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In the instance of Missouri's approach to ries :=substituted judgment, only the people of that state have the nit. , 1991, p 379. -38.  ? 9 Vol. 20, No. 5, September/October 1990, pp 7-8. ?/צAuthor:Charles Baronhi饀!.[G&TEXT Abstract:gh advanced medicine, the trials of dying in this modern C The United States6 ON TAKING SUBSTITUTED JUDGMENT SERIOUSLY KILL ,C:[.,( Charles Baron No. 5, September/October - Hastings Center Report, VAL14.TXTr f1EUTH2{ EUTH06.TXT f1v< EUTH07.TXT f1v<Y EUTH08.TXT f1vY EUTH09.TXT f1v EUTH10.TXT@`v EUTH11.TXT f1v EUTH12.TXT f1v EUTH13.TXT f1vEUTH14.TXT f1+`FG8`0($ p,&" COPYRIGHT APPLE COMPUTER, INC., 1984, 1985 C.LEUNGh&Y&&Y& 꽌ɪ\8`&&꽌ɪɖ'*&%&,E'зЮ꽌ɪФ`+*xH&x'8*7Ixix&&    ') +!  &п  x) +莶莸L莸LNO FILE SYSTEM.APPLE SYSTEM.APPLEJ) (jJJ>Lx "?I  `  C x Nx G .x- `V0^*^*>` aI꽌ɪVɭ*authority to vote for a change in the law.s. If physicians and 񄓡9 The United States Supreme Court does not rule on the wisdom צ*of state laws, rather it passes judgment where state laws e the TEXA I am a long-time advocate of patients' rights in general and צ?the right to die in particular, but I believe the U.S. Supreme  Missouri's approach to substituted judgment unconstitutional. to chews constantly, and gags often on hrt to have overturned the Missouri requirement as Aunconstitutional, it would have had to find that the measure had =been motivated by an illegitimate state purpose, or that the ce Bstate purpose it advanced and the reasons for advancing it byrely saying it was I am d Ä;permissible for Missouri (or any other state) to make that for h W/requirement part of its law - if it wanted to. collected 223,000 (ʅ Sometimes people ask me about my visiting Chris. Walking n A For the Couas ٕ:saying only that it did not find the requirement to be in for l d ?conflict with the Constitution or other valid federal law. It d lisAwas not approving of the requirement or imposing it on all those ":states that have not adopted it, but meas only the power to strike down state laws that =conflict with federal law, including the U.S. Constitution. eak 6AThus, when the Court refused to invalidate Missouri's "clear and Bconvincing evidence" requirement for substituted judgment, it wt took the real Chris an A The U.S. Supreme Court does not sit as a "super legislature" G?over the states. It has no authority to rule on the wisdom of r Astate laws or general power to promulgate uniform rules of state Blaw. The Court hAto kidnap Nancy and spirit her away to a place where she can die ܾBin peace. The Court, in my opinion, did not have legal authority $to do what the Cruzans asked of it. ld like to see her body on n finally at peace. The automobile acciden my immediate family three times in the last XT>five years. My heart goes out to the Cruzan family. But the e e Tex=Court's unwillingness to overturn Missouri law is no more to , צN@blame for the Cruzans' plight than is your and my unwillingness e of a clear and convincing her ?standard, but at times required it. Similarly, denying family @members a general power to make death decisions for patients is VBarguably more protective of patient liberty than less. Reasoning tedAbackward to approval of family decisionmaking from the fact that everyone in our neighborhood knows who committed a partinciples of self-government, to impose on >others our view of today's medical-ethical orthodoxy. If the s, @voters of Missouri decide their state's approach is not working ?for them, they have ample power to reject it for a better one. n th data as to t ;which legal approaches work and which do not. Those of us e nly ?concerned with the right to die ought to welcome the chance to ?develop and learn from that data. We ought not to attempt, by Ameans that undermine prtruggled to preserve for the states their constitutional power r >to seek justice according to their own lights. The Court has me 7even suggested there is value in viewing the states as ir t ng a ="laboratories of jurisprudence" providing us wiinding unconstitutional, for example, ?minimum wage and maximum hour legislation that conflicted with . >the Court's own notions of "liberty of contract." The modern d, BCourt, reacting to the counter-democratic abuses of that era, has @sind it cal staff -8-=unconstitutional. Not even to help the Cruzan family and to ould Bprotect the right to die would I return us to the not-so-long-ago Adays when a runaway Supreme Court regularly imposed its politics ?on state legislatures - ftheir most minimal form. h this 'life' on their worst enemy." So, how can he and the Supreme Court judge in this fashion? ly t > But as disturbed as I think we should be about the use of e t 8substituted judgment here, it would be wrong to fally to be the basis for decisions. o Vercould lead to abuse of substituted judgment in contexts where @patient preference ought rehat everyone ought to be upset about is that virtually all ?of our states (including Missouri) have not adopted rules that e ve t@openly and honestly apply the objective criteria really driving ;decisions in PVS cases. Pretextual use of the subs death over PVS. Or families are . P(>empowered to express patient preferences for death - with few P, K, questions asked. family's guidance, and knowing Nancy from her X(amvisits he would have withdrawn the feeding tube long ago. aith, @ Wetend that r צAwe are merely complying (however reluctantly) with the wishes of  :?the patient. The result in most states is mere lip service to @substituted judgment: Almost any evidence is deemed sufficient R?to establish a preference forng all this effort and money?" But the extreme discomfort ?of making death decisions for other people and our fear of the e צ@slippery slope ("Will we next decide that those born profoundly ward@retarded should be starved to death?") leads us to prusly. What actually drives death lock9decisions in PVS cases is an objective test based on the t see ing @convergence of "best interests" and economic criteria. "No one  >would really want to go on like this, so what is the point of r "Bexpendiicular s, crime. y...yet my thoughts are those of seeing her year after use year in this vegetative condition. . For a doctor to take from a ̂eA What upsets critics of Cruzan is that Missouri has taken the Asubstituted judgment test serioSt. Charles, MO. e National Hemlock Society - we have changed the face of the Death with Dignity debate forever, not only in this About the Author: ide. Despite the intense political conflict, < Charles Baron is professor of law at Boston College Law s School, Newton Centre, MA. s reserved. The campaign effectively articulated the tragic plight of the terminally ill. We have no regrets. al hundred individuals and organizations have already a active in the field of medical humanities and medical ethics, to @both in Holland and in the U.S. In aFenigsen, a Dutch cardiologist who renounced his >membership in the Royal Dutch Society of Medicine on June 24, ad <1984, the day the Society's board endorsed euthanasia. Dr. ce ;Fenigsen retired from his work (retirement is mandatory in byrely saying it was I am d Äpermissible for Missouri (or any other state) to make that for h W< What can Americans learn from Holland's experience with ,000 (ʅ@euthanasia? In search of the answer to this question, I turned @to Dr. Richard s ٕ@an "aid-in-dying" initiative effort failed in 1988), Oregon and d AFlorida. On previous occasions, Humphry, has expressed the hope lis?that America will follow the lead of Holland, where euthanasia e ""has become a common way of death. ut mea report in the May 18, 1990 issue of American t @Medical News, Derek Humphry, executive director of the National k 6@Hemlock Society, has said that the society hopes to see similar @proposals pass during the next three years in California (whereation, and, of course, n >Hemlock of Washington, a lobbying arm of the National Hemlock e" G Society. states. It has no authority to rule on the wisdom of r state laws or general power to promulgate uniform rules of state @ According to Awith Dignity, a coalition of pro-euthanasia groups including the ܾ As I write, voters in Washington State are being asked to  ALL About Issues, Vol. 13, No. 1, Winterpermission. Copyright (C) 1990 by The law 'Hastings Center. All rights reserved. as always honest, ctors to straightforward, scrupulously ethical, and consistently noble. to ddition to numerous papers &@and two books pertaining to cardiological subjects and internal Bdisease, he has authored an essay on the ethical and intellectual áBcosts of modernization in medicine (1964), and eight papers and a Bbook (1987) on subjects pertaining to the philosophy of medicine, euthanasia and medical ethics. are in PVS. But so do those g ign states that do not require clear and convincing evidence for ," > In June, Dr. Fenigsen responded to my many questions wially to be the basis for decisions. o Ver@ To my knowledge, euthanasia is not performed at present in ersAcases of Alzheimer's disease or other dementia. This situation, &?however, may change in the future as there is a certain public @pree candidates mes nurses without the involvement ofeuthanasia is accepted by 76% of the Dutch public, by >the largest professional medical association (The Royal Dutch in an BSociety of Medicine), the health authorities, and the judiciary. ?The law prohibiting euthanasia (article 293 of the Dutch ny PVS patients to be rooms. continued on life support are unconstitutionally burdensome but ndanAQ. What is the current status of euthanasia in The Netherlands? her sister Jill would laugh at my corny jokes. Whether times a AA. Active th s צb@answers which I hope will alert American citizens to the perils e me @inherent in accepting the notion that doctors should be allowed #to kill their patients on request. hinking that Missouri's such  :procedural safeguards that cause massure toward allowing euthanasia for "persons who are unable Bto make decisions and/or express their will," and the Royal Dutch ASociety of Medicine appointed a committee to work out guidelines :for euthanasia on demented and mentally retarded persons. l staff -8-unconstitutional. Not even to help the Cruzan family and to ould /Q. Is euthanasia always voluntary at present? he not-so-long-ago days when a runaway Supreme Court regularly imposed its politics 9A. Involuntary euthanasi they have shown the courage and dedication required to ares BA. It is our sad destiny to suffer and die. It is wrong to shun Athis truth, and to accuse instead those who bring relief as best Bthey can. In a hospital, the sick persn be widened, that patients with so little ely BQ. "Right to die" organizations claim that, in America, we treat @people "forever" without regard to their quality of life or the ;hopelessness of their condition. Can you comment on this? nly tion. That's why I am 7somewhat reluctant to discuss in length the "abuses of which ?euthanasia." Euthanasia, any euthanasia, is itself a terrible . abuse. t the law will eventually be changed, that mercy and - compassion ca @the media, and under the awesome pressure of social expectation Athat they quit the scene. Euthanasia, even "voluntary," is also Aan abuse of the doctor's calling, of human thinking and feeling, @and of the highest values of our civilizaasia in its "voluntary" form is an abuse of ?all those who submit their requests while weakened by disease, s 7under the influence of drugs, in a moment of transient ll sustain Bdepression, indoctrinated by the incessant propaganda of death inr knowledge - is a e Aterrible abuse of trust, of individual freedoms, of the right of ?choice, and of the fundamental human right: the right to life. e of Initiative 119. We must push ahead as soon as possible, while ? Finally, euthanB Much more important is the widespread practice of involuntary Aeuthanasia which, as the Dutch experience has shown, unavoidably @accompanies voluntary euthanasia. Involuntary euthanasia - the >medical killing of sick people without thein, entrusted with carrying out euthanasia, ;has its share of intellectual mediocrities and emotionally ors to unbalanced members. upulously ethical, and consistently noble. to Many terminal patients worked with us, and we lost many of them h t of impatience or ;in an outburst of anger. Occurrences such as these are an ively @unavoidable corollary of euthanasia because the availability of @unpunished killing attracts lowly motivated people, and because a @the medical professio?been published in Holland in which euthanasia turned out to be he >the result of criminal scheming, coercion of the patient by a s the motivation to do the utmost in investigating and treating a severely ill patients. from Amances in Great Britain and Canada, but are non-existent ?in Holland, where euthanasia is practiced instead. It is also ?true, that the practice of euthanasia adversely influences the y ;care of patients in general because, by offering "the ety becomes much more difficult @A. To some extent it is true that the acceptance of euthanasia =tends to diminish the efforts towards optimal pain control. BIndeed, the new perfected forms of palliative care are now making Aquick advhan in Reproduced 1992 with permission of the Humanist. Copyright (C) @Q. Do you think that allowing euthanasia will deter the search =for better methods of pain control and treatment of disease? whole concept of death with dignio with life, and much to do with death. It is used to Bmake arbitrary and wrongful decisions on behalf of other persons, @to hasten their deaths without asking them whether they cherish +their lives and what they themselves wish. long lasting ticable to all, cognizable by Aall, and allowing one person to determine the quality of life of Aanother; and that some lives, namely those of "low quality," are =not worth being lived. The concept of "quality of life" has Blittle to dcal e ?well-being, self-fulfillment, friendship and respect of peers, s. Areciprocated love and sense of belonging can all be expressed in 9a single dimension that can be measured; that this is an for @objective assessment, that is, appleading fear of doctors and hospitals. act, it is simply an affirmation of existing law) and that it would cost uch ; I reject the term "quality of life." This is a flawed true). ?concept based on several false assumptions: that joy, physi the patient die even a week @too soon, but they will refrain from acts that are senseless or ?inflict unnecessary suffering. The patient may and should ask s @questions, and he may refuse any treatment proposed. Little is 3gained by spre by 6experience, a human understanding, and common sense. tic recount BFortunately, most doctors fit this description. They may finally @not succeed, but they will certainly do their best to help, and Bnot to harm; they will try not to let Physicians' Association (NAV), with a membership of 1200, =is non-denominational. The Catholic bishops issued, several Ayears ago, a pastoral letter condemning euthanasia. A very well 7edited small-circulation Catholic newspaper, Katholiek The @Nieuwsblad, consistently opposes euthanasia. I am not aware of >the existence of any other organized Catholic anti-euthanasia groups. 6metastasized from beast to bone ended within an hour. luding the ܾAmerican Civil Liberties Union of Washington, Americans for ority @ Ten months later, Humphry was married again, to 33-year-old >American Ann Wickett. With her help, he ife of his cancer-stricken wife of 22 years, XT?Jean. At her request, he has always maintained, he gave her a e Tex;cup of coffee laced with secobarbital and codeine, and her o , צN6painful 2 1/2-year struggle with the disease that had for Death ly obvious irony of a צmade-for-television movie. ashington State are being asked to  consider Initiative 119, a measure that would legally allow e r @ In the spring of 1975, a British journalist, Derek Humphry, t @helped to end the lright-to-die empire. ate dignity was to determine their own he 񄓡9deaths. But his tightly knit Hemlock Society has unraveled om צ*somewhat since he left his second wife, Ann, after her breast e TEXA The tale has all the melodrama and overate dignity was to determine their own ide; f 0=deaths. But his tightly knit Hemlock Society has unraveled ct >somewhat since he left his second wife, Ann, after her breast ies :@cancer surgery, and questionable finances have threatened their . 90, pp 52-53. 4. 8.  ? Author:Charlotte Low Alleneptember/October 1990, pp 7-8. ?/צ Abstract: rles Baronhi饀!.[G&TEXT> Derek Humphry became a star in the business of persuading ern individuals in America can prevent legalization of euthanasia here? wrote a best-selling , n Cbook, "Jean's Way," narrating his part in his first wife's death. ?The book made him famous and even notorious, as police briefly r =considered a prosecution for assisting a suicide, a crime in ate >England as in 25 states. He and his second wife moved to Los n t BAngeles in 1978 and in 1980 founded the national Hemlock Society, 6=a nonprofit charitable organization devoted to promoting the ar Bconcept of assisted suicide ("self-deliverance" is Hemlock's na totals about $90,000, but l eath lock@observers say the amount at stake eventually could top $300,000 ng @if authorities broaden their audit. Hemlock's position is that t  Bthe funds were either loans or payments for mailing lists. After =some pr8. ar s, 9Federal law forbids the use of tax-deductible charitable s not se donations for lobbying. eat majority of cases, doctors who from a ̂eperform euthanasia do not state it as the cause of death on the : So far, the contested moneyock to affiliate entities, Americans Against Human that BSuffering and Hemlock Society of Oregon Inc., that have worked to @pass pro-euthanasia laws, most notably a failed effort to get a V;euthanasia initiative onto the California ballot in 198 a physician; a recent study er = The Internal Revenue Service and the California attorney ntly =general's office (Hemlock is incorporated in California) are nths VAinvestigating some questionable 1986 and 1987 transfers of money tedcancer. On Sept. 22, she underwent surgery that included the l =removal of most of her left breast and left her facing a six-tual á@month regimen of chemotherapy and radiation. On Oct. 13, after a Ban uncomforta the  Anewspaper op-ed pages, lobbing barbs at fundamentalist churches, ʅ5right-to-life groups and other euthanasia opponents. but remains active in the field of medical humanities and medical ethics, to > But last Sept. 14, Ann too was diys moved to a 50-acre ranch near Eugene, Ore., and Athe society, by then nearly a $1 million-a-year operation, moved ?along with them. The articulate, saturninely handsome Humphry >became a standard feature on talk shows, lecture circuits andhow to hoard prescription Ä@drugs for one's own self-deliverance (several dozen barbiturate h WAcapsules with an alcohol chaser works best, the book suggests). (ʅ?The ranks of the Hemlock Society swelled to 30,000. Two years Bago, the Humphrme ٕ!for it) for the terminally ill. rt failed in 1988), Oregon and d Florida. On previous occasions, Humphry, has expressed the hope lis@ Another Humphry best-seller followed. "Let Me Die Before I "AWake" contained explicit directions on odding from the California attorney general's office, ases BHemlock has arranged for the repayment of funds with interest and ,is prepared to hand over the mailing lists. n Holland is due to wardactive euthanasia. starved to death?") leads us to pretend that r צ@ "These are technical violations," says Hemlock attorney Lee  :@Kersten. But Henry Brod, a psychologist who was a board member s Hemlock's board voted to continue paying her medical expenses ly Bplus a $1,250 monthly disability stipend in lieu of salary for at least six months. sick people without theiher receipt of further salary and benefits ?on her agreement not to talk about Hemlock to the public. She to @refused to sign. Kersten says there was never any intention to o Acut off benefits and the language was merely a way to ensure the in November to a r ?reporter from a Sacramento, Calif., newspaper, Kersten (who is y =also representing Derek Humphry in the divorce case) sent to of ;Ann's lawyer a four-page "confidentiality agreement" whose ause a @language conditioned Athe break, she says, although his annual salary from Hemlock was #$65,000 and hers was only $18,000. ercion of the patient by a s spouse, coercion by the doctor, a nurse's error, a doctor's ct, > Soon after Ann Humphry gave an interview What do you say to that? t, to impose on = "Hemlock just turned against me," she says. "No one was s, ?willing to help me drive the 60 miles for radiation therapy or Beven send a card." Humphry has paid no support to his wife since , but Ann Humphry Asays he had no personal use for it, and she was left to haul hay Bby hand and feed 16 head of beef cattle and numerous farm animals 5Humphry had left, all while recovering from surgery. .S. say y there won't be abuses. ftermath. One of his first acts after moving to an apartment in @Eugene last October was to return to the ranch in the middle of Athe night and remove several pieces of farm equipment, including Aa large tractor. The equipment belonged to hima has been practiced along with mple, ? Hemlock insiders are particularly upset with Ann Humphry's @willingness to talk to the media about the couple's split - and , >about what seems like bizarre behavior on Derek's part in its led Baage Hemlock and -8-Aits work," says Don Shaw, a former Episcopal priest and abortion >clinic director in Illinois who is a Hemlock board member and ago vice president. way Supreme Court regularly imposed its politics A. Involuntary euthanasird. With the exception of Brod and his wife, all seem to have Bcircled their wagons around him, displaying a distinctly negative @attitude toward Ann. "We all feel very sympathetic toward what Ashe's going through, but she's been trying to damry's show," says Brod. "He's had sole Ver?authority over the money. The treasurer was treasurer in name ersBonly. In fact, Ann was the treasurer for some time." If Hemlock &Bis Humphry's show, he certainly has maintained the loyalty of his Bboafficer, ates mes Bexecutive director and board member of the national society. (He $!is now executive director only.) of patients with AIDS in t to  Holland were due to active euthanasia. ment in contexts where B "Hemlock is Derek Humphout of national funds. (Humphry says the money was payment :for services Brod rendered to the national group.) Until that e ve t7January, when the national board conducted a personnel driving ;reorganization, Humphry served as chief executive oys Humphry made a regular practice . P(nieces a full statement that you committed a crime in helping ain your parents to die." ted by the incessant propaganda of death insociety members make a point of Anot counseling people on how or whether to end their lives. But practically the only expressions of sympathy she has received ) since her cancer diagnosis. ng euthanasia will deter the search for better methods of pain control and treatment of disease? A To avoid criminal liability, frequent debate opponent of Derek Humphry. "I have a =great deal of respect for Ann," says Marker, who lectures on ons, Bethics at the University of Steubenville, Ohio. Ann Humphry says =that letters from right-to-lifers wishing her well have bicable to all, cognizable by ? Strangely enough, Ann Humphry, while not changing her mind f >about the desirability of assisted suicide for the terminally re Bill, has befriended Rita Marker, head of the Anti-Euthanasia Task BForce and aect. ="Ultimately, we'll decide as a society in favor of voluntary , s. @euthanasia," says Garbesi. "All the polls show people agreeing with our position." hat can be measured; that this is an for objective assessment, that is, appleading fear of doctors and hospitals. act, it is ; The case of accident victim Nancy Cruzan, in which the st uch ;Supreme Court is deciding whether her parents can remove a true). Afeeding tube, also has focused public attention on the subjrowth of the right-to-die ek ?movement, although such groups as the Society for the Right to ADie merely advocate so-called passive euthanasia - removing life )support - rather than active euthanasia. t proposed. Little is gained by spr by 4middle age or older, but since the rise of acquired tic recount ;immunodeficiency syndrome and the idea of suicide for AIDS inally Apatients, there has been an influx of younger male members. The ?society also has benefited from the gher, terminally ill with cancer, deliberately Act 0starve herself to death when he was a teenager. al thing for a patient in any medical situation is to be in good hands. A good > Until recently, the typical Hemlock member was a woman oflaw professor at Loyola en BMarymount University in Los Angeles, who believes in suicide as a ?legal right. Many more have stories like the Humphrys'. Brod ve =helped his cancer-stricken first wife kill herself, and Shaw ng =watched his mot@ The Humphry's close involvement in the suicides goes a long =way toward explaining why there is a Hemlock Society. A few shun BHemlock higher-ups joined strictly for intellectual reasons, such ?as former board member Curt Garbesi, a mphry has since declared he did not mean what he Asaid on the tape and that he was merely expressing his anger and -distress over the breakdown of his marriage. ity of life or the hopelessness of their condition. Can you comment on this? nly ide in 1986. Both am Bwanted to die, she says, and she wrote a fictionalized account of ?their deaths in a 1988 Hemlock-published book, "Double Exit." . ANonetheless, her family was deeply divided over the propriety of Bthe suicides. Hu the media, and under the awesome pressure of social expectation B That was a reference to the role Ann - and Derek as well, she @says - played in helping her 92-year-old father and 80-year-old end it. Julie Horvath, a onetime friend of both Humphrys who @dropped out of Hemlock after Derek left his wife, says: "These >are people who are very high-minded when it comes to deciding Bwhat the fate of other people should be, but they've never really Ahad to deal with it themselves. I used to be very much in favor :of this right, but I've come to see that when it comes to ing a Aeuthanizing someone, there's a he e  =leaders of the right-to-die movement - a loose federation of es, ʅ@several organizations that advocate the legalization of passive Bor active euthanasia - the Cruzan case is an important landmark. =If the Court finds a constitutional rys moved to a 50-acre ranch near Eugene, Ore., and B The Cruzan family and the community of legal scholars are not Athe only ones anxiously awaiting the Supreme Court's decision in @Cruzan v. Harmon, which is expected early this summer. For ting Nancy and her family Ä=to continued limbo. In their appeal, the Cruzans argue that te h WBtheir constitutional rights to privacy and to equal protection of (ʅ4the laws should prevent the state from intervening. Two years ago, the Humphrme ٕ When the hospital administration refused their request to ty, 6Bterminate her feeding, Nancy's parents turned to a county probate >court, which authorized the withdrawal of life support. Upon ae and by Missouri's , n Ataxpayers, who pay $130,000 a year to keep her "alive." She has Ano hope for recovery and could continue to "live" for another 30 years. red a prosecution for assisting a suicide, a crime in ate England as in 25 =accident in 1983. All physiological evidence indicates that the ܾ@Nancy has no thoughts, sensations, or emotions. If not for her y @artificial life support, she would have died, mercifully, years =ago. Nancy is supported by a feeding tubife of his cancer-stricken wife of 22 years, XT@ Nancy herself has been in oblivion for the last six years. e TexAShe lies comatose in a state hospital in a persistent vegetative צN:condition never having regained consciousness since a car Death ograms and talk shows, צ?she was a short-lived media phenomenon. But after December 6,  Bthe day the Supreme Court heard arguments in the case bearing her 'name, her story slipped into oblivion. urnalist, Derek Humphry, t helped to end the lAbstract:die empire. ate dignity was to determine their own he 񄓡9; Nancy Cruzan, a 32-year-old Missouri woman, had her 15 e, the *this, its first euthanasia case, it will vindicate their past l Aactions and confirm their convictions. December 6 was their day áin court as well. hemotherapy and radiation. On Oct. 13, after a an uncomfortable three weeks, Humphry left on a business trip and ? Ending Nancy's misery, and that of her family, would be an gn Aexample of "passive" euthanasia, which involves disconnecting or ?withdrawing artificial life-support systems, including feedthe heart. Or all of the above. sole Verauthority over the money. The treasurer was treasurer in name ers@ Karen Anne Quinlan's limbo made the utility of living wills k &@obvious. Large numbers of Americans became aware of her plight s Aand my dying." mes ?In the wills, people can also enumerate extraordinary measures He $Athey wish to forgo should they become incompetent - for example,  =artificial life support, respirators, tube feeding, unwanted But such documents were not legal in 1975. After the Quinlan ate :trial had no way צ?of knowing if an incompetent like Karen Anne Quinlan (or Nancy  :+Cruzan) wanted the treatment disconnected. o was a board member s of the Oregon chapter of Hemlock until Humphry demanded his ent R; A living will, a documentstion of consent. Sentient patients can refuse medical es Atreatment or order it withdrawn under almost any circumstances. @This is a right long established by a succession of precedents wardAin both common and constitutional law. But the court totals about $90,000, but l eath lockobservers say the amount at stake eventually could top $300,000 ng B The conundrum in the sensationalized Quinlan case, as well as  Ain many less publicized cases decided by other state courts, was ?the quepreme s, a similar fate. In the 18 months following the first Quinlan ive @trial, the Euthanasia Society of America and its affiliate, the ?Euthanasia Educational Council, received 1.25 million requests d -8-?for living wills. Between 1969 and 1975, they had distributed n about 750,000. in Illinois who is a Hemlock board member and ago vice president. way Supreme Court regularly imposed its politics @ Riding the wave of puBtransfers the decisionmaking powers of an incompetent person to a Aspecified party, now covers medial decisions in 31 states and in Aabout a dozen states specifically includes the right to withdraw >life-supporting treatment. The first smphry has since declared he did not mean what he = Another legal device for passive euthanasia that the SRD and ?advocates is extending durable power-of-attorney provisions to 9medical decisions. The durable power of attorney, which ? nly atives or taxpayers to =maintain a permanently comatose patient indefinitely. While t of ;living wills are no panacea, they can help to prevent such ." . situations from arising. as deeply divided over the propriety of the suicides. Hu ?life support once it is clear that the patient will not regain =consciousness. This may require a modification in the legal she @definition of death. Certainly we must reject the premise that @the state may properly require either rel He told her that if she continued "this of B Given this reluctance, there will continue to be Quinlans and The Society for the Right to Die, which has about 150,000 @members, now views living wills as its raison d'etre. Over the e s, and living hry Bwills are currently valid, in various forms, in 40 states and the @District of Columbia. In addition to giving living wills legal s Bforce, the statutes shield physicians who execute them from civil and criminal liability.egislative action almost immediately. In 1975 lone, 15 right-in Bto-die bills were introduced in state legislatures. And in 1976, ACalifornia enacted the first living-will statute, the California =Natural Death Act. Success has followed succesblic indignation and attention aroused @by the Quinlan case, the Euthanasia Society changed its name to Hemlock Society advocates "ratieliverance" that describes in explicit detail how n, not =several terminally ill people have ended their lives. These @publications, however, are not sold to the general public; they Aare available only to Hemlock Society members "for possovides information on how nt of =terminally ill people can commit suicide. It has produced a But Bchart of 18 different drugs and their respective lethal dosages. AAnd in 1981 Humphry published Let Me Die Before I Wake, a "guide ;to self-deen in B The Hemlock Society's professed primary goal is to "promote a ?climate of opinion that would tolerate the right of people who medication for his cancer-stricken wife, Jean, who was in her g Blast, excruciating days. In 1978, after publishing Jean's Way, a ?moving account describing his wife'ving wills can prevent misguided hospital officials >from prohibiting passive euthanasia in certain circumstances. uch Supreme Court is deciding whether her parents can remove a true). < Derek Humphry's involvement in the movement grew out ofto exclude other rights, ek Bwhen in fact the right to refuse treatment in inalienable. "Just Abecause a law exists or doesn't exist, doesn't mean people don't medical treatment can be interpreted e organizations; the SRD's Rouse described the relationship as "peaceful coexistence." Catholic bishops issued, several years ago, a pastoral letter condemning euthanasia. A very well B In nine years, the Hemlock Society has grown from 3 to 30,000 Bmembers. Run out of its national headquarters in Eugene, Oregon, Bit now includes 51 local chapters that conduct briefings, produce Avideos, and publish newsletters. At first, the Hemlock Society, ?like Concern, eschewed legi>"create a climate of opinion" - a phrase all the right-to-die ;leaders use - conducive to the practice of euthanasia. By >discouraging legal complaints and prosecution, such a climate ;would protect the right to die even when tors and judges to ensure dignified deaths may ?not be wise. As the SRD's Rouse says, "Laws don't always mesh :with reality." It would be impossible to make a law that ?provides for every medical possibility. The alternative is to rt will rule for the &Cruzans on narrow procedural grounds. A Even if the court were to issue a broad decision, relying on Benlightened legisla@passive euthanasia would also encourage legal protection of the ?practice in states where none exists. But the Rehnquist Court >has displayed little proclivity for broad decisions upholding @individual liberties. More likely, the Couurt decision articulating a constitutional @right to die and granting families the authority to remove life @support from hopelessly comatose relatives would prevent future =Nancy Cruzan scenarios. An unambiguous judicial sanction of gain by hanging on illnesses, life is a constant burden. And for those who feel Athey and their families truly have nothing tobehind the rest of this legislation is ?compelling. Competent people can make living wills requesting =that their lives not be prolonged artificially when they are can Bincompetent and feeling no pain. It only follows that people can on made in a he &moment of desperation and depression. patient advocacy, educational and legislative action organization headquartered in 6 While the six-month deadline was admittedly drawn >arbitrarily, the logic ll. But under the proposed law, those who had not done so prior Ato the terminal diagnosis could, after two weeks, make a similar Bwritten directive. Humphry says these safeguards ensure that any the patient must recertify in writing his or her wish to die, to that request active euthanasia under certain conditions: The i-Bpatient must suffer from a terminal disease and in all likelihood Bhave no more than six months to live, and at leasslation. But now the chapters take ?active political roles in in trying to enact the society's pet 2piece of legislation: the Death with Dignity Act. euthanasia here? B the law does not. A With regard to passive euthanasia, this is a done deal. The Bvast majority of doctors and hospital officials don't hesitate to Bwithdraw life support from patients who appear to be in permanent ?comas. The wrath that Missouri has incurred from the medical, Alegal, and religious communities over the Cruzan case shows just 7how strongly a wide spectrum of opinion favors passive dpoint the Missouri Supreme Court made the 0@appropriate decision when it refused to allow the withdrawal of Benough to stop this artificial treatment." These statements were >summarized in the testimony of Nancy's roommate to the effect ;that she "would not want to continue her present condition tomobile accident regarding &Alife-sustaining treatment did not constitute informed refusal of care.   Y0N "á צצצ ? Her paren<ƃצ 9clear understanding of the nature of the disease and its , ƃʅAprognosis. Since, under hypothetical circumstances, neither the "Abenefits nor the risks of treatment can be properly weighed, any Astatements Nancy made prior to her aunomy of each person to make decisions relating to /@his or her health and welfare. Informed consent requires: that Athe patient have the capacity to reason and make judgments; that =the decision be voluntary and uncoerced; and that there be a nt. צ Ä - %̅,ړצListƅ-~$ʅ.áW; The requirement that a competent patient give informed ̅)ʅ(ʅAconsent before treatment is based upon the law's respect for the Aindividual auton, ٕ?the question must be whether she expressed her wishes prior to dramatically...when it held that because Nancy is permanently V Aunconscious, she has lost the constitutional right...to have her V=family or another surrogate decisionmaker participate iity to digest nutrients (persons with Acystic fibrosis, liver disease, cancers of the stomach, liver or Apancreas); an impaired ability to absorb nutrients (persons with =gastrointestinal side effects of cancer therapy, short bowel feeding by tube: :persons with an impaired ability to ingest nutrients (for @example, persons with Alzheimer's disease, stroke, head injury, =or those who are comatose or have various cancers of head or =neck); an impaired abilTHE WARD'S BEST INTERESTS @ Four general categories of persons require guardianship statute and the guardian's Bduty to act in her best interest. This is true except when death is imminent. y to supervise &-8-Aguardians to insure that the guardians act in the best interests Bof their wards. Since feeding Nancy is necessary to preserve her ;life, it can hardly be disputed that continuing feeding is Arequired by the Missouri t are needed" and "promot[ing] and protect[ing] the care, 0צ Bcomfort, safety, health, and welfare of the ward." In exercising >this authority, the guardian is the "delegatee of the state's .@parents patriae power," but courts retain the dut@ˡ}צ&Ver? Under Missouri law, guardians are required "to provide for 3 vers@the ward's care, treatment...support and maintenance" including &Ainsuring that the ward "receives medical care and other services =thathermore, even es Aif Nancy's parents had rights over her as her parents, these may $Bonly be exercised in her best interests. The central issue them,  :is whether feeding Nancy Cruzan is in her best interests. h0=OXnted guardians of Nancy Cruzan under Missouri law, Nancy's Cparents are required to "act in the best interest" of their ward. t?At this point, therefore, both Supreme Court precedent and the Bduties of a guardian under Missouri law merge. Furstead that the personal liberties ate P(Benjoyed by those incapable of making their own decisions may only K, Bbe "meaningful" when "exercised by agents with the best interests (amBof their principal in mind" (emphasis added). Moreover, as state @appoi  צA The U.S. Supreme Court has never held that the rights of one  :@person are wholly transferrable to a surrogate, by operation of Bconstitutional law, when the person is herself unable to exercise ?them. The Court has ruled innt decisions cannot be derived from their relationship to occurred. Thus, the parents' right to participate in medical "Atreatmen her Bmedical treatment decisions..." That is, the Cruzans' attempt to Cclaim authority over Nancy as both her parents and her guardians. eAIt is clear, however, that they have no authority over Nancy "as Aher parents." Parents do have ?syndrome, malabsorptive disorders, Crohn's disease, enteritis, @ulcerative colitis, cancers involving the small or large bowel, Band radiation enteritis); and persons with other impairments such surrogate decisionmakers - authoritused without excessive pain or inconvenience. This Acommon law duty required the physician to provide her care, even @if she could not consent to it. Thus, the family's consent was Bnot legally required and does not confer a legal right to rancy was under the care of a Bphysician who had a common law duty to utilize the ordinary means >of providing treatment generally employed by other physicians :that offers a reasonable hope of benefit, and that can be Aobtained and Bgastrostomy tube was legally irrelevant. At that time, Nancy was ?a married adult and her husband consented to the gastrostomy. AFurthermore, the husband's consent was also legally irrelevant. BAt the time the tube was implanted, Naw treatment to which they originally had the power to consent." > In fact, the family's consent to the placement of Nancy's exempt themselves from >this legal obligation. Their first claim is polemical rather >than legal. After noting that they consented to tube feeding >originally, Nancy's parents contend that they "retain[ed] the =power to withdrA QUALITY OF LIFE EXEMPTION? ? Nancy's guardians, however, seek toding Nancy Cruzan is in her best interest. The =legal obligations Nancy's guardians assumed under Missouri's ,guardianship laws require them to feed her. total cost of her care, Feeding by tube is also not economically burdensome. The cording to expert @witnesses called by Nancy's guardians, Nancy would feel no pain @even if she were allowed to die by starvation and dehydration. BThus, the Missouri court concluded that "it is difficult to argue :with any convictionfeedings at home. @ Furthermore, feeding by tube is not physically burdensome. =This is certainly true in Nancy's case. Ac feeding is necessary to preserve the lives curiae brief filed with the U.S. Supreme Court in Cruzan, the ?Association for Retarded Citizens of the U.S., the Association ?for Persons with Severe Handicaps, and other disability rights @groups supported the Missarding their treatment and care. > The implications of quality of life decisionmaking deeply >disturb advocates for persons with disabilities. estimated 1.5 million Americans have >severe dementia, a population expected to increase 60% by the Byear 2000, and 7.5 million persons with mental retardation. Many @of these persons, like Nancy, are incapable of making decisions $reghandicaps @(who) might find the states seeking to terminate their lives." @The population at risk is enormous. It is estimated that there >are 10,000 people in the U.S. in a condition similar to Nancy @Cruzan's. In addition, an ty of life assessments is the most important holding of the AMissouri Supreme Court. The court was clearly influenced by the ?fact that they were deciding the case "not only for Nancy, but =for many, many others...persons with all manner of ents are beneficial to the patient Bto whether patient's lives are beneficial to them. As one critic ?has observed, it leads us to believe that "if we cannot cure," Athen there is "little point to continue care." The rejection of Aqualis. Thus the @claim that because Nancy will not recover she should not be fed B"is but a thinly disguised statement that her life in its present Bform is not worth living." Using "recovery" as a standard shifts @the issue from whether treatmuality of life assessment is implicit when recovery is Aadopted as the standard to determine when food and fluids should Abe provided a patient. Food and fluids only maintain life; they Bdo not treat an illness or restore damaged brain cello person or court should Bsubstitute its judgment as to what would be an acceptable quality of life for another." > A qnd death." >Recognition that surrogate decisionmaking inherently involves Bquestions of quality of life led to its rejection by the New York @Court of Appeals since "it is inconsistent with our fundamental 8commitment to the notion that nuri Supreme Court. The court held that this is "a case >in which we are asked to allow the medical profession to make ANancy die by starvation and dehydration. The debate here is not Cbetween life and death; it is between quality of life ased on their view of her quality of life. B That this is the crux of the matter was readily recognized by Athe Misso choice :their loved one would make." What they seek to end is an @"artificial existence" of "being preserved on machines," as the Aguardians describe providing food through a tube - that is, they Bseek to choose death for Nancy batate's interest in preserving life must diminish as "quality of =life" declines "plainly suggests a constitutionally imposed, ?sliding-scale standard of treatment and care that devalues the Alives and well-being of persons with disabilities and others who (fail some notion of 'quality control.'" : Other state supreme courts have rejected requests for ?withholding food and wacourts until a satisfactory resolution is achieved. tes that the ܾB Our response to the needs of disabled people is shifting from Aenhancing their lives to ending their lives. In this new social Bclimate, ethical barriers are being battebut we are learning that its timing can be al XT>arranged, not just for ourselves, but for others. Especially we Tex@others. Those poor disabled people shouldn't have to live like צNthat. How sad. n, these issues will continue to plague the eath ut hey, why think of , צabout such gloomy stuff. the United States Supreme Court will,  Reproduced 1992.me, decide whether a guardian has a ng through a = Now the social climate has changed. Not only is death a ion >fashionable topic, community could be counted on to support the rights of disabled 񄓡9persons. Proponents of euthanasia have eroded medical ethics to *@ Death used to be a topic that people shied away from. They TEX=knew the grim reaper would come for them, bunted on to support the rights of disabled f 0Apersons. Proponents of euthanasia have eroded medical ethics to Terre Haute, IN, and president, National Legal Center for the s the choice Nancy's being cared for in Missouri Rehabilitation Center where Nanother state. Lacking "clear &;and convincing evidence" that Christine would want to die, al of =required by Missouri law, Peter wants to move her to a state day á=where there would be less opposition to removing her feeding er a ,tube. A rehersed  @a January 16 probate court ruling. The appeals court said that ʅ=St. Louis Probate Court Judge Louis M. Kohn did not consider the  ALL About Issues, Vol. 13, No. 2, Spring 1991, pp 28-32. /צAuthor:Mary Senanderr.饀!.[G&TEXT Abstract:ed to be that friends, family, courts and the medical he ; The Nazi atrociti, GAZING IN THE MIRROR: ZI GERMANY AND ,; EUTHANASIA IN NAZI GERMANY AND CONTEMPORARY AMERICA  Scholl Institute of Bioethics1, p 7.February ( Mary Senander Spriy to supervise -8-8Reproduced 1992 with permission. Copyright (C) 1991 by nterests "International Life Services, Inc. cy is necessary to preserve her barism" will be in place and disabled persons will no longer be among us. ty, health, and welfare of the ward." In exercising this authority, the guardian is the "delegatee of the state's e parents patriae power," but courts retain the dutthe heart. Or all of the above. sole VerB But prevailing medical ethics are being eroded, and no one is ers?minding the store as laws that should protect disabled persons k &;are being undermined. Before we realize it, "that kind of vices @barr feeding tube es Bwould be, literally, to starve and dehydrate her to death because $?of her disability. That kind of barbarism is not supported by m,  6prevailing medical ethics or by the laws of the U.S." ts. ed operations, jump starts of nted guardians of Nancy Cruzan under Missouri law, Nancy's ? A number of disability groups are fighting for Christine's d. tBright to receive food and water. Edward R. Grant, vice president Bof Americans United for Life, stated, "To remove hee food by mouth, laughs, can signal P(9for food, and even indicate what soap opera she wants on may only K, Atelevision. That she responds appropriately is substantiated by (am8a 13-minute video that was shown at a press conference. as state appoide that those whom they Bconsider "burdens" on social, economic or emotional systems would =be better off dead (or never born) - not only for their "own ger &good," but for the benefit of others. sicians be counted upon to protect and assist them. "Better dead than disabled," may well t B While there is a wide aversion to comparisons between pre-war 6:Nazi Germany and contemporary America, there are striking Since Aparallels in attitudes toward the weakest and most vulnerable ie that doctors were never ordered ck=to kill those with mental or physical impairments. Hitler's not g Bletter merely authorized the power to kill - and doctors began to  Bdo so, carefully and methodically, without fear of prosecution or  reprisa incurably Aill according to the most crucial evaluation of the state of the  disease." ority over Nancy as both her parents and her guardians. e In 1989, Dr. Cranford conducted a forty-five minute ancy "as A It is important to recogniz the basic structure of the Nazi program. rain-damaged persons and also that he has dehydrated patients "who were ly to = In 1939, Adolph Hitler directed that "mercy death may be her VBgranted to patients who according to human judgment areeuthanasia, has been highly s r A A fall 1933 proposal by the Ministry of Justice to authorize >euthanasia was widely reported (even in the U.S.). Religious S) VAoutcry temporarily derailed the idea, but, only six years later, ted3it becamef t. e 2: In 1933, a law requiring sterilization of those "with d y Bhereditary diseases" (but forbidding sterilization of any "normal person") was passed. ly. with the Humphry marriage. rformed by ,  Dr. Cranford, a proponent of magazines, newspapers and propaganda films began to to @manipulate public opinion, justifying euthanasia in the name of e an /"mercy" and for the good of the volk (people). Nancy Cruzan's parents, and Roland Cranford, a Minnesota neurologist. Ialue, was soon required r is " Breading for German law and medical students. One avid reader was anAdolph Hitler. "to let her body finally die." ntent to decline all medical treatment once incompetency set in, few nursing home ? Books, o the צb;tremendous economic burden of those with "impossibility of ited e me Bimprovement," adding that a policy of killing was consistent with ?medical ethics. Their influential best-seller, The Release of I  :;the Destruction of Life Devoid of Vtwo distinguished German professors skillfully re nd >argued for "death assistance" by direct medical killing. Law ere Bprofessor Karl Binding advocated a carefully controlled process. AAlfred Hoche, considered a leading humanitarian, referred teugenics (sometimes called r &B"racial hygiene") and proposals for its practical application had flourished for several decades. wants to move her to a state day áwhere there would be less opposition to removing her feeding er a < In 1920, sed  persons. 16 probate court ruling. The appeals court said that ʅSt. Louis Probate Court Judge Louis M. Kohn did not consider the > The program to provide "final medical assistance" did not ny @emerge spontaneously. The theory of realize that, before any Jews, political This ;dissidents, homosexuals or Gypsies were touched, the Nazis from 9developed and fine-tuned a relentless killing machine by 5, 1991 >eliminating up to 300,000 physically and mentally handicapped the center of a family Ädetermined battle in the courts to deprive her of her life, and h WGERMAN EUTHANASIA PROGRAM competent patient give informed ion of (ʅconsent before treatment is based upon the law's respect for the 9 Many do notn ٕ@both societies. It might be advised that Americans in 1991 look d ?in the mirror. They may see, reflecting back, another face, a ng lis3face from earlier this century: the face of death. barrier. Now "another disabled young woman has becomel. Cranford's "observation" flies in the face of reality. Christine Busalacchi is not in PVS. She is "conscious, she is B Discussions involving "merciful release" for sick people were ardAgenerally broached in terms of it being a private matter between צAa doctor and the patient (or if the patient were unable to speak  :for him/herself, the family). rses and occupational therapists s who work with Christine report that she is making steady exercise B The first recorded (1937)B Although the program was not devised for scientific research, ;opportunists soon saw that many, simultaneous deaths could eir y &provide excellent "patient material." t physically burdensome. t This is certainly true in Nancy's case. Acmed math students calculating possible ives 9financial savings to the Third Reich if those considered le he to "burdensome" were eliminated. tals, 54,400 people received tube o feedings in nursing homes, and 14,400 people received tube e the tes of juvenile e 6homes and orphan asylums ("troublemakers" and chronic not o is y 3bedwetters), even WWI veterans who had lost limbs. Senate bill It is evident both that many people benefit from nutritional < Propagandists filAstarvation, lethal injection, and poisonings - had taken on the Brole of "normal hospital routine." Victims then included dwarfs, 8the blind, schizophrenics and depressives, persons with ents such =afflictions such as Huntington's chorea, inmaavored euthanasia for their mentally on deficient children. er disease, cancers of the stomach, liver or pancreas); an impaired ability to absorb nutrients (persons with 7 By the end of 1941, euthanasia - practiced through bowel he e feeding by tube: > While many parents mourned, many others were eager to rid the ;themselves of the stigma of having a "defective child" and ury, s Brequested relief. As early as 1920, a poll indicated that 73% of no prospect e es of meaningful life. to starve and dehydrate her to death because $of her disability. That kind of barbarism is not supported by m,  @ One such program was located at the Eglfring-Haar hospital, ?where children were slowly nted guardians of Nancy Cruzan under Missouri law, Nancy's : Within months of the "mercy death" of Baby Knauer, an ne's d. t:advisory committee was appointed to prepare a program for esident @managing the killing of children considered to have child-victim is known only as "Baby P(?Knauer." She was blind, missing a leg and part of an arm, and ly K, Bmay have been retarded. Her father asked the Fuehrer that she be (amput out of her misery. was shown at a press conference. as state appoicording to expert e ; The genocidal potential of euthanasia had not yet been pain s 8actualized. Jewish and Gypsy patients were excluded as ation. ?"undeserving" of the "merciful act" of euthanasia. (Remember: ue Athe original plan was to cull the German race. Testimony by the BNuremberg defendants implies that it was conceived as a privilege 3of citizenship and not a punishment of the state.) hout the g ain Feeding by tube is also not economically burdensome. The rawsed on their view of her quality : The American eugenics movement provided the model for a But ?sympathetic German scientists and politicians. But, while the . ?eugenics movement attracted many followers, euthanasia was not by 6publicly pheld e Bthe practice, with Justice Oliver Wendell Homes writing, "Society Acan prevent those who are manifestly unfit from continuing their kind." ns describe providing food through a tube - that is, they seek to choose death for Nancy bae. The guardians assert that "quality of life is an a < Twenty years before the German Third Reich approved its ation :sterilization law, the U.S. was routinely sterilizing the ved one ?chronically disabled. In 1927, our Supreme Court Court ucluded the mentally retarded, @the insane, deaf-mutes, criminals, prostitutes, alcoholics, and e 9others. Institutionalization was essentially a life-long cision /internment designed to "kill off the species." he value of tion k Nancy's lifn, est Bprohibition of marriage to persons with certain disabilities, and ?institutionalization of the "feeble minded" were incorporated. In addition, Nancy's guardians claim broad authority as ay, a A The category "feeble minded" inused without excessive pain or inconvenience. This @ In the late 19th and early 20th century, eugenicists feared @that American "racial stock" was being polluted. Policies such . >as selective immigration, forced "therapeutic" sterilizatio Humanist and/or birth of a >control movements: Havelock Ellis, Julian Huxley, H.G. Wells, ans :Margaret Sanger, Charles Francis Potter, Robert Frost and ans 't !Somerset Maugham, to name a few. benefit, and that can be s is obtained and es =embraced "Social Darwinism," speaking easily of persons with was Bsuperior or inferior blood. They were heavily represented in the @medical and scientific communities and among the intelligentsia The hospitals were schools for murderadvocated in the U.S. - at least not widely. is "a case in which we are asked to allow the medical profession to make ? In 1906, the Iowa legislature considered a bill "providing t Afor the removal by the chloroform route...of certain individuals :who are, by officials designated in the bill, found to be ves lly Bpermanently and fatally diseased; and also...of certain ones that 9are permanently incapacitated owing to mental weakness." mental commitment to the notion that nintravenous nutrition and hydration [the court would be eir authorizing] the death by starvation and dehydration...[F]or all CONTEMPORARY PARALLELS e Court [would be authorizing] mercy l killing, arguably of a cruel nature." That iming the National Center on Death and g ?Dying. The organizations continue their quests to gain social Band legal acceptance of euthanasia, although they carefully avoid allusions to genocide. "by authorizing the withholding of ple can es and others who = In 1975, the ESA changed its name to the Society for the ?Right to Die and in 1978, the EEC became Concern for Dying. A n Ayear later, the two organizations severed formal ties. In 1990, =they again merged, beconcapable of speaking for themselves" were to "wait until the of Bgeneral public accepts the fact that man has an inalienable right to die." cale standard of treatment and care that devalues the ny lives and well-being of persons with disabilitiouri Supreme Court's decision since it ? To those who already agreed with the concept of deliberate t Aeuthanasia, EEC explained the need to "walk before we can run." BThe problems of "who shall speak for those who are incompetent or >ides toward s ans =death, dying and euthanasia. It promoted the "living will," s, >which intentionally blurred the critical distinctions between to ?deliberately causing death and allowing a dying person to die. h groups supported the Missi euthanasia program and the Holocaust, the ESA made little ls @progress until 1967 when it established an educational arm, the but Chas the choice Nancy's ? Today, children who may be mentally retarded or physically ?handicapped routinely are aborted for eugenic reasons. School->based clinics and abortion providers target minority and poor >neighborhoods. Artificial insemination, genetic engineering, l @"embryo selection," and fetal experimentation are no longer the =stuff of science fiction. Some handicapped "Baby Does," who bel, Amanage to be born, have become victims of infanticide. The U.S. ght to kill. on should be made without interference from the government. 1 Euthanasia is going on in our country today. : We musttation 6legislatures, in classrooms, in the legal and medical o =professions, in some churches, in the media. Americans must uld ?recognize that the issue is not about a "right" to die - it is 0about the "duty" to die, and the riet, the killing continued - and escalated. "About two million people die each year, 80% of them in @ In contemporary America, the concept of euthanasia has been 5openly promoted (and readily absorbed) by courts and consulchoice is not between life A The June 1941 Reader's Digest, America's largest circulation Amagazine, described the Nazi euthanasia program. It is naive to >presume that ordinary German citizens remained unaware of its 8existence. Yined ?silent. As with the American abortion holocaust, and with the euthanasia movement, that there is such a thing as a life not worthy to be lieuthanasia. @ Dr. Leo Alexander, who documented the Nuremberg War Crimes, :said it well: "Whatever proportions these crimes finally And the Bassumed, it became evident to all who ie profession. ents who appear to be in permanent comas. The wrath that Missouri has incurred from the medical, legal, and religious communities over the Cruzan case shows just SUMMARY ngly a wide spectrum of opinion favors passive ised in soothing >phrases: "mercy," "compassion," "dignity," "choice," "medical ?treatment," and "sanctity of the family." And, as in Germany, e Bthe earliest victims are already those who are at the first mercy of the health car@and those with mental disabilities. As in Germany, the "right" observed, we are no=exports its elitist population control programs to the Third he World. e in states where none exists. But the Rehnquist Court has displayed little proclivity for broad decisions upholding A American euthanasia promoters are quick become informed so that we can help others to Aunderstand these issues. We must become advocates for those who Aare disabled, elderly, chronically ill, despairing or dying. We =must insist on public policy which protects and enhances the @lives of those who are medically vulnerable. We must encourage Ahealth care professionals not to lose sight of the principles of @the Hippocratic Oath, as valid today as it was 2400 years ago. We must pray. ulmination of at least five cultural trends. If Awe understand these trends we should be much better able to deal 6'with clones of 119 in the years ahead. there are striking Since parallels in attitudes toward the weakest and most vulnerable ie 119, especially if ey =these represent shifts in public opinion. Not long, I fear. ould be better off dead (or never born) - not only for their "own ger B Initiative 119 was no surprise apparition. It represents the Aconvergence and c?judgment. But Schwarz's prediction may be close to the mark. ܾ>The medical profession is usually, and often enough properly, and @conservative on these matters, but one wonders how long it will >hold out against proposals like Initiativ119, and its senior vice-president of medical XTBeducation and science, M. Roy Schwarz, stated that the profession TexBwould not soon change its position. "Maybe in five or ten years, N=but not soon." Five or ten decades would be too soon, in my ich ic Health) approve of צ9physician-assisted suicide. It was somewhat surprising, se ,  =therefore, that an initiative to legalize it was defeated in .and BWashington State on November 5. The American Medical Association Aopposed Initiative views of medical treatment for "defective" citizens. disabled 񄓡9Abstract:azi atrocities started with the acceptance of the cs to *= Most Americans (64% of those questioned this year by the s - TEXABoston Globe and the Harvard School of Publzes some of the medical and social trends - f 0Adeplorable ones, in his view - that have made physician-assisted  MAKETOP.TEXT@NEWLIBr@{ MAKETOP.CODEODEᲫ DIRTEST.CODAReproduced 1992 with permission. Copyright (C) 1991 by American DIS Life League.  APPFIBM.TEXT@ APPFIBM.CODE@ ARTODEb9Z[8 Mary Senander is Public Information Director of the NCED.TEXTb8International Anti-Euthanasia Task Force, University of GRAFCHARS'Steubenville, Steubenville, OH 43952.  SETUP.CODE9br SSTEM.APPLEb9 SYSTEM.9 $ SYSTEM.LINKERb9$, LIBRARY.CODEb9,7 LIBMAP.CODEb979 6502.OPCODESbL9@ 6502.ERRORSb@GFORMATTER.CODEb9GNFORMATTER.DATAb9NS BINDER.About the Author: LINEFEED.CODEb9UZSET40COLS.CCHEYLE@-8 SYSTEM.EDITORb98V SYSTEM.FILERb9V@ We ought not weep for the victims of abortion, infanticide, HARSE=and euthanasia. We must save our tears for those who let it SYSTEhappen. Rn ٕB The absolutization of autonomy. The past 20 years or so have ?witnessed the flowering of patient autonomy as over against an ng lis@earlier medical paternalism. Paternalism refers to a system in "9which treatment decisions are made against the patient's family ÄBpreferences or without the patient's knowledge and consent. It is W?now all but universally admitted, at least in Western circles, of (ʅAthat individual decision-making regarding medical treatment is a =necessary part too easy. צAHave we forgotten that dependent old age is a call to cling to a  :?power (God) beyond our control? I think so. Rejection of our s Aown dependence means ultimately rejection of our interdependence =and eventually of our very mol. Cranford's "observation" flies in the face of reality. @ Have we forgotten this? I think so. Assisted suicide is a ?flight from compassion, not an expression of it. It should be re ard@suspect not because it is too hard, but because it isrust. The question must be dered ck: asked whether the practice of voluntary euthanasia is 's not g 9 consistent with the fostering of such care and trust began to  A [On Dying Well, p. 22]. reprisan ncurably 9 their own eyes and seemingly none for society. Such of the ; neighbor-love is costly and sacrificial. It is easily dians. e: destroyed. In the giver it demands unlimited caring, cy "as ; in the recipient absolute tve. Love, agape, is the equal and unalterable damaged ; regard for the value of other human beings independent ly to < of their particular characteristics. It extends to the her V9 helpless and hopeless, to those who have no value iving and receiving. At hly s r 3 the beginning and at the end of life receiving to authorize 9 predominates over and even excludes giving. But the ious S) V= value of human life does not depend only on its capacity er, ted8 to gi t. e 2Bconsciousness, "death with dignity" means:to die in my way, at my ;time, by my hand. Yet the Anglican Study Group was surely normal correct when it wrote in 1975: the Humphry marriage. rformed by , 9 There is a movement of gimagazines, newspapers and propaganda films began to to : The second concomitant of absolutizing autonomy is an me of e an 9intolerance of dependence on others. People abhor being zan's :dependent. Given the canonization of independence in ouronomy has become overstated " ;and distorted. That overstatement translates into a total er was an?accommodation to the patient's values and wishes. If physician- 1assisted suicide is one of those wishes, well... ew nursing home  Books, t-the צbAmaking characteristic. But as Daniel Callahan notes, "there are me Agood choices and there are bad choices." Unless we confront the @features that make choices good or bad, autonomy alone tends to  :?usurp that role. When it does, autt-making characteristic of the choice. I call that ?absolutization. We have seen this approach in the way the pro-re ?choice position on abortion is frequently presented. The fact . =that the choice is the woman's is regarded as the only righsolutizing autonomy. First, &>very little thought is then given to the values that ought to had @inform and guide the use of autonomy. Given such a vacuum, the á@sheer fact that a choice is the patient's tends to be viewed as a Athe sole righ sed  Alegalism can lead us into the dangers of antinomianism. When we ʅBtry to stop being overauthoritarian, we risk becoming anarchists.  The program to provide "final medical assistance" did not ny B I see two noxious offshoots of abof individual dignity. What is not so widely is 8realized is that the current heavy emphasis on autonomy is from autonomy and the secularization of the medical profession are ia twin sisters. al categories of persons require guardianship statute and the guardian's duty to act in her best interest. This is true except when death ? When the medical profession is fully secularized, clinical , ;judgments will also become secularized. And one important der ht :oical knowledge -8-@is viewed as something that "belongs' to the physician and that Bcan be dispensed on her own terms in the marketplace, and illness them, people will easily view physician-assisted suicide as a lly Bpreferable alternative. I am compelled to note here that certain Cfanatical fringes of the pro-life movement are counterproductive. ABy saying that Nancy Cruzan wasion of the process. And this is where the nutrition-se ;hydration question directly touches the issue of physician-ke ?assisted suicide. If our public policies are going to mandate t Anutrition-hydration treatments and prevent the discontied indefinitely in a PVS because @they do not regard this as a benefit to them. Indeed, they are @appalled at the prospect. This is the second thing people fear Aabout dying: the needless, heedless and aimless (as they see it) >prolongatpheld e the practice, with Justice Oliver Wendell Homes writing, "Society A I cannot argue the case further here. My purpose is to note ?that the overwhelming majority of people I have polled on this y Bmatter do not want to be maintainexhaustively defined by medical effectiveness alone. >Other authors (such as Gilbert Meilander of Oberlin) view the ion Acessation of artificial nutrition-hydration from PVS patients as direct killing. bled. In 1927, our Supreme Court Court us, even though they do not d, >reverse their vegetative state. To me, that judgment defines d e ?usefulness to the patient so narrowly that personal benefit is Breduced to the maintenance of physiological functioning. Patient Abenefit is J. st ;Myers of Peoria, Illinois, in his Pastoral Instructions to s, and Ahealth-care administrators. He argues that artificial nutrition- ;hydration efforts are not useless, since they "effectively ay, a >deliver nutrients" to these patient them with fluids by means of tubes is not useless >in the strict sense because it does bring to these patients a d >great benefit, namely, the preservation of their lives." The h . ?most recent statement espousing this view is by Bishop Johnmple, some saw continuance a ;in a PVS as a "great benefit" to Nancy Cruzan. A group of s, ans ?authors writing in Issues of Law and Medicine in 1987 stated: t B"In our judgment, feeding such [permanently unconscious] patients @and providingy s feedings. Social Darwinism," speaking easily of persons with was superior or inferior blood. They were heavily represented in the A Others, however - a minority, I believe - view this decision @in much more sinister terms. For exa that continuing in a PVS is not a benefit to the ?patient and therefore is not in the patient's best interests. =This is my own conviction, and I wrote as much in support of ood ?Lester and Joyce Cruzan's decision to stop Nancy's gastrostomed around cases like that >of Nancy Cruzan. Many ethicists and physicians are convinced s a =that artificial nutrition and hydration are not required for ve Apersons diagnosed as irreversibly in a PVS. They base this view Aon the judgments. ?But must or ought we do so? Few would argue for doing so when a 8the patient has expressly declined such treatment while s and in ;competent. But what about those who have not so expressed hdraw Athemselves? Here controversy has swirlin California) have propelled this problem onto Ccenter stage. This was especially true in the Nancy Cruzan case. >People can now be maintained in a persistent vegetative state B(PVS) for years by use of nasogastric tubes or gastrostomy tube "starved" and "killed" they will 4drive people to embrace physician-assisted suicide. ca (ESA, now called Society for the Right to Die) was formed in New York. The ? Closely connected with the nutrition-hydration discussion, a, As Dr. Robert Bernhoft, a surgeon and president of Washington t ?Physicians' Against Initiative 119, put it: "These people [the @elderly of limited means] are already under tremendous pressure r ;tdes toward s ans death, dying and euthanasia. It promoted the "living will," s, A Such economic pressures constitute a coercive atmosphere for Bthe debilitated elderly and chronically ill. "Why must I hang on Clike this? Am I not a dr6, 414 hospitals closed, and an Arthur Anderson study predicts >conservatively that 700 more will close by 1995. Acquisition e >decisions, hiring practices and incentive proposals are often ood closely tied to market forces. e in public attiture costs. We are now spending 12% of Cthe GNP for health care, more than any other nation in the world. ;Hospitals are pressured to cut costs by Health Maintenance Many BOrganizations and by Diagnostic Related Groups. Between 1980 and B198handicaps ,000 New York again attempted legislation in 1945 and 1947. In , @ The financial pressures of health care. No one needs to be s :told that there is great pressure on everyone, especially ude the Ahospitals, to cut health-caudges confuse the removal of life supports with homicide, e =they make homicide look all the more acceptable. One way to res" @soften resistance to the unacceptable is to confuse it with the acceptable. ny others...persons with all manner of atients from ventilators or other ed ?life supports. Judge Robert Muir did this at one point in the ic BKaren Quinlan case. Those who removed Karen from the respirator, ?he said, would be subject to New Jersey's homicide laws. When h ?the jhe limited e @distinction has served us well for many decades and it would be n @irresponsible to abandon it. Yet it is being fudged, not least t ;by some courts that threaten with murder charges those who shifts ?withdraw hopeless and dying p6 COVENANTAL ETHICS AND CARE FOR THE DYING SION , EUTHANASIA IN NAZI GERMANY AND CONTEMPORARY AMERICA , Mark A. Duntley, Jr. 35, December 4, 1991, - The Christian Century, her shaman, witch doctor, priest or physician - hat Amaintained almost complete control of treatment decisions. This =legacy of paternalism in medicine has come under fire in our t . >generation, as patients - and physicians - promote individugical medicine have made st, &?patients more dependent upon medical professionals than ever. ad 7Ironically, however, patients today have more clout in uum, the á@determining their own treatment. For most of human history the a =healer - whet sed  3 But, in defence, by mercy, 'tis most just. ism. When we ʅ2 Shakespeare ing anarchists.  The program to provide "final medical assistance" did not ny > Recent innovations in biotechnoloom be in suffering. O my lords! not so widely is - As you are great, be pitifully good: n autonomy is from 3 Who cannot condemn rashness in cold blood? becoming 1991 3 To kill, I grant, is sin's extremest gust; against edwhen the hopelessly mily ÄAsuffering should be allowed to choose a quick and merciful death W(at the hands of a medical professional. st in Western circles, of (ʅthat individual decision-making regarding medical treatment is a / If wisdby ٕ@Derek Humphry, have become best-sellers in part because so many e Bpeople fear a prolonged, painful death. Since such a death seems lisBto be anything but good, it is understandable that many have come ";to believe that there are indeed times ing measures and as more people join the ranks :of the elderly, the ultimate issue of individual choice - o deal 6@determining if, when and how to end one's own life - grows more Burgent. The books Last Wish, by Betty Rollin, and Final Exit, ng people end their ey lives - and their suffering. lic opinion. Not long, I fear. ould be better off dead (or never born) - not only for their "own ger B Louise is not alone in her wish. As medical technology gives @more life-prolong=herself to give him the pills they had set aside. Jack died ܾ;three days later. Louise is both proud and ashamed of her y, and Ainability to help her son die. But most of all, she wonders why =health-care professionals cannot help dyim his eyes, Jack told Louise that he wanted to T?end his pain. He asked her if she would help him die when the on Tex>time came. Reluctantly she agreed. But when the day arrived rs, NAwhen Jack begged his mother to help him die, she could not bring d grace." A prove of צ> Jack was dying of AIDS. Toward the end, in spite of huge  >doses of morphine, Jack's pain became almost unbearable. His and @mother, Louise, cared for him and watched him suffer. One day, n Bas tears rolled fro=but would provide the context for showing mercy to those who ed 񄓡9suffer.n physician and patient have a covenantal and not merely a *contractual relationship, contends this author, "assisted suicide TEXcan indeed become an experience of mercy and patient have a covenantal and not merely a 0Bcontractual relationship, contends this author, "assisted suicide 8can indeed become an experience of mercy and grace." A ese ide, :?covenantal relationship would not eliminate all moral dilemma, a ng 1991, pp 28-32..  ? : Vol. 108, No. 35, December 4, 1991, pp 1135-1137. 32. /צAuthor:Mark A. Duntley, Jr., S.J.!.[G&TEXT Abstract: d to be that friends, family, courts and the medical he B When physician anal he צb@rights and patient autonomy. One recent poll found that almost me Btwo-thirds of Americans believe that a terminally ill patient has ?the right to stop treatment under any circumstances, even when  :@facing imminent death. Patients' d