One immediate implication of the Court decision agreed to by all parties is that new and more effective steps must be taken to insure that the best possible care of the dying is provided. The goal would be that, because life continues to be desirable or at least tolerable, the request for help in dying would not arise. This is probably not possible in every case. That is why in extreme cases when a quick death is preferable to prolonged dying in agony, assisted death should be legalized. Reports indicate that many patients do not receive the relief of pain and suffering that current medicine is capable of providing is increasing. No excuse can be given for this failure. Opponents of assisted death express fear that the poor, the disabled, and the marginalized might be put under pressure to end their lives if doctors were legally allowed to hasten death. Then let them, and all of us, demand that society and doctors find ways to provide for every dying patient and for everyone who requires long-term care the most effective relief of suffering that contemporary medical science has at its disposal.
At the same time the debate will go on. A recent CNN/USA TODAY poll indicates that 55% of people are in favor of physician-assisted suicide, while only 37 % express opposition. The Supreme Court did not rule out the possibility that individual states might legalize assisted suicide. It only concluded that it is not unconstitutional to prohibit it. Hence, the new battleground moves to each of the states.
A few days after the Supreme Court decision of June 26, 1997, I received a response to this article from someone whose mother had died a few days before after a prolonged period of unrelieved agony. The story was powerful and heartbreaking. In their despair parent and child prayed for a quick death that would relieve the intolerable suffering that doctors could not manage. The writer was justifiably angry that the law did not allow means to be taken that would have brought merciful relief by hastening the death that mother and family so earnestly desired. Since then I have received other e-mail messages from people with debilitating and life-threatening illnesses that are leading them to think about ways to end their suffering without putting those who assist them in jeopardy of prosecution. Stories like this provide the most powerful argument in favor of legalizing physician-assisted death in extreme cases under carefully defined and limited circumstances with all necessary safeguards provided to prevent abuse.
The only appropriate way to make this claim is with deep humility and in fear and trembling. We must always stand in awe and reverence when life itself is at stake. As Dr. Timothy Quill has said, anyone who thinks this question has a simple or obvious answer has not thought very deeply or seriously about the matter. Those who oppose the legalizing of physician-assisted death make arguments and voice fears that are formidable indeed. Nevertheless, I conclude that the stronger case rests with those who advocate the legalizing of assisted death under carefully regulated conditions.
This essay consists of several parts. First, I present the main arguments for and against assisted death. While the current controversy centers on providing medicines or other means that patients can use to end their lives (physician-assisted suicide) I also make a case for physician-administered death (voluntary active euthanasia) in which the doctor gives a lethal injection or other medicines that cause death. I use the term assisted death to cover both. After that I offer more extended treatments of the major objections and make the positive case. In Part 1, I reject some of the common objections made against it. In Part 2, I state arguments in favor of the practice. Finally, I contend that the dilemmas, ambiguities, complexities, and tragedies involved in these life and death issues point to a religious resolution beyond everything that law, medicine, and morality can provide.
The Slippery Slope
Letting Death Happen and Causing It
Relieving Suffering and Causing Death
1. It violates Medical Ethics. The Hippocratic Oath expressly forbids the giving of deadly medicine to anyone who asks. This ancient document also requires doctors to swear by Apollo and all the gods and goddesses. It also forbids the taking of fees for teaching medicine. This tells us that we have to judge each tenet by its own merits and not regard it as a final authority in all matters. The American Medical Association has consistently condemned physician-assisted suicide as an unethical practice. Nevertheless, attitudes may be changing. According to recent surveys a majority of doctors in some areas -- 60% in Oregon, 56% in Michigan, and 54% in Great Britain -- favor the practice in extreme circumstances. Specialists in medicine and ethics are not in agreement on the question.
2. It undermines trust between doctor and patient. We expect physicians to heal and preserve life, not to kill on request. I reply that I want to be able to trust my doctor to do what is best for me in every situation, including assisting me to die with dignity if life becomes an intolerable burden, and I choose not to live any longer. I would not ask a doctor to do anything illegal, but if physician-assisted death were permitted by law, I would not want to be abandoned in my final hours. The trust issue, then, works both ways. A doctor may be as likely to lose the confidence of patients by not consenting to their request for assistance in dying as by consenting.
3. It is God's place to decide the time and place of a person's death. I reply that assisted death is a moral issue that has to be resolved on the basis of principles we use to deal with every other question about right and wrong, not a special case. Moreover, the implication of this objection is that we should never interfere with the course of any life-threatening condition. If a person is bleeding to death from an accidental cut, should we not just watch and let death occur? To intervene would challenge God's prerogative to determine the time and place of death. In some cases this objection is made by proposing that to take innocent life is "playing God." Anyone who makes this claim ought to state the criteria that tell us when human action is about to encroach on divine prerogatives and on what basis this claim is made. Otherwise, it remains an empty assertion that contains nothing one can argue against rationally. It is not a self-evident, self-defining premise that settles the question merely by being invoked. Sometimes when one person accuses another of "playing God," the charge appears to be based on intuition or a feeling and is not associated with explicit principles or careful reasoning.
4. It is a slippery slope. If we permit even the most limited forms of assisted suicide, the argument goes, we might eventually be killing off the handicapped, the poor, the elderly, abnormal babies, and anyone else who becomes inconvenient. In this extreme form it is surely groundless, given the values that prevail in our society. Nevertheless, we should be deeply concerned about this and see to it that proper safeguards are instituted. However, the idea that one should not make a reasonable choice now because it might lead to other measures later is not a sound basis for policy making unless (1) subsequent moves are inevitable and (2) are clearly wrong. Neither is necessarily the case. The guard against slippery slopes is the virtue, character, and good sense of the majority of our citizens. Our hope is that reasonable people know when to draw a line between going far enough and going too far. It is not at all clear that where the line is presently drawn is where it ought to be drawn. A More Extended Treatment
5. It is killing. Nearly everyone agrees that sometimes it is permissible to cause the death of another. The question in each case is whether the action is justified under the circumstances. The same is true of assisted death.
6. The patient may be depressed temporarily or may undergo a change of mind. Depression, when present, should be treated. Patients should be given sufficient time and counseling to enable them to make sure their decision represents their deepest wishes. But at some point we have to decide whether patients are to be permitted to be the authors of their own destiny or not.
7. It violates the crucial difference between passive and active procedures. The argument is that there is a decisive moral difference between (1) letting nature take its course by ceasing or withholding treatment in hopeless cases when death is close and certain and (2) taking active steps that deliberately hasten death. I reply that this distinction in and of itself is not morally crucial. To put the focus here misses a far more important point. The proper question is this: What is the best thing to do under certain extreme circumstances? The answer may be: (1) cease futile treatment, or (2) do something that will bring about a merciful death that shortens the time of intolerable, unnecessary suffering. The patient may legitimately request either one, and we may morally comply. Death occurs in either instance, and human choice and agency are involved in both. More Detailed Consideration
8. A misdiagnosis could occur, or a miracle cure might happen. Perhaps, but keeping this in mind implies that we should be extremely cautious not that we should never act under any circumstances. Besides, the possibility of an unexpected recovery or a misdiagnosis implies that we must do absolutely everything in our power to extend life as long as possible. Hence, we would never cease or withhold treatment even though the case looked hopeless if so doing hastened death ever so slightly.
9. Ending life to relieve suffering interferes with the role that suffering plays in God's plan. The extreme view that all suffering is sent by God to serve a purpose implies that we should never do anything to relieve suffering of any kind. It is true that suffering may lead to spiritual gains and moral maturity, but not all suffering does. In any case, most people would agree that it is our duty to relieve suffering to the extent that is possible, especially that which is excruciating and robs life of its meaning and joy. If this is the case, one can reasonably argue that in some extreme cases relieving suffering takes priority over extending life.
10. Personal autonomy is not absolute. We wisely do not allow people to do anything they want, even if the consequences will affect them most or altogether. We do not allow people to duel with lethal weapons. We do not permit people to sell themselves into slavery. And, so the argument goes, we do not have a right to have other people kill us or assist us in committing suicide. Deciding what choices should be wisely left to individuals and which options should be forbidden by law is difficult for any society. We have been divided over the abortion question for many decades. Often society changes its mind. Once certain sexual practices between consenting adults were forbidden. Now we recognize that this was an unnecessary and unwise intrusion of the government into private affairs. My argument is that when it comes to the ultimate matter of choosing death to relieve unbearable suffering for which there is no remedy, it is time for the state to stop interfering with a decision made by the person whose life and death are at stake. The choice should rest with the only person who is experiencing the intolerable agony that cannot be relieved.
11. Bad consequences would follow. Guidelines would inevitably be violated. Mistakes would be made. Patients might feel guilty for staying alive and choose death to lift the financial burden or the strain on loved ones. Families out of desperation and emotional exhaustion might give up too quickly and give their support to ending the misery of a relative. Some patients might conclude that their lives were not valued if society provided a way to kill them. Doctors might feel less obligation to provide the best possible care if administering death were available as a solution to the agonies of life. Society might be tempted to put less priority on providing needed assistance for the disabled, the poor, and minorities and let the choice of death make things easier and cheaper. We might all become less sensitive to suffering and more callous about death once we got used to the idea of choosing death as a way out of life's tribulations. So the list goes.
These dangers must be taken seriously, and steps taken to prevent them if assisted death becomes legal. Let us notice that no arrangement is free from abuse. Many of the pressures that might be felt by patients and families or urged on them by institutions already exist with regard to the approved practice of withdrawing life-sustaining treatment. Since doctors can administer heavy doses of pain medicine that hasten death, the present system allows for covert instances of assisted death. Fewer abuses might occur if current practices were open to scrutiny and regulation. Far from lessening efforts to manage suffering, the option of assisted death might well inspire greater efforts to make life tolerable for patients so that they would not want to die. The main abuse now existing, however, is that by denying terminally-ill patients a choice in hopeless situations, we consign those whose misery cannot be relieved to pointless, needless agony.
Deciding what is right is especially difficult when the permissibility of deliberately ending a human life is involved. In these extreme situations the normal rules of morality are stretched to the breaking point. Self-defense against a would-be murderer, killing enemy soldiers in war, capital punishment for the most horrendous crimes, intentional suicide by a spy to prevent torture or a coerced disclosure of vital military information, killing a berserk man who is systematically murdering a line of hostages -- all these instances pose questions that severely test our moral wisdom.
Nearly everyone would agree that in some of the cases listed it would be legitimate to end a life deliberately. This fact tells us that killing a person is not always and necessarily regarded as wrong. It all depends upon the circumstances. Now enters the question of physician-assisted death.
I want to make a cautious argument that under some carefully limited circumstances, it is permissible for a physician to assist a person hasten death to end unwanted, intolerable, unnecessary suffering. This includes providing medicines or other means the patient can use to commit suicide or by directly administering medicines that end the patient's life.
1. In some situations the choice of the patient takes priority over other considerations. Consider a person with an incurable illness or severe debility such that life has become so racked with pain or so burdensome that desirable, meaningful, purposeful existence has ceased. Suppose that person says, "My life is no longer worth living; I cannot stand it any longer; I want to end it now to avoid further pain, indignity, torment, and despair." In the end after all alternatives have been thoroughly considered, I believe this person has the right to make a choice to die and that it ought to be honored. We would want to urge consultation with physicians, clergy, lawyers, therapists, family, and others so that such a serious and irreversible decision can be made after sufficient time has passed and every alternative thoroughly weighed. We have obligations to others and should take their needs into account. The state has an interest in protecting life. But, in the end, individuals should be given wide latitude in deciding when life has become an unendurable hardship.
2. The role of the physician is to do what is best for the patient, and in some extreme situations this may include hastening death upon the voluntary request of the dying. Many doctors protest that they are committed to preserve and enhance life, not to end it deliberately. If the role of the physician is defined solely in terms of healing, then, of course, this excludes assisting someone to die. This is the wrong way to go about defining the scope and limits of the doctor's proper function. I suggest that the question should be put this way: What is the best thing I can do to help my patients in whatever circumstances arise, given my special knowledge and skills? In nearly every case the answer will be to heal, to prolong life, to reduce suffering, to restore health and physical well-being, i. e., to preserve and enhance life. But in some extreme, hopeless circumstances, the best service a physician can render may be to help a person hasten death in order to relieve intolerable, unnecessary suffering that makes life unbearable as judged by the patient. This would be an enlargement of the physician's role, not a contradiction of it.
3. Sometimes ending suffering takes priority over extending life. Assisted death is so troubling because it involves an agonizing conflict between values. Life is a wonderful gift full of the promise of pleasure, joy, happiness, and love. But circumstances may turn it into a heartbreaking, hopeless burden filled with suffering, pain, and despair. We desire to live, but in some situations death may be preferable to the continuation of an intolerably burdensome existence. If some person comes to that dreadful conclusion, what is our duty? The moral imperative forbids us to kill, but it also enjoins us to be merciful. We have a term that puts the dilemma before us -- mercy killing. While insisting that we must make every effort possible to guard against abuse, I sorrowfully conclude that, at a patient's request, it may sometimes be more merciful and loving to end suffering than to extend a joyless, unendurable life.
4.When death becomes preferable to life, everyone would benefit if it were legal to show mercy. Compassion and benevolence demand that we legalize assisted death for the sake of the afflicted and those who love them. The most powerful argument in favor of physician-assisted death comes from the families of those who have witnessed loved ones die in extreme agony. When medical science has done all it can and death has not yet brought merciful relief, family members suffer a sense of powerlessness and despair as they watch in horror someone they love dearly writhe in torment as they wait and hope for a quick end to their awful suffering. That these extreme cases are rare is indeed fortunate, but it does not render less important the appalling plight of whose who must live -- hopeless and helpless -- through such distress. It would benefit everyone if choosing death in hopeless, intolerable situations were allowed under defined circumstances that prevent abuse.
The most forlorn of all are those who agonize over whether to take action in violation of the law to end the life of someone dear to them who pleads and prays for death. A few in desperation, unable to stand it any longer, take a gun or a pillow and do what they dread and hate to do but must do in order to bring relief to a parent or child or spouse who is glad for the intervention but is fearful of the legal consequences for those who have shown them mercy.
You have seen them, or heard them, or read about them. Their faces are sometimes hidden and their voices are disguised as they tell their sad stories. They must witness in secret to what has happened because the law condemns their compassion and calls them murderers. Yet they loved the deceased with all their hearts and were moved to do the dreadful deed out of pure benevolence.
Physicians are more fortunate in that they can take refuge in the principle of the "double effect" and write on the death certificate the cause of death. Many of us have heard doctors report that they have, out of compassion and mercy, given heavy doses of morphine to relieve the intolerable distress of patients who are near to an inevitable death, knowing full well that the result will be to hasten the end. Somehow this is all right, since the primary aim is, we say, to relieve suffering and not to kill, but it would not be right, we are told, to do the very same thing with the primary aim of hastening death, while getting the secondary result of comfort.
Why do we force good people full of love, mercy, and compassion to such extreme measures to bring an end to hopeless torment when no cure or relief is possible for the dearest people on earth to them? Why do we force physicians to justify their mercy in hastening death by denying that they did it for that reason, when we all know what is really going on?
I am a theologian, a philosopher, an ethicist, and a Baptist minister. I hold our moral, legal, and theological heritage in high regard. But there are times when we need to rethink received wisdom by subjecting our principles, codes, and traditions to a fresh exposure to real life experience. Sometimes ideals that are designed to protect and enhance life may actually degrade life and be the source of unnecessary suffering. So it is I believe with the prohibition of physician-assisted death under any and all circumstances. We can provide an opportunity for patients in certain extreme and rare cases under strictly regulated conditions to manage their dying without endangering our reverence for life. In so doing we can provide a way to be merciful to the dying without branding those who show mercy as criminals. We can avoid the agony of family members and of physicians who must do in secret what love and compassion urge upon them and thus serve the dying while honoring the living.
I deal here in more detail with some of the most powerful objections to my thesis. The first is the fear of the slippery slope. Nearly everyone worries about this. This argument comes in two varieties.
THE LOGICAL VERSION
The logical form claims that the endorsement of a certain practice entails that other related practices become reasonable. But since the more extensive applications are obviously wrong, the first action must not be taken. The argument for assisted death typically begins with a very narrow definition that assumes three conditions: (1) the patient is near death, (2) in unmanageable pain or other unbearable discomfort, and (3) mentally competent to make a voluntary request. Some opponents are willing to admit that in a few instances in which these restricted conditions are met, physician- assisted suicide is warranted. However, they maintain that we must not take the step of legalizing the practice because its application cannot logically be limited to the stated criteria.
In order to work slippery slope arguments of this type must find an axiom in the situation that is more inclusive than the original case. A premise must be present that when spelled out extends the original limitations. It is here that the logical version of slippery slope arguments get slippery. If one maintained, e. g., that the tacit principle in assisted death, even on the narrow grounds stated, is the legitimizing of the taking of innocent life, then obviously this would open the door as wide as the most extravagant critics claim. However, while the taking of innocent life is involved in the situation, to abstract that component and make broad deductions from it ignores the whole set of conditions that have been previously specified as justifying the taking of innocent life. To say that it is sometimes acceptable to take innocent life does not mean that it is always right to do so.
We readily see the fallacy of this type of ambitious slippery slope argument in other situations that are more familiar. Most people recognize that taking the life of a violent aggressor to preserve ones own life is permissible if this is the only way to keep from being murdered. Yet no one argues that this is a slippery slope that logically entails the proposition that one can take the life of another who pulls into a parking place ahead of you. Yet implicit in self-defense at some level of abstraction is the principle that one citizen may kill another. This principle, without qualification, would include killing someone who took the one remaining parking place that you had your heart set on.
The restricted argument for physician-assisted suicide does not logically authorize the killing of all innocent people but only those whose who meet all three requirements stipulated. It is illegitimate to abstract some remote generalized feature and make deductions from it as if all the other factors don't matter. They do matter. Circumstances alter cases. Hence, each situation must be taken up on its own with all its necessary features intact. Each situation has a configuration of components that are essential to it -- all of which must be honored. To show that a slippery slope is present, it would be necessary to show that no relevant differences exist between a first step that is justified and subsequent steps that are not. If no relevant differences arise, the subsequent steps should also be acceptable. If relevant differences are present, they must be taken into account to determine whether they draw a line that should not be crossed.
A more formidable version of the slippery slope argument contends that the more general postulate in the defense of assisted death is the principle of individual autonomy. If one believes that an individual has an unlimited right to determine when life has become intolerable, then obviously this cannot logically be restricted to cases in which the patient is dying and in intractable physical distress. People in all sorts of conditions might conclude that life had become hopelessly intolerable and opt for death. Young people, e. g., with an incurable progressing degenerative disease with many years of unendurable existence ahead might decide at some point to die rather than go on. Here the slippery slope objection is stronger. Nevertheless, this expansive view of patient autonomy is not logically essential to the original argument. One could argue that only when the conditions of competence, imminent demise, and intractable pain or some other unmanageable torment obtain does the patient have the right to choose death.
How far a person's right to elect death voluntarily can be extended is a matter for debate. The final issues around which the issue has to be resolved relate to the tension between individual self-determination, the responsibility of people to maintain even an unpleasant existence for the sake of others, and the interest of the state in protecting life. While acknowledging that it is important to take our interdependence with others into account, I give considerable weight to the liberty interest of the individual in being able to make the fundamental decision between life or death. When any reasonable possibility of meaningful, enjoyable existence lies ahead, the preference will be for life. Therefore, every possible effort must be made to make continuing life preferable to death. Obviously, people who are mentally ill or severely depressed present special cases. We must proceed with utmost caution when we are dealing with people who are not near death without closing the door entirely. Hence, I readily acknowledge that I go further than the restricted case I argue for initially, although not everyone would, nor need they logically do so. Nevertheless, the strongest argument can be made for the restricted case. Furthermore, the request of assistance in ending ones life must be voluntary.
One can, of course, imagine an extreme situation in which even the voluntary principle would not necessarily hold, if it requires an explicit request. Suppose a person were trapped in a burning car with absolutely no possibility either of being rescued or of surviving. Suppose further that the person is conscious and in torment but cannot communicate. Would it be permissible to kill that person immediately with a gun, if one were available? In some drastic circumstances like this, it would be immoral not to violate the voluntary principle. To invoke the Golden Rule, I would earnestly hope that if I were in that situation, some kind soul would do the dreadful deed to relieve me of useless agony. Nevertheless, except for these fortunately rare circumstances at the furthest margins of life, the principle that a request to be killed must be made voluntarily by a competent person is inviolable. Finally, no one in the current debate has endorsed the killing of a person who explicitly objects. That is the absolute line that must never be crossed.
In short, I conclude that no slippery slope is necessarily logically present in the initial case that restricts physician-assisted suicide to mentally competent patients whose death is imminent, who suffer some intolerable condition, and who voluntarily request it. If one insists that all three requirements are essential to the legitimizing of physician-assisted death in every instance, then no principle of formal reason necessitates its extension beyond that. We all draw lines somewhere. Wider implications may arise in particular cases depending on the assumptions actually underlying the arguments of a given advocate. In short, it all depends on the postulates that are actually present, not those arbitrarily imposed or wildly imagined to be necessarily presupposed.
THE EMPIRICAL VERSION
The second version of the slippery slope is empirical in nature rather than formal or logical. While some objectors might admit that slippery slopes are not always logically inescapable, they contend that as a matter of fact, once the first step is taken, other steps will inevitably or might follow, and this would be disastrous. Many are afraid that assisted suicide voluntarily chosen by the dying presses inexorably toward the dreadful possibility of death administered to vulnerable members of society who will have no choice in the matter. In its extreme form this uneasiness is surely groundless.
The more troubling worry is not that anyone would ever explicitly propose the deliberate killing of the elderly, the disabled, the poor, or any other group of innocent, vulnerable people. It is rather that once assisted suicide, no matter how restricted is legalized, the power of money will come into play. Insurance companies, HMOs, hospitals, nursing homes and others who stand to gain by reducing the cost of caring for the seriously ill might seek ways to put subtle pressure on the dying (and their families) to choose death sooner rather than later in the name of "quality of life." As abhorrent as this sounds, we must be realistically alert to this possibility of exploitation and initiate the most stringent safeguards possible to prevent it. It is possible, of course, that other abuses could be instigated by scheming or exhausted family members, physicians, and health care institutions for a variety of monetary and non-monetary reasons. Obviously, we should fear pressures on patients to choose death from those who stand to gain by that choice. But these same dangers exist now with regard to expensive treatments that might prolong life. Therefore, we should also fear pressure to persuade patients to order life support systems to be removed or to refuse other treatments that would cost somebody a lot of money. Abuses can occur under any set of conditions. No policy can be guaranteed in advance to be foolproof. Vigilance is essential to keep mistreatment to an absolute minimum under any system of permitted practices. Finally, opponents who warn us of the dangers of permitting a right to choose death in the absence of guaranteed universal health care must be listened to. The proper response, however, is not to deny the former but to establish the latter as well.
The empirical version of the slippery slope argument is unprovable, impossible to disprove, and difficult to assess. When new ground is being explored, we cannot be certain what the ultimate consequences will be. Nevertheless, while analogies may be deceptive, they may be helpful if well chosen. Most states threaten capital punishment for the most brutal crimes. Does anyone fear that this is a slippery slope that will eventually have the state killing its citizens for a parking violation? Does the fact that people may voluntarily donate bodily organs upon their death set in motion an inevitable process that leads to the involuntary harvesting of hearts and livers from the poor and the disabled who are still living? Once the practice of granting a state license is established for anything, e. g., to practice medicine or drive a car on public highways, surely this is a slippery slope that will inevitably lead to the requirement of a license for a six-year-old child to ride a tricycle. Surely we must not regulate the most repugnant forms of pornography that feature the rape and dismemberment of children and the violent degradation of women, because, alas, the end result would eventually be the total abolition of free speech.
The reason most of us do not fear these absurd extremes is that we have confidence that our citizens have the virtue and the intelligence to distinguish between the wise and the foolish, the reasonable and the unreasonable, between going far enough and going too far. Reasonable people can recognize the crucial differences between one practice that is acceptable and another practice that is not. If we cannot count on the basic good sense and moral sensibilities of the majority of people in the long run to make relevant distinctions between situations, then no one is secure from outrage anyway. It is bad policy to refuse to take a prudent and needed step now because of some extreme that might possibly come about at some time in the future. The cost of not legalizing assisted death under restricted, carefully safeguarded conditions is to consign some hopelessly ill patients -- fortunately not very many -- to needless suffering because of greatly exaggerated if not groundless fears. The abuses now actually occurring call for a remedy that will allow mercy to do its work in the open rather than secretly.
Troublesome questions arise, of course, regarding personal competence, mental illness, and the definition of voluntary. They are, however, no more difficult than those the courts and legislatures have been struggling with for a long time. The question finally is how far the state is willing to go to prevent people from exercising their choice to die. How much suffering are we willing to impose on people to negate their choices, and how far will we go to drug them or force them to submit to the will of the state in a show of power? I do not pretend answers are available that any of us can be fully comfortable with, but if the issue is one of logic or mutually exclusive alternatives, I assert that finally the individual's choice of life or death takes precedence over the state's interest in protecting life. I fear the tyrannical power of the government as much as I fear the excesses of individual freedom. I repeat, however, that we must to do everything within our power to nourish the desire to live in all people and make death a far worse choice than living.
The variety of individual circumstances in which a person might choose to die rather to go on is so wide-ranging and manifold that an exhaustive coverage is impossible. Suppose a person were badly burned all over and in constant excruciating pain but that recovery with good life prospects is ultimately likely. One might reasonably resist the pleas of the person to be killed to obtain immediate release. How far one would go would depend on the circumstances, and we shudder in horror at the prospect of having to confront the problem for ourselves or someone we love dearly. Likewise, in the case of mental illness or depression, perplexing choices arise as to what extreme we should go forcibly to prevent suicide in the long-term best interest of the patient. Every possible effort through counseling and medication should me made to make life tolerable if not desirable for every person. But that suicide should always be prevented by whatever means are necessary seems as cruel and inhumane as the decision to do nothing would be callous and uncaring. We are fallible and nearly helpless in the face of some dilemmas. We can only do the best we can with love, mercy, and compassion as our guide.
The slippery slope argument seems to assume that just beneath the surface are dangerous impulses so powerful that if we make a small move to legalize assisted suicide, reasonable restraints will fall away. Sooner or latter all sorts of people will want to kill themselves or do away with the most vulnerable among us who need special or expensive care or who are just inconvenient to bother with. I don't believe it. With few exceptions, everyone loves life, appreciates it, and wants to preserve it for themselves as long as any possibility of tolerable, hopeful existence remains. Hardly anyone desires to force involuntary death on the innocent or to manipulate the dying to choose death, even if doing so would be convenient or save money.
In the last analysis, I think that the analogy of the slippery slope is basically wrong. We are not at the top of a hill so that the slightest nudge of the boulder will start it downward into an abyss. It feels more like we are at the bottom of a steep incline trying to push a boulder upward a few inches. The notion that success in moving the stone slightly suddenly creates a downward slope that cannot be resisted does not make sense. The implication seems to be that once we legalize assisted suicide, we lose our power of choice and some irresistible process takes over and inevitably propels us into disaster. Society has a choice at every step. Unless our citizens have the virtue, compassion, and good sense to know where to draw the line and enough realism to be on guard against abuses, we are in trouble anyway. In every area of life we have to make distinctions, sort out differences between one situation and another, and in general make decisions in the light of all the relevant factors that pertain to particular cases. The same need for wisdom, discernment, and good judgment in relating principles to a diversity of circumstances holds for this issue.
One consideration does make me hesitant. It is not that once assisted death is legalized under the most restrictive conditions, we will be inevitably driven by the force of logic or sheer momentum into unacceptable extremes. It is rather that the baffling problems involved in having to make decisions in a multitude of circumstances would bewilder the most discerning and compassionate minds and hearts. Situations would arise replete with such complexities, ambiguities, conflicting values, uncertainties, and relativities that the line between going far enough and going too far would be extremely difficult to draw. Incompetent administration of the rules, the possibility of error, and the likelihood of injustices springing from a failures of judgment and abuses originating from malice would further complicate the matter.
All these factors almost persuade me that it would be better to forbid any deliberate taking of life even when requested by a mentally competent, terminally ill patient in unmanageable agony already at death's door. Some maintain that only a very few of those persons who request assistance in dying meet these requirements anyway. Most people who consider suicide are not near death, are not in immediate physical pain, and may not even have a terminal illness. Life has become intolerable, or so they think, because depression or anxiety or other life circumstances that have created a sense of utter despair. Let us note, first of all, that this is a statistical point, not a moral one. Just because only a few meet the most stringent requirements that have been laid down does not mean that they should be denied the privilege of requesting assistance to make their imminent death easier. However, the fact that most people who contemplate suicide are not near death does raise the terribly difficult question of how far this privilege should be extended. I refrain from abandoning the cause only because to admit the difficulty is merely to acknowledge that decisions in this area of life are no different from what we unavoidably face in private and public life all the time with respect to a horde of other problems. Life is filled with perplexing choices. To seek to avoid them in the cases of assisted death is not a mark of prudence. Wisdom urges us to be circumspect not to flee from responsibility. Avoidance is impossible anyway, since legislatures and the courts are already deeply involved. Let us grant that we deal here literally with life and death. Moreover, firm lines have to be drawn somewhere. But it is not at all self-evident that to deny the possibility of assisted death absolutely regardless of circumstances is the course that makes most rational and moral sense.
One final comment can end this section. The assumption seems to be not only that the slippery slope propels us onward to ever wider extensions of the right to choose death but also that once having taken a step, there is no going back. This is patently false. Every policy choice can be rescinded if experience and deeper insight demand it. Given this fact, the fear of making a small warranted move now because of what might happen later is unfounded. Ultimately, slippery slope arguments with respect to voluntary death rest on a deeper distrust of the capacity of society to make responsible judgments in the long run or to correct errors of policy when they become apparent. If this skepticism is well-founded, we are doomed anyway, slippery slopes or not. Slippery slope arguments are not always wrong, but neither are they always valid. Care must be taken in every particular instance to separate insight from error, wisdom from folly, and caution from the groundless scare tactics of overzealous opponents.
Another argument against assisted death relates to the distinction between letting death occur and intentionally causing death to happen. The claim is that a crucial moral difference exists between ceasing or withholding a futile measure in irreversible cases when death is imminent and taking active steps that deliberately hasten death While accepted by eminent authorities in law, medicine, and ethics, the reasoning involved here, in my opinion, is spurious. In a set of circumstances in which the occurrence of death involves more than a single important factor, to isolate one and call it the real or sole cause of death is bad logic. Whether one has removed life support or provided lethal medicine, the death occurs most immediately, directly, and sooner because of that specific act. Moreover, a positive human action is involved. Someone does something, i. e., either removes a life support system or provides lethal medicine. Moreover, an underlying terminal disease or intolerable human circumstance is involved in both cases. A request for assistance in hastening the end of life would not be made if it were not! Even if what is involved is withholding a new treatment rather than ceasing a current treatment, human choice and agency are involved, and the result is a quicker death than otherwise would be the case. Furthermore, the quicker death is often desired by patient, doctor, and family. And the quicker, desired death is exactly the outcome of providing or administering lethal medicine. Hence, while the distinction between passive and active euthanasia has a kind of surface appeal and logic, deeper analysis reveals it to be non-decisive. A difference of a sort is present, but I deny that the difference is conclusive in determining what is morally permitted or mandated.
The proper question is what is the best thing that can be done under the circumstances when no alternative is desirable. We get our answer by determining what values and obligations are paramount and what the consequences of various actions will be. In some instances the best of ambiguous choices is to hasten death by deliberate means for those who choose that alternative or when proxies act for an unconscious or incompetent patient.
Suppose an infant is born with multiple disabilities so severe that the only prospect is to engage in a series of painful, invasive procedures that are highly unlikely to succeed. The parents decide against treatment. Is it better to put the child aside and provide comfort care until death comes or to hasten death mercifully by deliberate action? Imagine a young person who has been in a coma for years with no reason to believe that recovery will ever occur, but with artificial hydration and nutrition could live indefinitely. If the courts agree to the removal of these life support systems, should the patient be allowed to die slowly or quickly terminated by a lethal injection? When compassion is the only motive in all involved, I fail to see the moral superiority of letting die over causing death in these cases.
The literature is filled with subtle and profound discussions of what is the true cause of death, as if this would resolve the moral issues. Since we are obligated not only to do no harm but also to do good, the issue turns on motivations, the values expressed, the obligations lived out, the nature of the acts, and their consequences. Declarations that we are guilty of wrong if we are the direct and immediate cause of death but innocent if nature, disease, or the condition is the underlying cause miss the main point. If death is hastened, whether (1) by lethal injection or (2) by ceasing or withholding treatment, then human choice and agency are implicated in shortening life in both instances. The relative degree of human causation is secondary to more fundamental factors of motivation, the values expressed, and the consequences.
Another claim along this line is that it is permissible to give massive doses of medicine to dying patients if the intent is to relieve suffering even though the unavoidable consequence is to quicken death. But it is wrong to do exactly the same thing if the intent is to cause death more quickly in order to relieve unnecessary, pointless suffering. It all depends on the motive, according to the theory of the "double effect."
The first rejoinder is that motive alone is not the sole determinant of morality. The nature of the act and the consequences count too. Imagine someone who burns down the barn to kill the rats who were rapidly eating up all the corn. We would not be impressed with the claim that this act was justified because the sole aim was to kill the rats and not to destroy the barn and the corn. The point of this absurd example is that both effects matter and must be evaluated, not only the intended one. In cases in which death is going to occur soon no matter what we do, hastening death by administering pain medicine may be warranted by the relief of suffering that results. Why not admit that the medicine is given to accomplish both effects, if that is the patient's choice? Only a very fine line separates that from deliberately administering a drug that causes death quickly in order to relieve pointless, excruciating suffering. The line gets even finer when the only way to relieve suffering is to administer anesthetic levels of medication that keep the patient in a deep sleep-like state until death comes.
Putting all this together, we have four possibilities:
1. giving medicine to relieve intolerable suffering despite the fact that it hastens death,
2. providing continuous anesthetic levels of medicine and thus terminal sedation to relieve suffering until death,
3. giving medicine in order to relieve suffering and to hasten death, and
4. administering a lethal injection that causes death quickly in order to relieve suffering.
Moral reasoning that permits 1. and 2. if the sole motive is to relieve suffering but forbids 3. and 4. because the intent includes the deliberate hastening of death is spurious in my opinion. The objective result is the same. Extreme instances may arise in which it may be preferable to end suffering by causing death than to extend life slightly at the cost of immense, needless suffering. In any case, the decision in these circumstances should be made on the basis of how the value of extending life is weighed against the value of relieving suffering, not on motive alone when the "double effect" cannot be avoided.
That leads me to the second response. To permit the administration of medicine in order to relieve suffering even though it hastens death gives the case away. It does so because the principle of that action is that in some instances, relieving suffering is preferable to extending life a little bit longer. That is exactly the principle I am contending for. If extending life even a little bit always takes absolute precedence over relieving suffering, one could not administer medicine to relieve even the most excruciating suffering if it hastens death even slightly. If it does not always take absolute precedence, then it becomes a relative value to be weighed against others. That is my contention, and I have expressed the view that sometimes ending suffering takes priority over extending life. Once that judgment is made, we will no longer worry about "double effects" purified by intent or the distinction between letting death happen and causing it to happen.
Given the importance of the issue and the dangers posed by the slippery slope, I make two suggestions.
A. Let us legalize physician-assisted suicide under very restricted conditions. (1) The patient must be hopelessly ill and near death, (2) mentally competent, (3) in great and uncontrollable pain or discomfort, and (4) make a voluntary request to be given assistance in hastening death. The law should require confirmation of all these conditions by appropriate means. The several states could devise their own procedures, so that many options might be tried and evaluated. Let us then have an extensive period of experimentation to determine what actually occurs when assisted suicide is legalized under these strictly limited conditions. Meanwhile, the issues should be widely discussed by a variety of citizens from all walks of life in light of all the facts that become available from the various experiments. Only then should any consideration be given to whether the circumstances under which persons may request assistance in dying should be broadened and, if so, in what ways. Only by actual experimentation of our own can we know what would actually occur in this country, how many people would be involved, what the consequences would be for physicians, the families of patients, and others. If after thorough evaluation, a majority of citizens are convinced that any step taken was a mistake, the legislation could be rescinded. The Supreme Court decision of June 26, 1997, throws the issue back to the states. Hence, my proposal provides a cautious way to proceed with ample opportunity for citizens to participate in democratic processes to establish the will of the people.
B. Let us make mercy killing a legal defense in the way that self-defense is now. Here I am following the lead of my former student James Rachels. He proposes that if a defendant can show that the killing had been done in mercy in circumstances that made the plea reasonable, the charges would be dropped. He suggests this as an alternative to making assisted death legal. It does have the advantage of making it unnecessary to have a lot of regulations or a committee to determine when a request for assisted dying could be honored. I propose it as an additional move that would be especially advantageous outside of formal medical settings that could be regulated and scrutinized.
In many circumstances of the sort discussed here, human beings confront limits to their wisdom. We make decisions in the presence of objective uncertainty and conflicting values. Tragedy and ambiguity pervade the scene. No solutions are foolproof, infallible, or free from the possibility of abuse despite good intentions or because of ill intent. Sometimes every possible course of action makes us uneasy. We can continue to subject our own convictions to the scrutiny of others whose criticism we trust in the hope that deeper insight will dawn regarding what love bids us do for each other when life becomes a burden rather than a blessing. Meanwhile, our final recourse is to the mercy of God, who has pity on us pathetic, error-prone creatures, who "knows our frame," who "remembers that we are dust" (Psalm 103: 13-14 RSV).
The distinction comports with fundamental legal principles of causation and intent. . . . when a patient refuses life sustaining medical treatment, he dies from an underlying fatal disease or pathology; but if a patient ingests lethal medication prescribed by a physician, he is killed by that medication. James Rachels, The End of Life: Euthanasia and Morality (New York: Oxford University Press, 1986).