A Michigan physician thought carefully about what he would say to a cancer patient about the results of his latest tests. The news was not good—his patient was near death and needed to be told so directly. This part of the job never became easy—it was never "routine." As gently as possible, the doctor started to speak. But the patient cut in: "Please don't tell me you'll be willing to talk about physician-assisted suicide," the patient pled. "I just don't want to hear it."

The doctor was shocked. Assisted suicide was the last thing on his mind, but in Michigan, the chosen haunt of assisted-suicide specialist Jack Kevorkian, it is apparently on many dying patients' minds—and it is radically changing their feelings about their physicians.

Diane Komp, a hematologist/oncologist at Yale University and a popular Christian author, has for years gone by the moniker "Doctor Di." In the course of a book and speaking tour through Michigan in the fall of 1996, several emcees made nervous references to "Doctor Die." As it happened again and again, Komp realized that physician-assisted suicide (PAS) advocates had accomplished just what they set out to do: For good or for ill, physician-assisted suicide was now on everybody's mind.

Advocates of physician-assisted suicide have tapped into the frightened psyche of our aging and ailing population, addressing a fear that, unfortunately, politicians, physicians, and the church are refusing to address: We die differently than we used to, and many of the elderly have plenty to fear.

Less than a century ago, death was spread fairly evenly across most age groups. Because we could not control bacteria very well and accidents were more common, a 10-year-old was scarcely more likely to survive to age 20 than a 40-year-old was to reach age 50. Today, all that has changed. Those of us who survive infancy and the accident-prone late teens and early twenties are likely to live well into our eighties; when we die, we will likely do so after a protracted illness that exhausts our life savings.

Massive social pressure and enterprising individuals are converging to force us to address this new reality of dying, and our society is actively revisiting a question that once needed little or no debate: Why should we oppose physician-assisted suicide?

Four professionals give us their perspective from the frontlines of this new reality. These individuals come from different traditions (evangelical, Roman Catholic, and mainline Protestant) and different vocations (a moral theologian, a medical ethicist, a lawyer, and a geriatrician). Each one has a different perspective on the sobering end-of-life challenges facing our society.

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The moral theologian: A different way of death
Allen Verhey, professor of religion at Hope College in Holland, Michigan, was confronted by a question that many of us will face. His parents—both of whom are still alive—asked him to exercise on their behalf a durable power of attorney for health care. Verhey's specialty is medical ethics, and he is well acquainted with the issues that such a responsibility raises—when to refuse treatment, the management of pain, and the growing controversies surrounding how we die.

"We die more slowly today," Verhey notes. "Even worse, we do it in hospitals, surrounded by technology rather than by friends and family. And this is what makes it especially frightening to some people."

When Verhey first began teaching medical ethics in the early seventies, PAS was not discussed that much. There was a "clear consensus" about the immorality of PAS. What he did speak (and write) about was a growing "shallowness of effort" in medical ethics, which looked to "generic principles." Verhey's book Amoral Medicine argued that medicine was losing its moral foundations and required religious traditions to guide it.

Verhey served for a time as the director of the Institute of Religion at the Texas Medical Center, providing him with the opportunity to pursue his "passion in the academy," which is to "retrieve religious traditions" as relevant to medical ethics. The fact that Verhey now teaches in Kevorkian's state has pushed the particular problem of PAS to the forefront. But the thought behind Kevorkian's actions has been building for decades as people have encountered stories of how other people have died.

"There is a kind of 'I don't want to die the way Aunt Sarah did,' " Verhey points out, "and in order to gain some control over that happening, people are beginning to insist more and more on their own right to determine the conditions of their dying."

Moreover, "freedom has become the most important value in our society," and PAS is being touted as a way to provide people with yet more freedom. "Then the argument becomes, 'Who can be against maximizing freedom in this culture?' "

The foundational issue, however—one that seems to determine a person's position on PAS—is that "the distinction between killing and allowing someone to die is less compelling than it once was." It was one thing in the late seventies and early eighties to discuss refusing or discontinuing heroic medical treatment, which is now uncontroversial; but today such refusal is being likened to the intentional killing of sick people. This moral leap is at the root of the pressure to legalize PAS and it is in part what drives Verhey to address it today. The Christian story, he points out, has traditionally preserved a sort of "dialectic about life" in which life is viewed as "a great gift," but not as the greatest good.

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"This dialectic is woven through Scripture's narrative from Adam's first breath in the garden to sanctions against killing after the Flood, to the prohibition against murder in the Ten Commandments and, not least, to the significance of an empty tomb. It's clear that God intends life and that God's cause is life, not death. At the same time, because the Cross stands at the center of the story, Christians may not regard their own survival as the law of their being." The Christian tradition has sought to express this dialectic by prohibiting suicide while accepting death.

But this distinction is being assaulted by a culture that has a "myopic concern about consequences." "When we focus on consequences alone," Verhey warns, "the distinction [between active and passive euthanasia] isn't very compelling. Whether someone is killed or allowed to die, the consequence is the same [death]; so the distinction appears trivial, like moral nitpicking."

But to Verhey it is anything but moral nitpicking. He has been involved in questions about the refusal of treatment for some time, raising his "pastoral sensibilities" on the issue, and these sensibilities have led Verhey to become concerned that the new technologies surrounding a dying patient have not only increased physicians' and patients' options, but they have also taken one option away: the option of staying alive without having to justify one's existence. In other words, Verhey warns, the society that approves PAS under the guise of freedom may usher in a future in which suffering patients are no longer asked why they want to die, but why they want to go on living.

Though he served on a panel in April with PAS-advocate Dr. Timothy Quill, Verhey is adamant that it is not enough simply to engage in arguments. The Christian response to PAS must not be simply "to shout the prohibition." Churches should bear witness to their convictions and the biblical narrative that forms them by the way it cares for the dying. "The Christian community has the responsibility to model a better way to deal with dying than either keeping the patient alive as long as possible or eliminating a patient's suffering by eliminating the sufferer."

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The medical ethicist: Avoiding the slippery slope
Working with the dying is a regular part of Edmund Pellegrino's medical practice. He has, at times, been asked to "assist" a patient in dying. Pellegrino's response to one such request is typical: After the patient expressed his wish, Pellegrino sought to meet the real needs behind the request.

First, he used the best methods of pain relief and increased the patient's sense of control by enabling the patient to self-administer the pain medication. This patient was also feeling guilty, clinically depressed, and concerned about being a burden to others. Pellegrino treated the depression, brought in a pastoral counselor to address the guilt, and gathered the patient's family to help them see how their response to this man's illness was aggravating his sense of unworthiness.

Once these needs were met, the patient thanked Pellegrino for not responding to his earlier request to die. "The most valuable days of my life have been the last days I have spent," he said.

Pellegrino approaches PAS on the wave of a long and storied career, having taught for over 50 years. He is currently professor of medicine and medical ethics at the Georgetown University Medical Center and is consulted regularly on issues surrounding medical ethics, particularly as they relate to the dying.

In Pellegrino's experience, the demand for PAS is a shortcut that attempts to address legitimate concerns in illegitimate ways. That is why he believes it is important to maintain the distinction between active and passive euthanasia, or, as he prefers to call it, between killing and letting die. However, as a professor who regularly engages in debate with leading PAS advocates, Pellegrino acutely understands that such a distinction is increasingly less respected by medical and public attitudes.

Pellegrino believes that underlying this erosion is a general assault on traditional medical ethics that was unleashed in the turbulent sixties. "The benign authoritarianism of traditional medical ethics gave way to participatory democracy. All of the sudden, people wanted to be involved in decisions that affected them." This converged with the civil-rights movement, the consumer movement, and the fight for women's and others' rights, shifting the focus of decision making from the physician to the patient and her family.

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Now the situation is worsening as the economic pressure of "managed care" programs has entered the picture. Hardly a week goes by when Pellegrino isn't approached by another physician who is struggling with the ethical issues raised by managed care. Doctors feel caught between their loyalty to the patient and to the managed care corporation.

In such a climate, Pellegrino is particularly concerned that adding PAS to a doctor's options would be disastrous for many at-risk patients. "In this era of managed care, economic pressures may put the seriously ill infant, the elderly and senile, or the retarded at serious risk from distorted compassion." Pleas for assistance in suicide are in reality "desperate pleas for help, including emotional and spiritual support." They should therefore be met with "comprehensive, intensive, palliative care, not the accelerated demise of the person suffering."

Pellegrino takes issue with those who see PAS as an act of compassion. "It is often more compassionate for the frustrated physician or hurting family than it is for the patient. In fact, assisted suicide is really a noncompassionate form of moral abandonment."

The specter of PAS goes beyond individual cases, however, to encompass a radical reworking of medical ethics. In Pellegrino's mind, it is the same radical reworking that has resulted in legalized abortion and in states such as Illinois and California insisting that physicians participate in state-ordered executions.

"What I'm talking about is the integrity of medical ethics, which must be independent of what either the state or law says it is. We need to examine the presuppositions, be aware of the conclusions they lead to, and detect in our own society any sign of the eroding of the substantial integrity of the ethics of medicine which has persisted for twenty-five hundred years: thou shalt not kill the patient, thou shalt not perform an abortion, and thou shalt act in the best interests of the patient."

Though he still hopes people are responsive to moral argument ("Otherwise, I wouldn't be teaching and writing about it"), Pellegrino expects that euthanasia will eventually be legalized. "We have already disassembled most of traditional medical ethics," he concedes.

In Pellegrino's mind, history, medical ethics, and contemporary experiments in countries such as the Netherlands all point to the fact that once a form of PAS is legalized, we will begin a desensitizing process that will inexorably lead us from bad to worse. "The Dutch are not malevolent people by nature, yet they're sliding down the slippery slope."

First of three parts; (click here to read part 2)

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