Some 30 years or so I was far more sympathetic to euthanasia and physician assisted suicide (PAS) than I am now, and will use this occasion to say why I changed my mind, growing slowly disillusioned.
In the late 1980s the Hastings Center Report published an article by a Dutch cardiologist reporting that there was considerable abuse of euthanasia in his country (where was still legally prohibited but de facto permitted as a result of court decisions). The article drew an immediate and well-organized response from a number of important Dutch medical groups: it was simply wrong in its facts and interpretation of what was going on–and irresponsible of us to publish it.
Then, in 1991, the Dutch government released the Remmilink Report, an anonymous survey of physicians’ practices on euthanasia and PAS. It turned out that less than 50% of physicians had been reporting, as required by law, that they performed either act. And in some 1,000 instances, they had performed euthanasia without patient consent. Worse still, the absence of consent did not seem to much bother the pro-euthanasia activists I had come to know from trips to Holland.
Now that was the Netherlands and we live in America. The point of comparison I would note is that ever since Oregon and Washington legalized PAS, it has been claimed by the state and advocacy groups that there have been no abuses. Perhaps that is true, but we will not know for sure until there is an anonymous physician survey; and there is little likelihood one will ever be carried out. In Oregon and Washington, and now with the proposed Massachusetts legislation, little other than statistical information will be available to the public.
But the Dutch experience left me with some doubts. Then, as I followed the progression of the American debates, with two failed efforts to legalize euthanasia in the 1980s in California and with a fresh effort in Oregon, something else emerged that gave me further pause. It was a shift away from euthanasia to gaining a PAS law, recognizing correctly that PAS was likely to be less controversial than euthanasia. That shift was the beginning of what I call the euphemism word game.
The word “suicide” would be eliminated along with the phrase PAS. Suicide, advocates decided, was something of a downer and, as one group put it, is “prejudicial” language.
Indeed it is, but a look at the language of the proposed Massachusetts legislation is revealing. “The Patient [may obtain from a physician] medication that the patient may self-administer to end his or her life in a humane and dignified manner.” Well, that sounds suspiciously identical to the dictionary definition of suicide: “the action of killing oneself deliberately.”
Then there is that word “dignity,” which the dictionary defines as “the state of being worthy of respect.” But do people suffering at the end of life lose the respect of others because of that? I don’t believe that is so at all. Instead, an entirely new and stipulative meaning of the word has been invented, having nothing to do with worthiness of respect. Instead, its new meaning seems to be that a personal sense of suffering, particularly the loss of autonomy, is itself a threat to dignity. Fewer than 500 or so people have chosen to make use of the Oregon and Washington state laws, with many thousands choosing not to avail themselves of them–many of whom surely lack self-control and autonomy–suggesting that the laws appeal mainly to people who uncommonly value self-control, really a lifestyle reason not a medical one.
Nor should we pretend that there is something more dignified about dying with the aid of physician-provided drugs than shooting oneself. We have no trouble calling the latter suicide. Physician assistance is sought, I believe, because it confers the legitimacy we usually ascribe to physician skills and competence. But I am not enthused about that form of legitimacy: doctors are far more skilled than the rest of us in knowing how they can directly kill us or give us drugs to do it for ourselves, and their authority should be severely limited to do so. I suspect that reasoning must have been why the Hippocratic Oath forbade it.
I have not said much about the potential abuse of “death with dignity” laws. I have no special reason to believe there are serious abuses in Oregon and Washington, or that there need be any in Massachusetts, but we will never really find out if there is. The potential for abuse that most worries me is the legitimization of suicide, whose numbers are now rising. There are all sorts of reasons for people of all ages without terminal illness to want to get rid of their unhappy lives. They should not think that suicide is an acceptable and rational way to cope. Beyond that, I cannot see any good that can come of legalization of PAS. “Choice,” that all-purpose value word these days, used by the liberal left and the market right, is not a good enough reason to change some deep and valuable traditions of the doctor-patient relationship.
And, oh yes, let me mention one feature of the Dutch scene now: a proposal to extend euthanasia and PAS to those who “are tired of life.” Of course that could never happen here, could it?
Daniel Callahan, 82, is President Emeritus of The Hastings Center and the author of two new books, a memoir, In Search of the Good: A Life in Bioethics (MIT Press), and a collection of essays and papers, The Roots of Bioethics (Oxford University Press).