession should not eliminate the suffering, depressed patient, but work to alleviate the patient’s suffering and depression.

In addition to arguing from so-called compassion, proponents of physician-assisted death also argue for a fundamental right to control one’s body, and thus, one’s medical treatment. They include medicide as a new form of medical treatment. This is an obvious unfolding from the idea of radical autonomy that has popular appeal in the current rights-oriented culture. Yet autonomy requires two indispensable conditions: life and consciousness. The argument, therefore, fails in terms of validity. How can the principle of self-determination be upheld by eliminating the ability for such determination? John Stuart Mill said, "It is not freedom to be allowed to alienate freedom." This is why it is illegal – and rightly so – to sell one’s self into indentured slavery. Daniel Callahan, director of the Hastings Center, once wrote: "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."¹⁸

Personal rights are not necessarily the issue. In some states, where suicide and attempted suicide are no longer illegal, only physicians are granted new powers by legalization of physician-assisted death. In Oregon’s Death with Dignity Act, language actually limits patients’ rights because a physician assisting suicide is protected, as long as she acts in "good faith," even though she diagnoses the patient incompetently or fails to identify available treatment options because of professional ignorance.

"Death with dignity" has become a battle cry for proponents of euthanasia. Some begin this argument by declaring that death is simply a part of life.¹⁹ The same can be said of disease, injury and congenital defects. Child abuse, rape and pillage are part of life for some. Where are the campaigns for doing these with dignity? The rationale behind death with dignity is based on the sentiments that are expressed in the statement members of the Euthanasia Society of Great Britain and America sign. It says, in effect, ‘I do not fear death as much as I fear the indignity of deterioration, dependency and hopeless pain.’ Again we see in this the absolute value given to radical autonomy, the loss of which is feared as an indignity. According to this logic, of course, not a single infant or child has a dignified existence. Neither does a patient recovering from severe burns. Similar to the argument from compassion, this reasoning would include not only those who are terminal and suffer physical or mental discomfort, but also any who fail to otherwise meet some internal (or external) criteria for meaningful life. But the very real fear that many have of prolonged suffering and being trapped in a claustrophobic, machine-dependent existence must not be scorned, but assuaged. "The understandable fear has to do with connections, being connected to burdensome technology and disconnected from a community of caring."²⁰ The appropriate response is to demonstrate true compassion: suffering together with the vulnerable.

To hold that natural death is somehow less dignified than assisted death is simply wrong. History and literature are replete with examples of virtuous people facing not only death, but dying, with dignity. They understand what C. S. Lewis expressed when he said, "Pain hurts." And they recognize the value in persevering. Among other benefits is the basic testimony to the sacredness of life.

Several years ago, the governor of a western state opined that the elderly had an obligation to society to go on and get out of the way. Obviously to him, physician-assisted killing is the expression of the right to kill for the good of society as a whole. In an analogous sentiment, Earl Shelby, a proponent of eugenics, warned against "a tyranny of the dependent in which the production of able persons is consumed by the almost limitless needs of dependent beings."²¹ Whether out of a Nazi-like desire to purify society, a more utilitarian desire to balance the state budget, or to better allocate limited resources, this view pushes well beyond the level of comfort for most Americans. Perhaps this is why it is not frequently verbalized by proponents of physician-assisted killing as validation.

A final line of argument for legalizing physician-assisted death points to the support for it revealed by opinion polls. The built-in bias of opinion polls are common knowledge. "Do you believe that the elderly have an obligation to go on and get out of the way?" would elicit a different level of support than "Do you believe that physicians ought to be able to help the hopelessly suffering end his life peacefully, even by giving him enough pain medication to hasten death?" A person aware that virtually all pain can be effectively treated may answer differently than one led by the questions to believe that unbearable pain was hopeless.

Parallel to the opinion poll is the finding of a certain behavior or understanding widely held in a society. The fact that nearly everyone lies does not make it right. Such plebiscite ethics is seriously flawed. "There have . . . been morally distorted societies in which popular approval and law condoned serious violations of human rights (Nazi Germany, Stalinist Russia and Fascist Spain and Italy, for example). Something more philosophically cogent than public opinion, national sentiment, or law is needed to make a cogent case for the moral acceptability of euthanasia."²²

The reasoning for physician-assisted killing is mistaken, invalid, deceiving and flawed. Truth is certainly being hewed into a thousand pieces. All the arguments moralizing physician-assisted death can also be used to argue that it is immoral to remain alive if one is in pain, terminally ill, or a "drain on society." Those that argue for death as a benefit should be reminded that "there can be no benefit without a beneficiary. Death eliminates the beneficiary."²³

Slide toward a Moral Morass
Physician-assisted death is dangerous public policy under current juristic conditions because of the overwhelming probability that it would lead to involuntary euthanasia. This is commonly referred to as a slippery slope.²⁴ The argument from personal liberty would then usher in the loss of liberty for those euthanized without their consent, either because they are unable to give their consent, or irrationally consent to participate out of depression or coercion, or because someone decides against their wishes that it is best for them. Law professor Yale Kamisar recognized this forty years ago:

I am perfectly willing to accept liberties as a battlefield, but issues of "liberty" and "freedom" mean little until we begin to pin down whose liberty and freedom and what need and at what price. [Proponents] champion the "personal liberty" of the dying to die painlessly. I am more concerned about the life and liberty of those who will needlessly be killed in the process or who would irrationally choose to participate in the process.²⁵

Backers of medicide have no compulsion to see it limited. The majority of those who they feel "merit" it cannot request it for themselves. Once medicide is recognized by law as a right for any group (e.g., terminally ill, hopelessly demented), proponents could use the due process clause of the Fourteenth Amendment to erase any legal restraint to it for any other group with the application of nebulous "burdens and benefits" tests.²⁶ If a right to be killed is founded on the grounds of self-determination, it

"cannot reasonably be limited to the terminally ill. If people have a right to die, why must they wait until they are actually dying before they are permitted to exercise that right? Similarly, if the warrant for euthanasia is to relieve suffering, why should we be able to relieve the suffering only of those who are self-determining and competent to give their consent?"²⁷

A political climate that would legalize voluntary physician-assisted killing would be conducive to killing patients without their consent for their own good or for the good of society. Allowing physicians to assist in or directly cause the death of their patients would be most dangerous for the poor and socially disadvantaged. If access to such killing becomes readily available, incidences "needing" this option would escalate just as divorce accelerated following the loosening of divorce laws. Only with physician-assisted death there would be no opportunity for the victims to "make a new life." The risk to vulnerable members of society would be inordinate, especially with the emphasis on cost containment in health care. Under managed care plans, this threat would peak. Physicians would be financially rewarded to coerce the terminally ill, and other incurable patients with long-term expensive health needs, to choose physician-assisted death rather than alternate effective symptom relief measures that would be ongoing. Dr. Brian Pollard warned of the ultimate zenith of this mentality: "Killing is not proposed as the solution to any other human calamity. If killing the victims was really a valid solution to suffering, even when other available solutions had not been fully exploited, then it should be as valid for those who suffer for reasons other than medical."²⁸ It is sobering to realize that the "law is a weak reed in the absence of moral reasoning."²⁹

If it is moral for a physician to assist the death of a conscious, terminally ill patient, what are the moral grounds for withholding this option from a healthy individual who desires to end his or her life? And what are the moral reasons for withholding this option from those unable to decide for themselves? In the postmodern world, there is a lack of an ethical underpinning to regulate on behalf of the individual’s good. Yet, ethics committees in hospitals around the nation are developing quality-of-life indexes by which they may determine the best interest of patients. They apply these to determine what a "reasonable" person, acting in his own best interest, would decide to do. This, says Neuhaus, has led to the concept of "surrogate suicide." He goes on to point out, "of course it is always the other person who dies."³⁰

Loosening the laws that prevent assisted killing may lead to an increased incidence of suicide at a time when it is already rampant. Currently, "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. . . . 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."³¹ There would be at least five million fewer Americans.

The experience in the Netherlands over the past quarter century is pedagogical. Though a law against assisting in another’s death is still on the books, physician-assisted death is for all practical purposes sanctioned legally. This is illustrated by the story of a physician suspected of killing at least twenty patients in a senior citizens home. He pleaded guilty to five, was convicted of three, and fined. Dutch organized medicine likewise has sanctioned the practice, as illustrated by guidelines developed by the Royal Dutch Society for the Promotion of Medicine.³² Though officials of the society claim that their guidelines don’t explicitly condone euthanasia, Dr. Carlos Gomez correctly deduces that the "establishment of guidelines, guidelines that could subsequently be used as a defense in courts, is a de facto form of acceptance.³³ In 1993, the Dutch Parliament passed legislation that guarantees immunity from prosecution to physicians who follow these guidelines.³⁴

Dr. Gomez has provided an in-depth look into Dutch medicide. He found that "the guidelines put forth are being variously interpreted, and in some cases, they are ignored altogether."³⁵ His on-site research revealed that euthanasia was not always a last resort, was not always voluntary, and was not well-regulated (government and organized medicine guidelines notwithstanding). He concluded that "something other than an argument from autonomy was at work. I had the sense that some felt that certain patients were better off dead, that it was a humane act to kill them."³⁶

In 1991, a government commission on euthanasia under the leadership of the attorney general, reported on the practice in the Netherlands. Usually referred to as the Remmelink report (so named for the attorney general), it documented two very disturbing facts. First, in 1990 there were 2,300 cases of euthanasia and 400 cases of physician-assisted killing. Of these 2,700 cases, 1,000 were carried out without an explicit request. Thirty-seven percent of the cases were involuntary. The study also revealed that only 18 percent of the cases were reported, as is required. Other studies have shown that "the overwhelming majority of cases are falsely certified as death by natural causes and are never reported and investigated."³⁷

A second national investigation was commissioned in 1995. It was to reevaluate the frequency and practice of euthanasia in the Netherlands, and to measure any effect of a new notification law enacted in 1994. The subsequent two reports document that: the incidence of euthanasia increased; there has been little change in the occurrence of involuntary killing of patients; and reporting jumped from 18 to 41 percent.³⁸ Amazingly, one commentator could look at this evidence and conclude that there is no slippery slope in the Netherlands.³⁹

At some hospitals in the Netherlands, "general practitioners seeking to admit elderly patients are advised to administer lethal injections instead."⁴⁰ The elderly fear for their lives. Ninety-three percent oppose euthanasia and 68 percent fear that they will be killed against their wishes.⁴¹ "Many Dutch citizens carry cards called ‘Life Passports’ which declare they do not want a physician’s ‘aid in dying’ if they become unconscious or comatose."⁴² Even elderly physicians in the Netherlands fear admission to the very hospitals to which they have admitted patients for the reason that they, too, may be involuntarily euthanized.⁴³

The Dutch experience, far from alleviating concerns about legalizing physician-assisted death, illustrates the untoward consequences of such public policy. There, physicians have again shown themselves as human: radical individualists who "don’t like to be told what the rules mean."⁴⁴

In addition to the public policy implications of legalizing medicide, the professional virtue of medicine directs that physicians not expand their practices into this realm. Since the fourth century BC, physicians have provided healing and care, not killing. Postmodern thinking has made large strides in reforming the profession as purveyors of skills that improve the quality of life. Traditionally, the profession resisted death and disease on behalf of those who are incapable because of knowledge or skill deficits to resist themselves. Proponents of physician-assisted killing seek death for those who have no desire to resist.⁴⁵

The proper roles of the medical profession are to promote health, restore it when disease occurs, enable the disabled to manage life with disability, and encourage those facing death for whom no cure is possible. The physician, therefore, should never remove the need for dispensing such care by intentionally killing the patient.

Killing one’s patients, however noble the intentions, is outside the "physician’s frame of reference" (to borrow Albert Jonsen’s phrase). . . . the prohibition against killing is embedded within the Hippocratic Oath and is part of the ethos intrinsic to the proper practice of medicine. Thus a change that would allow physicians to kill their patients, even within the most tightly controlled circumstances, would not be a mere addition to the physician’s techniques and drugs. Rather, it would fundamentally alter that established "frame of reference."⁴⁶

William Rose, foreign secretary of the Netherlands Society for Voluntary Euthanasia, belittles this logic. "Doctors here are not like . . . American doctors. Here, doctors are just chaps, like any other of us. They just do a job. And all the talk you have about ‘professional ethics’ is a way of disguising what you really think: that you know what is good for the patient better than the patient does. Well, here in the Netherlands we don’t think that way."⁴⁷ What has traditionally been understood as professional is deemed by Rose mere paternalism. But this begs the question: What would society really think about a profession that has once again become healer and sorcerer? Is the physician nothing more than a laborer who is simply to "do his job?" As Dr. Edmund Pellegrino puts it, "How can patients trust that the doctor will pursue every effective and beneficent measure when she can relieve herself of a difficult challenge by influencing the patient to choose death?"⁴⁸

Finally, biblical principles mandate life. Two central doctrines of the Christian faith speak to this: the imago Dei⁴⁹ and the sovereignty of God.

Then God said, "Let Us make man in Our image, according to Our likeness; and let them rule over the fish of the sea and over the birds of the sky and over the cattle and over all the earth, and over every creeping thing that creeps on the earth." God created man in His own image, in the image of God He created him; male and female He created them.⁵⁰

Man’s nature as the image of God separates him from the rest of creation. It gives human life its inestimable value. In fact, God bases the institution of capital punishment on the sacredness of human life in the image of God.⁵¹ Thus, sanctity of life is ordained and established by the Creator Himself. This is the basis of the high biblical opinion of human life. That this includes corporal life is also established by Scripture.⁵² God’s pronouncement of the sacredness of human life comes after the fall of man. This confirms that the value of human life is not contingent on its character or ability. There is no place for a quality-of-life ethic in the teachings of Scripture.

God’s sovereignty denotes that humans are stewards of their lives, not masters. A person does not own her body or self. She is owned, body and soul, by the Sovereign One. Man is created by and destined for Him. Man’s purpose, as the Westminster divines penned, is to glorify God. Human choice, about all matters, must be exercised only within the framework of the sovereignty of the One who granted it. "Physician-assisted death is . . . a logical consequence of the presupposition that the meaning of our lives . . . is determined by ourselves and by no one else, including God."⁵³ To act as if our lives are mere possessions or things that we can give others the authority to dispose of is not only "profoundly dehumanizing"⁵⁴ but also reprobation.

Sanctity of life is truth established by Him who is truth. To lose this foundational understanding is to trip onto the quality-of-life slippery slope. To hold to this foundational understanding brings meaning to life, even to life which is experiencing heart-wrenching suffering.

Flattening the Slippery Slope
What should be the response to the prevailing rhetoric of the proponents of euthanasia? First, there must be a focus on the implementation of better care. Throughout the long history of civilization a primary obligation has been to care for the suffering. Physicians who care for the dying are obliged to know and use the most advanced methods of providing pain relief. Depression must be dealt with by those who know best the psychiatric aspects of terminal illness. Better care also implies better communication. This implies clear, appropriate dialogue between the physician and the patient. The professional must balance these with warm, loving support. In the classic example of suffering, Job is visited by three friends. They came and "sat down on the ground with him for seven days and seven nights with no one speaking a word to him, for they saw that his pain was very great."⁵⁵ What is missing most in the care of the dying and suffering is this suffering together with, this compassion. Promotion of hospice care centers and programs should also be encouraged. This includes participation by physicians who care for the dying. It also entails referral of patients to these programs. And it means providing for their financing through private philanthropy and encouraging third-party payer coverage.

There is also a public policy role for the physician. Dr. Edmund Pellegrino, director of the Center for Advanced Study of Ethics at Georgetown University, explained this.

The advocates of legalized euthanasia are right when they insist that the physician is crucial to any effective social policy permitting patients to be killed on request. Doctors do have the necessary knowledge. They do control the prescription of the necessary lethal agents. They do know when the patient’s diagnosis and prognosis portend a painful and inevitable death. These very facts impose an enormous moral responsibility on the profession to resist becoming moral accomplices or society’s designated killers.

If euthanasia is legalized, the medical profession will bear a large burden of blame if it does not educate the public to the dangers and it fails to refuse to participate.⁵⁶

The Netherlands again serves as an illustration. During World War II, the medical profession in the Netherlands was ordered by the Nazi commissar of the country to cooperate with Hitler’s regime by, for example, prioritizing care for those who could be rehabilitated for labor. The physicians unanimously refused. The commissar then threatened to take away their licenses if they did not at least cooperate to the extent of providing information to Nazi authorities. Unanimously, the Dutch doctors handed in their licenses, took down their shingles and continued seeing their patients secretly. They declared that they would not compromise their medical oath, which pledged them to work only for the welfare of their patients. When the commissar arrested and sent a hundred of their colleagues to the concentration camps, the medical profession remained adamant. They took care of the widows and orphans of their imprisoned colleagues and would not capitulate. During the entire Nazi occupation not one Dutch physician cooperated in the Nazi programs of slave labor (except, of course, as laborers), euthanasia, eugenic experimentation, and non-therapeutic sterilization. "But that was a long time ago, and the Dutch doctors of today have so far forgotten it . . ."⁵⁷

Conclusion
"A good death does not . . . include killing the patient, nor can one be a good physician and do so."⁵⁸ Euthanasia is usually interpreted as "good death." But it can also mean, literally, "easy death." In a culture lacking an infrastructure capable of comprehending any absolute, there is no shared concept of the good. It is quite understandable, then, that a good death (and a good life) is perceived as one that is easy.

Physicians in South Carolina no longer solidly agree that euthanasia is murder and should remain illegal.⁵⁹ If the public policy battle over physician-assisted killing is lost, may it not be said of the medical profession that in our lazy inattention, we were accomplices after a fashion.⁶⁰

The boundary between healing and killing is being destroyed. Hard questions are being asked, and answers are being advanced. Many ignore the debate, perhaps hoping that they will have no culpability when innocent, vulnerable lives are extinguished. Physicians who do not participate in this debate abrogate an important professional obligation to society. Let all who understand the preciousness of life muster the fortitude to engage the debate, reveal the flawed logic of the quality-of-life principle, and commit to caring for the weak, the tired and the suffering. If we cannot cure, we must care, not kill.

Endnotes

1. Transactions of the South Carolina Medical Assoc, XIII-XVII, 1879
2. Kinsella, D.T., Singer, P.A., Siegler, M. "Legalized Active Euthanasia: An Aesculapian Tragedy." Bulletin of the American College of Surgeons, 74(12): 9, 1989.
3. Cameron, Nigel M. de S. The New Medicine: Life and Death after Hippocrates. Wheaton: Crossway Books, 1991, p 9.
4. This author does not use the term "physician-assisted suicide" because it is inaccurate. Suicide comes from the Latin sui meaning one’s self, and -cida meaning to cut off or kill. Suicide, by definition, cannot involve another in the killing. This is especially so if the killing would not be possible without the participation of another. Besides physician-assisted death, alternative terms are physician-aid-in-dying, physician-assisted killing, and medicide.
5. Neuhaus, R.J. "The Return of Eugenics." Commentary, 85(4): 19, 1988.
6. Osler, William. Aequanimitas. Philadelphia: The Blakiston Company, 1948, p 7.
7. Op. cit. supra, n. 5 at p.15.
8. Heimburger, D.C. "Physician-Assisted Death Should Remain Illegal: A Debate." Journal of Biblical Ethics in Medicine, 8(3): 42, 1994.
9. "Life not worthy of life"
10. "Subhuman"
11. This word is derived from a conjunction of two Latin words, com, meaning together or with, and pati, to suffer or endure.
12. Op. cit. Supra, n. 8 at p.41.
13. Bernhoft, R. "Don’t Kill the Patient, Train the Doctor." Citizen 7(9): 3, 1993.
14. Foley, K.M. "The Relationship of Pain and Symptom Management to Patient Requests for Physician-assisted Suicide." Journal of Pain and Symptom Management, 6: 289-297, 1991.
15. Op. cit. supra, n. 13 at p.3.
16. Op. cit. Supra, n. 8.
17. Hendin, H., Klerman, G. "Physician-assisted Suicide: The Dangers of Legalization." Journal of Psychiatry, 150: 143-145, 1993.
18. "Euthanasia: Final Exit, Final Excuse." First Things (December): 5, 1991.
19. It is not. Death is the negation of life. It is the antithesis of life. Death is not the final part of life, but that which is after life.
20. Ibid., p.4.
21. Op. cit. supra, n. 5 at p.21.
22. Pellegrino, E.D. "Doctors Must Not Kill. The Journal of Clinical Ethics 3(2): 98, 1992.
23. Op. cit. supra, n. 13 (Emphasis in original.)
24. Richard John Neuhaus has a superb comment on the concept of the slippery slope: "I am sometimes asked whether I ‘believe in’ the slippery slope, as though it requires an act of faith. I believe in the slippery slope the same way I believe in the Hudson River. It’s there. There is no better metaphor to describe those cultural and technological skid marks which are evident to all who have eyes to see." Op. cit. supra, n. 5 at p. 18.
25. Op. cit. supra, n. 2 at p.8. (Emphasis in the original.)
26. Ibid.
27. Arkes, H., Berke, M., Decter, M., et al. (Ramsey Colloquium) "Always to Care, Never to Kill: A Declaration on Euthanasia." First Things, 46, Feb., 1992.
28. Quoted in Helfer, D. "What’s Wrong With Physician-assisted Suicide?" Illinois Family Citizen, 6(10): 3, 1997.
29. Op. cit. supra, n. 5 at p.25.
30. Ibid., p. 22.
31. Op. cit. supra, n. 13 at p.6-7.
32. According to Dr. Marcia Angell, "The guidelines require that four conditions be met before euthanasia is performed: (1) the patient must be a mentally competent adult; (2) the patient must request euthanasia voluntarily, consistently and repeatedly over a reasonable time, and the request must be documented; (3) the patient must be suffering intolerably, with no prospect of relief, although the disease need not be terminal; and, (4) the doctor must consult with another physician not involved in the case. Angell M: Euthanasia in the Netherlands: Good News or Bad? New England Journal of Medicine 355(22): 1676, 1996. (Actually, there are five guidelines. Angell has recombined them. The five are voluntariness, a well-considered request, a durable death wish, unacceptable suffering, and consultation and reporting. See Keown J: The law and practice of euthanasia in the Netherlands. Ethics & Medicine 8(3): 36-37, 1992.)
33. Gomez, Carlos F. Regulating Death: Euthanasia and the Case of the Netherlands. New York: The Free Press, 1991, p. 156.
34. Orr, R.D., Biebel, D.B. "Why Doctors Should Not Kill." CMDS Journal, 24(1): 11, 1993.
35. Op. cit. supra, n. 33 at p. 96-97.
36. Ibid., p. 137.
37. Keown, J. "The law and Practice of Euthanasia in the Netherlands." Ethics & Medicine, 8(3): 40, 1992.
38. Angell, M., "Euthanasia in the Netherlands: Good News or Bad?" New England Journal of Medicine. 355(22): 1676-1677, 1996.
39. Ibid.
40. Op. cit. supra, n. 5 at p.20.
41. Fatal Compassion, Deadly Dignity. Oregon Physicians Resource Council, Salem: Oregon Center for Family Policy, 1997, p. 12.
42. Ibid.
43. Op. cit. supra, n. 8 at p. 45.
44. Op. cit. supra, n. 33 at p.95.
45. Op. cit. supra, n. 2 at p.8.
46. Op. cit. supra, n. 33 at p.14.
47. Ibid., p. 165-166. (Emphasis added.)
48. Op. cit. supra, n. 22.
49. "Image of God"
50. Genesis 1.26, 27
51. Genesis 9.6
52. See, for example, the apostle Paul’s teaching in 1 Corinthians 15.
53. Op. cit. supra, n. 8 at p. 43.
54. Op. cit. supra, n. 27 at p. 46.
55. Job 2.13
56. Op. cit. supra, n. 22 at p.101-102.
57. Op. cit. supra, n. 5 at p.20-21.
58. Op. cit. supra, n. 22 at p.102.
59. Dickinson, G.E., et al. "Attitudes toward assisted suicide and euthanasia among physicians in South Carolina. Journal of the South Carolina Medical Association 92(9): 395-399, 1996.
60. Op. cit. supra, n. 33 at p.139.

G. Steven Suits, MD, is Chairman of the Board of Palmetto Family Council, an organization working with Focus on the Family to promote pro-family policies and served as the Chairman of the Board of Directors of SCAIHS for several years. He is also an ambulatory medicine physician in Irmo and adjunct professor of ethics at Erskine Theological Seminary, South Carolina, USA.

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