Thursday, April 13, 2023

Legalizing euthanasia and/or assisted suicide is morally dubious and extremely dangerous.

Alex Schadenberg
Executive Director, Euthanasia Prevention Coalition

Leon Kass
In August 1996 Dr Leon Kass, who was a physician, scientist and educator and later (2001 to 2005) the chairman of the President's Council on Bioethics, wrote an insightful article titled: Dehumanization Triumphant concerning the legalization of assisted suicide. 

Kass accurately predicted the outcome of the legalization of assisted suicide. Kass wrote:

Recent efforts to legalize physician-assisted suicide and to establish a constitutional “right to die” are deeply troubling events, morally dubious in themselves, extremely dangerous in their likely consequences. The legalization of physician-assisted suicide, ostensibly a measure enhancing the freedom of dying patients, is in fact a deadly license for physicians to prescribe death, free from outside scrutiny and immune from possible prosecution. The manufacture of a “right to die,” ostensibly a gift to those not dying fast enough, is, in fact, the state’s abdication of its duty to protect innocent life and its abandonment especially of the old, the weak, and the poor.

Kass recognized that the Oregon Assisted suicide law would give physicians (in some states nurses) the right in law to prescribe lethal drugs with full immunity from possible prosecution. These laws are not about a right to die but rather a right to abandon people at a difficult time in their life. Kass continued:

The legalization of physician-assisted suicide will pervert the medical profession by transforming the healer of human beings into a technical dispenser of death. For over two millennia the medical ethic, mindful that power to cure is also power to kill, has held as an inviolable rule, “Doctors must not kill.” The venerable Hippocratic Oath clearly rules out physician-assisted suicide. Without this taboo, medicine ceases to be a trustworthy and ethical profession; without it, all of us will suffer—yes, more than we suffer now because some of us die too slowly.

The doctor–patient relationship will be damaged. The patient’s trust in the doctor’s devotion to the patient’s best interests will be hard to sustain once doctors can legally prescribe death. Even conscientious physicians will have trouble caring wholeheartedly for patients once death becomes a “therapeutic option.” The prohibition against killing patients, medicine’s first principle of ethical self-restraint, recognizes that no physician devoted to the benefit of the sick can serve the patient by making him dead. The physician-suicide-assistant or physician-euthanizer is a deadly self-contradiction.

Kass recognized that legalizing assisted suicide would undermine the Hippocratic Oath and the doctor-patient trust relationship. This is exactly what has happened. Doctors and nurses who participate in euthanasia or assisted suicide have decided that certain lives are not worth living or protecting. Further to that they have redefined the meaning of Do No Harm. Kass continued:

Physician-assisted suicide, once legal, will not stay confined to the terminally ill and mentally competent who freely and knowingly elect it for themselves. Requests will be engineered and choices manipulated by those who control the information, and, manipulation aside, many elderly and incurable people will experience a right to choose death as their duty to do so. Moreover, the vast majority of those who are said to “merit” “a humane and dignified death” do not fall in this category and cannot request it for themselves. Persons with mental illness or Alzheimer’s disease, deformed infants, and retarded or dying children would thus be denied our new humane “aid-in-dying.” But not to worry. The lawyers, encouraged by the cost-containers, will sue to rectify this inequity. Why, they will argue, should the comatose or the demented be denied a right to assisted suicide just because they cannot claim it for themselves? With court-appointed proxy consentors, we will quickly erase the distinction between the right to choose one’s own death and the right to request someone else’s.

Kass accurately predicted that euthanasia and assisted suicide would begin with the assurances that it would be limited to the terminally ill and mentally competent who freely choose to have their life ended. When considering the Canadian experience with euthanasia, in a few short years the Canadian law went from being limited to people whose "natural death was forseeable" and requiring the ability to consent at the time of death, to allowing euthanasia for people with chronic or disabling conditions who are unable to consent at the time of death. Canada is now considering euthanasia for children, newborns and by advanced consent for people who are unable to consent. Kass continued:

The termination of lives someone else thinks are no longer worth living is now occurring on a large scale in Holland, where assisted suicide and euthanasia have been practiced by physicians for more than a decade, under “safeguards” more stringent than those enacted in the Oregon law. According to the Dutch government’s own alarming figures, there are over one thousand cases per year of direct in voluntary euthanasia; also 8,100 cases of morphine overdosage intending to terminate life, 61 percent without the patient’s consent. Although the guidelines insist that choosing death must be informed and voluntary, over 40 percent of Dutch physicians have performed involuntary euthanasia. As the Dutch have shown, the practice of assisted suicide is in principle unregulable, because it is cloaked in the privacy of the doctor–patient relationship.

In this paragraph Kass was refering to the Remerlink report. This is also a common problem in other countries, but at least the Netherlands did research to uncover the reality. The Netherlands officially legalized euthanasia in 2002 to further regulate euthanasia and control the problem of involuntary euthanasia, but in fact further reports from the Netherlands proved that involuntary euthanasia persisted even after it was officially legalized. Kass continued:

Legalizing assisted suicide would mark a drastic change in the social and political order. The state would be surrendering its monopoly on the legal use of lethal force, a monopoly it holds under the social contract, a monopoly it needs if it is to protect innocent life, its first responsibility. It should surprise no one if physicians, once they are exempted from the ban on the private use of lethal force, wind up killing without restraint. Here, by the way, is a genuine violation of the Fourteenth Amendment: deprivation of life without due process of law.
We must care for the dying, not make them dead. By accepting mortality yet knowing that we will not kill, doctors can focus on enhancing the lives of those who are dying, with relief of pain and discomfort, moral and social support, and, when appropriate, the removal of technical interventions that are merely useless or degrading additions to the burdens of dying—including, frequently, hospitalization itself. Doctors must not intentionally kill, or help to kill, but they may allow a patient to die.

Kass did not comment on the fact that legalizing euthanasia will change the practise of palliative care. Since some palliative care physicians will willingly participate in euthanasia and since many people who request euthanasia are being cared for by palliative care physicians, the demand that palliative care provide euthanasia is the inevitable outcome of legalizing euthanasia. Kass continues:

Ceasing medical intervention, allowing nature to take its course, differs fundamentally from assisting suicide and active euthanasia. Not the physician, but the underlying fatal illness becomes the true cause of death. More important morally, in ceasing treatment the physician does not intend the death of the patient, even if death follows as a result. Rather, he seeks to avoid useless and degrading medical additions to the already sad end of a life. In contrast, in assisted suicide the physician necessarily intends primarily that the patient be made dead.
One cannot exaggerate the importance of the distinction between withholding or withdrawing treatment and directly killing, a distinction foolishly dismissed in the recent Court of Appeals’ decisions. Both as a matter of law and as a matter of medical ethics, the right to refuse unwanted medical intervention is properly seen not as part of a right to become dead but rather as part of a right protecting how we choose to live, even while we are dying.

Kass is completely correct. There is a clear difference between killing and letting die. The Supreme Court of Canada, in its Carter decision, also foolishly dismissed the distinction between killing and letting die. The distinction is always a reality. When a person accepts the limits of life and agrees to the withdrawal of treatment, death is not the result of the withdrawal, but rather the person dies a natural death. Further to that, the person, after having treatment withdrawn, does not always die. But death by lethal drugs (euthanasia) always causes death, and is the cause of death. Kass continues:

Once we refuse the technical fix, physicians and the rest of us can also rise to the occasion: we can learn to act humanly in the presence of finitude. Far more than adequate morphine and the removal of burdensome chemotherapy, the dying need our presence and our encouragement. Withdrawal of human contact, affection, and care is the greatest single cause of the dehumanization of dying. People who care for autonomy and dignity should try to correct this dehumanization of the end of life, instead of giving dehumanization its final triumph by welcoming the desperate good-bye-to-all-that contained in one final plea for poison. Not the alleged humaneness of an elixir of death, but the humanness of connected living-while-dying is what medicine—and the rest of us—most owe the dying. The treatment of choice is and always will be company and care.

Once again Kass is completely correct. Providing pain and symptom management and caring for someone is humane and bolsters the humanity of a person. Caring is a human act, killing dehumanizes the person. When communicating with people who are considering death by euthanasia, I have always found that the reason that they are asking to be killed is different than the reason that they are being approved for death. After explaining their medical condition, once asked, they always talk about their loneliness, their lack of hope, that they feel like a burden on others. All of these feelings require a caring response, not a death by lethal injection.

Thank you Dr Kass.


Unknown said...

Extremely very well explained...Thank you very much
Marc Quevillon

gordon friesen said...

This article by Dr. Kass is just amazing. It contains almost all our experience, and was written in 1997! The only thing I would add is that Kass (like veryone else at the time) restricts himself to speaking of the dangers unleashed by liberty. Even he did not envisage the systematic normalization as deliberate public policy which is just beginning to openly emerge.

In other words, when Kass says, "With court-appointed proxy consentors, we will quickly erase the distinction between the right to choose one’s own death and the right to request someone else’s", he is stll appealing to the common perception that this would be a bad thing.

However, we will soon see such warnings dismissed with comments like "and that is bad why?" or more simply with a yawn and a sarcastic quip: "and your point is?"

It must be understood, now, that when there is substituted consent for euthanasia, that this will mean professional and institutional "consent" for all of those who do not have families (and probably financially independent families) protecting them. In other words: this will not be a danger of people's (or even family member's) choice, but a deliberate systematic institutional policy.

And gross as it might seem: for the first time since the Second World War, "experts" will openly and publicly claim that such policies are desirable and progressive.

All that remains is public opinion, and the moral compass of that opinion (abetted by extraordinary historical ignorance) is apparently in free-fall. Our job, daunting as it may seem, is to correct that civilizational trajectory.