STEPPIN' IN TO THE TWILIGHT ZONE :

The Principle of Hope : a review of The Case Against Assisted Suicide: For the Right to End-of-Life Care edited by Kathleen Foley and Herbert Hendin (Sherwin B. Nuland, 05.16.02, New Republic)

Leon Kass ably states the argument of the self-determinationists and his response to it, which is reiterated and verified by clinical observations, surveys, case reports, studies of the pertinent literature, statements by participants, and data that are to be found in various chapters of The Case Against Assisted Suicide:

"[Its advocates state that] the request for assistance in death is to be honored because it is freely made by the one whose life it is, and who, for one reason or another, cannot commit suicide alone. But this too is fraught with difficulty: How free or informed is a choice made under debilitated conditions? Can consent long in advance be sufficiently informed about all the particular circumstances that it is meant prospectively to cover? And in any case, are not such choices easily and subtly manipulated, especially in those who are vulnerable?"

Truth to tell, the ideal of rational autonomy, so beloved of bioethicists and legal theorists, rarely obtains in actual medical practice. Illness invariably means dependence, and dependence means relying for advice on physician and family. This is especially true of those who are seriously or terminally ill, where there is frequently also depression or diminished mental capacity that clouds one's judgment or weakens one's resolve. With patients thus reduced--helpless in action and ambivalent about life--someone who might benefit from their death need not proceed by overt coercion. Rather, requests for assisted suicide can and will be subtly engineered.

Every physician and every nurse who has spent long hours at the bedsides of dying patients knows that Kass's description of their common inability to make rational or consistent decisions is accurate. These experienced witnesses know also that choices made in previous circumstances, when they seemed proper and wise, are often changed in the face of the reality of grimmer circumstances. A very sick person is not the same man or woman who months or years earlier calmly signed an advance directive or described for
closest relatives and a trusted doctor the point at which they should desist from further efforts to maintain life. Family members and caregivers--including the putatively distanced doctors--have goals and agendas that not infrequently confuse what is best for the wavering patient with what is in fact best for themselves.

That much of this understanding is below the level of actual awareness, that much of it proceeds from the best of intentions, does not make it less influential on the minds of the sick. Unknowing coercion is as effective, if not more so, than that which is deliberate. Add to this the well-known fact that the most common reason given by people asking for assisted suicide is not pain or some other specific form of suffering, but their wish not to be a burden to those whom they love. In this way, sometimes unwittingly and sometimes deliberately, loved ones too often influence the decisions of the debilitated and needful.

Among the issues I've disputed with libertarians, none has perplexed me more than their support for assisted suicide, with its necessity for allowing one individual (the patient) to force a course of action, and one with serious moral implications, on another (the "assistant"). This outstanding review makes in compelling fashion all of the points I've feebly tried to make in the past. If you read only one article today, make it this one. Posted by Orrin Judd at May 22, 2002 9:23 AM