Euthanasia II
Michael A. Gillette, Ph.D.

The most important distinction in the discussion of physician assisted suicide is the one that I presented last month between voluntary, nonvoluntary and involuntary euthanasia. I argued last month that we are perfectly comfortable as a nation with the practice of voluntary passive euthanasia. An example of this sort of activity is when I specifically refuse a treatment which is designed to prolong my life when I feel that my quality of life has deteriorated beyond an acceptable limit. A DNR order (if my physician agrees with my choice) and signing myself out of the hospital AMA -- against medical advice -- (if my physician does not agree with my choice) are the two most common tools of voluntary passive euthanasia.

Last month I also noted that we are relatively comfortable with the practice of nonvoluntary passive euthanasia. Nonvoluntary euthanasia takes place when someone must make a decision regarding the prolongation of life for another person who has lost, or never gained, the capacity to make such choices. The easy examples of this sort of choice surround cases where loved ones leave specific directions to those who survive them. My wife, for example, may hold my durable power of attorney, and she might legitimately decide to withhold care from me if I suffer a serious and irreversible illness. Another example, although it moves us toward more difficult cases, is when we allow parents to make treatment refusal choices for severely debilitated neonates.

This last case begins to take us down the slippery slope toward a dangerous destination. We fear that while parents and loved ones usually make decisions in the best interests of those whose lives will not be prolonged, they may be tempted at times to make decisions on the basis of more illicit grounds. This fear is based on a concern that what begins as nonvoluntary euthanasia will slowly, imperceptibly, and insidiously translate into involuntary euthanasia.

Involuntary euthanasia is defined as the killing or letting die of an individual in order to provide a good end to his or her life, but over his or her objections. In its best manifestation involuntary euthanasia contains a paternalistic concern for the patient, and operates on the assumption that when the patient objects to euthanasia it is only because the patient does not know what is good for him. In its worst presentation this sort of killing isn't euthanasia at all. Rather than providing a "good death" for a suffering person, it is a guise for murder that obscures a selfish end in the elimination of costly or troublesome people.

As promised, I must supply the argument this month to show that while we humans are certainly capable of inhuman activity, and that while we have a history of using euthanasia itself as an excuse for murder, I do not believe that such risks should be decisive in the American debate.

In order to support my claim that the slippery slope is not an insurmountable obstacle to an effective system of physician assisted suicide, it is imperative to show that vulnerable populations such as the elderly, the very young, those in a distinct minority, those with mental illness or those with mental retardation are not likely to fall victim to a good system gone bad or beneficent motives run amok.

The best counter argument to the slippery slope is to point out that the American experience with euthanasia has developed out of a broadly based movement toward patient autonomy. Rather than seeing euthanasia develop in this country on the recommendation of an established medical system or governmental agenda, the American call for euthanasia has been based on a recognition that patients should have the right to make decisions regarding their own lives.

The paradigm example of euthanasia in this country developed in the late nineteen-sixties and early nineteen-seventies when we began to tell each other stories that posed questions like "whose life is it anyway?", and "how do I want to spend my last days"? The rally cry of the DNR has not been "spare my family the expense", but rather "spare me the indignity and pain".

I honestly believe that the roots of the American move toward physician assisted suicide is an expression of autonomous response to technologies that are capable of restricting individual liberty at the very same time that they are meant to serve. A loss of quality is linked to an increase in quantity when euthanasia is discussed. This concern is patient generated, and is therefore much safer than other historical analogues.

Having made this point about the central role of autonomy in American euthanasia, I must still recognize two serious counter arguments to my view. First, I must recognize that as cost becomes a serious problem in the provision of healthcare, the euthanasia movement may be co-opted and used illicitly to justify improper euthanasia. Second, it is necessary to consider what the legalization of physician assisted suicide would do to the doctor-patient relationship. Euthanasia may be damaging to American medicine even if the practice is not abused.

Next month, we will continue the debate.