p@9 %  L$MUST BOOT FROM SLOT 4, 5 OR 6CJJJJ \  i=l x ? L N9 +i C* ɭЅ?0ȱ L Ѕ?iȱi L CPly being extended to euthanasia. Even within 0>specific cases of euthanasia the standards of the courts have Bgradually lowered. As long as people feel they have the right to :?make judgments on the lives of others it is expected that this , 10, 1992, pp 7-10.  ? Author:Rev. Leo John Celano, O. Praem., 1990, p 10. 1137. 32. /צ Abstract: Charles E. Rice., S.J.!.[G&TEXTB The concept of killing the innocent, already established with Babortion, is graduall, KILLING WITH KINDNESS RING TO KILLING , EUTHANASIA IN NAZI GERMANY AND CONTEMPORARY AMERICA + Dr. Charles E. Rice ruary 10, 1992, pp 7-, @ The New American, Vol. 8, No. 3, February EUTH4{4 EUTH21.TXT f1v4g EUTH22.TXT f1vg EUTH23.TXT f1v EUTH24.TXT f1v EUTH25.TXT f1v new volume: 1"Please insert a disk for Volume = Ǎ.End of disk reached before transfer compl+`FG8`0($ 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^*^*>` aI꽌ɪVɭtrend will continue. ath, which denounced abortion, is now edited 9 Four centuries before Christ, a Greek physician named sisted *Abstract:es turned medical ethics in a new direction. Medicine a TEXB When legalized abortion was first proposed in the Model Penal צ=Code in 1962, opponents warned that the concept would extend thin 7beyond the unborn, ultimately leading to euthanasia of s have ory Adefectives, the chronically ill and others. On December 1, 1991 =the federal Patientirect 2A In a balanced, perceptive critique of the PSDA, John LaPuma, @MD, David Orentlicher, MD, JD, and Robert J. Moss, MD, note the f provides an opening for health care providers to persuade and f an 2unfairly induce patients to execute living wills. Poles and other non-Aryans, but rather to purify the German race by the dospital or other health care ?provider to furnish a living will or power of attorney form to ed an@the patient. But it also does not prevent the institution from f Bgiving a form to the patient on admission or mailing it to him in Aadvance. Tdures צb9to ensure compliance with that law." The regulations to trapped me implement the PSDA are pending. in this case, the trial judge and Was not the judge's reply of "because it's legal" a refrain  :@ The PSDA does not require the h is required to assist any individual in formulating :ad advance directive. All that is required is that adult a ion ?individuals be provided with information concerning applicable AState law and that...providers establish policies and procemedical care and to execute &Cappropriate documentation for the enforcement of those decisions. @No individual seeking services from a...provider is required to e á>execute a living will or a durable power of attorney. And no gh Bsuch provider1988  > The "primary purpose" of the PSDA, according to the House t r ʅ>Budget Committee Report, "is to ensure that adult individuals "I ?have the information they need in order to protect their legal e, Arights to make decisions about their ve." The PSDA itself, however, does not contain a @conscience provision protecting personnel and institutions from g -compelled provision or refusal of treatment. estions about the 1 The Supreme Court of Missouri, in overruling in November I attended a friend's wal B The PSDA permits "the application of a state law which allows W@for an objection on the basis of conscience for any health care f (ʅ?provider which, as a matter of conscience, cannot implement an , Badvance directihe ٕmedical schools from which they graduated, including those who profess to be Christians. ental natural right expressed in our lisLANGUAGE OF THE LAW the 'right to liberty' which permits an y E. " To offer an example, two years ago ce directives at facilities of the provider or t organization"; and standard of medical morality remained largely 6> *To provide for "education for staff and the community on l o 'issues concerning advance directives." ysicians today or even t; give no blic was not ? *Not to discriminate against an individual on the basis of on 7"whether or not" he has executed an advance directive; an er use 9 *To ensure compliance with requirements of state law in her s @"respecting advan Blaw to accept or refuse medical care and to execute a living will ܾ.or durable power of attorney for health care; nsider for f (now @ *To document in the patient's medical record whether or not +he has executed such an advance directive Self-Determination Act went into effect, s T>requiring hospitals, nursing homes, home health agencies, and It Tex hospices: the art of medicine for nearly two thousand five d rs, N@ *To advise patients on admission of their right under state lnfused because of the frequent n Acomplexity of state laws in the area and the uncertain impact of Bthe common law and federal constitutional law. The authors go on Vto to raise ethical questions: f the U.S. Supreme Court. ions. ted; The Act was part of the Omnibus Reconciliation Act n, and ; of 1990, which is expected to reduce or limit payments ath ; to Medicare-reimbursed providers, including hospitals, ls, ts V8 nursing homes, and managed care organizations. Sixrt held that Missouri could require, if it of attorney. In Cruzan v. Director, Missouri Dept. of Health r B(1990), the Supreme Couurable power of attorney, which appoint an agent to make terms t %treatment decisions for the patient. f respectability to an ugly reality, euthanasia, an infamy, a wedge, a first step in having A Some courts have allowed the withdrawal of other agent as to the patient's best =interest. This practice has been reinforced in almost every "a s =state by statutes authorizing the execution of living wills, he may be asked to make choices about which they have little y  understandable informatioectives to contain costs is critical. Potential since . 9 financial conflicts of interests arise, as providers ions, f : may use the Act to meet institutional economic goals, ship. ard6 such as minimizing Medicare losses...to patient'sally the elderly - will womb) she ck9 opt to limit the expensive, intensive treatment they lly will  may receive in hospitals. g the killing of other humans for  8 This caution about the unethical use of advance legal the 8 dir lity of y ; percent of Medicare enrollees die annually, their care est is 9 amounts to 28% of annual Medicare expenditures. The ortion) e9 Act is expected to decrease provider costs, assuming s of age 7 that many patients - especiof the Euthanasia Movement. In 1968 the Euthanasia Educational A But Cruzan does not forbid the states to allow withdrawal of Bfood and water on a lesser showing of the patient's intent. And ?Cruzan does not bar a holding in a future case that the states , 9are bound to give effect to the treatment decisions of a or life Asurrogate, such as a health care agent appointed by the patient. ANor does Cruzan prevent the states from, in the words of Supreme 9Court Justice O'Connoed st BInitiative 119, which would have authorized physicians to provide B"aid-in-dying" to "conscious and mentally qualified" patients who =request it in writing. Initiative 119 would have authorized r a Aeuthanasia by injections or other aversions of the device Kevorkian had used in June by >1990 to help Alzheimer's patient Janet Adkins commit suicide. a helpless, living human being is no different than feeding an h . > In November 1991, the voters of Washington state rejectachine that administered a e 9lethal injection. The other was afflicted with multiple n if to Asclerosis and used a Kevorkian machine to inhale carbon monoxide ?through a mask. Neither one was terminally ill. The machines s ?were refined e s Alicense of Dr. Kevorkian and the prosecutor is seeking to indict Bhim for homicide in the deaths of two women who ended their lives =with "suicide machines" he had invented. One, with a severe the @pelvic disorder, was hooked up to a mer step from the passive to the active mode of cal 6killing. That reluctance, however, is bound to fade. nt, thereby causing or with the intention of causing death, constitutes be = The Michigan Board of Medicine has suspended the medical ans are incidental. The Awidespread condemnation of the suicide machines used by Dr. Jack =Kevorkian and the rejection by Washington state voters of an r or >active euthanasia initiative indicate a popular reluctance to hen >take this furthhe @ In both the "passive" withholding of food, water, and other incompetent patient who had never indicated any intent on the ell subject. he advice of the doctors who are specially competent in the matter...They may also ju involuntary killing. If starvation or an active, ia, ut ;painless release by injection is provided to the competent nse of @patient who requests it at that time, if it is also provided to Athe incompetent patient on the basis of his earlier essive" and "active" euthanasia, . Athat would allow the "passive" starvation of patients but forbid Atheir "active" killing by injection, will not endure. Nor is it a substituted judgment on her behalf." Like Hilda Peter, 65, f ;Nancy Ellen Jobes, 31, had an indefinite life expectancy. her. ;Conroy, Peter, and Jobes appear to foreshadow the dominant ements d have wanted her 's Afeeding tube withdrawn. In a companion case, however, the court =allowed withdrawal of a feeding tube from Nancy Ellen Jobes, The Balthough there was no sufficient proof that she would have wanted Bthat done. The Jobes8distinguished from the forced continuance of biological edical l vegetative existence." en must be continued irrespective of its lack of success or benefit to the patient in effect gives one's ? The court concluded that Hilda Peter woulnt criterion in determining whether life-f Bsustaining treatment may be withdrawn. For this kind of patient, ?our focal point...should be the prognosis as to the reasonable id 8possibility of return to cognition and sapient life, as ife year easons to tient is dying 9 terminate the patients' lives without their consent. produced 7 In 45% of the cases in which the lives of hospital uce pain 4 patients were actively terminated without their re of its 8 consent, this was done without the knowledge of the  families. e "follows the same pattern that we saw years back THE NANCY CRUZAN CASE IS NOT... an extreme case, you put it in the most favorable light, and you attempt then to justify i law to accept or refuse medical care and to execute a living will ܾ@ So, like thousands of other Americans, Musolino tried to do Bwhat he could to chart his own medical destiny. In 1989 he wrote Ba "living will" stating that if he ever hly fear of going to hospitals," says Edith TBMusolino, his wife of 50 years. "He was afraid of medical stuff," Tex@adds his daughter, Edith Scott, a nurse. "When he had to start , N8taking insulin shots, that was a very traumatic thing." r state lught to the hospital צ>possibility that his diabetes and heart disease might someday hin 1sweep him onto the shoals of medical technology. ia of s have ory Reproduced 1992.chronically ill and others. On December 1, 1991 > "He had a deathAbstract:l continue. ath, which denounced abortion, is now edited 9 Living wills are supposed to enforced a person's dying isted *< Rocco Musolino hated hospitals. A big, friendly, blunt-ation TEX7spoken man, Musolino had given a lot of thosupposed to enforced a person's dying within 0Bwishes, right? As this family's story emphasizes, interpretation Aof a living will is at the mercy of the family, doctor, hospital :and the law. on the lives of others it is expected that this , y Edition, p 7-10.  ? 6 Vol. 8, No. 35, July 1-7, 1991, pp 11-12. 37. 32. /צAuthor:Susan Okies E. Rice., S.J.!.[G&TEXT Abstract: ncept of killing the innocent, already established with ; Living wills are 0 LIVING WILLS AND DYING WISHES TO KILLING , EUTHANASIA IN NAZI GERMANY AND CONTEMPORARY AMERICA ' Susan Okie kly Edition, Vol. 8, No. , 8 The Washington Post National Weekl need or [ting a young woman to die naturally without state-b9,7compelled medical intervention. It is comparable to a case where bpressures make the fight against euthanasia hopeless in hase don't kill me" type of ade @document specifying one's intent not be starved, dehydrated, or Aotherwise put to sleep." Perhaps the best protection is to make Aone's intent known to a trusted family member or friend who will 2not be afrat in n APPEALING TO A HIGHER JUDGE ct to the Nancy Cruzan case ends with an understanding of what this case is not. It is not a case that B We are headed in the same direction. To some extent, one can >gain protection by executing a "plead a terminal condition, .he didn't want to be kept alive artificially. on the basis of on "whether or not" he has executed an advance directive; an er use A He signed a "durable power of attorney" authorizing his wife Ato make medical decisions if he became incompetent. He told his Afamily and his doctors that he never wanted to be hooked up to a 6/"damn machine" or "kept alive as a vegetable." e community on l o issues concerning advance directives." ysicians today or even tecision in the case of Nancy ) she ck=Cruzan, a Missouri patient, focused public attention on such will Aquestions. Like Musolino, Cruzan was being kept alive by medical  Atechnology. But, unlike him, she was severely brain-damaged and @had lef patient's ;future "quality of life" and cost of treatment in deciding est is 2whether to expend every effort to keep him alive? . The ortion) e Act is expected to decrease provider costs, assuming s of age < Last year's Supreme Court dment, what kind of evidence should be used to divine his :wishes? When doctors disagree with family members on the ath Alikelihood of recovery and the benefits of aggressive, expensive VBtherapy, who should prevail? Should doctors consider as, lawmakers and the public are =grappling with the question of who should make life-or-death of ;choices in using medial technology, Musolino's case raises go on VBdisturbing questions. When a patient becomes unable to guide his tedBown treatnning 2?not to know who to pray to anymore. Do I pray to you, or do I , pray to God?'" licher, MD, JD, and Robert J. Moss, MD, note the f possibility that patients could be incorrectly informed and ed , A At a time when medical expertong battle was almost over. n this and other respects provides an opening for health care providers to persuade and f an A "At this point, if something didn't stop, it was killing all ?of us," she says. "I said, 'You know, doctor, I was begiospital or other health care A When a Georgetown doctor at last told Edith Musolino in late an8January that he would agree to stop Musolino's dialysis on from f >treatments, she says she felt only anger, not relief that her in 'husband's ldures צb>guardianship over Musolino - a step that would have taken the ed me =responsibility away from his wife - in order to continue his and treatment. the judge's reply of "because it's legal" a refrain  : The PSDA does not require the hd recover from an emergency heart operation, and ing @opposed the efforts of Musolino's wife and children to stop his n ?dialysis treatments. The case turned into a painful ordeal in ;which hospital lawyers threatened to go to court to obtain s as the family saw it, his &?dying - was prolonged by Nevin Katz, the Georgetown surgeon in s. :charge of his care. Katz had operated on Musolino, whose ed to e áAcardiologist had referred him to the surgeon. Katz believe that >Musolino coule 88  8than $385,000, which the family says will be covered by House t r ʅ insurance. ittee Report, "is to ensure that adult individuals "I have the information they need in order to protect their legal e, A Rocco Musolino's fragile life - ao a kidney dialysis machine several times a week a family members say that most of the time he did not recognize 1 ?them. The final bill for his hospital stay alone came to mor. Despite his living wal >will, he was kept alive by a respirator and could not speak. ows W9Despite his wife's efforts, through the durable power of h care f (ʅ?attorney, to get the hospital to let Musolino die in peace, he , @was hooked up the ٕ@ Despite those measures, Musolino's life ended this year, at :age 72, in a tangle of tubes and machines after a 102-day our lishalf-million Americans contacted the National Society for the ho  :+Right to Die to request living-will forms. ves' significance d by may be asked to make choices about which they have little y @ Musolino's case also diffA Rocco Musolino's ordeal began when he suffered a major heart @attack in 1988. A catheterization revealed severe blockages in ?his coronary arteries, and one-quarter of his heart muscle was o Balready dead, his son recalls. Doctors tolespecting patients' wishes, and that it had >not violated the living will. Katz, the surgeon, declined to h o comment. medical treatment." Some state courts already permit ts withdrawal of food and water from an incompetent patient even if hree months, I am , Bconvinced that the patient has basically no chance for survival." surrogate, such as a health care agent appointed by the patient. @ The hospital said in a brief statement that it had followed Aits usual policy of rof the Euthanasia Movement. In 1968 the Euthanasia Educational @ "When medical treatment with artificial support measures is Bfutile, the patient clearly chose not to have it," he wrote. "In ?view of...all that has happened in the last trt held that Missouri could require, if it B But Angelo M. Taveira Da Silva, the doctor who finally agreed >to let Musolino die, wrote in the medical record last January n 9that he believed the living will's conditions did apply. hakers s nt was not ter if Bterminal. "His chances of recovery constantly fluctuated between A25 and 75%," Rubin says. "I don't feel that the hospital or any ?of the physicians went against the terms of that living will." r (1990), the Supreme Couays. "We were looked upon like vicious criminals." make terms t treatment decisions for the patient. f respectability to an ugly A Rubin says that both he and Katz felt that the conditions of :the living will never applied because the patieng. She says that on more than one t =occasion doctors accused her of wanting to kill her husband. "a s state by statutes authorizing the execution of living wills, he B "We weren't supposed to have any feelings or any rights," she 5sgenerally allow -8-decisions on treatment, including artificially provided nutrition ? In the ensuing clash, it seemed to Edith Musolino that her s @husband's previously recorded wishes, which she was prepared to =defend, counted for nothiire to live, even if it meant being on dialysis for the rest e =of his life. "The family came back later and said that they the @didn't think that was his philosophy. But I heard him say it,"  he says. a patient is incompetent, courts today octors and family members all wanted f Ver?what they thought was best for the patient, yet their opinions n ers>were diametrically opposed. Musolino's cardiologist, Richard nt. &?Rubin, says that before surgery his patient expressed a strong , @des that a ates a es Bpatient is dying but may be of little use if doctors or relatives $%see even a small chance of recovery. l you with a needle ouri's e  PATIENT INTENT y your children. This is the terrible 'an to ys @ In the Musolino case, dal dilemma: whether to stop a life-sustaining treatment when =a chance of recovery, however small, still exists. The case an . tAillustrates the limitations of so-called living wills, which can ;help guide treatment decisions when everyone agreesers from most other "right-to-die" t P(@cases that have reached the courts because his doctors believed . , Bthat he might, in time, recover. The notes in Musolino's medical (ambadly damaged that he was not a candidate for coronary bypass hat surgery. fluid, or nutrition and hydration, especially artificial Once euthanasia is authorized by withholding food and water, A Over the next two years, Musolino grew weaker and shorter of Bbreath as his heart continued to fail. Last fall, Edith Musolino =told her daughter that she was expecting him to die any day. ng tube from a 48-year-old nonterminal patient who was in a food omoceed," Katz wrote in the record >that morning. "He is aware of the risk. I have reviewed the @high risk of death (40%), high risk of renal failure (long term ;about 50%) with wife and daughter." Scott says she has no e it) #recollectgo ahead Awith the bypass operation, obtaining his wife's consent over the telephone. the total fertility rate in the U.S. has been around e 1.8; a level of 2.1 is needed for a population merely to replace B "He is awake and wishes to prests. "They called us and said he probably would not 1make it through the night," Edith Scott recalls. thanasia in this country. The demographic reality of an aging population, with e B But Musolino survived, and Katz and Rubin decided to situation and what was best e &for him, and that we should proceed." ition, and hydration. l t inconvenience and discomfort that may be brought on to the has a ; On the night before the surgery, Musolino suffered two at of Acardiac arr form for dialysis. , which would have authorized physicians to provide "aid-in-dying" to "conscious and mentally qualified" patients who A "He trusted his doctors, he had faith in them," Rubin says. ?"He said he knew we understood the heterization, to surgery and to dialysis treatments =if necessary. Notes by Katz and Rubin in the medical record a Astate that they discussed the possible need for long-term kidney Adialysis with the patient. Edith Musolino signed a consentmbers Katz telling her. a e lethal injection. The other was afflicted with multiple n if to > Musolino stayed in the hospital and doctors scheduled his de Aoperation for last Nov. 12. Rubin says his patient consented to Aa cardiac cat the 5only hope of saving him was coronary bypass surgery. g to indict him for homicide in the deaths of two women who ended their lives > "He'll die without an operation. He's got a 50-50 chance he =with it," is what Edith Musolino reme4, after a night of chest pain and breathing f cal @trouble, Musolino told his wife he couldn't stand any more. He y @was taken to Georgetown Hospital, where doctors - contradicting Bthe medical opinion given two years earlier - told his familym alive as a vegetable," =according to a letter Folsom wrote on the family's behalf in ack )January when it was battling Georgetown. state voters of an r or active euthanasia initiative indicate a popular reluctance to hen < Last Oct. 2he Bspent the winters. During a hospitalization there for intestinal Ableeding in 1990, Musolino told Folsom he was "adamantly against Blong-term dialysis" for kidney failure, and instructed Folsom not @to use life-support systems to "keep his. utinely. Such a process would not be very far from euthanasia, and the natural question is: Why not use s < He had discussed his wishes regarding medical care with ?" >Robert J. Folsom, a physician in Marco Island, Fla., where he tsical disability like n B Musolino was a fat, gregarious man who had run a liquor store Ain College Park, Md., with his wife and son until his retirement >in 1988. "Everybody liked him because he was so outgoing and me funny," Scott say ? "If he made it to the bathroom, that was a big deal," says BEdith Scott, the daughter. "He couldn't shave. He would get all out of breath." ifficult, painful and gruesome death: the cause of death would not be some underlying phyion of such a discussion. . People aged 85 and older - are increasing three times faster than the population as a whole. B After the operation, Musolino needed dialysis several times a >week. He could not breathe without a respirator, so his wife e >reluctantly consented to a tracheostomy, in which a permanent st Abreathing tube was inserted in his neck. "It was setting him up @for more suffering, because then he couldn't talk again, and my r /husband was very verbal," says distinguished from the forced continuance of biological edical l ? In late December, Steven A. Epstein, a psychiatrist at the Ahospital, examined Musolino to determine whether he was mentally Bcompetent. At that time, Musolino's physicalino was mentally competent to guide his -f Aown care. Under D.C. law, if Musolino was declared incompetent, @the durable power of attorney would go into effect, authorizing d &his wife to make treatment decisions. sapient life, as ife year ed withdrawal of a feeding tube from a vegetative patient who, unlike Claire Conroy, A She says that the hospital's ethics committee met on Dec. 21 Ato consider the case and recommended a psychiatric evaluation to ?determine whether Musolouldn't stand being off the respirator" because he could not st, ?breathe on his own, she says. "Everything that could be wrong nt ?with him was wrong with him. I knew he was dying. I knew his an body couldn't take any more." preme court allowird, purely-objective test, is nicate n satisfied. Under that test, as under the limited- moral s t < "He had the trembles. From all the antibiotics, he had er @itching...They would try to take him off the respirator, but he r >cat all, ormally > By December, Edith Musolino had made up her mind that she e Awanted her husband's dialysis treatments stopped, even though he Awould die without them. She says she had watched him suffer too long. aire Conroy if a thp one of Musolino's medications, he angrily responded: "I cts >stay awake at night trying to keep your father alive, and you he 6want me to kill him. What is wrong with you people?" ny patients trustworthy evidence, or indeed any evidence ther cardiac arrest. She says Katz at Bfirst refused. He did write such an order about two weeks later. evidence that the patient would have refused the s. Quill's ? She says that around the same time, when she asked Katz to nd >stohat he would 0 =never recover. Scott says that in late November she and her a , Bmother met with Musolino's doctors to ask them to place a "do not Bresuscitate" order in his hospital chart, so that he would not be Brevived in the event of ano go in and have a conversation." ancy of one year or less. The court held that, with respect to incompetent patients "who f A As the weeks passed, Musolino did not appear to improve, and @his wife and children grew increasingly convinced tdge that the techniques applied d rs The leading case of Matter of Conroy, in New Jersey in 1985, @ "Sometimes he looked real disgusted and sometimes he looked a consciousness was caused by his severe heart, lung and kidney ell ?failure, and said his mind would probably clear if his medical n condition improved. y also jushow that on some days he would mouth words, nod or shake Ahis head in answer to questions and would follow simple commands ?such as "squeeze my fingers." On other days, he slept most of >the time and responded only with a grimace. NeurologEdith Musolino. ve" euthanasia, . that would allow the "passive" starvation of patients but forbid ? The family says that his level of consciousness fluctuated t Bbut that he was never fully alert. Doctors' notes in the medical Arecord condition seemed to ability to evaluate information and communicate decisions re: ee &complex issues is s?Musolino more responsive and asked him a series of questions: an ;"Do you want to live?" "Nods yes." "Do you want to die?" stomy 8"Shakes head no." "Do you want the doctors to stop all article, treatments?" "No." was published as part oith Musolino asked her husband the same questions. +This time, he nodded "yes" to all of them. vocates for those who In the big picture, however, the demographic and cost g. We A "I said, 'Dr. Katz, what are you trying to prove here?'" she /recalls. "'You have made him suffer so much.'" imension. It e requires a reconversion of the American people to the conviction # "He said, 'What do you want?'" t no one ever has the right t intentionally to kill oneself or 2 THE "LIVING WILL" AND EUTHANASIA O KILLING , EUTHANASIA IN NAZI GERMANY AND CONTEMPORARY AMERICA + Raymond Voulo, M.D. bruary 1990, pp 16-18. ? ALL About Issues, Vol. 12, No. 2, Februaras I am concerned there are no further legal issues." But he he DIS(still was not willing to stop dialysis. who might benefit. In Nancy'sare until [?the hospital gradually began to treat him as a dying patient. Tbwith paralysis, diabetes, and injuries causing amputation all ed me =could be called seriously incapacitating - and this list can and easily be expanded. e's reply of "because it's legal" a refrain  : The PSDA does not require the h, the words" reasonable expectation of recovery" are ?much too vague. What would fulfill such a definition? When a n ?patient's chances of recovering are 10-90, 30-70, 50-50? Even Avaguer is the phrase "seriously incapacitating illness." Sthru feeding tubes were all &>that was necessary for recovery. Now these would be withheld s. under the Living Will. tz had operated on Musolino, whose ed to e ácardiologist had referred him to the surgeon. Katz believe that B Also, Joee 88  >designation fraught with error. Medical history abounds with t r ʅ>instances of spontaneous recovery from so-called "permanently "I @unconscious states." In many of these cases, good nursing care , Aplus the provision of food and fluid a kidney dialysis machine several times a week a for months. Bedsores kept him in almost constant pain, and rom g B And that's not the only misleading use of language, Joe. The 8phrase "permanently unconscious" is purely a judgmental o mor. Despite his living wal ? "Artificial means," Joe, include not only respirators, but ws W;also food and fluid - the most basic necessities of life - care f (ʅ?administered thru feeding tubes. What's so "artificial" about , food and water? I ٕ3do not wish to be kept alive by artificial means." his year, at age 72, in a tangle of tubes and machines after a 102-day our lis! What are "artificial means?" e care units at Georgetown y E. "University Medical Center in Washingtonery word in it has significance. Allow me to s @read to you part of a sample Living Will: "If I am permanently 6Aunconscious or there is no reasonable expectation of my recovery Bfrom a seriously incapacitating or lethal illness or condition,ad a terminal condition, A Joe, the Living Will is a legal document which would prevent ?me, under civil penalty, from using "artificial means" to keep e Byou alive in the event of certain illnesses. Since it is a legal ?document, Joe, ev law to accept or refuse medical care and to execute a living will ܾ@ Doc, what's this Living Will that I've been hearing so much about lately? to chart his own medical destiny. In 1989 he wrote a "living will" stating that if he ever hse times, I envisioned the following exchange T=between myself and an imaginary patient "Joe" concerning the ff," Tex@burning issues of the "Living Will" and euthanasia. I imagined , N+Joe's questions and my answers as follows: atic thing." r state l their doctors enough צ;to seek guidance on difficult questions concerning medical ay hin treatment. 1992.he shoals of medical technology. ia of s have ory Reproduced 1992.chronically ill and others. On December 1, 1991 A Longing for tho Do Living Wills really serve a patient's interests? Should d 9B Recently, while reminiscing about the "good old days" of what *Bonce was called the art of the practice of medicine, I remembered TEXAhow, in contrast to today, patients trustedssigned to your case in an emergency situation. His true. You don't need a Living Will to prevent hese groups want you to believe, Joe, @that if you suffer from an incurable disease, and you're at the s Doc, what you're saying is that if I had signed a "Living cal (amorder. This could force patients to sign Living Wills purely y 9defensively, and would thus ft no living will. The Supreme Court held that the state . @ Conversely, both doctors and hospitals will feel obliged to advantageous for the doctor not to try to save the patient at al  all. ology. But, unlike him, she was severely brain-damaged and had lefbeginning @and that the doctor, therefore, violated the "Living Will." On s Athe other hand, if the patient survives with a major disability, e?the patient could make a claim that the doctor inappropriately ge Cused extraordinary means in a " If the doctor employs "artificial" or "extraordinary" Bmeans in cases when only a minimal chance of survival exists, and Athe patient dies, the surviving family could make the claim that VAthe condition was an incurable condition from the very s, lawmakers and the public are  That's right. question of who should make life-or-death of choices in using medial technology, Musolino's case raises go on VA And there's more. The Living Will places doctors in a legal tedAquandary.that, you need if !trust in your doctor and family. ry constantly fluctuated between 25 and 75%," Rubin says. "I don't feel that the hospital or any @ Well, Doc, it sounds to me like this Living Will could be a r @dangerous thing, and that it really doesn't give me any options t Bthat I don't already have - so who's pushing for this Living Will and why? solino die, wrote in the medical record last January n that he believed the living will's conditions did apply. hakers s mbers Katz telling her. a e > With this groundwork accomplished by the time Hitler took to Apower, it was a small step to justify the extermination of other Bgroups of people deemed "burdensome" or "subhuman" - such as Jews patients with food and fluid is basic human care, not medical r, Btreatment, even if linger on? usolino's ordeal began when he suffered a major heart attack in 1988. A catheterization revealed severe blockages in B Joe, death by deliberate starvation and dehydration is a very answered that it would save the state of Florida five billion nd Bdollars in ten years. In such a view, human life ie old people "live too long" and rs Ahave a "duty to die" when their medical needs become financially burdensome. es he looked real disgusted and sometimes he looked a really sad," says his daughter. "But it was never like you to < We ts who or accordingly. wrote in the record that his fluctuating state of d consciousness was caused by his severe heart, lung and kidney ell A Already, Joe, there are politicians like ex-Governor Lamm of >Colorado, who stated that somt's 81), further increasing the number of elderly, it ake Abecomes obvious that the strain on our social welfare and health ;care systems will soon be tremendous - and the pressure on of 7elderly patients to "get out of the way" will increasif abortion continues. hanasia, . that would allow the "passive" starvation of patients but forbid B When you add to these figures the fact that people are living Alonger (in 1969 the average age of nursing home patients was 64, =today iems we're =presently having in "cost containment" in health care. It's st Bpredicted that in the year 2010 there will be three people in the =work force to every one on Social Security - and in 2040 the my r 6ratio will be only two to one, e. of such a discussion. . People aged 85 and older - are increasing three times faster than the population as a whole. B Right now we have five people in the work force for every one Aperson on Social Security, and you know about the probld every year out of the 5.2 cord :million conceived. This means that between 25 and 28% of the :pregnancies end in abortion. As the years progress, this term ?translates into a loss of one quarter or more of the potential ) work forcgo ahead with the bypass operation, obtaining his wife's consent over the B Much of it is economic in origin. You see, since the release >of the abortion holocaust in our country, there are about 1.5 ce =million preborn children destroyeLegislatures in states such as Hawaii are pushing to 5decriminalize active euthanasia by lethal injection. asia in this country. The demographic reality of an aging population, with e " What accounts for this trend? z and Rubin decided to situation and what was best e > Joe, euthanasia is here, now. At least 25 states already t =have Living Will statutes. There has been a series of court as a ?decisions mandating the starvation and dehydration of tube-fed f @patients. at all, ormally ; The real answer to your question, Joe, is based on the he e >previously secure principle that all human life has intrinsic he Avalue simply because it is human life, because it comes from God Band is therefore sacred. We do not own it, it belongs to God and is returned to God. r that test, as under the limited- moral s t "He had the trembles. From all the antibiotics, he had er A You will say that this is a religious approach. Yes it is. @Is, which the document directs doctors to , 0=avoid, may be just what a patient needs to save their life. s;on dialogue format. is at the mercy of the family, doctor, hospital :Abstract:aw. on the lives of others it is expected that this , 1991, pp 42-43.  ? Author:Richard G. Nilges, M.D.ly 1-7, 1991, pp 11-12. 37. 32. /צ Abstract: an Okies E. Rice., S.J.!.[G&TEXT? This doctors warns against the dangers of signing a living h >will. Heroic measure2 THE WAR BETWEEN BENTHAM AND KANT O KILLING , EUTHANASIA IN NAZI GERMANY AND CONTEMPORARY AMERICA - Richard G. Nilges, M.D. ng 1991, pp 42-43.8. > ALL About Issues, Vol. 13, No. 2, Spring AReproduced 1992 with permission. Copyright (C) 1990 by American Life League. and barely responding to voice. Today he clearly n o, M.D., is a physician in private practice d %living in Port Washington, New York. to the patient. When a we The family pressed for a decision on Musolino's competency and sent telegrams to Katz and Rubin "firing" them from the case.f an effort to Nazis DEATH IN THE NETHERLANDS e to determining whether an incompetent Epstein's notes concluded: "Indicates will to live, but t About the Author: e information and communicate decisions re: ee ? Raymond J. Voul9the desire to annihilate the unwanted elderly and ill by ons: an /starvation and eventually by lethal injection. t to die?" stomy "Shakes head no." "Do you want the doctors to stop all article, " Joe, when will we ever learn? as part octity of human life as we did in Roe v. Wade absolve your doctor of the respon in the face. You can designate that you want all s @treatment given to preserve your life, but pressure will be put an =on you to sign the directive for avoiding "heroic measures," all Bwhich could be as simple as intravenous feedings for a dad your spouse are upset and ?worried at the time of hospital admission, and these forms are e anAeven more upsetting and cruel. Perhaps you came to the hospital >expecting to get well, not to die, but here is your mortality in >staring youtroke צb>already signed one, you'll have to sign a "living will" or an ed me ?authorization designating a close relative to make health-care nd @decisions for you if you are unconscious (a so-called "power of  :?attorney for health care"). You ans. he words" reasonable expectation of recovery" are much too vague. What would fulfill such a definition? When a n @ Now, according to the new law, you will be presented with a ;form to sign on admission to the hospital. If you haven't t a doctor's prognosis is at &Bbest an educated guess. If he or she tells you that life support @for your child, your wife, or your husband will be discontinued e á@because there is no hope, is there really no hope? You have to accept a guesper  Bthan dying now, compared to lingering in an intensive care bed at ʅ?well over a thousand dollars a day. But what if there is some "I ?hope that further treatment might save you or your loved one? , BWhat then? I've already told you thact (or the Danforth/Levin law after its sponsors). @Notice that it is therefore part of "budget reconciliation," if g Anot in spirit at least in actuality. It will have the effect of Asaving money for Medicare and insurers. There's nothing chea. Despite his living wal  "Artificial means," Joe, include not only respirators, but ws WB As part of the Omnibus Budget Reconciliation Act of 1990, the (ʅ7death-lovers have tacked on the so-called Patient Self-" about , CDetermination A I ٕA The next morning, my patient was sitting up in his intensive Ccare bed, talking to his wife and the nurses and asking for food. isBWas this evidence of my skill in operating, my unreliability as a "forecaster...or God's mercy? Washingtony prognosis, and she said simply, "I know you've ?done everything you could, doctor. He's in God's hands. I'll 6pray for him - and you." o reasonable expectation of my recovery from a seriously incapacitating or lethal illness or condition,re of years ago. He was Bunconscious and had unstable vital signs after a fall. I drained :a massive hemorrhage from his brain. When I finished the keep e Coperation at midnight, I did not expect him to live till morning. BI told his wife m Asurprised, but death advocates are in the business of destroying ܾ all hope. hat's this Living Will that I've been hearing so much about lately? to chart his own medical destiny. In 1989 he wrote B I'll never forget a patient I took catelling the outcome of a disease or injury, is T:the most tricky art in medicine. No one can predict with he ff," TexAcertainty the circumstances of death in the far or even the near N9future. Doctors are continually surprised, even happily state lsibility for making "heroic" re @efforts (and causing more expense, of course) to save your life /and possibly return you to a normal existence. case raises go on V And there's more. The Living Will places doctors in a legal ted> "Life support" measures have a bad name nowadays. But we y" @must remember that they are what they are called. They support d Band save lives by the thousands. Respirators saved polio victims V@in the polio epidemic of the fifties. Unconscious persat it really doesn't give me any options t A Several days previous my patient was a vigorous woman of 50, >in perfect health, a wife and mother, an executive in a local n @bank, and a volunteer in the hospital gift shop. Now she was a s that, you need if A "You're her doctor, and you know she's dead already. I'm in @charge of intensive. Get her out!" The doctor ended his phone call. ll, Doc, it sounds to me like this Living Will could be a r dangerous thing, and thour will, put you on a respirator and keep you alive ake terms t @ "Where?" I asked. "She's dying. She'll die on the general . floor." s is not true now, never was true, and never will be of true. You don't need a Living Will to prevent death on her chart. The hospital , @can't lose money. We've got to survive. We're not in business s Bfor our health. You're keeping a corpse alive. At least get her off intensive care." breathing tube put in your trachea, against y patient has an -8-Beconomic future, and insurance will pay his bill. Your patient's ?dead, brain dead. That smart young MBA in the business office s Bsays her insurance company will not pay any more because you have =all the findings of braine. on for you. You've always had he right to refuse he rest e treatment, you have it now and you will always have it, the the ? "I need the bed for a cardiac patient. We've got to treat Athe quick and not the dead in intensive care. Myrespects including a beating heart, f Ver@such a patient could give a "gift of life," a vital organ - his ers@or her heart or liver - to save another person. So I'll always &@remember that phone call from the doctor in charge of intensive care yesterday. es AThe "foot in the door," the grease for the initial slip down the $Aslippery ethical slope toward euthanasia, was the promise of the  ?organ transplanters that if a patient could be declared "brain s ?dead," yet living in other barrel investment. e thru a feeding tube, and that I would n die of starvation even though I had some chance of recovering? . tA The focus on economics reminds me of another patient, from a Afew years ago but fresh in my mind as though it werients alive in this country who e" t P(?might (or might not) be hopeless is truly insignificant in the . , Bscope of our national budget. Life should be accorded more value (am?than a Representative's pet development project or a Senator's nt pork tment, of a צ3allowing them to better compete with the Japanese. seen in the  :treatment of patients who have not signed a "Do Not Resuscitate" = Economics rules and the budget must be balanced, but the y =annual expense of keeping patight" you'll have left then is your "right to die." Why? BBecause society says it is cheaper that way. Insurance companies Awill be spared expense. Our auto manufacturers will not have to ard You could be signing away your right to such "heroic" but al  Alife-saving treatment when you sign one of these documents. The Bonly "rons with Bsevere head injuries and inability to breathe are sometimes saved Bby being placed on a ventilator which breathes for them. Cardiac e;monitors, medications, and intensive care have reduced the ely ge @mortality rate of first heart a@medical wreck, held to life only by a respirator forcing oxygen Bin and out of her lungs. An auto accident had damaged her brain. nutrition from patients becomes accepted and decriminalized "In > I stood by her bed. Her chest rose and fell mechanically ier with the respirator's sigh. ve fallen. Step two will be the al." observation that death by starvation is a painful, drawn-out nt. @ "Clara," I called. No response. I did the tests again: no @reaction to pinch, no =killing of one person by another in the name of their mutual ing ܾAright to be killer and killed if they freely agree to play those @roles. This turn flies in the face of a longstanding effort to e Alimit the circumstances under which one phe first is that of the legitimate conditions Tof another, from efforts to control the free flow of guns and ned Aarms, to abolish capital punishment, and to more tightly control Bwarfare. Euthanasia would add a whole new category of killing to Aa society that already has too many excuses to indulge itself in  that way. thing you could, doctor. He's in God's hands. I'll 6pray for him - and you." o reasonable expectation of my recovery ? The second turning point lies in the meaning and limits of ttacks from 40% to less than 5%. . ckIn marginal cases, therefore, it would become legally n such will < How are we to make the moral move from my right of self-t al  @determination to some doctor's right to kill me - from my right Bto his d by the Amoral and physical assistance of another. Euthanasia is thus no =longer a matter only of self-determination, but of a mutual, diac eAsocial decision between two people, the one to be killed and the other to do the killing. eart aof suicide, where a person takes her own life without " ?assistance from another, that principle might be pertinent, at d Aleast for debate. But euthanasia is not that limited a matter. V@The self-determination in that case can only be effecteg to their own beliefs about re Bwhat makes life good, how they will conduct their lives. That is ?an important value, but the question in the euthanasia context on VBis, What does it mean and how far should it extend? If it were a ted?question y or so, 2basic cardiac medications, or antibiotics for an elderly person A Central to most arguments for euthanasia is the principle of @self-determination. People are presumed to have an interest in , >deciding for themselves, accordinia and medical practice. signate that you want all s treatment given to preserve your life, but pressure will be put an on you to sign the directive for avoiding "heroic measures," all SELF-DETERMINATION imple as intravenous feedings for a daell-being; (2) the moral nd >irrelevance of the difference between killing and allowing to e anAdie; (3) the supposed paucity of evidence to show likely harmful @consequences of legalized euthanasia; and (4) the compatibility n $of euthanastroke צb:proponents of euthanasia push us in the wrong direction. an ed me 8Arguments in favor of euthanasia fall into four general h-care nd Acategories, which I will take up in turn: (1) the moral claim of  : The third turning point is to be found in the claim beingmedicine, to help them al @pursue that life, even at the risk of harm to the common good. s WBThis works against the idea that the meaning and scope of our own (ʅ;right to lead our own lives must be conditioned by, and be out , Bcompatible with I ٕAself-determination. The acceptance of euthanasia would sanction @a view of autonomy holding that individuals may, in the name of . isBtheir own private, idiosyncratic view of the good life, call upon ">others, including such institutions as right? Where does the doctor's moral warrant to kill come Afrom? Ought doctors to be able to kill anyone they want as long >as permission is given by competent persons? Is our right to to ardBlife just like a piece of property, to be given away or alienated צBif the price (happiness, relief of suffering) is right? And then :4to be destroyed with our permission once alienated? Resuscitate" Economics rules and the budget must be balanced, but the y ? In answer to all those quAis unbearable. And if it is difficult to measure suffering, how :much more difficult to determine the value of a patient's really -statement that her life is not worth living? beat? Could a very corpse have a beating heart? Her heart woule in Holland at the euthanasia conference treating the patient's values. To be responsible, the doctor n decide, on her own, whether the patient's life was "no longer "In worth living." her bed. Her chest rose and fy one will find the suffering unbearable. APeople suffer, but suffering is as much a function of the values Bof individuals as it is of the physical causes of that suffering. >Inevitably in that circumstance, the doctor will in effect be a s diseases and if @their dying, and whether they find life more of a burden than a Bbenefit, has very little directly to do with the nature or extent ?of their actual physical condition. Three people can have the r Bsame condition, but onlecome so burdensome it no longer seems worth living. ake terms t "Where?" I asked. "She's dying. She'll die on the general . A The doctor will have a difficulty at this point. The degree =and intensity to which people suffer from their then they must have their own tal , 9independent moral grounds to kill those who request such siness s >services. What do I mean? As those who favor euthanasia are her ?quick to point out, some people want it because their life has t 6b patient has an -8-8 There is another problem as well. If doctors, once patient's 9sanctioned to carry out euthanasia, are to be themselves ffice s >responsible moral agents - not simply hired hands with lethal ave 8injections at the ready -tever their motives, whatever the circumstances. Consenting e Badult killing, like consenting adult slavery or degradation, is a  strange route to human dignity. c patient. We've got to treat the quick and not the dead in intensive care. Myno less a wrong for another person to VerAhave that kind of total, final power. Like slavery, dueling was ers9long ago banned on similar grounds: even free, competent always &:individuals should not have the power to kill each other, nsive @what one person es @should not have the right to own another, even with the other's $?permission. Why? Because it is a fundamental moral wrong for e  ?one person to give over his life and fate to another, whatever s Athe good consequences, and and then give to another the power to take that life, uld n 7requires a justification yet to be provided by anyone. vering? . t The focus on economics reminds me of another patient, from a @ Slavery was long ago outlawed on the ground thaestions, I will say this: I have t P(Byet to hear a plausible argument why it should be permissible for , @us to put this kind of power in the hands of another, whether a e (am@doctor or anyone else. The idea that we can waive our right to t However one might want to answer such questions, the very e, Bneed to ask them, to inquire into the physicians's responsibility Band grounds for medical and moral judgment, points out the social ?nature of the decision. Euthanasia is not a private matter of t, >self-determination. It is an act that requires two people to s. Amake it possible, and a complicit society to make it acceptable. well...we think...Gee, doc, she gave me 30 years of happy food omonly its timing and the 5.2 cord Acircumstances, not its ultimate inevitability - moral rules were Adevised to set forth their obligations. Natural causes of death @were not thereby banished. They were, instead, overlaid with a :medical e or head :wrong, and to devise moral rules to deal with them. When er the >physicians could do nothing to stop death, they were not held ase @responsible for it. When, with medical progress, they began to 5have some power over death - but ty and culpability are confused, second, when we fail ?to note that judgments of moral responsibility and culpability is Bare human constructs. By that I mean that we human beings, after =moral reflection, have decided to call some actions right in contrast, bring the life :of a sick person to an end because of an underlying fatal ady t disease. ng Will statutes. There has been a series of court as a decisions mandating the starvation and dehydration of tube-fed f A Causalif orm @injection will kill both a healthy person and a sick person. A e ?physician's omitted treatment will have no effect on a healthy ho ;person. Turn off the machine on me, a healthy person, and ays. @nothing will happen. It will only, morally responsible for the death, if we have ents Amorally judged such actions wrongful omissions. But it confuses Breality and moral judgment to see an omitted action as having the 9same causal status as one that directly kills. A lethal oan underlying lethal disease Ais construed as causing death. On the contrary, the physician's Bomission can only bring death on the condition that the patient's @disease will kill him in the absence of treatment. We may hold s there is no moral difference between stopping life-sustaining ore ;treatment and more active forms of killing, such as lethal rican Binjection. Instead I would contend that the notion that there is Bno morally signif married life...I can't say this...You're the doctor - do what you KILLING AND ALLOWING TO DIE l will have me dig into our - I mean my - savings to pay when her insurance will no longer pay." less, @ Against common opinion, the argument thics designed to determine moral culpability in lder - deploying medical power. s faster than the population as a whole. Right now we have five people in the work force for every one ? If we fail to maintain the distinction between killing and e 5allowing to die, moreover, there are some disturbing . It's st Apossibilities. The first would be to confirm many physicians in Btheir already too-powerful belief that, when patients die or when @physicians stop treatment becau? Why would it be hard to precisely write, and then enforce, l @the law? The Dutch speak about the requirement of "unbearable" Asuffering, but admit that such a term is just about indefinable, Aa highly subjective matter admitting of no obce in Holland was the casual, seemingly -f =indifferent attitude toward abuse. I think that would happen use everywhere. same time Judeo-Christian principle. The anti-life cult demand that we do so, by once again perverting the meaning t priority in the =criminal justice system. Like other laws of similar status, not ?unless there is an unrelenting and harsh willingness to pursue ut Aabuse, violations will ordinarily be tolerated. The worst thing ?to me about my experienubstantial number of cases of nonvoluntary euthanasia, that is, =euthanasia undertaken without the explicit permission of the g nt >person being killed. The other reason abuse is inevitable is an Athat the law is likely to have a low enforcemenions to me by Dutch proponents of od and ?euthanasia, and from the corroborating information provided by t Athe Remmelink Report and the outside studies of Carlos Gomez and ?John Keown, I am convinced that in the Netherlands there are a Asalmost all laws ?on delicate, controversial matters are to some extent abused. =This happens because not everyone will agree with the law as he Bwritten and will bend it, or ignore it, if they can get away with ;it. From explicit admiss inherent slipperiness of the moral reasons for legalizing ole euthanasia in the first place. rom? Who "owns life" and where e does life go in the end? t is wrong with you people?" ny patients A Why is abuse inevitable? One reason is that o control my own body, so don't atz at A Three consequences seem almost certain, in this or any other 9country: the inevitability of some abuse of the law; the Quill's Bdifficulty of precisely writing, and then enforcing, the law; and >theons in ng more AHolland, and from the articles on that subject in this issue and =elsewhere, I believe we can now fully see most of the likely not "consequences of legal euthanasia. chart, so that he would not be Doc, I have the right ttting euthanasia are raised, its advocates tend to dismiss next, most reasonable step, on grounds of both humaneness and d Beconomics. I do not see how that logic could easily be rejected. Already, Joe, there are politicians like ex-Governor Lamm of Colorado, who stated that som should not be attributed the powers of the gods. The ke ?second possibility would be that, in every case where a doctor h Ajudges medical treatment no longer effective in prolonging life, ?a quick and direct killing of the patient would be sese of the futility of continuing Ait, they are somehow both morally and physically responsible for @the deaths that follow. That notion needs to be abolished, not g @strengthened. It needlessly and wrongly burdens the physician, >to whomjective standards. BA requirement for outside opinion is nice, but it is easy to find @complaisant colleagues. A requirement that a medical condition o @be "terminal" will run aground on the notorious difficulties of d .knowing when an illness is actually terminal. did in Roe v. Wade has called forth the slaughter of over 26 million helpless, , f B Considered from these angles, there are no good moral reasons ?to limit euthanasia once the principle of taking life for that d al phenomena, not that our arm ;suffering which comes from anguish or despair at the human , or condition. usolino shook his head "no." st protection is to make one's intent known to a trusted family member or friend who will ; Doctorsway of @evaluating such claims on the part of patients, and they should h Bhave no right to act in response to them. Medicine should try to Brelieve human suffering, but only that suffering which is brought :on my illness and dying as biologicch turns on the meaning we assign to the decay of @the body and its eventual death. It is not medicine's place to @determine when lives are not worth living or when the burden of Blife is too great to be born. Doctors have no conceivable sure to do, it moves beyond its proper role. time. ts' lives without their consent. produced In 45% of the cases in which the lives of hospital uce pain B It is not medicine's place to lift from us the burden of that ?suffering whih ed Bmedical and philosophical or religious. "Why must I die?" can be Aasked as a technical, biological question or as a question about suicide, turning judgments about its wohey find life empty, oppressive, or meaningless. @Their judgment is a judgment about the value of continued life, @not only about health (even if they are sick). Are doctors now o @to be given the right to make judgments about the kinds of life aims of medicine. I @would note at the very outset that a physician who participates Ain another person's suicide already abuses medicine. Apart from Bdepression (the main statistical cause of suicide), people commit Csuicide because t Reproduced 1992 with permission. Copyright (C) 1990 by American : A fourth kind of argument one often hears both in the arly n @Netherlands and in this country is that euthanasia and assisted >suicide are perfectly compatible with theodious expressway. cian in private practice d living in Port Washington, New York. to the patient. When a we The family pressed for a decision on Musolino's competency EUTHANASIA AND MEDICAL PRACTICE ubin "firing" them from the case. seems cruel and azis Bcapricious to deny it to the incompetent. There is, in short, no Areasonable or logical stopping point once the turn has been made :down the road to euthanasia, which could soon turn into a re: ee &convenient and commmedically accompany serious illness and the threat of death. ho @They should relieve pain, do what they can to allay anxiety and ?uncertainty, and be a comforting presence. As sensitive human e Bbeings, doctors should be prepared to respond to patients who ask @why they must die, or die in pain. But here the doctor and the Apatient are at the same level. The doctor may have no better an Aanswer to those old questions thality offered by neighboring nations. Those in need of @resettlement outside of Africa are refugees in life-threatening o >situations or refugees who cannot easily be assimilated - for t f n2example, urban Ethiopians and some South Africans. the coceive refugees.t to argue its > For most of those African refugees needing protection and re Aassistance from the international community, resettlement to the BUnited States is not the desired solution. Most can benefit from Bthe hospitas, or, ? The continent of Africa suffers from a complex and dynamic to Arefugee situation. There are some 35 African countries offering @asylum to refugees fleeing from at least 17 African countries. 2Many countries both generate and reling of 4,000, and will expand the current refugee n *processing priorities used for the region. in 1965, and the ical Refugee Act of 1980. The degree to which the above is superceded $ AFRICAo the Status of Refugee trouble many countries in are not available. To achieve this goal, we have proposed an , o @increased ceieady Ato resume its obligations under the agreement, we will not do so ?until the Cuban government agrees to fulfill its obligation to t -accept the return of the Mariel excludables. aws. The complexity @ As political turmoil continues toluded sufficient numbers in our proposed Latin s.. BAmerican ceiling to admit 3,000 Cubans as refugees in fiscal year >1987 should the Government of Cuba lift its suspension of the ity BMariel Migration Agreement. While the United States stands r political prisoners and ?former prisoners. I am pleased to confirm that over 100 Cuban ns =political prisoners and their families arrived in the United a w States on September 15.o three thousand - a figure difficult to > We have ince ; In light of the Cuban release of a number of long-held al as Bpolitical prisoners in 1986, and consistent with our deep concern ?for the welfare of these individuals, the President authorized @processing in Havana of long-term Cuban situation, there is not the slightest suggestion that her .TEus to process not only the hopen to depart the Soviet Union has continued to decline in ?the past year. We continue to press for freer emigration from s, 9the Soviet Union and have adjusted our admission ceiling iolence The numerous humanitarian issues confronting the region - m ex>refugee and displaced persons, political violence, hunger and rd N>medical problems - must be dealt with more adequately or they one the developments inside El Salvador. The U.S. should explore m o Bwith the Salvadoran government th is by far the largest component of the relief ican r Aprogram, WFP is empowered to assume a coordinating role if asked. an > However, the role of international coordinator would even eir Bmore appropriately and effectively be played by the UNHCRSimilarly, the WFP is moving n @to establish a more permanent program to meet what clearly will dan;be on-going food needs among displaced persons. Since the h the ;provision of food - and the food-for-work programs for the e l e :displaced -of ees b:accomplishment in El Salvador and could easily expand its ts is e me ;operation and staff to provide needed coordination, if the ong d Bgovernment of El Salvador requests it and if the United States is :@willing to support its expansion. RC, the U.N. World Food Program (WFP) or, the good , ?offices of the UNHCR, as the international coordinating agency +for humanitarian assistance in El Salvador.hurches and synagogues > The ICRC already has a substantial presence and record coordinate humanitarian to &Bassistance, as well as to assure that needs are equally met among @the various groups now being assisted - and to depoliticize the o á?use of such aid - the U.S. should support efforts to designate an @either the ICelp.  @As outlined in this report, there are currently three different t ʅpersons in El Salvador, and too little coordination or mutual t - >support exists between them. Both toStates should lend strong diplomatic support to ;the creation of an international coordinating agency in El o n e. >Salvador to stimulate and channel additional assistance to an d Cestimated half million internal refugees who are in need of h provide refugee to use e ;protection. However, in El Salvador no such international ible W:umbrella exists for an even more serious displaced person he he s (ʅ problem. It is urgently needed.ocation.s the movement providing ? The United e ٕ;of the Red Cross (ICRC) and the U.N. High Commissioner for ds, is ;Refugees (UNHCR). In Honduras, the UNHCR is performing an to the is@outstanding role as coordinator for international assistance to "8refugees, and fulfilling its mandate toeffort to bolster and expand the work of the me Aseveral international and voluntary agencies already involved in 6=the area, and to encourage others to join in the effort. Of ve Aparticular importance is the work of the International Committe 4,000 so much the A 1. Strengthening international protection and assistance to >refugees and displaced persons. If the needs of refugees and um Bdisplaced persons throughout the region are to be adequately met, >there must be an in El t es BSalvador was not addressed by the United States or the government >of El Salvador. The first effort to assess their numbers and n ̂ethe dark days of the La Virtud situation are behind us and an program to assist and protect a growing number of Salvadoran, In ?Guatemalan and Nicaraguan refugees in Honduracomplementary program of humanitarian aid esi@is also needed to help El Salvador provide basic assistance and ona9protection to its citizens displaced by the conflict and ng for or violence.ave resulted most immediately in a halt to the departure Genited States, the at B There must be a commitment to improving the conditions of the hus?displaced persons as part of the overall strategy for economic e Rosht continues; o -8-; * The nation's economy, and its support of the health, e d t to Beducation and welfare programs (such as they exist) will continue out to decline.ance of continuity does not change the fact that the r bB In short, the humanitng civilians in rural areas and contested zones cut-off by the fighting;ion camps, and their close family members.an exclusive @ * Human rights violations will persist in many areas of the y >country as the violence from the left and the rigdent upon regular distributions of n Ver=food and medicines, some in short supply and both subject to erly ersmaldistribution;m. Our commitment is to accept all Amerasian ing &? * Pockets of serious malnutrition and disease will persist Bamoremain in need es @of help as the conflict in the countryside continues and as the economy continues to flounder;applied for recognition as efugee  ? * Tens of thousands of displaced persons, mostly women and ng >children, will remain depenh are still sub-standard in some areas) - or to respond to e  shortages of food and medicines.Southeast Asia. We are s the to e t. In the days ahead, El Salvador can expect:mong those who have B * A large population of displaced persons will enerating, food-for-work type of ent P(?project, and an immunization program. However, by mid-1983 it d K, Bbecame apparent that such efforts were inadequate to meet growing (amprovided a small employment gng in "extremely deplorable conditions." Over the We d Bfollowing year, but particularly since the beginning of 1983, the @number of displaced persons in such conditions has increased as s ardAthe problem in many locations increased into large-sc and the Honduran civilian and military ve n authorities.orking-level meeting in Hanoi, the Vietnamese nce d B Camp conditions in Mesa Grande, where some 10,000 Salvadorans Bare settled, are good by international standards. Although there Ais not enough land to allow them to become self-sufficient, even Aif the Honduran government permitted them to farm it (which they ?do not, except under strict controls), the camp is nonetheless ;relatively spacious, the programs of suppor 6 THE TRADITIONAL POLITICAL OFFENSE EXCEPTIONts to d's ܾ@ The standard employed by the courts in the United States to , ?determine whether extradition should be refused on the grounds ol Bthat the offense in question is a politicr 30 countries. Based on this experience, the T;Committee has testified in Congress and prepared papers on - m ex*various asylum and refugee policy matters.iolence, hunger and rd Nmedical problems - must be dealt with more adequately or they onede representation to t צ@individual asylum applicants in the United States. The Project s Autilizes volunteer lawyers whom it trains and supervises. Since A1978, the Lawyers Committee has represented more than 250 asylum Bapplicants from oveA Since 1978, the Lawyers Committee has been a public interest 9>law center working in the area of international human rights, for *=refugee and asylum law. The Political Asylum Project of the m ty EX@Committee has created in late 1980 to provirence between legitimate political asylum t 0;and refuge from some crime or offense in a foreign country.ersity in their homelands.a, Orderly Departure, political prisoners, Ray :Abstract:ugh several years old this Senate Committee report ach d :. ? Abstract: Arthur C. Helton (Director, Political Asylum Project) צB This article describes the legal basis for granting political TBasylum to refugees. Court decisions are used as a foundation for ?determining the diffe* WHAT IS A REFUGEE? AMERICAMENTICAIMONY, VIDEOTAPED TESTIMONY,= By Arthur C. Helton (Director, Political Asylum Project)87)A Judiciary H.R. 99th Congress (Sept. 1986)protection is more than >satisfactory and it deserves the strong support of the United ns States.al prisoners and their families arrived in the United a w e ? The longer-term problem of reaching a durable solution for s =the refugees in Honduras, especially for the Salvadorans who cern infrastructure of personnel and programs has been established at =under UNHCR auspices and it should be able to handle such an are influx easily. LATIN AMERICA AND THE CARIBBEANledge the ern npanying relatives have ? In general, refugee conditions in Honduras are stable, and . alleged that he would be denied a fair trial if extradited to to =Italy, ucture of >the state," and those that disrupt "the social structure that ent 9established the government." Terrorist activity, unlike and n ̂e=political activity conforming to the test, "seeks to promote er Aspecial chaos," in contrast to ng the social foundation of the government."r, ose in e? B The court drew the distinction between terrorist activity and Aactivity eligible to the classified as political offenses as the VAdifference between "acts that disrupt the political str (1) The civilian status of the ;victims and the randomness of their selection; and (2) the is n y ;objectives supposed common to both terrorist and anarchist of h V;activity, namely "the destruction of a political system by e for ted5underminie by an 2Aanarchist. The political exception was held not to apply on the 6ground that "the party of anarchy is the enemy of all tied to e Agovernment." The court in Eain identified the following factors Aas relevant to the determination:nineteenth century British case which excluded from r Bacts classified as "political offenses" those which are "directed an bombing and the political goals of the PLO. The individual's is :Amotives in committing the offense, plaining that those "cases involved ongoing, good , @organized battles between contending armies, a situation which, ;given the express nature of the PLO, may be distinguished."gogues A As to the question of whether or not the act was "incidequirement, the court noted &?that it must constitute a "war, revolution or rebellion." The ng >court distinguished the nature of the conflict in Israel from e o áBother disturbances where the political offense exception had been :sustained, ex lp.  >alleged to have planted a bomb in the market area of Tiberias t t ʅ?during a Jewish religious festival and youth rally. The blast en ?had killed two boys and maimed and/or injured 36 other persons. - A As to the political disturbance rcase, Eain v. Wilkes, involved a Jordanian t to Liberation Organization (PLO) whose extradition to Israel was d >requested on charges of murder and aggravated harm. Eain wasite of the commission of e =the offense; (2) whether Mackin was a member of the uprising ble W?group; and (3) whether the offense was "incidental to" and "in s (ʅ'furtherance of" the political uprising..s the movement providing : The second e ٕA In Mackin, the court reviewed the case law and distilled the ?following factors to determine whether the Offense in question he isBwas political: (1) Whether there was a war, rebellion, revolution "@of political uprising at the time and sthe court did, in fact, discuss the nature of Italy's e d ?judicial procedures. In rejecting the individual's claim, the he =court emphasized that Sindona has "not even made a threshold as s ard@showing that he would be subject to procedures in Italy that he צBwould be so violative of human rights as to prevent extradition. :?There is no indication that the materials submitted by Sindona , @that the Republic of Italy subjects accused persons to anything d Bapproaching summary proceedin@on the contrary, a "political" crime, regard should be given in @the first place to its nature and purpose, i.e., whether it has ?been committed out of genuine political motives and not merely @for personal reasons or gain. There shoulded political purpose and objective, ary ve n Bincluding whether the offense is grossly out of proportion to the 0alleged objective. It states in pertinent part:0,000 Salvadorans A "In determining whether an offense is "non-political" or is, n determining what >constitutes a political offense. It teaches that the inquiry , ;should focus upon the nature and purpose of the offense in an =question, including motive; and the relationship between the in e 9offense and its allegBDetermining Refugee Status under the 1951 Convention and the 1967 cto;Protocol Relating to the Status of Refugees" (Geneva 1979) r in re *("Handbook") in order to decide the issue.mber of Salvadoran, In @ The Handbook provides specific guidance iulations do not define what constitutes a esiAserious, non-political crime. In a leading administrative case, ona?the Board of Immigration Appeals looked to the United Nation's or =High Commissioner's "Handbook on Procedures and Criteria for ture Gem, however, can be at >denied if there are "serious reasons for considering that the the hus>alien has committed a serious non-political crime outside the e RoUnited States..."lvador. While some military assistance is hat t tA The statute and regas been persecuted or has a well-founded fear of persecution ts roBupon return to his country of national origin on account of race, ti@religion, nationality, membership in a particular social group, ly Bor political opinion. An application for asylurefer to the procedures and standards by ts >which it is determined whether a crime is political in nature ew t o4and, therefore, does not preclude a grant of asylum.grams in El ena@ An alien merits political asylum in the United States if he and>hted of a crime. -8-justice system which comports with standards of the civilized ing (amAworld." The Italian government, the court noted, is "evidencing >its i also be a close and ?direct causal link between the crime committed and its alleged e the caravan left the following morning on the next leg of its o , @journey. A very young Guatemalan family, Alfredo (not his real l @name), his wife, three-year-old daughter,d I was working toward the organization of the T>another task force on Central America within the Presbyterian m ex(Synod of Southern California and Hawaii.s.iolence, hunger and rd N? A Sanctuary caravan arrived that afternoon from Phoenix; a ners; we are well ntry t צ=informed about suffering and oppression in Central America. ct s 7Gloria had just been invited to serve as the Sanctuary s. Since @coordinator of the Southern California Interfaith Task Force on >Central America, an The sanctuary movement is - in its broadest common interest 9@ My first direct exposure to the Sanctuary movement occurred r *Ain June 1984. Gloria and I had served as missionaries under the EX;Presbyterian Church of Guatemala for 13 yean. This article demands that we reach out 0@and help the Central American refugees who come to this country y 'on the basis of a mandate of our faith., political prisoners, Ray :Abstract:ugh several years old this Senate Committee report ach d :. ? Abstract: Ross and Gloria Kinslertor, Political Asylum Project) צ7 The sanctuary movement is - in its broadest common political T;denominator - a deeply human, humanitarian, and interfaith on for @response of compassio; REFUGEE SANCTUARY: FOR THOSE LOOKING FOR A SAFE PLACE NY, VIDEOTAPED TESTIMONY,. By Ross and Gloria KinslerAsylum Project)87)A Judiciary H.R. 99th Congress (Sept. 1986)eady a means of securing their extradition. The most that wish to take reprisals against their political opponents w ?living in exile would simply charge them with violation of the Acriminal law as a 0political opponent of the requesting government.e solution for s < A decision by the State Department to grant extradition cern 8without adequate judicial review would raise a distinct me, ed Bpossibility that innocent people would These charges are the pretext for arbitrary one Bdetention, in some cases without a proper trial or due process of ?the law. In these situations it would be highly inappropriate e Bfor the United States to grant an extradition request involvingections guaranteed by Aour judicial system. In many countries where a pattern of human ;rights violations are occurring, it is often the case that l of @political opponents of the government are charged with criminal s =law violations. considerable cost and effort. This is particularly the case if & CONCLUSIONoncagua is moved from the y ; There are many countries throughout the world that are ime s ?unable, or unwilling, to provide the prot and baby, and another a @young man, who had recently come across the border from Mexico, ?were being accompanied to a sanctuary church in Seattle. This um :was not done secretly. The caravan cars carried banners; y few , >services open to the public were held at each stop; the media t >were invited. I was asked to translate when the young couple in 6:gave their testimony that evening and when they talked to ve to journalists after the service.dard.f the International Committer hearts are moved with e contest ocktry to explain why churches in the United States - as well as n y Bsynagogues, universities, and other organizations - are declaring V(sanctuary for Central American refugees.olitical system by e for ted7 The Se by an 2? Alfredo concluded with these words: "There are hundreds of e >stories like mine. Some we can tell. Others no one can tell e /because whole families have been exterminated."following factors ? It is with these stories in o my family, to see who would claim them in order to r Bkill them as well. When it was all over, we found my family made an Cinto balls of meat and bone. We were unable to recognize anyone. 5The children were for the most part reduced to ashes. cafcountry, who with their own e 6hands in their official uniforms carried out the act."arly will danB It was two o'clock in the afternoon. "No one could enter the :hamlet as the army continued guarding the 24 cadavers, in relied ?addition tos were b?there, along with Anita, his oldest niece, her little brother, d me Banother nephew, and his youngest niece, who had just been born 17 Bhours earlier. They were burned alive in their home, "accused of :?being guerrillas by the army of my e older children, fleeing in any direction., good , B Alfredo's mother and father were not at home but working on a Bplot of land about two miles from the house. He and his wife and Bchildren were also outside the village. But his two sisterd hear the trees topple ted &=over. After about ten minutes a helicopter arrived where we e ng @were, machine-gunning indiscriminately. The women were crying, o áAshouting, praying, carrying along the smallest children, the men 8pulling on th lp.  =struck again. Two airplanes arrived to bomb the neighboring t t ʅAhamlet. "I remember when the bombs fell. I felt my heart burst Afrom the noise they made. We looked and saw how the black smoke =rose, and then at a distance you coulnd two brothers-in-law were assassinated in 1980 Bby soldiers dressed in civilian clothes. His brothers-in-law had Abeen rural school teachers, and they left behind his two widowed them along the way, Alfredo explained that theirs is just one ion "=among "hundreds and hundreds" of familithe court did, in fact, discuss the nature of Italy's e d A For Christians in the Sanctuary movement this is a matter of Bconscience. It is not a minor issue, a debatable ethical choice, ard?a legal controversy. It is a matter of faithfulness