William F. May, Rising to the Occasion of Our Death

For many parents, a Volkswagen van is associated with putting children to sleep on a camping trip.  Jack Kevorkian, a Detroit pathologist, has now linked the van with the veterinarian's meaning of "putting to sleep." Kevorkian conducted a dinner interview with Janet Adkins, a 54-year-old Alzheimer's patient, and her husband and then agreed to help her commit suicide in his VW van.  Kevorkian pressed beyond the more generally accepted practice of passive euthanasia (allowing a patient to die by withholding or withdrawing treatment) to active euthanasia (killing for mercy).

 

     Kevorkian, moreover, did not comply with the strict regulations that govern active euthanasia in, for example, the Netherlands. Holland requires that death be imminent (Adkins had beaten her son in tennis just a few days earlier); it demands a more professional review of the medical evidence and the patient's resolution than a dinner interview with a physician (who is a stranger and who does not treat patients) permits; and it calls for the final, endorsing signatures of two doctors.

     So Kevorkian-bashing is easy. But the question remains: Should we develop a judicious, regulated social policy permitting voluntary euthanasia for the terminally ill? Some moralists argue that the distinction between allowing to die and killing for mercy is petty quibbling over technique. Since the patient in any event dies -- whether by acts of omission or commission -- the route to death doesn't really matter. The way modern procedures have made dying at the hands of experts and their machines such a prolonged and painful business has further fueled the euthanasia movement, which asserts not simply the right to die but the right to be killed.

     But other moralists believe that there is an important moral distinction between allowing to die and mercy killing. The euthanasia movement, these critics contend, wants to engineer death rather than face dying. Euthanasia would bypass dying to make one dead as quickly as possible. It aims to relieve suffering by knocking out the interval between life and death. It solves the problem of suffering by eliminating the sufferer.

     The impulse behind the euthanasia movement is understandable in an age when dying has become such an inhumanly endless business.  But the movement may fail to appreciate our human capacity to rise to the occasion of our death.  The best death is not always the sudden death.  Those forewarned of death and given time to prepare for it have time to engage in acts of reconciliation.  Also, advanced grieving by those about to be bereaved may ease some of their pain.  Psychiatrists have observed that those who lose a loved one accidentally have a more difficult time recovering from the loss than those who have suffered through an extended period of illness before the death.  Those who have lost a close relative by accident are more likely to experience what Geoffrey Gorer has called limitless grief.  The community, moreover, may need its aged and dependent, its sick and its dying, and the virtues which they sometimes evince -- the virtues of justice and love manifest in the agents of care.

     On the whole, our social policy should allow terminal patients to die but it should not regularize killing for mercy. Such a policy would recognize and respect that moment in illness when it no longer makes sense to bend every effort to cure or to prolong life and when one must allow patients to do their own dying. This policy seems most consonant with the obligations of the community to care and of the patient to finish his or her course.

     Advocates of active euthanasia appeal to the principle of patient autonomy -- as the use of the phrase "voluntary euthanasia" indicates. But emphasis on the patient's right to determine his or her destiny often harbors an extremely naïve view of the uncoerced nature of the decision. Patients who plead to be put to death hardly make unforced decisions if the terms and conditions under which they receive care already nudge them in the direction of the exit. If the elderly have stumbled around in their apartments, alone and frightened for years warehoused in geriatrics barracks, then the decision to be killed for mercy hardly reflects an uncoerced decision. The alternative may be so wretched as to push patients toward this escape. It is a huge irony and, in some cases, hypocrisy to talk suddenly about a compassionate killing when the aging and dying may have been starved for compassion for many years. To put it bluntly, a country has not earned the moral right to kill for mercy unless it has already sustained and supported life mercifully. Otherwise we kill for compassion only to reduce the demands on our compassion. This statement does not charge a given doctor or family member with impure motives. I am concerned here not with the individual case but with the cumulative impact of a social policy.

     I can, to be sure, imagine rare circumstances in which I hope I would have the courage to kill for mercy -- when the patient is utterly beyond human care, terminal, and in excruciating pain. A neurosurgeon once showed a group of physicians and an ethicist the picture of a Vietnam casualty who had lost all four limbs in a landmine explosion. The catastrophe had reduced the soldier to a trunk with his face transfixed in horror.  On the battlefield I would hope that I would have the courage to kill the sufferer with mercy.

     But hard cases do not always make good laws or wise social policies. Regularized mercy killings would too quickly relieve the community of its obligation to provide good care. Further, we should not always expect the law to provide us with full protection and coverage for what, in rare circumstances, we may morally need to do. Sometimes the moral life calls us out into a no-man's-land where we cannot expect total security and protection under the law. But no one said that the moral life is easy.

(1990)