Introduction Chapter 1: In Praise of Maria: a memoir

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Intention is an important factor in human action but the intention is not always clear That is especially the case where large doses of potentially lethal drugs are given to a patient. Is the intention to relieve pain or is it to bring on death? Does it make any difference? Many people are inclined to say it does not matter. And yet both legal and moral traditions have always considered intention to be one of the major factors in determining the legality or morality of particular actions.

It must be admitted that there are times when it is unclear to an outsider and even to the actor what his or her intention is. A son removes the respirator from his father who is dying. If the intention is to allow his father to breathe his last and complete a peaceful death that is one kind of action. If the son’s intention is to get hold of his inheritance, that is a different kind of action. The external behavior is the same, but the moral value differs. Is the son completely certain of his intention?

If one provides a pain killer that might hasten death by some days in the distant future, the intention to relieve pain seems obvious. If one administers the same drug and death follows in a few minutes (or hours? or days?), can one still claim that the intention is pain relief? The traditional language was “double effect,” rules for intending a good effect while acknowledging an unintended bad effect. The new medical technology, especially pain-killing drugs, has complicated the issue. Nevertheless, one cannot abandon the principle of double effect; it applies to practically all human actions. We are seldom in control of all the effects of our actions.

In most circumstances, the difference between allowing death and killing is clear. The fact that there are cases where the difference blurs and genuine debate is possible does not eliminate the difference between an intention to kill and an intention that is not to kill. Night and day are different, although it may not be clear exactly when one passes into the other. Analogously, thirty miles per hour and seventy miles per hour on the road are different. The difference between twenty-nine and thirty-one miles per hour may be difficult to determine but it does not follow that there is no difference between speeding and not speeding.lxxxv

To those who say there is no clear line between letting die and killing, Robert Burt responds: “From my perspective, however, it is precisely the tenuousness of the logical distinction that recommends its preservation as a way of giving expression to the inherently limited force of rationality.” He goes on to ask “how the format for decision-making can be structured so that this ambivalence, this tension, can be most effectively and visibly preserved. On this score, terminal sedation has clear advantages over physician-assisted suicide.”lxxxvi

The decisions in two United States Circuit Courts approving physician-assisted suicide opened a new level of discussion about euthanasia.lxxxvii The U.S. Supreme Court overturned both decisions by a vote of nine to zero. The unanimity of the Supreme Court was somewhat misleading because several opinions indicated an openness to challenge the traditional distinction.lxxxviii

The Ninth Circuit Court in the state of Washington ruled that a prohibition of suicide violated the fourteenth amendment’s equal protection clause that requires all persons similarly situated...be treated alike.” Judge Stephen Reinhardt said that the prohibition of suicide “places an undue burden on the exercise of that constitutionally protected liberty interest.”

As to whether disadvantaged persons might be pressured into suicide, the court said that was “ludicrous on its face.” This dismissal of a serious issue was shocking. “It did not occur to Reinhardt that helplessness might undermine voluntariness, that an individual’s wish for continued life could be clouded by a disability that undermined accustomed self-confidence, even though the diagnostic label of ‘mental incompetence’ might not clearly apply.”lxxxix

Judge Robert Beezer in his dissent took a more balanced view. He said that the change in health care “has forced us to step back and reexamine the historic assumption that all human lives are equally and intrinsically valuable. Viewed most charitably, this reexamination may be interpreted as our struggle with the question of whether we as a society are willing to excuse the terminally ill for deciding that their lives are no longer worth living. Viewed less charitably, the reexamination may be interpreted as a rationalization for house-cleaning and burden-shifting – a way to get rid of those whose lives we deem worthless. Whether the charitable or uncharitable characterization ultimately prevails is a question that must be resolved by the people through deliberative decision making.”

The Second Circuit Court of Appeals in New York State made a similar ruling shortly afterward. It said that those on life-support systems are being treated differently than those who are not, in that the former may “hasten death” but the latter may not hasten death through physician-assisted suicide. The premise here is that refusing life-saving treatment “is nothing more nor less than assisted suicide.” Chief Justice William Rehnquist, in the Supreme Court’s ruling, reaffirmed the difference between allowing to die and killing: “Adistinction recognized and endorsed in the medical profession and in our legal traditions is both important and logical; it is certainly rational.”xc The Supreme Court saw no unfair discrimination. “Everyone, regardless of physical condition, is entitled, if competent, to refuse unwanted, life-saving medical treatment; no one is permitted to assist a suicide.”

The Second Circuit Court used inflammatory language in describing the allowance of death. “The withdrawal of nutrition brings on death by starvation, the withdrawal of hydration brings on death by dehydration.” The Court also used two spurious arguments in referring to “active/passive” and “natural.” It claimed that “the writing of a prescription to hasten death...involves a far less active role for the physician in bringing about death than through asphyxiation, starvation and/or dehydration.” I noted earlier that it may be desirable to restrict the physician’s role but the issue is muddled by contrasting the act of writing a prescription and the act of disconnecting a respirator. Both are actions but they differ in meaning and intention. Removing a respirator is a condition for death to occur; writing a prescription for lethal drugs can be a contributing cause of suicide.

Even more muddled was the Court’s contention that by the discontinuance of a life-support system “a patient hastens his death by means that are not natural in any sense. It certainly cannot be said that the death that immediately ensues is the natural result of the progression of the disease.” As I commented previously, no human action is merely natural. The moral issue is whether the natural is being shaped for good and human purposes or whether the natural is being violated with a violent intrusion into the cycle of life and death. The introduction of life-support systems and their discontinuance are deeply personal acts that affect the rhythms of human nature. One might well make the case that some hastening of death is sometimes compatible with the natural process leading to a human death but only in cases where as the Court said “death is imminent and inevitable.” When intervention stops and death immediately ensues, the death is indeed the result of the disease. The intervention has merely stopped a previous intervention.

In a 1999 case before the Supreme Court, Justice Anthony Kennedy contrasted “active intervention” and “nature taking its course.” The phrasing could have been better. Lawrence Tribe rejected Kennedy’s opinion; but Tribe’s statement that “none of these patients is in a state of nature” introduces worse phrasing. Talking about a “state of nature” is a distraction from the important question about the limits of the control of natural processes in a human life.

The erasing of the line between allowing death to occur and killing someone can be looked at from opposite directions. Looked at from the side of allowing death, the act of letting die can be said to be not “essentially different” from killing. However, erasing the line can also be a move from the opposite direction so as to make killing seem a form of letting die.

What is natural and what is not natural remains an issue. If the result were the only thing important, without regard to what is natural, why would one merely hasten death instead of bringing it about immediately and certainly? Why would a quick acting bullet to the back of the head not be preferable to hastening death through drugs?xci

The question is a serious one. When the state executes prisoners it looks for means that appear to be medical procedures. The guillotine or the firing squad are too revealing of what the state is doing, arrogating to itself the power to kill human beings. If the state is licensing physicians or other specialists to kill, the language for this permission ought to be clearer than “hastening death.”

An American Hospital Association study found that seventy percent of deaths in the United States included “negotiated settlements regarding technology.”xcii In the majority of cases there is a clear difference between killing and allowing death to occur. The joint effort should be directed at comforting the patient physically and spiritually. No doubt there are cases when the effort to reduce pain has an immediate connection to the ending of the life. Physicians should be given some leeway of interpretation lest they generally under-medicate those who are in pain. But extreme cases do not make good law.

A legal approval of physician-assisted suicide creates a new context of medical treatment. Then the unclear line shifts to voluntary and involuntary which many Dutch physicians seem to cross. The result is that euthanasia “solves the problem of a runaway technological medicine with a final resort to technique. It opposes the horror of a purely technical death by using techniques to eliminate the victim.”xciii I would subscribe to the two guidelines that Robert Burt offers:

1. Intentional, unambiguous infliction of death in any context should be rigorously avoided and socially disapproved.

2. Where death cannot be avoided, ambivalence about its moral status is unavoidable and should be self-consciously honored through design of practical techniques for highlighting, even amplifying its presence.

In our attempt to master death through rational means we are in danger of creating new horrors. The attention of the country ought to be on improving health care rather than finding a quick and technically efficient solution. We now have medicines and technology that can do wonders in curing many diseases. But dying is part of what physicians, researchers, and the rest of us must still accept and we will always feel some ambiguity when our decisions concern our own or another person’s dying.


CHAPTER SIX: CONSIDERING AND RECONSIDERING SUICIDE
Talking about dying must include considering suicide. Albert Camus wrote that “there is but one truly serious philosophical problem and that is suicide.”xciv How immediately and practically the considering of suicide for oneself is a theme that can be explored within a more general examination of suicide. The considering of suicide refers to a phenomenon that is presumably as old as the human race. Are there any perennial truths that the considering of suicide reveals?

Reconsidering suicide implies that one is open to new considerations and a different attitude to suicide. The premise of reconsideration is that suicide is so different in the present that a revision of past judgments is called for. Some of the changes concerning suicide are easily documented. For example, the number of teenagers and young adults committing suicide has taken a startling jump in recent decades. David Satcher, Surgeon General of the United States, felt compelled in 1999 to issue a Report on Suicide for the first time in the two-hundred year history of that office.xcv Whether greater numbers are symptomatic of a change in the nature of suicide is one question to be asked.

The biggest obvious change affecting suicide has been the difference in medical practice since the middle of the twentieth century. The effects of this new medicine have been complex. We now know more about medical conditions that contribute to suicide and about medicines that can be helpful in stabilizing potentially suicidal lives. That knowledge has led to a more compassionate, less harsh judgment in most cases of suicide.

The other side of medicine’s reshaping the question of suicide is the possibility of prolonging the dying process almost indefinitely. Some people wish to end their lives because they have reached a point where nothing remains to their life but machinery keeping them alive. In such cases, dying seems to be more appropriate and more desirable. The situation of a ninety-year-old in an intensive care unit, who is being kept alive by a feeding tube, is genuinely new in human history. So also are questions about a person refusing to use such technology. A study in the 1980s found that nine percent of people who are on kidney dialysis came to a point where they simply decided to stop. The decision clearly means that their lives are ending. Is that suicide?

The answer to that question raises the issue of whether all forms of ending one’s life should be covered by a single term. We may need a new term if the nature and forms of ending one’s life have drastically changed. Attempts at neologisms usually do not work and I do not propose to offer one here. At present, descriptive phrases are sometimes used, such as “voluntary death.” If there is essential change in reconsidering suicide, a new term is likely to emerge.

“Suicide” was itself invented in the seventeenth century as part of a shift of attitude, or at least as the signal of the beginning of a shift. Previous terms, such as self-murder or self-homicide, carried a strongly negative judgment. “Suicide,” meaning to kill oneself, left open the possibility that the killing is neither a crime, nor a sin, nor a sickness. The first citation in the Oxford English Dictionary is from 1651: “To vindicate one’s self from inevitable calamity by Sui-cide is not a crime.”xcvi John Donne had already broached that position in his 1644 essay Biathanatos: A Declaration of that Paradox or thesis, that selfe-homicide is not so Naturally Sinne, that it may never be otherwise.”xcvii

A survey of eighteenth- and nineteenth-century uses of suicide suggests that there was limited success in “suicide” becoming a neutral term. “Suicide” picked up most of the meaning of “self-murder” and to this day it remains overwhelmingly negative in its meaning. Advocates of legal, ethical, socially approved suicide will probably not succeed without the birth of a new term that is not burdened with the connotations of “suicide”xcviii

For considering and reconsidering suicide an impressive body of literature has been built up in recent decades. These studies allow for some measured judgments about the past and some medical understanding of suicide’s past and present.xcix One must nevertheless approach the subject with humility. Suicide remains one of the great mysteries of human life. The reflections in this chapter can only nibble at the edges of the mystery.

Suicide in Education

I noted earlier the parallel between “sex education” and “death education” insofar as both of these names are used for courses taught to children in schools. That usage places an impossible burden on school teachers of the young because neither sex nor death fits comfortably into a classroom. Education in matters of both sex and death should begin in infancy and continue into old age. Education belongs in the home, in the work setting, in leisure activities, and in all of school life, not just the classroom. When the classroom for children is given exclusive educational rights to delicate and controversial issues, there is pressure to preach against what is not socially accepted. Or else teachers wishing not to be accused of advocating the socially unacceptable may take the safer route of silence.

Jocelyn Elders lost her job as Surgeon General of the United States when she casually acknowledged, in response to a question, that masturbation should be part of sex education. She was stating an obvious truth, namely, that a sexual education cannot neglect discussing a nearly universal practice, such as masturbation. The classroom’s part in education should not be to advocate or to condemn a practice but to understand it. If education were thought of as lifelong and life-wide, the teacher in a classroom of children could concentrate on the students learning how to ask the right questions and how to understand the history and meaning of each aspect of human experience.

If an official can lose her job for saying masturbation should be included in sex education, it would no doubt be dangerous to say that suicide should be part of everyone=s death education. However, similar to sexual education, the main burden for education in matters of dying and death should not be placed upon classrooms for children. Unless suicide is acknowledged as a practice throughout history, it is likely to emerge from hiding as an emotionally charged subject for the classroom. The teacher in the sixth or ninth grade may prefer to avoid the subject, or if it is unavoidable, the schoolteacher may just condemn suicide as disgusting, sick, horrifying, immoral or criminal.

The trouble with telling young people that a practice is unspeakably bad is that, while a majority may consciously accept that judgment, the condemnation creates a fascination for some people. Even for those people who are rationally convinced that the practice is not to be entertained, an allure may remain. Talk about suicide can be a prelude to committing suicide; but everything depends on the kind of talk. Discussion of the history of suicide, its conditions, causes and prevention, is not a guarantee that suicide will not be attempted. But trying to suppress suicide through silence or unequivocal condemnation is even less of a guarantee that suicide will not happen.

The mechanism of psychological repression is better understood today than it generally was in the past. Although it may seem dangerous to acknowledge some practices concerned with sex or death, they can be more dangerous when hidden in the shadow of consciousness. On a scale of practices that are dangerous, suicide would seem to hold first place. Sexual experimentation can have unwanted or embarrassing effects, but there are usually remedies and corrections. Suicide does not have the same room for experimental error so a society’s dire warnings are understandable but they are of doubtful effectiveness.

Suicide in History

Western society after the fourth century C.E. offers a case study in the control of suicide. The early Christian movement, instead of clearly condemning all suicide, seemed to offer reasons for ending one’s life. Jesus had said “I lay down my life....No one takes it from me.”(John 10:17-18). Jesus’ followers did not presume to have the same power over life and death but they did expect to share in the same joys of heaven. Jesus went willingly to his death in anticipation of being raised by his Father. So, too, Christians believed that death was entrance into eternal life and reunion with their loved ones.

Becoming a martyr was highly honored in the early church. However, the martyr was not someone wishing to die but a person willing to die rather than renounce the faith. As G.K. Chesterton formulated the difference, “A martyr is a man who cares so much for something outside him, that he forgets his own personal life. A suicide is a man who cares so little for anything outside him that he wants to see the last of everything.”c In principle the line was clear but there were borderline cases. Apollonia, who died in 249 C.E., did not wait for her executioners to push her into the flames; she jumped. Was that martyrdom or suicide?

There were enough questionable cases in Augustine’s time that he felt the need to condemn suicide as “detestable and damnable wickedness which is never justifiable.”ci Augustine thereby extended the commandment forbidding wrongful killing to include oneself. The Hebrew Bible has more than a dozen suicides, including Sampson and Saul, that do not receive divine censure. Jewish law allowed suicide if it was necessary to escape murder, incest or idolatry.

A turning point came in 73 C. E. after the suicide of 964 Jews at Masada to avoid Roman idolatry. Although Masada is to this day celebrated in Jewish memory, the Jewish attitude to suicide shifted toward a more universal condemnation of the practice. The social and religious acceptance of suicide could threaten the continued existence of the community.

Augustine, like the Jewish leaders, saw his own Christian community endangered by the prevalence of suicide. Augustine was very successful in setting the direction of Western church law and even secular law. Suicide became “the sin against the Holy Ghost,” the one sin for which repentance was impossible. Thus, Judas Iscariot, the clear case of suicide in the New Testament, was consigned to hell. Anyone who attempted suicide was condemned as a sinner and a criminal. If the suicide was successful, punishment was directed to the corpse and to the possessions and the relatives of the dead person.

What happened in the centuries after Augustine could not have been foreseen by him. Alfred Alvarez, in his history of the Christian attitude to suicide, writes: “The Christian ban on suicide, like its ban on infanticide and abortion, was founded on a respect for life....Yet what began as moral tenderness and enlightenment finished as the legalized and sanctified atrocities by which the body of the suicide was degraded, his memory defamed, his family persecuted.”cii




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