Originally published by First Things, February 1996
by Dr Leon Kass
Recent efforts to legalize physician-assisted suicide and to establish a constitutional “right to die” are deeply troubling events, morally dubious in themselves, extremely dangerous in their likely consequences. The legalization of physician-assisted suicide, ostensibly a measure enhancing the freedom of dying patients, is in fact a deadly license for physicians to prescribe death, free from outside scrutiny and immune from possible prosecution. The manufacture of a “right to die,” ostensibly a gift to those not dying fast enough, is, in fact, the state’s abdication of its duty to protect innocent life and its abandonment especially of the old, the weak, and the poor.
The legalization of physician-assisted suicide will pervert the medical profession by transforming the healer of human beings into a technical dispenser of death. For over two millennia the medical ethic, mindful that power to cure is also power to kill, has held as an inviolable rule, “Doctors must not kill.” The venerable Hippocratic Oath clearly rules out physician-assisted suicide. Without this taboo, medicine ceases to be a trustworthy and ethical profession; without it, all of us will suffer—yes, more than we suffer now because some of us die too slowly.
The doctor–patient relationship will be damaged. The patient’s trust in the doctor’s devotion to the patient’s best interests will be hard to sustain once doctors can legally prescribe death. Even conscientious physicians will have trouble caring wholeheartedly for patients once death becomes a “therapeutic option.” The prohibition against killing patients, medicine’s first principle of ethical self-restraint, recognizes that no physician devoted to the benefit of the sick can serve the patient by making him dead. The physician-suicide-assistant or physician-euthanizer is a deadly self-contradiction.
Physician-assisted suicide, once legal, will not stay confined to the terminally ill and mentally competent who freely and knowingly elect it for themselves. Requests will be engineered and choices manipulated by those who control the information, and, manipulation aside, many elderly and incurable people will experience a right to choose death as their duty to do so. Moreover, the vast majority of those who are said to “merit” “a humane and dignified death” do not fall in this category and cannot request it for themselves. Persons with mental illness or Alzheimer’s disease, deformed infants, and retarded or dying children would thus be denied our new humane “aid-in-dying.” But not to worry. The lawyers, encouraged by the cost-containers, will sue to rectify this inequity. Why, they will argue, should the comatose or the demented be denied a right to assisted suicide just because they cannot claim it for themselves? With court-appointed proxy consentors, we will quickly erase the distinction between the right to choose one’s own death and the right to request someone else’s.
The termination of lives someone else thinks are no longer worth living is now occurring on a large scale in Holland, where assisted suicide and euthanasia have been practiced by physicians for more than a decade, under “safeguards” more stringent than those enacted in the Oregon law. According to the Dutch government’s own alarming figures, there are over one thousand cases per year of direct in voluntary euthanasia; also 8,100 cases of morphine overdosage intending to terminate life, 61 percent without the patient’s consent. Although the guidelines insist that choosing death must be informed and voluntary, over 40 percent of Dutch physicians have performed involuntary euthanasia. As the Dutch have shown, the practice of assisted suicide is in principle unregulable, because it is cloaked in the privacy of the doctor–patient relationship.
Legalizing assisted suicide would mark a drastic change in the social and political order. The state would be surrendering its monopoly on the legal use of lethal force, a monopoly it holds under the social contract, a monopoly it needs if it is to protect innocent life, its first responsibility. It should surprise no one if physicians, once they are exempted from the ban on the private use of lethal force, wind up killing without restraint. Here, by the way, is a genuine violation of the Fourteenth Amendment: deprivation of life without due process of law.
We must care for the dying, not make them dead. By accepting mortality yet knowing that we will not kill, doctors can focus on enhancing the lives of those who are dying, with relief of pain and discomfort, moral and social support, and, when appropriate, the removal of technical interventions that are merely useless or degrading additions to the burdens of dying—including, frequently, hospitalization itself. Doctors must not intentionally kill, or help to kill, but they may allow a patient to die.
Ceasing medical intervention, allowing nature to take its course, differs fundamentally from assisting suicide and active euthanasia. Not the physician, but the underlying fatal illness becomes the true cause of death. More important morally, in ceasing treatment the physician does not intend the death of the patient, even if death follows as a result. Rather, he seeks to avoid useless and degrading medical additions to the already sad end of a life. In contrast, in assisted suicide the physician necessarily intends primarily that the patient be made dead.
One cannot exaggerate the importance of the distinction between withholding or withdrawing treatment and directly killing, a distinction foolishly dismissed in the recent Court of Appeals’ decisions. Both as a matter of law and as a matter of medical ethics, the right to refuse unwanted medical intervention is properly seen not as part of a right to become dead but rather as part of a right protecting how we choose to live, even while we are dying.
Once we refuse the technical fix, physicians and the rest of us can also rise to the occasion: we can learn to act humanly in the presence of finitude. Far more than adequate morphine and the removal of burdensome chemotherapy, the dying need our presence and our encouragement. Withdrawal of human contact, affection, and care is the greatest single cause of the dehumanization of dying. People who care for autonomy and dignity should try to correct this dehumanization of the end of life, instead of giving dehumanization its final triumph by welcoming the desperate good-bye-to-all-that contained in one final plea for poison. Not the alleged humaneness of an elixir of death, but the humanness of connected living-while-dying is what medicine—and the rest of us—most owe the dying. The treatment of choice is and always will be company and care.
Leon R. Kass, M.D. is Addie Clark Harding Professor in The College and The Committee on Social Thought at The University of Chicago. An earlier version of these remarks was presented by Dr. Kass to the Oversight Hearing on Assisted Suicide, Subcommittee on the Constitution, The Judiciary Committee, The U.S. House of Representatives.