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AAPLOG Practice Bulletin No. 1: Perinatal Hospice-Care with Compassion for Families with an Adverse Prenatal Diagnosis *(April 1, 2015)

The Epidemiology of Abortion And Its Prevention in Chile(April 1, 2015)

Sociological Environmental Causes are Insufficient to Explain Autism Changepoints of Incidence(April 1, 2015)

Preface(April 1, 2015)

Parental Notification/Consent for Treatment of the Adolescent(April 1, 2015)

Diagnosis of Fetal Anomaly and the Increased Maternal Psychological Toll Associated with Pregnancy Termination(April 1, 2015)

Epidemiologic and Molecular Relationship Between Vaccine Manufacture and Autism Spectrum Disorder Prevalence(April 1, 2015)

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Tolstoy's Manifesto on the State, Christian Anarchy, and Pacifism
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The Russian Director Who, After Making a Film About the End of the World, Learned He Was Dying of Cancer
The Stranger (May 20, 2015)

Can Psychology Help Spur the Re-birth of African Civilization? Notes on the African Personality (Psychological Africanity) Construct: Normalcy, Development, and Abnormality
The Journal of Pan African Studies (Online) (June 1, 2015)

Cyclic Time in Indian Art Music & Creativity
Indian Musicological Society. Journal of the Indian Musicological Society (January 1, 2011)

The Faulkner Journal (April 1, 2012)

Other People's Lives: Reflections on Medicine, Ethics, and Euthanasia
Issues in Law & Medicine (July 1, 2011)

Spice, Bath Salts, Salvia Divinorum, and Huffing: A Judge Advocate's Guide to Disposing of Designer Drug Cases in the Military
The Army Lawyer (April 1, 2012)

Publication: Issues in Law & Medicine
Date published:
Language: English
PMID: 30263
ISSN: 87568160
Journal code: ILME

Part Two: Medicine Versus Euthanasia

Chapter XXI. The Philosophy of Euthanasia

"Use logic to overcome the scruple."245

Francois Mauriac

The advocates of physician-assisted suicide, or voluntary euthanasia, present the following argument:

* Hopelessly ill people who in the end will have to die in unbearable pain, wish to be freed from a life that has become a burden to them. They should not be compelled against their will to endure their meaningless suffering. Medical progress can now extend the lives of the gravely ill; in doing so, the doctors are guided by technical considerations, without regard for the human aspect of such interventions. As a result, people are condemned to an unbearable life and to a death unworthy of human beings.

* Another important factor is the aging of the population, the prevalence of disabling infirmities inherent in old age, and the proliferation of nursing homes and institutions for chronically ill residents, who are cut off from their families, isolated from the rest of society, and who have lost faith in the meaning of their lives.

* And let's not forget the terrible scourge of Alzheimer's disease. "Do any of us want to end out lives with the paralyzing fear and anxiety and the complete loss of one's mental faculties? Do any of us want our spouse to spend ten long, lonely years after losing all real contact with a lifetime partner?" asks a proponent of death by own choice.246

* Like every important social problem, this one can and should be solved by society. We have achieved freedom of belief and expression. All problems can now be discussed, all taboos can be shaken and outdated dogmas doubted. The old taboo on killing is at odds with compassion and a truly humane attitude. Suffering people desire to put an end to their lives. The rational autonomous beings' right to make such a decision should be recognized as a fundamental human right.

* However, the extremely painful problem of unnecessary human suffering cannot always be solved by the victims' conscious and voluntary decision. By rigidly adhering to the voluntary principle we deprive infants who are severely disabled and people who are demented or comatose of the chance for a painless death.247 A number of comatose persons are being kept alive by artificial means, at great effort and expense, and to the despair of their families. Caregivers do not dare to make a decision and cut short these lives. But to keep a comatose person alive is also a decision and the one who makes such decision should be obliged to justify it.248

* Steps should be taken to avoid errors and abuses. The patient's families should be involved in the decision. The carrying out of euthanasia and assisting patients in suicides must be entrusted to doctors. The conclusion that the patient's condition is hopeless should be confirmed by a committee or at least another doctor. Physicians who carry out euthanasia or assist their patients in committing suicide should proceed with due care.

While appealing to noble emotions, the argument of the proponents of euthanasia also makes a logical, cogent impression. But assertions that entail irreversible consequences for human life must be supported by irrefutable proof. Thus, all elements in the narrative and all assumptions in the reasoning of the advocates of euthanasia, or assisted suicide, ought to be meticulously examined.

The Abolition of All Taboos. The overthrowing of taboos occurs selectively. Perhaps it is worth reflecting on the fact that society offered little resistance in defending the inviolability of human life while still defending with great force the taboo on private property. Not only have we maintained certain old taboos, but we also have created new ones, like the inviolate right of growing and grown children to live their own lives without the restraining intervention of parents and without concern for them. When Dr. P killed her mother at her request in a home for the chronically ill (the Leeuwaarden trial, 1973), she was reproached in a letter to the editor of Time Magazine: "probably taking the mother home would have solved the problem, but this did not occur to Mrs. P." Indeed it did not. Killing her mother was an acceptable solution, but disturbing her own well-ordered life was not. In Dr. P's eyes, the taboo on killing had already been abolished, but the taboo on privacy was binding. The issue of abolition of taboos would not seem to require further commentary.

All Problems Are Solvable and Every Important Problem Should Be Solved by Society. This is the basic idea and point of departure for the proeuthanasia movement. It is an expression of the triumphant self-confidence of Western industrialized society which has succeeded in solving so many problems. We produce great wealth, we have created a government of law and order and a pluralistic, tolerant community; we are approaching the ideal of peaceful and free life for all citizens. If there are problems, they can always be solved providing there is a genuine will to solve them. If some minority is being discriminated against, we will enforce the appropriate laws and launch an educational campaign. We will set up special classes for children having difficulties with learning. When ice damages the highways, we will repair them. There are no unsolvable problems, only problems awaiting a solution, for example, that people must suffer and then die. The time has come to solve this problem, and it can be done.

But it cannot be done. The notion that all problems are solvable is quite obviously at variance with the truth. It denies the sad reality and man's inevitable tragedy. It is man's fate on this earth to be born, to strive, to struggle, to hope, and in the end, to be disappointed in all he sought, to suffer defeat in every battle, to lose those he loved, to be conscious of the inevitability of death, to suffer and to die; this is a tragic fate and one without a solution. We can solve many problems, but not the ultimate ones.

The "solution" proposed by the pro-euthanasia movement is obviously a sham. We can blow up a ship that is taking on water, but we cannot assert that thereby we have solved the problem of leakage. No problem is solved by destroying the thing involved.

Institutions for the Elderly and the Chronically III. These institutions have been created due to a great demand, are maintained at high financial cost, and perform a very useful function. On the other hand, the negative aspects of these institutions are also evident. Some people, isolated in an institution, lapse into depression and may even think of hastening their own death. But to use this argument to justify euthanasia is logically (not to mention morally) inadmissable. Institutions for the ill and aged are not natural disasters to which, with all their consequences, we must resign ourselves. These institutions are the result of our own deliberate actions. They were created as places where the elderly can live. Had our efforts produced only the opposite result, leading to people asking for death, then the logical conclusion would have been to close the institutions, not to kill the residents.

But, of course, in reality this is not necessary. Married couples manage well in institutions and many single persons adapt quite reasonably. And we should encourage other solutions for those who fare poorly: first of all, quality care for the elderly who stay with their families or alone in their own apartments. It is less expensive than maintaining the institutions.

The assertion that "we have done so much to improve the lives of the elderly that now we must kill them" is obviously absurd.

Keeping the Sick Artificially Alive with Modern Technology. The allegation that it is modern technology that produces the demand for voluntary euthanasia can hardly be substantiated. In Holland, in the majority of cases, euthanasia is performed by family physicians, at patients' homes, on patients treated without any special techniques. Hospital patients who are conscious and tired of treatment and all the machines, have the right to refuse treatment, and have always had this right and exerted it. If the patient is unconscious there in no question of "voluntary" euthanasia.

The theorists of euthanasia do not take into account that the hated "modern technology" can actually encourage patients' will to live. Patients in respiratory failure, admitted to intensive respiratory care units, after a few days of assisted ventilation, clearing the airways, antibiotics, and steroids, leave the hospital in improved condition and an optimistic frame of mind.

And let's note that the allegations of senseless prolonging life through use of modern technology were already made in 19th century: In 1875, Ernst Haeckel wrote about "improved modern medicine" which supposedly was not permitting "those unworthy of life" to die,249 and in 1899, Baldwin accused "subcutaneous injections, transfusions and intravenous infusions" of allowing medicine "to keep us from the grave in a state of constant struggle for life."250 And yet at that time the ability of medicine to prolong human life was almost nil. Thus, to use the "modern technology" argument it is not necessary for somebody's life to be prolonged, or even for any such technology to exist.

Death Unworthy of a Human Being. The fate of people who die after long suffering is decried as "unworthy of a human being." A value judgment, of course, but one worth reflecting on. Death, after a short, long, or very protracted illness and suffering, is not an invention of modern medicine, it was always the sad fate of many people. Victims of plague pneumonia died in few days, but patients in congestive heart failure dragged on for a couple of years, breathless and on swollen legs, and soldiers with abdominal wounds sometimes took months to die. To believe the advocates of euthanasia, the majority of our predecessors on this planet, hundreds of millions of human beings, Mozart, Goethe, and Einstein, my grandfather and your grandmother, all died a death unworthy of a human being. It was not their privilege to die in a way worthy of a human being, that is our discovery alone: to be put to death by a professional. The use of the "death unworthy of a human being" argument is a display of considerable arrogance, and an insult to our ancestors, and to mankind's entire past.

Meaningless Suffering . Does suffering have meaning? Various answers can be given that question depending on the way the issue is formulated. To wit, it maybe formulated from the point of view of religion, biology, or from an anthropocentric standpoint. Dualistic religions consider evil (and human suffering) to be on an equal footing with the good in the universe, whereas monotheistic religions assume that evil and suffering have a meaning which cannot be understood by man, but is clear to God. The latter construct is necessary to reconcile the existence of evil and suffering with a beneficent and omnipotent God, and thus is useful to those who have the good fortune to believe in such God. The theorists of euthanasia leave both of these religious concepts of suffering out of consideration, for which the present author will not reproach them.

From the biological standpoint, the suffering and the pain are meaningful in so far as they elicit reactions that tend to reduce the injury, i.e., favoring a broken limb, the reflex to raise from supine posture when there is congestion of the lungs, etc. These reactions are expressions of adaptation to the external world, an adaptation of a high degree, formed during the evolution of the species. The biological role of pain is demonstrated by pathological conditions that deprive the patient of pain sensation, as for example, syringomyelia or leprous neuropathy: unprotected by the ability to feel pain, these patients are prone to severe injuries and burns. From the biological point of view, suffering and, in particular, pain, become "meaningless" (cease to be of use to the organism) when they overstep their functions of warning, correcting, and reducing injury.

The idea of "meaningless suffering" as used by advocates of euthanasia cannot be reduced to the biological concept because it leads to consequences farther reaching than a biological reaction to suffering. The biological reaction to suffering contains no impulse to self-destruction.251

From the anthropocentric point of view (which I share with the proponents of euthanasia, though not their conclusions) suffering that exceeds its biological function has no greater "meaning" than an earthquake or other natural phenomena. The "meaning" of such suffering depends on how we deal with it. Some people find their suffering a stimulus to creativity; thus Dostoyevsky exploited his epilepsy, Pascal his headaches, and Van Gogh his mental illness. Others have been spiritually enriched by suffering. The following truth applies to everyone: when it is no longer possible to live without suffering, one will suffer in order to live. And that is the "meaning" of suffering: the price we pay for preserving the higher, singular, and unique value: our lives.

To be sure, the adherents of euthanasia consider the value of human life to be relative, a value that can be quantitatively estimated and weighed against other values like relief from pain, unburdening of family or even society; having weighed these values one can make a choice. But this is not a true choice. The values compared are incomparable. Suffering is only one of the elements in the life of a suffering person, the burden on his relatives is only one of many things in their lives, not to mention society's; but for the person making the "choice," his life is everything, and the only one he has. This is also not a true choice because if the person chooses death, and dies, the values he had chosen cease to exist. There is no more suffering, nor is there liberation: only a person can be liberated, but the person no longer exists. A dead man has no family and is not a member of society. To opt in favor of one's own death is a desperate step and must be seen as such; someone who attempts to justify that "choice" logically is deceiving himself, or others.

But let us return to the concept of "meaningless suffering." This is a value judgment derived from the principle of utilitarianism ("man desires as much happiness and as little suffering as possible, and nothing else is worth desiring"). I shall discuss this principle in the next chapter. Let us bypass that and examine the role of the concept of "meaningless suffering" in the argument in favor of euthanasia. Let us compare the standpoint of an oldfashioned person O who has never heard of euthanasia, with that of the "modern" individual M, who considers euthanasia a possible solution. O says, "I hope that my suffering will pass and I'll live a while yet." M replies, "But your suffering may not abate, what then?" O says, "That would be very bad, but what can I do- I'll have to go on suffering." M replies, "That's not true, your suffering is meaningless, I mean unnecessary, so there is no need for you to go on suffering at all; you can accept euthanasia and be immediately freed of suffering." Thus, the concept of "meaningless suffering" finds application only when an end can be put to suffering, and to life, through euthanasia. The entire line of reasoning proves to be a vicious circle. The possibility of euthanasia makes the suffering meaningless; in turn, we use the concept of "meaningless suffering" to justify euthanasia. This is the wellknown logical fallacy called circulus in probando. One may use the concept of "meaningless suffering" to express one's personal feelings, but not to prove anything.

Unbearable Suffering. Before taking a position on how to act in the event of unbearable suffering, it makes sense to consider how not to let it happen. Our present ability to alleviate pain is very great, and in extreme cases, one can resort to blocking or surgically destroying the nerve pathways carrying the pain stimuli or the cells receiving them. Patients suffering from trigeminal neuralgia, who in the past sometimes committed suicide out of fear of a new attack, never do so now thanks to effective medical treatment. I will go as far to say that there is currently no reason for pain, in and of itself, to bring a sick person to despair. Severe disfigurements of the face, with the exception of those caused by malignancy, can to a large extent be corrected by plastic surgery; isolation hospitals for the "gueules cassées," which were created after the First World War, are no longer needed. The situation of people irreparably paralyzed, who require help of others in their daily functioning, cannot unfortunately be changed, but a great deal is being done to ensure them good care and, most importantly, the majority of those who care for such patients do so willingly, with patience, and humanely; it is thanks to them that the affected persons are able to bear their fate.

But progress in these good works in recent decades has been accompanied by changes in the way sick people are dealt with, changes that have exerted a perverse influence and have caused sick people to feel that their sufferings are unbearable. I have in mind, first of all, the new way of informing the patients. This is the result of a new role that the public has imposed on doctors and that some doctors have imposed on themselves: the doctor is no longer a person who brings people help and solace, but is now an "impartial expert." This is an unfortunate change because no one really wants or needs to be brought before an impartial medical judge, nor is a doctor really able to perform that new function. Luckily, the majority of physicians have kept some common sense and empathy with the patient; the majority still remember what medicine is about. Without these qualities, the "impartial expert" becomes a true sower of misery. With a morose expression, he informs the patient of his gloomy suspicions.252 When a patient asked me, "Doctor, how long can I live with this?" I answered, "How can I know? I don't even know what will happen to me this evening. Let's all try to live as long as we can." And this is more or less the answer given by my colleagues, the "traditionally" educated doctors. And in answering this way we are faithful to the truth because the fate of each of us is uncertain, and I really don't know who will die first, my patient, a sick person, or I, though I seem healthy. And in answering this way we make the patient feel that he shares the common human fate with all of us, the common hope, and the common uncertainty. We do not exclude him from the human community. But in recent years I have seen patients who have been given a death sentence, they have "another two months" or "another two weeks" to live. A prediction of this kind can never be true,253 it can only come about through pure chance; but how is a person supposed to live while awaiting a fixed date for execution? Fortunately, the patient usually maintains a bit of healthy skepticism, but the more he believes in the doctor's expertise, the more unbearable his life and, of course, every symptom becomes to him.

There are a few simple and sensible rules that a good doctor follows when speaking to a patient:

* Don't tell him anything you yourself don't know;

* It is not your task to make this world crueler than it is; and

* Don't let yourself think you know the future; many patients with a bad prognosis have lived to attend his or her doctor's funeral.

But today these rules no longer seem to be followed. We are greatly contributing to making suffering- and life- unbearable for the sick.

Before one begins to legally kill patients "upon their own request," it would make sense first to put a stop to doctors' actions which drive patients to consider suicide.

To present a gravely ill person with the prospect of an "easy death" is an act which directly intends that the patient begin to view his suffering as unbearable. People have an admirable ability to reconcile themselves to protracted suffering. Stroke victims, dependent for years on help from others, are able to enjoy all the little pleasures of daily life, and beam with happiness when visited by a grandchild. Patients who twenty years before had part of their intestine removed because of cancer, and have an artificial anus created on their abdomen, bravely empty the plastic bag containing their own excrement a few times a day, and work, attend concerts, and are happy in their marriages. There are patients who have had their larynx removed, but who work in their garden and take an interest in everything that is happening in the world; to be able to speak, they adroitly put a finger on the tracheostomy opening on their throat. What will-power and endurance these people must have, and renew it each morning! I have for them the greatest admiration and respect. Who would dare to shake their willpower, sow doubt in their mind, force them to wonder if all that effort was worth it, and tempt them to give up? And yet that is precisely what we are doing today, showing these people euthanasia as a possibility, as a desirable solution, and a brave, wise decision. We justify the need for euthanasia referring to unbearable human suffering, while at the same time the prospect of euthanasia causes people to view their suffering as unbearable and instills in them the desire to be freed of it by death. We are in a vicious circle once again.

Doctors and all people of good will should seek to relieve suffering, not exterminate the sufferers.

The Decision to Leave a Person Alive. The case of Mr. and Mrs. S became well known in Holland because of press reports and TV broadcasts.254 As a result of an error in anesthesia, Mrs. S had been in a coma for years. Her husband did not abandon her, visited her every three months, and had been very involved on her behalf. He had devoted all those years to intense reflection, and many times had requested the doctors to put an end on her life. "No one wanted to make this kind of decision." But- so reasoned Mr. S- to keep a comatose patient alive is also a decision, and one that needs to be justified.

Is it really a decision? We get up every morning and don't commit suicide; is that a decision? We don't set our houses on fire; is that a decision too? A mother feeds her child several time a day; is she making a decision in doing this? Only if we assume that she could have acted otherwise; but a mother cannot act otherwise. We only make decisions when we have a choice. But a mother has no choice. She feeds her child and does not consider allowing him to die of hunger or thirst. She makes no decision, and does not need to. People who nursed and fed Mrs. S were still not aware that one could put a person to death (though Mr. S knew that already). They had no choice and did not have to make a decision.

A Higher Necessity: Euthanasia an as Act Performed Under Constraint. The theorists of euthanasia maintain that under certain circumstances a doctor may decide to kill a person. The Dutch Supreme Court went farther: the high-ranking justices have acknowledged that under certain circumstances a doctor must kill his patient.255 This is when a conflict of duties occurs: on one hand, there is the doctor's duty always to preserve life, and the law (art. 293 of Dutch Penal Code), which prohibits euthanasia; but, on the other hand, there is doctor's duty toward his desperate patient who begs to be delivered of his misery. It is in such situation of higher necessity that doctors decide to carry out euthanasia. After several such rulings by the Supreme Court, a provision providing for "acting out of higher necessity" has been included in the official guidelines instructing doctors how to avoid prosecution (i.e., the "rules of careful conduct").256

Higher necessity is not an independent and separate concept, but depends on the actions that are considered admissible in a certain situation; actually it is an offshoot of these actions. Someone who has robbed a bank will find it fruitless to plead that he acted out of higher necessity (his family's poverty, impending bankruptcy), fruitless because his act- theft, bank robbery- is considered absolutely inadmissable under any circumstances whatsoever. A doctor who kills a patient can only appeal to higher necessity if his action is a priori considered as possibly permissible. It is only the a priori acceptance of euthanasia which creates the "higher necessity" stipulated by the Supreme Court. Once again we find the vicious circle. "Higher necessity" is an argument based on a logical fallacy, circulus in probando, and cannot be used to prove anything.

Furthermore, whatever state of necessity, "higher" or otherwise, the doctor is in, he has brought himself (and his patient) to that state. The "ordinary" doctor, who treated and guided his patient the traditional way, was never asked by a patient to put an end to his life.

And if a patient driven to despair requests to be killed, is the doctor then compelled to kill him? Shouldn't he rather do his best to alleviate the patient's suffering, and explain that killing is a savage, unthinkable, and entirely unnecessary act?

The Right to Self-Determination. The demand to recognize a person's right to decide about his own life and death reflects the change in the value system accepted by society. Traditional society considered human life the value worthy of highest protection and the life of every individual a value in which all other people had a share. The death of each person was a loss to all people; when any individual's life was in danger, the intervention of all people was required; all other values, including freedom, must be subordinate to the defense of a person's life (at least in peacetime). Thus, not only could no one take the life of another, but there also must be a limit on the freedom of anyone who would put an end to his own life: forcible hospitalization was justified in cases of mental illness that posed a danger of suicide. That social attitude and practice has not only been codified in law but is consistent with the deep belief we all share and which is a natural reaction: everybody rushes to help at the sight of a clothed person preparing to jump from a bridge into a river. "No man is an Hand, intire of itselfe," wrote John Donne four hundred years ago, "every man is a peece of a Continent, a part of the maine; if a Clod be washed away by the Sea, Europe is the lesse . . . any man's death diminishes me, because I am involved in Mankinde." There is no argument to justify this stance, and no need for one; whoever believes it is true can appeal to "the evidence of his heart."257

Thus, the traditional view of the value of human life cannot be logically proven true. One can, however, apply logical analysis to point out fallacies in the opposite position. The "permissive" society makes of freedom an absolute value, placing it higher than human life: everyone should be free to commit suicide and no one should interfere; a person should also be free to aid others in committing suicide, or to kill them at their own request.

These postulates are questionable. Freedom is certainly a high value, but in a society a person never has absolute freedom, his freedom is always limited. We are not free to steal, rape, or commit arson. We are not even free to spend our earnings without limit: we have to pay taxes. Since, one way or another, limits must exist on freedom, those limitations that defend human life are particularly justified. A person's life is unique, irreplaceable, and clearly a higher value than private property or social security.

Moreover, in making freedom an absolute value and placing it above life, still another and basic error in thinking is committed. Suicide and voluntary euthanasia are not the realization, but the destruction, of a person's freedom. Only the living have freedoms. A corpse is utterly and forever devoid of all freedom.

Thus, the absolute right to self-determination is a controversial concept, to put it mildly. Yet it is the basis and the justification of voluntary euthanasia. In recognizing the individual's right to self-determination, we supposedly recognize eo ipso the right to voluntary euthanasia.

The latter assertion is, however, untrue. Those who recognize the right to self-determination recognize the right of each individual to decide what will happen to his own body, his own life. But assisted suicide or voluntary euthanasia includes more than that. Other people take part in carrying out these acts: a doctor, often a nurse, and sometimes others. The right to assisted suicide or voluntary euthanasia (were we to recognize such right) would thus include not only the right to exert control over one's own person, but over other persons as well, their acts and their conscience. The person deciding on his own death would also have the right to make killers of the doctor and the nurse, and to make others accomplices to the killing. He would have the right to compel society to renounce the principle of inviolability of human life, to destroy the barrier protecting the life of each person. The right to assisted suicide or voluntary euthanasia is thus not identical with the right to self-determination, but is broader in content. It is not true that anyone who accepts a person's right to self-determination eo ipso accepts the right to voluntary euthanasia. This is the first reason why the pro-euthanasia movement cannot invoke the right to self-determination as an argument.

But in addition, the movement in favor of euthanasia cannot invoke the right to self-determination because this movement itself does not accept such right, either on principle or in fact. It is the basic tenet of pro-euthanasia argument that rational autonomous human beings who are hopelessly ill should have the right to decide when and how they will die. But why only the suffering and the hopelessly ill? Healthy people also are rational, autonomous human beings. Why don't euthanasia advocates recognize their right to assisted suicide? The movement that denies the right of self-determination to some (actually, the majority of) human beings does not recognize this right at all. It cannot invoke the right to self-determination in its arguments.

On the other hand, no mention is made of targeted individuals' right to self-determination when American and British proponents of mercy killing call for compulsory non-voluntary "euthanasia" of people with dementia,258 children who are gravely ill,259 people who are mentally retarded,260 disabled newborns,261 people who are comatose,262 or when Dutch patients who never asked for death are given lethal injections.263

The Patient's Own Request. From the point of view of pure logic, a request to die is not valid because the person making it cannot fully know the meaning of that request, since "no one can imagine his own total absence, without that being a contradiction in terms."264 But also other questions must be asked: Does such request always signify a death wish? And, to what degree is that request the patient's own?

It is common knowledge that, in reality, a request to die very often signifies something else: it can be a cry for help, for understanding, or an attempt to dramatize the situation.265 Even when someone requests death repeatedly and emphatically, in writing or in the presence of witnesses, this does not preclude the possibility that he is actually asking for help and attention. Many such cries for self-destruction have traits of hysterical behavior, typically marked by theatricality and hyperbole. Such an hysterical cry for help may, indeed, prove effective if it is addressed to good and wise people who would understand its true significance and show the despairing person that he is important to them, that they are staying at his side. However, the danger is now great that such a request will be taken literally, will be seized upon, and the person crying for help will be killed! Hysterical persons most often survive suicide attempts; euthanasia does not give them that chance.

The other important question is, to what degree a request for death is a genuine request of the person involved? In a widely publicized Dutch case, a retired professor of geology coerced his healthy 72-year-old wife into submitting to euthanasia, promising to take recourse to it himself in three days, but instead he went off to Austria where he married another lady.266 We will never know whether this was all planned as a cold-blooded murder in advance, or whether he changed his mind only after his wife's death. If that was so, I would not condemn him for shrinking from his own "euthanasia"; it's good that at least somebody survived this heinous affair (the only pity is that he escaped punishment). What good would it have done if he had also bid life farewell three days after his wife had been killed by a doctor? Would it have annulled his wife's death, her desperate struggle for life, her futile entreaties for a postponement, one more weekend with friends? We saw all that on the TV, the proceedings had been filmed on husband's request! And who was the culprit here? Was it only this old man or was society which had created the atmosphere favorable to "euthanasia," which treated that man's murderous plans as a respectable, trend-setting idea, which prompted a doctor to be a killer, and which so bewildered a TV journalist that he wanted to turn this sordid affair into a morality play about the leading figures of our time?

That woman did not want to die, but was in fact killed at her own request. The dominating husband coerced her into asking for death. Sometimes it is not the husband but a wife who dominates in a marriage. A wife who no longer wished to care for her sick husband offered him a choice between euthanasia and admission to a nursing home.267 The man, afraid of being in unfamiliar surroundings and in the care of strangers, chose death. The family physician, though aware of the coercion, performed the euthanasia. The patient's daughter, a nurse by profession who took part in carrying out the euthanasia, developed a severe depression and for a long time remained under psychiatric treatment.

One might object that these two cases belong to the registers of crime rather than the chronicle of euthanasia; he would be mistaken. Indeed, both these persons were killed by doctors, and though both cases were published, and widely publicized, no judicial inquiries were launched.

But it is not these flagrant cases that matter here, it is all the others. For thirty-five years many countries, including the U.S., and in particular Holland, have been subjected to all-intrusive propaganda in favor of euthanasia and physician-assisted suicide. Large-scale brainwashing is taking place; all efforts are made to convince people that this is what they ought to desire, and what is best for themselves and their families. Anyone who doubts that such a fatal step can be taken under the influence of fashion and the pressure of public opinion, should remember that less than a century ago in several European countries serious people, fathers of families, allowed themselves to be shot in duels only because this was what public opinion expected of them in certain circumstances.

Apart from fashion, there is almost always another important factor operative in the request for death: the doctor. It is striking that some doctors publish articles in which they boast of having already dispatched many people to the next world "at their own request" (Dr. K gave a figure of seventeen268), while traditional physicians have never heard any such request from their patients. Evidently we, the traditional doctors, are not suited for euthanasia; all we know is to treat sick people, bring them relief, encourage them, support their hope and will to live. But the euthanasiadoctor knows what to do to fulfill his calling. He begins by acquainting the patient with the situation, sparing him no description of the horrible complications which have already ensued or "may ensue" in the future. He terms the patient's condition hopeless (without mentioning that sooner or later a hopeless fate awaits us all). He speaks with the full power of infallible science (and omits saying how many errors science has made). He predicts precisely how long the patient has to live (predictions which never come true), and excommunicates the patient from the community of the living while he is still alive. Such a harangue (and not the illness itself) plunges the patient into depression, and, sometimes into reactive psychosis. And when the patient driven to despair requests death, that request will not be treated as a call for help, or a complaint which escaped the patient's lips at a moment of mental breakdown, no, that request will be seized upon, treated as a possible solution, discussed in all seriousness, often in the presence of family members or other persons, so that the sense of shame will prevent the patient from retracting "his own decision."

The Patient's Own Request- A Case Report. As already mentioned above, the patients of traditional doctors do not request to be put to death. Yet it did happen to me once. The patient was swollen all over and suffering from such shortness of breath that he had not slept for three weeks and had spent all those nights sitting in a chair, breathing heavily. Two hours after his transfer to my department he said to me: "Doctor, I cannot take it anymore, please give me that injection, you know what I mean." Obviously he had a fatal injection in mind. Had he chanced on a euthanasia-doctor, probably this request would have been granted. He was suffering horribly. His condition seemed to be an irreversible congestive heart failure with no prospect of improvement, and it could even be assumed that "the dying process had already begun."269 And the patient himself demanded that he be put to death, didn't he?

But he had addressed the request to the wrong person. I'm only an oldfashioned doctor, I often doubt my diagnoses and never trust my prognoses. It never entered my mind to turn the words the patient spoke in a moment of despair against him. It also never entered my mind that I might kill anyone and I don't even know how it is done. Along with a curt letter, I had sent back the Handbook of Responsible Euthanasia which, like all doctors in Holland, I had once received from a society involved in such matters. So, I must admit that I did not pay due attention to the patient's request. My reply was: "Please don't bother me with this kind of talk, you see I'm very busy trying to give you some relief." This patient survived his request for many years. His heart failure was linked to inordinately quick heart rate, and it occurred to me that this atrial flutter could have been caused by multiple pulmonary emboli; a diagnosis which I subsequently confirmed by pulmonary artery angiography. Step by step, I succeeded in expelling excessive fluid from his body, restoring normal heart rhythm, and preventing further embolization by anticoagulant treatment. The patient was followed at the out-patient clinic for six years; he never again mentioned the request he had made in a moment of despair, nor did I.

The Patient's Family Should Take Part in Making the Decision. A person may appoint his relative or somebody else as his proxy in medical decisions in case he himself is incapacitated. However, as long as an adult patient is competent, in all countries I know, the law does not allow his family to decide the treatment. This is not an error or a gap in the law, but a correct position taken by lawmakers. It is the rights of the patient himself that are assured in the first place: only he can decide whether to submit to a therapy or surgery proposed by his doctor. He also retains full freedom as to whether or not to consult with his family. The relatives are spared the need to make a decision that they are, anyway, not particularly qualified to make, and a responsibility which they are in no position to bear. Also, in this way the law precludes decisions that would be to the detriment of the patient and those dictated by questionable motives. However, in recent decades this wise legal principle has often been disregarded in practice; especially in cases of grave illness, when doctors seek permission for treatment from a competent patient's family. No one has ever provided justification for these practices and no such justification exists; the consequences are detrimental. An unbearable burden of decision is thrust onto unwilling family members. Relatives indifferent or hostile to the patient are granted rights not vested in them, including the veto-right. This course of action hampers the doctor in his professional duties and inadmissibly relieves him of his personal responsibility. Decisions of vital importance to the patient are made behind his back.

It is now demanded that the patient's family take part in the decision on euthanasia. This is indeed a logical demand in the eyes of those who hold it permissible to put a person to death in the interest of other people, especially in the interest of his family.270 I will not discuss this "moral principle" or the actions resulting from it. Let's confine ourselves to those situations in which a patient's life is to be cut short "for his own good."

In the great majority of cases we still see normal human reactions of family members: fear for the life of the seriously ill person, hope, even against all odds, desire that he recover and remain alive as long as possible. But we do sometimes encounter families who ask doctors to cut a patient's life short.

It is tacitly assumed that the motives of the relatives who ask that a patient's death be hastened cannot be other than pure and disinterested compassion, a desire to free the patient from his suffering. But can that be assumed uncritically?

In reality, families' less-than-noble motives are sometimes quite obvious. The wife of an unconscious patient under my care said: "I see him only as a corpse" which clearly suggested a feeling of indifference to the patient. Ten days later he was discharged from the hospital in fair condition, fully recovered from his subarachnoidal bleeding. The son of another patient, an elderly man who was slowly recovering from congestive heart failure, told me: "My father has lived his life, and actually has lived too long," and gave me a "choice": either euthanasia or admission to an institution. Caring for the father at home had become too burdensome for the son.

These are, of course, quite exceptional cases; as a rule, the situation is otherwise. Family members request euthanasia "because the father cannot take it any longer" and they sincerely believe that this is what moves them to ask for euthanasia.271 They do not realize that it is themselves who can no longer bear this extremely trying situation, the enormous psychological burden, the sheer physical torment, the hours, days and nights spent in the hospital, nearly sleepless, unwashed, without clean clothes or regular meals; every few hours they hear that the patient's condition has not improved. We should see and understand the relatives' ordeal, support them in every way, but not kill the patient for their sake!

Genuine empathy with another person, especially with a suffering family member, is possible, but this is an infrequent occurrence and one that borders on mystical experience. As a rule, people capable of such empathy do not ask for euthanasia.

Granting a patient's family the right to take part in the decision on euthanasia has still another important aspect, to wit, the influence such right must have on the institution of the family. There are already reports of older people overcome by fear of their own families in connection with the possibility of euthanasia.272 And indeed, in a society that permits euthanasia, a person, even one young and healthy, will look with different eyes on his own family; they will no longer be the persons who enrich lives, lend them scope, purpose, and meaning, but those who, at the decisive moment, will decide whether or not to put an end to our lives. A person will always be aware of this, even when concluding marriage, if not before. Just as a world harboring stockpiles of nuclear weapons is no longer the world it once was, so in an age of euthanasia a family will no longer be what it once was- nor will society be what we had hitherto known it to be.

Consultations, Coordination and Agreements. "I am appalled" said the president of the British Association of General Practitioners when he learned the sentence received by the doctor defendant in the Leeuwaarden trial (a week in prison, suspended for a year, for killing her mother). But a different reaction was expressed by a young woman, Dr. D, with whom I discussed that case at the time: "Dr. P did indeed act improperly, she should have first consulted with another physician." Thus, it's O.K. to kill one's mother, but remember to talk first to a colleague. The majority of the theorists of euthanasia recommend, or require, that there be some form of consultation or that decision be made by a committee.

The value of consultation with another physician picked by the euthanasia doctor (if such a consultation occurs at all), can be learned from the report of the 2001 government-ordered Dutch study: even before the consultation, the attending physician already had promised the patients to carry out euthanasia, and in some cases, even set the date.273

The idea that the decision on euthanasia should be taken by a committee belongs to "the founding father" of Dutch euthanasia, professor Jan Hendrik van den Berg.274 Is it true that errors may be avoided in this way? I doubt it. The outcome of deliberations will always be influenced by the composition of such bodies: the committee will only include people who accept euthanasia in principle; understandably, a person who entirely rejects euthanasia cannot be a member. What role is such a committee supposed to fulfill? The doctor submitting a case will not want to act alone, but have a group of people assume legal and moral responsibility for putting a patient to death. Everyone makes the decision and everyone shares the responsibility, meaning no one does. And this is what the euthanasia committee's role will in reality be: to dissolve, dilute, and destroy personal responsibility. This is not an especially praiseworthy role. And from the linguistic point of view, "committee meeting" is not the most accurate term for an agreement among several people to act against the law and, in particular, to deprive someone of his life. Language has more accurate terms to describe such behavior, such as "conspiracy" or "collusion."

Moreover, can one on principle accept committee determination of whether or not a person is to be put to death? Meetings, debates, and voting are indeed the right path to take when various important human affairs are to be resolved, like the expenditure of money, sharing burdens among the members, and so on. But no group or meeting has the right to decide whether a person lives or dies- not by voting, and not by unanimous decision. Speaking one's mind about somebody's life or death is a matter of conscience. But there is no collective conscience, only the individual has conscience. It is a meaningless act to assemble several people to decide a question of conscience.

Agreements Not to Resuscitate. When too broadly and indiscriminately applied, and in particular, when issued without the patient's consent or knowledge (as is often the case275), Do Not Resuscitate ("DNR") orders create the danger of untimely and unnecessary deaths. The following situation is typical: a patient with hemiparesis due to an old clot in a brain artery is admitted to the hospital with a myocardial infarction and an euthanasia-minded doctor orders "do not resuscitate." A few hours later the CCU nurses allow the patient to die of a trivial ventricular fibrillation. What is the cause of that person's death? Not the myocardial infarction and its complications because that ventricular fibrillation could be stopped with a single discharge of the electrical defibrillator. Neither is it the old partial paralysis with which that person had lived for years and could continue to. This person died by agreement. Another feature of these agreements is that they are made in advance, in the false belief that those making them have knowledge of future events. We know how deceptive such predictions are, e.g., a patient with severe emphysema can give the impression of having died -he lies there, dark blue-grayish, not reacting, not breathing- but a few minutes later he sits up and lights a cigarette "because that helps him clear his airways." An agreement entered in advance also means that no one is responsible any more, responsibility dissolves and vanishes. The "agreement" is made but nothing immediately happens, it will only happen later; one person issued the order, but does not directly cause the patient's death, others just carry out the doctor's order, that is, do nothing at a critical moment. ... Of course, as in any field of human endeavor, mistakes can happen in connection with such agreements; but these are macabre mistakes. In a university hospital, I was witness to a conversation between Dr. G, who had just finished duty, and his colleague, Dr. M. Dr. G said that he had been summoned to Dr. M's patient who had suffered a respiratory arrest, but he had done nothing because the nurse had informed him that it had been agreed not to resuscitate the patient. "What do you mean?" cried Dr. M in genuine despair, "and she died? That can't be! There never was any such agreement! I mean there was one, but it was for another patient!" I tried to explain to him that the point here was not the mistake, mistakes do happen, the point was that such agreements are dangerous. He did not understand.

Of course, we cease treatment if there truly is nothing more to be done. We also cease attempts at resuscitation when after an hour and half s battle no pulse can be detected. But that has to be your personal decision, made after losing the battle, hie et nunc, in a situation you have seen with your own eyes. It should not be a decision made in advance, based on a prediction of a future that is unforeseeable, and never a decision imposed on others. It can only be a concession of our defeat, never a conspiracy.

The question arises how in a country where the "Protestant spirit" is so deeply rooted that people reject all intermediary between their own conscience and the One they consider the judge of their deeds, how nurses and doctors accept orders allowing another person to take charge of their own conscience. The answer is simple- and frightening. The decision of whether someone else is to live or die is no longer considered a matter of conscience. It has become an administrative matter to be handled through the channels.

Agreements Not to Resuscitate II. When one speaks of the dangers entailed in modern science, one usually has in mind nuclear fission or genetic manipulation. But there is still another danger: the wreckage suffered by weaker minds when they come in contact with Science. Years ago, when I was working in one of the Scandinavian countries, I observed a sad example of this in the person of Dr. S, head of a hospital department of internal medicine. A patient at the department had fallen into severe hypoglycemic coma (loss of consciousness caused by low blood sugar), which reached the point of cardiac arrest; it became necessary to apply external heart massage and a ventilator. However, after intravenous injection of glucose the heart resumed beating normally, and the patient regained consciousness.276 Dr. S protested against such medical action. "The guess diagnosis that it was hypoglycemia was brilliant," he said, "but you had no right to inject glucose until the lab report on blood glucose was known! I forbid such unscientific277 proceedings in my department!" The lab report came half an hour later and could not have been obtained earlier. It was impossible for a patient in such a deep coma that it had caused cardiac arrest to survive that long without intravenous glucose, as was entirely obvious to Dr. S as well. But this doctor was not concerned with whether someone lived or died; his concern was Science. To die in accordance with the rules of Science was just how it should be. To survive against the laws of Science was forbidden.

Well, this eminent scientist also issued orders "not to resuscitate" and "not to treat" and also in doing so he was guided by strictly scientific criteria. A 55 year old woman had surgery for a brain tumor (non-malignant at microscopy), but the growth could not be totally removed. After the operation the patient was in fair condition except for a moderate weakness of one arm and one leg. She was entirely independent, walked a great deal, and devoted her time to reading and going to the movies and theatrical performances. When she was admitted to the hospital with a severe pneumonia, Dr. S "forbade" that she be treated! There are, however, other doctors who do not take such prohibitions to heart, the patient was given penicillin, and quickly recovered.

On another occasion, ambulance attendants brought to the hospital the body of a 16 year old boy who had suddenly lost consciousness and had no pulse or breath. The paramedics had applied neither heart massage nor ventilation because the boy's (well-trained) parents showed them a note from Dr. S written two years before, containing the words "do not resuscitate." The patient had a congenital heart defect, a so-called transposition of the great vessels, and the university hospital decided that surgery was not possible (it is possible now). The boy was the best student in his class and intended to study law. Due to Dr. S's note, the disturbance in heart rhythm, which could have been corrected had life-saving action commenced at once, put an end to the boy's life.

By now we have gained sufficient insight into the mentality and value system of Dr. S. He is a true servant of Science. For him Science is neither a means nor even an end, it is the Supreme Judge, empowered to pass death sentences. There are people whose health Science was ready to improve- but look what happened! They proved unfit! They were disqualified by Science! And, in their foolishness, these people feel well, run around, study at school, date girls, attend the theater, while according to the rules of Science, they are unfit for life! These rebels against Science do not have the right to live. But the necessary steps have already been taken, orders issued, and, sooner or later, one of those rebels will get pneumonia, another a ventricular fibrillation, and we have already seen to it that when such occasions present themselves these people disappear from the face of the earth.

It is a good rule which requires that our arrangements be "foolproof," safe even in hands of a stupid person. Alas, agreements "not to resuscitate" or "not to treat" do not meet this requirement.

Prevention of Alzheimer's Disease? ?? of us want to avoid this personal disaster and spare our families the sorrow and the torment. The proponents of death by one's own choice point out that assisted suicide, or otherwise caused death of the person involved, would prevent the misfortunes of Alzheimer's disease.278

But the concept of preemptive death as a way to escape Alzheimer's disease, logical as it may seem when considered in the abstract, makes us shudder when imagined as a reality. Moreover, in every case of suspected or presumably diagnosed Alzheimer's disease, and in any society abiding bylaw and fairness, an attempt to put this idea into effect would present insurmountable difficulties.

Several questions must be asked: Who is the person we want to save by destroying? How and when is he supposed to state his will to die? By whom and how is this will to be executed?

The Person. Please don't let yourself be convinced by sophistries, assertions that "the person is gone," that "what's left is an empty shell." You know very well this is your mother, your husband, the same person you've always loved, only afflicted by terrible disease.

Making the Decision. To avoid Alzheimer's disease, says a proponent of death by one's own choice, "we must place securely in our own hands how we end our life."279 This seems to suggest that the patient himself should decide; thus, the issue is placed in the familiar context of autonomy and freedom of choice.

But a patient with Alzheimer's dementia, durable memory loss and deep cognitive disturbance, unable to fulfill simple functions, obviously cannot make the decision to end his life; nor do these patients even utter such wishes. A resolve to end such a life can only be other people's decision, not the patient's.

How about earlier stages, when periods of confusion alternate with relatively lucid intervals? A death wish uttered by a patient in this stage must raise terrible doubts. It takes considerable pro-euthanasia bias to view it as a duly weighed decision.

Apparently, we are relegated to "living wills" or other directives issued in advance by still sane, fully competent persons. But a substantial study showed that- in spite of all encouragement and tremendous pressure- most Americans avoid signing living wills;280 and rightly so. They are guided by caution, wisdom, and moral objections.

Cautious people are reluctant to issue clear instructions about what to do in the future, in always complex, often difficult to grasp, and never entirely predictable situations. The textbooks list, besides Alzheimer's, sixty other possible causes of dementia, of which thirty are curable or otherwise reversible.281 In principle, all persons tentatively diagnosed with Alzheimer's disease should first be tested for all thirty curable causes of dementia, but in practice this is not always done. What if the patient were killed while her confusion could have been cured with a shot of vitamin B12 or B6?

Wise people understand that what they feel and desire while healthy and unwilling to accept any limitations, is not the same as what they may desire when gravely ill.282 Morally sensitive people question whether their present selves have the right to bind their future, changed selves, in the ways contemplated in living wills.283

Putting the Decision to Die into Effect. Let's suppose there is a "living will" stipulating to end the patient's life when she no longer recognizes her daughter; the fatal moment arrives; and we decide to break the law, overcome our instinctive repugnance, and grant the request the patient had expressed years ago.

Shall we inform the mother what we are doing? The patient at that stage of cognitive disability will not understand. If she does, she will probably shriek and defend herself.

Shall we cheat the unsuspecting patient, approach her with the milkshake into which nine grams of barbiturate had been mixed, and say "Mum, I brought you a drink"? Is this our idea of "patient taking firmly in her own hands how she ends her life"? What advocates of "prevention of Alzheimer's disease" propose would in reality boil down to is lethal injections administered to patients without their knowledge. That's how the "compassionate society"284 will prevent the tragedy of Alzheimer's.

Chapter XXIL Utilitarianism of Bentham-Mill-Singer and the Philosophy of Euthanasia285

Jeremy Bentham was born in 1748 and died 84 years later, but it was said that nothing ever happened to him; that he never experienced any human misfortunes or elations; that he was arid, devoid of imagination; that instead of living people he saw schematic diagrams; that being busy with reforming the prisons and the penal system, he by mistake applied the same considerations to the field of ethics and social reform. This description of Bentham's personality has not originated with his critics, it was penned by his true follower, John Stuart Mill.286

But Bentham had at least one very human trait: he was particularly sensitive to suffering both in people and in animals. That's why he readily adopted Helvetius' opinion287 that living beings are governed by the search for pleasure and the desire to avoid pain. Bentham elevated this hypothesis to the position of natural law.288 He also assumed, on less certain grounds, that these are the only motives of animal and human behavior. He therefore proclaimed the principle of utility as the only criterion of moral evaluation: good deeds are those that increase the sum of happiness, the acts that increase the sum of sufferings are morally bad. All other criteria Bentham not only rejected, but sharply condemned.289 Having grounded the whole of ethics on a single principle, allowing only one criterion of evaluation, Bentham was able to build an exceptionally consistent system. Moreover, in the true spirit of the Enlightenment, Bentham tended to see ethics as a science, a branch of natural sciences; he demanded rigorous reasoning and did not take anything for granted. He was not willing to admit that murder, robbery, or arson were bad acts, until convincing proof was presented.290 Premises had to be verifiable; appealing to privileged information, such as intuition, or revelation, was prohibited. It is owing to these scientific qualities that Bentham's ethical system- utilitarianism- became so popular among the philosophers of our time. Utilitarianism is still sharply criticized, for instance by Bernard Williams291 and John Rawls,292 but in the Englishspeaking countries it is generally regarded as the most serious attempt to create a reasoned system of ethics.

John Stuart Mill, raised since his childhood in an atmosphere of adoration of Bentham, as a young man suffered a nervous breakdown and rebelled against the Master's stiff doctrine, but later did a great deal to make it more humane.293 Mill's original contribution (in many ways linked to the subject of our interest, euthanasia), is his excellent treatise On Liberty.294 In this book Mill asserted that neither the state, society, nor neighbors should interfere with what an individual is doing as long as his actions are not injurious to anybody but himself. The modern intellectual current directed against paternalism in social relations and in medicine traces its origin back to that treatise On Liberty first published by Mill in 1859.

Several variants of utilitarianism have been developed, which shows that their originators have been aware of certain faults in Bentham's classic doctrine; but it also means that these authors wished to maintain the utilitarian tradition. "Preferential" utilitarianism295 recommends making people happy not after some universal pattern, but in accordance to each individual's preferences. The utilitarianism of rules postulates that not so much our acts but rather the rules we follow should aim at increasing the general happiness.296 Further, the "non-hedonistic"297 and the so-called "negative utilitarianism"298 are worth mentioning, but we now turn to a more detailed discussion of the views of professor Singer.

Peter Singer, formerly a lecturer at Monash University in Melbourne, at present Ira W. DeCamp professor of bioethics at Princeton, is a brilliant and undoubtedly the most influential utilitarian philosopher living. Among Singer's publications, his monograph with co-author Helga Kuhse, Should the Baby Live? (1985),"299 Rethinking Life and Death: The Collapse of Our Traditional Ethics (1995),300 and Animal Liberation (1975)301 are pertinent to the issues here, but I'll focus on Singer's Practical Ethics,302 which contains a full exposition of his views.

Always quite readable and usually sharply reasoned, this book first appeared in 1979 and has since been widely acclaimed as the conceptual framework of the New Morality. The second edition (1993) was expanded and revised, but the core of the doctrine was preserved in its pure form:

* Ethics begins when we exceed the self-centered attitude and start to think and act in consideration of others. Everybody's interests must be equally considered. The moral order is concerned with sentient beings, that is, beings capable of experiencing pleasure and pain, because only such beings have any interests. In fact, seeking pleasure and happiness and avoiding pain are the only interests they have. Actions, says Singer, should be judged according to their consequences. They are morally right when they increase happiness (or reduce suffering) for the greatest possible number of beings. Actions which result in less happiness and/or more suffering are morally wrong.

* Murder is usually wrong because the pleasure of the killer is outweighed by the suffering of the victim, the loss of his future pleasures, the grief of his family, and the anxiety caused to others who knew him. However, if somebody who could expect only further suffering is killed instantly in his sleep, in complete secrecy, the classical utilitarian would find no reasons to condemn the act. Mistaken as they may be, some persons wish to stay alive even when they cannot expect anything pleasant in the future, and a "preference utilitarian" (but not the classical utilitarian) would respect their preferences.

* Animals, in particular those with a nervous system similar to ours, are capable of suffering and feeling pleasure. Therefore, their interests must be considered in the same way as our own. Partiality to the interests of those of one's own species (speciesism) is as unfounded and morally untenable as tribalism, racism or sexism. Killing animals in order to use their bodies as food is morally wrong because important interests of those killed (all pleasures of their continued existence) are sacrificed for the negligible and unnecessary pleasure of human consumers.

* The intensity of a wrongdoing depends on the degree of consciousness of beings that are killed. It may be particularly wrong to kill a person that is a rational self-conscious being able to remember himself in the past and conceive of his own future. At least some animals are persons. Chimpanzees and gorillas taught a sign language recall facts from the past, are aware of their own identity, and inquire about future events. On the other hand, large groups belonging to our own species, Homo sapiens, are non-persons: fetuses, newborn babies, infants, the severely brain-damaged or mentally retarded, and the permanently comatose. Non-persons may be killed if the net result of the act is an increase of general happiness. Fetuses may be killed if they carry a defect or if the mother does not want the child. Obviously, the event of birth does not bring about any morally relevant change. Therefore, infanticide is as admissible as abortion, and should be left to the parents' decision.

* Morally praiseworthy results can be achieved not only by increasing the happiness, or diminishing the suffering, of already existing beings, but also by increasing the number of happy beings, or reducing the number of unhappy ones. This means that some beings, in particular fetuses and infants, are replaceable. If a couple intends to have two children, and one of these turns out to be a hemophiliac, it is right to kill this baby as it will enable the mother to conceive again, and, it is to be hoped, give birth to a healthy child who will have a longer and happier life than the one killed would have had.

* Persons should be killed if they express the wish to die, and also when they are unable to do so, but, if they were, would consent to euthanasia.

* Causing death by omission is discussed in connection with euthanasia and also a broader context. We are guilty of murder if we fail to donate a sufficient part of our income to aid the Third World where millions die prematurely.

A surprisingly large part of Practical Ethics is concerned with killing. One only refrains from killing if the prospective victim truly desires to continue living, and is able to express such wish.303 A peculiar image of the world ensues. Killing seems to become not a transgression but the regular course of action. Living beings seem to be constantly preoccupied with decisions whether to put an end to their lives or to go on living.

Practical Ethics makes intellectually stimulating reading right to the very last chapter. In the appendix to the second edition, the author, whose grandparents perished in the Holocaust, tells the story of his troubled visit to Germany: the association of people with disabilities accused him of reviving the Nazi program of extermination and barred him from lecturing.

Singer is a philosopher who, with some unavoidable exceptions, practices what he preaches: he is a vegetarian, does not wear leather shoes, and shares his income with the needy in the Third World.

The strength of Singer's convictions, and the impressive logic of his writings keep his readers under the spell. All the more is it important to verify what he writes.

The Facts. In the New York Review of Books, H.L.A. Hart praised Practical Ethics as a book "packed with admirably marshaled and detailed information, social, medical, and economic." I do not share this favorable opinion. In reality, Singer's command of the biological, medical, and historical information he quotes is rather sketchy. When writing the first edition, Singer believed that no animals had a cerebral cortex!304 In the second edition this blunder had been only partially corrected.305

The author condemns using animals for food,306 and can well hold his ground as long as his arguments are moral. But he also contends that eating meat is an entirely unnecessary luxury.307 However, the meat of animals, birds, or fish, is the fullest and easiest accessible source of the nine "essential" amino acids which we need to build our bodies' proteins. Thus, consumption of meat does serve a biological purpose. The fact that it can be replaced by (duly supplemented) vegetarian diet does not make it a thoughtless fancy.

Singer presents as conclusive the few experiments with teaching sign language to apes.308 The interpretation and reproducibility of these studies are still quite uncertain. On these shaky grounds Singer projects human mental states onto animals, anthropomorphizing them in the best prebehaviorist, pre-Pavlovian, and even pre-Cartesian tradition.

Singer incorrectly makes Christianity solely responsible for proclaiming the sanctity of human life.309 In fact, the foundations of this doctrine had been already laid in the Old Testament,310 and the Hippocratic ethics.

Singer uncritically accepts the Nazi's claim that their euthanasia program was aimed at the "elimination of useless eaters."311 All evidence indicates that the supposed "savings" were not more than rationalizations of what was on its face a hate crime, just as the mountains of eyeglasses, children's shoes, and human hair amassed in the death camps were macabre rationalizations, and not the aim, of the genocide.

"Perhaps one day," writes Singer, "it will be possible to treat all terminally ill and incurable patients in such a way that no one requests euthanasia . . ., but this is now just a Utopian ideal."312 The statement is a curious distortion of truth. For hundreds of years, and until the present proeuthanasia campaign, sick and dying people rarely requested euthanasia, and in most countries of the world, still never do.

Singer derides the idea that euthanasia could ever be performed without a competent patient's consent, and denies that such practice exists in the Netherlands.313 But the official report of the Dutch government's Committee on Euthanasia, available to Singer in English translation since 1992,314 states that in 1990 the lives of 1,000 patients who did not request or consent to euthanasia were "actively terminated" by doctors, and that 140 of these patients were fully competent.315 Moreover, doctors intentionally caused the deaths of patients without their request, consent, or knowledge, by giving them lethal overdoses of morphine; among 4,941 patients who underwent this form of involuntary active euthanasia, 27 percent (1,334 persons) were fully competent.316

The Corrections. Statements which irritated the readers of the first edition of Practical Ethics: demeaning people with Down syndrome,317 calling retarded people "vegetables,"318 and assessing the mind of a one-year old child as below that of many animals319 were excised in 1993, and do not appear in the second edition.

Ironically, these corrections have also drawn attention to Singer's original, apparently more genuine views. Among statements that were expurgated from the second edition of Singer's Practical Ethics were his remarks on Nazi euthanasia. In the first edition of Practical Ethics, Singer wrote that "[t]he Nazis committed horrendous crimes, but this does not mean that everything the Nazis did was horrendous. We cannot condemn euthanasia just because the Nazis did it, anymore than we can condemn the building of new roads for this reason."320

Thus, in 1979, Singer did not see anything horrendous in the Nazi euthanasia program. Yet Nazi euthanasia ("Aktion T4") was horrendous. Psychiatric patients who guessed or, due to indiscretions of the personnel, knew what awaited them, loudly protested, begged not to go, tried to defend themselves, fled and hid themselves, screamed at transport personnel "our blood cries out for revenge," clung to their hospital beds and had to be dragged from the building.321 In Absberg, a hundred "feebleminded" persons resisted and had to be loaded with physical force into busses which transported them to the euthanasia center.322 At these centers (Grafeneck, Brandenburg on the Havel, Hartheim, Sonnenstein, Bernburg, and Hadamar) the patients were gassed with carbon monoxide. It took about an hour to cause death in this way; the victims, crowded into closed chambers, experienced extreme terror and visibly suffered before dying.323 Doctors and other attendants liked to watch the scene through a reinforced glass aperture.324 The atrocities provoked a widespread indignation in Germany, and not only among the families of the victims and the general public, but in the Wehrmacht and in the Nazi party; on August 28, 1941, Hitler had to order a halt on "Aktion T4." A number of doctors, nurses and other personnel who gained experience in the Nazi euthanasia program were later transferred to death camps and were also involved in gassing the Jews.325

I'm not suggesting that Singer was cynical when he exonerated the Nazi euthanasia in 1979. 1 think he was biased due to his general preference for euthanasia and ignored the true facts.

Singer's Reasoning is superb most of the time but not all the time. Contrary to his assertion,326 the presence of a disability only allows one to conclude that a person's life is more difficult, not that it is less worth living. The latter is a value judgment reflecting the author's bias against people with disabilities.

Singer explains why, on paternalistic grounds, we may prohibit the use of heroin but not voluntary euthanasia: the choice for euthanasia should not be prohibited because it is a rational choice.327 Value judgment again, this time on what is rational. Yet it can be argued, and on firmer grounds, that the choice to use heroin is less irrational than the decision to have oneself killed. An addict is very much a living person with many choices open to him, including the choice to undergo detoxicating treatment; a dead man has no choices.

Singer's argument in favor of voluntary euthanasia for the incurably ill and suffering persons328 is inconsistent. If respect for a person's autonomy is the reason to kill him upon his request,329 why must this person be incurable, suffering, or even sick? Aren't healthy people autonomous persons? Since Singer does not recognize the autonomy of healthy individuals, he does not recognize the autonomy of human beings in general. He has, therefore, no right to put forward personal autonomy as an argument for euthanasia.

Drawing hard conclusions from soft premises is Singer's frequent error. If we aid the Third World by donating the ten percent of our income, arbitrarily proposed by Singer,330 we are righteous men, but if we give less, we are murderers.331 Singer approves of killing "someone who has not consented to being killed, but if asked would have consented."332 What someone would have said "if asked" is an uncertain premise, but if we kill him based on that uncertain premise, the resulting death is certain.

Singer argues that one may waive the right to life because "it is an essential feature of a right that one can waive [it] ." The utilitarian tradition, which Singer here abandons, used to offer a sounder logic. "Over himself, over his body and mind, the individual is sovereign," wrote John Stuart Mill, but "an engagement by which a person should sell himself ... as a slave would be null and void ____ The reason for not interfering . . . with a person's voluntary acts is consideration for his liberty ____ But by selling himself for a slave, he abdicated his liberty ... He therefore defeats . . . the very purpose which is justification of allowing him to dispose of himself."333 Mill's objection is a fortiori valid against the freedom to have oneself killed, as this would abolish the person's freedom once and for all.

All Criticism On Principle, to which utilitarianism has been subjected for almost two centuries, and which utilitarians never were able to refute, applies to Singer's philosophy. Is it true that "Nature has placed mankind under the governance of two sovereign masters, pain and pleasure"?334 No, it is not true, and even the very dichotomy of pain versus pleasure is false. Everything that is important in a human being's life, growing up, learning, love, marriage, giving birth, parenthood, work and creativity, ambition and struggle- all this brings about happiness and sorrow, pain and pleasure inseparably tied together, and people by no means shun these happenings and strivings, they seek them passionately.

People act out of a sense of duty, stand up against injustice, risk their own lives for the sake of others, toil and mortify themselves in search of perfection, and none of these endeavors fits the utilitarian description of man's aim.

The utilitarian doctrine completely disregards the real contents of a person's life. Gradation of values, the source of all diversity and richness in our lives, does not exist for a utilitarian: eating a freshly baked roll and making a scientific discovery are converted to a common currency and added up.

The utilitarian seeks the balance of general happiness by adding up all people's pleasures and subtracting all pains. The fallacy of this moral arithmetic is evident. Mankind only exists as individual human beings. Only individuals suffer or are happy. There is no intermediate moral substance between individuals, no common pool of happiness. The pleasures or sufferings of an individual cannot be added to or subtracted from those of other people's. Wrongs done to a human being cannot be compensated, outweighed, or justified by increased happiness of other persons: they remain wrongs.

John Rawls correctly pointed out that in pursuit of greater happiness of the greatest numbers utilitarianism justifies the sacrifice of innocent persons for the general welfare. Let's note that this principle can even justify acts of extreme violence if perpetrated by large crowds to their full satisfaction, at the expense of a few victims, for example, pogroms, lynching, or cannibalism, which allows all the villagers to enjoy the nutritive and magic properties of the organs of the one person sacrificed. Not so, reassure us John S. Mill and Peter Singer: justice takes precedence. Not that justice derives from any source other than utility: it provides the sense of security people so much need. However, if justice is not an independent moral principle, but one founded on utility, the protection it lends in unreliable. Other utilitarian considerations may prevail. Exterminating a hated minority may bring the populace a stronger feeling of security than justice ever would.

It is his defense of animals that has originally helped Singer to win so many followers; but he is not a reliable defender of our biological brethren. In fact, some of Singer's views can be used to justify the extermination of whole animal species. Singer's doctrine that the wrongfulness of killing depends on the degree of consciousness of the prospective victim is particularly dangerous in this respect. At present, some frogs are threatened with extinction, but why should we protect them since their level of consciousness is rather low? And why shouldn't we exterminate some fish, or burrowing rodents, which have hardly a memory of their past, no awareness of their own identity, no conceivable will to continue their existence, and distinct plans for the future? We are free to do that, even more so if the removal ofthat species will create more space for another one, blessed with a higher degree of consciousness.

It has often been argued that utilitarianism is a "parasitic" philosophy because it subsists on criticism of other systems. Singer excels in pointing out the inconsistencies of intuitive and deontological ethics. We proclaim the sanctity of all life but do not hesitate to pull up a cabbage. And would we attempt indefinitely to keep alive a child born without brains and missing most of his skull? But Singer's claim to victory is mistaken. Intuitive and duty-based ethical systems can live with some inconsistencies. These ethical systems have never claimed full consistency, perhaps because it was felt that man, life, and the universe did not seem to exist or operate in a fully consistent way. It is the reasoned utilitarian ethics that stands or falls with its consistency. It falls. Why is "happiness of the greatest number" the standard? Reason can also justify opposite aims, for example, "happiness for myself and misery for everybody else." The choice of the "happiness for the greatest number" was Bentham's moral intuition. It turns out the utilitarian ethics flow from a source utilitarianism has forsworn and condemned.

But it is not only this original sin of inconsistency, there is more. The reader of Practical Ethics has accompanied Dr. Singer on the vertiginous adventure ofthat book, construing with him consequentialist ethics free of moral intuitions, only to be told that "[i]n real life ... it is simply not practical to try to calculate the consequences ... of every choice we make . ... It would be better if, for our everyday ethical life, we adopt . . . soundly chosen intuitive moral principles."335 The view is Richard M. Hare's, but Singer concurs. This is not just a pragmatic concession, this is a capitulation on principle. Singer has himself admitted that "an ethical judgment that is no good in practice must suffer from a theoretical defect as well, for the whole point of ethical judgment is to guide practice."336

I wholeheartedly respond to Singer's appeal never to torment animals, and, if possible, to avoid killing them. But we don't owe it to them, we owe it to ourselves. Animals are objects of our moral order; a moral order they haven't created and cannot obey. Only Man has attempted that. Abandoning the human point of view and adopting that of the universe, Singer tries to create a scientific system of ethics that is not partial to Man. We are thrown into a nightmarish moral moonscape where the strong and the "normal" stay alive, but the weak and "different" are killed, where murdering children is no crime, and the pleasures of a sadistic killer are a positive moral value to be weighed in the balance of general happiness. We are told this is the New Morality, but in fact it is quite ancient. I am sure it prevailed in the Neanderthal.

Chapter XXIII. Doctors Who Practice Euthanasia

Even in the early days some observers warned that euthanasia was not just another procedure added to the medical practice but would change the physician's whole attitude and also their professional performance. The predictions proved right.

Handling the Facts of the Case. Dutch doctors are excellently trained professionals and many of them are strikingly talented individuals. Family physicians impress the specialists by their ability to report from memory every patient's medical history in every detail. And yet two series of cases have been published, one by Innemee from the Dutch Patients' Association,337 and the other by myself,338 showing factual errors, misrepresentation of the facts, and negligence on the part of doctors in their attempts to justify euthanasia.

A family physician phoned me three times to request that I allow his patient to die. The man had suffered cardiac arrest in the street, and had been resuscitated by passers by and transported to my intensive care unit. The family physician argued that the patient also had lung cancer and that the family wanted euthanasia. Both statements proved false. Six months before, the family physician had indeed suspected this patient of lung cancer and had referred him to a chest specialist; the specialist ruled out cancer. The patient's two daughters (he had no other family) categorically denied that they had requested euthanasia; they stated that they had not spoken about their father to the family physician or any other doctor.

When transferring to me an acutely ill patient with myocardial infarction and pulmonary edema, an internist colleague of mine tried to persuade me to let the patient die "because he was a widower without family, entirely alone in the world." Of course, that argument had no influence on my actions and also proved untrue. This patient, Mr. T, was under my care for the next eight years and always came to the outpatient clinic accompanied by his loving sons, daughters, and in-laws.

After examining a woman patient of mine, the consulting neurologist wrote in his opinion: "this elderly man is deeply comatose and, in my view, should not be resuscitated again." Having examined the patient, this doctor still did not know whether the patient was a man or woman, but he did know that this person's life should not be prolonged. To be sure, the patient's sex had no bearing on the conclusion; but the incident showed that decisions about life and death could be made in a distracted state of mind.

The actions of Dr. W339 were not marked by scrupulousness, to put it mildly. This doctor, who routinely put patients to death without their consent or knowledge, considered it unnecessary personally to examine the patient before making such a decision. If, when making his (quick) ward rounds, he had the impression that a patient was in critical condition, he would ask the nurse: "Is hij euthanasieachtig?" ["Is he suitable for euthanasia?"] The nurse's answer would decide the patients fate. In the case cited in Chapter XXIV, Dr. W ordered that the patient be given a lethal injection though nobody knew what was wrong with the patient (if anything). The patient was in a dimmed state during the ward round because he had been stupefied by valium (diazepam), which that same Dr. W had prescribed a few days before. Dr. W had forgotten that he had prescribed valium and it did not occur to him that this might have been the cause of the patient's stupefaction. He did not even glance at the patient's chart which would show that the patient was receiving the drug.

That's how scrupulously the doctors proceeded who attempted to subject patients to euthanasia. In my entire medical career I have never encountered such a series of crude errors and transgressions as those committed by doctors in their rush to euthanasia: lies, distortion of fact, impaired powers of observation and concentration (to mistake a woman for a man!), and, finally, complete negligence and carelessness as displayed by Dr. W.

Such wholesale departure from the rules of professional conduct cannot be accidental, it must have definite causes. In part, this has a simple explanation. In fact, it is not surprising that the "euthanasia doctors" overlook, distort, or disregard facts; rather it is surprising that "ordinary" doctors are able to master and remember such an immense number of facts concerning their patients. There are dozens of patients from 10, 20, or even 40 years back whom I and my colleagues still recall with all the details of the course their illness ran. Practicing doctors keep in their memory innumerable points of information concerning all their hospital patients and outpatients. I set myself the task of analyzing the case history of one gravely ill elderly man; he was in congestive heart failure due to aortic and mitral valvular heart disease. Six thousand two hundred pieces of information were gathered on him in four years of outpatient treatment and during his three stays in the hospital. In my daily work during this patient's third hospitalization I used the data arranged in more than 130 complex information sets such as "the kidney function gets but moderately impaired under diuretic treatment," "pleural effusion recurs with three days after each tapping," "the relative tricuspid incompetence had disappeared," etc. To retain this amount of complex data and use it all effectively requires a considerable mental effort which is only possible when the doctor is constantly, strongly, and unambiguously motivated. Why should a doctor make such extraordinary effort if he has already written off the patient?

But that only explains the carelessness of "euthanasia doctors" in part. To put someone to death with impunity, with a clear conscience, in the belief that one is doing the right thing, excites certain people. This could be seen in the days of the death penalty in England: before each execution excited crowds would gather at the prison gate. The instances cited in this chapter show that some of the doctors who practice euthanasia are no strangers to this kind of excitement. They make their great decision, are powerfully driven to put it into effect, and will not allow any minor, inconvenient facts to stand in their way.

Doing Less Than We Can, and Not Doing What Should Be Done. Called in Den Bosch by two internist colleagues to a freshly admitted patient with uremia (kidney failure), I found that he had pericarditis, an inflammation of the membranous sac around the heart. This is a common complication of advanced uremia.

"Oh, that's good," said the doctors, "uremic patients who develop pericarditis soon die of hyperkalemia (excess of potassium in blood), and that's an easy death.

They still did not know what the cause of patient's kidney failure was, whether his condition could be improved or outright cured, but that did not interest them. Why do all that painstaking work to see if there was urinary infection curable with antibiotics, or an obstruction to urine flow, removable by surgery; to see if the patient was dehydrated, and, if so, supplement fluid; why prescribe diet, correct the secondary disturbances in bone metabolism, consider kidney biopsy, renal dialysis, or kidney transplant? Why do all that when the doctor's mind had already been set on euthanasia? Uremic pericarditis indicates severe kidney failure- well, fine! We'll just wait for an easy death.

On his first day at work in Nakskov Hospital's coronary care unit, a young doctor told me that his primary interest was "scientifically based contraindications to resuscitation, a precise definition of cases in which one should not reanimate." He had come to work in a unit that had been created to resuscitate people, to reactivate "hearts that are too good to die." He had not yet taken part in any resuscitation, still did not know the practical side of the procedure, the difficulties entailed, and how to avoid these; but that did not interest him. What interested him was the "scientific basis" for doing nothing and waiting for patients to die. In the mind of this young man euthanasia was replacing medicine!

I vividly recall a 14 year old girl who two years before the event here described had been examined for fainting spells. At that time the pediatrician found nothing and declared her in good health. Now she fell unconscious on the school's sports field. Those on the scene began heart massage and mouth-to-mouth ventilation. When the ambulance arrived, it turned out that the girl had ventricular fibrillation (a fatal disturbance in the heart's electrical activity, which can, however, be reversed by a shock from an electric defibrillator). The attendants defibrillated the girl and she was brought to our emergency room, breathing and with a normally beating heart, but still unconscious. I found a young pediatrician with her and asked him why he was not moving the patient to the intensive care unit which offered optimal facilities for resuscitation; after all, she might relapse in ventricular fibrillation! "Oh, in that case I wouldn't do anything further," said the pediatrician- that is, he would allow the girl to die.

This doctor did not want to give Life a chance, instead, he wanted to give Death a chance. He knew everything about euthanasia, but did not want to know anything about medicine. He did not know, or did not want to know, that ventricular fibrillation is the form of cardiac arrest with a good chance of full recovery; that a patient's unconsciousness fifteen minutes after cardiac resuscitation did not mean anything, people may regain consciousness after hours or days; that adolescents have a particularly good chance to recover from a cardiac arrest without brain damage. He was enchanted by the concept of euthanasia and did not want to consider anything else. Euthanasia had dislodged medicine, reason, and compassion from this doctor's mind. In his ideal, healthy, society, there was no place for girls whose hearts suddenly stop beating on a sports field.

My voice hasn't been the only one to warn that euthanasia, or even its mental acceptance by doctors, leads to abandonment of viable treatment options. Similar observations had been reported early on by other Dutch and American authors.340 Then, the nationwide surveys, ordered by the Dutch government in 1990 and 1995,341 indicated that the trend was significantly narrowing the range of therapeutic interventions. It showed that in many cases doctors proceeded to active euthanasia and disregarded the existing treatment options.342 When "passive euthanasia" was intended (25,000 cases in 1990), doctors arbitrarily withheld or withdrew potentially effective treatments.343

How Do We Treat a Cardiac Emergency. The following example344 will illustrate how the acceptance of euthanasia is influencing the performance of highly skilled nurses at an intensive care unit.

This fifty-two year old lady (Figs.2 and 3) was admitted to the intensive care unit because of breast cancer spreading through her lung to the pericardium, with some accumulation of fluid around the heart. This was improving quite satisfactorily on chemotherapy, and three weeks later the patient was discharged in fair condition. During her stay in intensive care, her heart rate slowed down in an alarming way (Fig. 2). The intensive care nurses knew very well what to do in this situation: quickly check the patient's clinical condition, call the doctor on duty, get the equipment ready for the eventual insertion of a pacemaker, and in the meantime make sure that the patient is not given any medicines that cause slow heart beat.

The internist, however, had ordered "NR" (not to resuscitate) this patient (Fig 3). Therefore, the nurses had not reacted in any way to the emergency seen on the monitor ECG. Moreover, the medicines which worsen (and probably had caused) the patient's slow heart rhythm, the betablocker sotacor and the digoxin, were not stopped! (Fig. 3). Medicine's basic rule- "Whether or not you can help, first of all, do no harm!"- was no longer valid.

This was precisely what the traditional clinician had foreseen and feared: the attitude of easily accepting, even inviting the death of gravely ill but treatable patients; the suppression of traditional medical thinking, of medical working habits, of the medical way of reacting to events. Euthanasia was not just changing medicine, it was replacing medicine.

A substantial study showed that "Do Not Resuscitate" (DNR) orders inhibit doctors' readiness to administer other treatments, those unrelated to resuscitation. If the patient had a DNR order, the doctors were signifi cantly less willing to order blood cultures, place a central line, or give blood transfusions.345

Carefulness and Professional Integrity. It has been repeatedly stated in the Dutch euthanasia debate that doctors should act with due care. This is, indeed, a legitimate demand to make of any person and any action and especially of a doctor. But need a doctor who decides to terminate a person's life also act with such scrupulousness? A number of reports from Holland indicate that he need not. Published cases and studies revealed grave errors346 and criminal negligence347 on the part of doctors carrying out euthanasia, lethal injections administered to get rid of troublesome patients,348 or to free a needed hospital bed,349 decisions taken and euthanasia carried out in unseemly haste,350 lethal injections given to patients who had clearly stated they did not want euthanasia, 351 euthanasia carried out by doctors aware that the patients had been coerced to ask for death.352

Are these exceptional deviations from an otherwise orderly and conscientious practice? Alas, this is not so. The nationwide surveys of the practice of euthanasia ordered by the Dutch government in 1990 and again in 1995 revealed that the doctors practicing euthanasia, that is, the majority of the Dutch medical profession, in an exceedingly high percentage of cases transgressed the "rules of careful conduct" established by the authorities.353

Should Doctors Promote Death? TheNewRole of the Physician. Facing a patient with a chronic and incapacitating illness the "traditional" doctor tried to improve her condition, relieve her symptoms, avoid side effects, and give her some encouragement. But now we are witnessing a complete reversal of the aims of medicine. The following case history,354 perhaps the saddest in my experience, illustrates the physician's "new role."

Mrs. P was a seventy-two year old widow who after a bad myocardial infarction was left with a grossly dilated heart and congestive heart failure. She was treated with digoxin, an aldosterone antagonist, a diuretic, and an anticoagulant, and for a whole year had almost no symptoms at rest. True, she needed help with cleaning her house, and her only exercise was walking a few blocks. One night her breathlessness recurred; this required adding a third pillow and an increased dosage of the diuretic. Another time she complained of dizziness, which turned out to be due to a fall in blood pressure in upright posture; she was taught the necessary precautions. Mrs. P was an extremely nice, mild-tempered lady who never showed any impatience and complied with the doctor's every order and advice. Barring some clot or a sudden disturbance in heart rhythm (both of which could of course occur), she might have survived for years in that condition. When she failed to appear at the outpatient clinic, I was very much worried. Responding to my inquiry, her family physician, Dr. K, paid me a visit. He had had a talk with Mrs. P, he said, and explained the situation to her: This wasn't going to get any better, and living such a limited life, with all those pills, made no sense at all. Mrs. P accepted everything he said. He stopped her pills, and three days later she died. My only answer was to nod. I couldn't emit a sound. I was overcome by deep sorrow. It returns every time I think of Mrs. P.

245 Francois Mauriac, La Pharisienne 112 (Grasset, Paris 1972).

246 G. Bachrach, Death with Dignity, Boston Globe, June 14, 2004.

247 J. Fletcher, Ethics and Euthanasia, in To Live and To Die: When, Why, and How 113-22, and in particular 118 (R.H. Williams, ed., Springer Verlag, New York, Heidelberg,& Berlin 1973); The "Right" to Live and the "Right" to Die, in Beneficent Euthanasia 44-53 (M. Kohl, ed., 1975); G. Tindall, Ifs My Life andTUDie IfI Want To, The Independent (London), Sept. 18, 1987; and Hoofdbestuur KNMG, Reactie op vragen van de Staatscommissie Euthanasie [The Board of the Royal Dutch Society of Medicine, Answers to the Questions Asked by the State Committee on Euthanasia], Medisch Contact (Official Sec), Aug. 3, 1984, at 1002.

248 A. van den Akker, Hoe lang moet sterven duren [How Long Must It Take to Die?], Brabants Dagblad, Feb. 25, 1985 (Interview of Gerard Stinissen, the husband of a comatose woman).

249 Ernst Haeckel, Natürliche Schöpfungsgeschichte 154 [The Natural History of Creation] (6th ed., Georg Reimer Verlag, Berlin 1875).

250 E. Baldwin, The Natural Right to a Natural Death, 1 St. Paul Med. J. 877 (1899).

251 The suicide of a scorpion when surrounded by flames is a myth.

252 See subsec. entitled The Lethal Avalanche, 24 Issues in Law & Med. at 223-27 (2009).

253 See subsec. entitled The Oregon Law, in Ch. XXVIII (to be published in a future edition of Issues in Law & Mediciné).

254 Van den Akker, supra note 248.

255 H.J.J. Leenen, Euthanasie voor de Hoge Raad [Euthanasia (heard) at the Supreme Court], 129 Ned. Tijdschrift v. Geneeskunde 414, 414-17 (1985).

256 Regelen met betrekking tot de hulpverlening door een geneskunde die zieh beroept op overmacht bij levensbeeindiging op uitdrukkelijk en ernstig verlangen van een patient [Rules Concerning Assistance Rendered by a Physician Who Pleads Higher Necessity When Terminating the Life of a Patient Upon His Explicit and Serious Request], in Tweede Kamer derStaten-Generaal,Vergaderjaar 1987-1988, at 383 (Nos. 1-2, 20).

257 "Evidence of one's heart" is the phrase used by Polish philosopher Tadeusz Kotarbinski to denote moral intuition.

258 Tindall, supra note 247.

259 D.C. Maguire, Death by Choice 173-79 (i977); G. Williams, Euthanasia and the Physician, in Beneficent Euthanasia 154-57 (M. Kohl, ed. 1975); and H. T. Engelhardt, Jr., Ethical Issues in Aiding the Death of Young Children, in Beneficent Euthanasia 180-82.

260 E. W. Lusthaus, Involuntary Euthanasia and Current Attempts to Define Persons with Mental Retardation as Less Than Human, 23 Mental Retardation 148 (1985).

261 J. Lachs, On Humane Treatment and the Treatment of Humans, 294 New Eng. J. Med. 838 (1976); J. Fletcher, Ethics and Euthanasia, in To Live and To Die: When, Why, and How 113-22 (H. Williams, ed., Springer Verlag, New York- Heidelberg- Berlin 1973).

262 S. M. Wolf, Nancy Beth Cruzan: In No Voice At All, Hastings Center Rep., Jan./Feb., 1990, at 38; W.H. Colby, Missouri Stands Alone, Hastings Center Rep., Jan./Feb., 1990, at 5; P. Busalacchi, How Can They? Hastings Center Rep., Jan./Feb., 1990, at 6; R.E. Cranford, A Hostage to Technology, Hastings Center Rep., Jan./Feb., 1990, at 9.

263 See Chs. XIX and XX, 26 Issues in Law & Med. 63 & 69 (2010) (respectively).

264 L. Kolakowski, Fabula mundi and Cleopatra's nose, in: Czy diabel moze by6 zbawiony? [Can the Devil be Redeemed?] 71 (Aneks Pub., London 1982).

265 This is also the case in many attempted suicides. An attempt to kill oneself is by no means always a step taken out of despair and hopelessness; more often it is dictated by hope that this will come as a shock to other people, attract their attention, and change their attitude by arousing a feeling of guilt.

266 W. van den Linden, Zu moest eerst . . . Het dossier van Bommelen: een geval van euthanasie? [She Had to go First . . . The Van Bommelen File: A Case of Euthanasia?] (Strengholt Pub. Naarden 1984); Waarom heeft Wibo niet ingegrepen? [Why (the TV journalist) Wibo (van den Linden) Did Not Intervene? Zondag (Beusichem), Jan. 22, 1984; G.A. Lindeboom, Een z.g. euthanasie-drama [The Drama of the So-Called Euthanasia], 11 Vita Humana 100 (1984).

267 H. Ten Have & G. Kimsma, Geneeskunde tussen drrom en drama [Medicine Between Dream and Drama] 83-87 (Kik- Agora Pub., Kampen 1987); G. F. Koerselman, Hoe mondig zijn moderne patienten? [How Mature are the Modern Patients?], 130 Ned. TlJDSCHRIFTV. GENEESKUNDE 2017 (1986).

268 E.G.H. Renter, Euthanasie in de huisartspraktijk [Euthanasia in Family Physician's Practice], 38 Medisch Contact 1179 (1983).

269 This term is particularly "elastic," and anyone may stretch it according to his own opinion. It may also be asserted on good grounds that every human being's dying process begins at birth.

270 The husband of a woman in coma requested her doctors to put his wife to death, arguing that he wished to marry another woman but as a Catholic could not divorce his wife. Werkgroep euthanasie van het Katholiek Studiecentrum [Catholic Studies Center, Working Group on Euthanasia], Vragen om de dood: Beschouwingen over euthanasie [Requesting Death: Reflections on Euthanasia] 172-73 (G. Dierick, ed., Amboboeken, Baarn 1983).

271 Tolstoy noted this form of self-deception a hundred and twenty years ago: "[Nekhludov] recalled how toward the end of [his mother's] illness he frankly desired her death. He tried to tell himself that he wished her deliverance from suffering; actually he wished himself to be delivered from the sight of her suffering." L.N. Tolstoy, Voskreseniye [Resurrection], in 11 So br. Khud.Proizved. 88 (Pravda Pub., Moscow 1948).

272 M. Wagner, Stervenshulp: Wensen vanpatienten [Assisted Death: The Wishes of Patients], 49 Medisch Contact 1569 (1984).

273 G. VAN DER WAL ETAL., Medische BESLUITVO RMING AAN HET eindevan het leven: De PRAKTiJKEN de toetsing procedure [Medical Decisionmaking at the End of Life: The Practice and the Checking and Verifying Procedure] 149, 188 (De Tijdstroom, Utrecht 2003).

274 J. H. van den Berg, Medische macht en medische ethiek [Medical Power and Medical Ethics] 41, 50 (GV. Callenbach, Nijkerk 1969).

275 MEDISCHE BESLISSINGEN ROND HET LEVENSEINDE. II. HET ONDERZOEK VOOR DE COMMISSIE MEDISCHE PRAKTUK INZAKE EUTHANASIE [MEDICAL DECISIONS ABOUT THE END OF LIFE. II. The Study for the Committee on Medical Practice Concerning Euthanasia] 75 (State Publishing House SDU, The Hague 1991). Volume II appeared in English translation in P. J. van der Maas, J. J. M. van Delden, & L. Pijnenborg, Euthanasia and Other Medical Decisions Concerning the End of Life: An Investigation Performed Upon the Request of the Commission of Inquiry into the Medical Practice Concerning Euthanasia (Elsevier, Amsterdam- London-New York-Tokyo 1992). [The page number cited here refers to the Dutch original.]

276 See case described in subsec. entitled Sudden Insights, in Ch. VII, 24 ISSUES IN LAW & MED. 229, 234 (2009).

277 In the opinion of Dr. S and those of like-mind, that which we see with our own eyes cannot be science. Scientific information comes written on forms from the laboratory signed by a technician.

278 Bachrach, supra note 246; A. Dorf man, Alzheimer's and a Caring Society, Boston Globe, June 17, 2004.

279 Bachrach, supra note 246.

280 A. Fagerlin & CE. Schnedier, Enough: The Failure of the Living Will, Hastings Center Rep., Mar./Apr., 2004, at 30.

281 M. M. Brown & V.C. Hachinski, Acute Confusional States, Amnesia, and Dementia, in Harrison's Principles of Internal Medicine 183, 190 (12th ed., J. D. Wilson et al. eds. 1991).

282 People's intuitive understanding that the wishes of the gravely ill are different from those of healthy persons has been confirmed by substantive studies. Cf., M. L. Slevin, Attitudes to Chemotherapy: Comparing Views of Patients with Cancer with Those of Doctors, Nurses, and General Public, 300 Brit. Med. J. 1458 (1990); D.E. Patterson, When Life Support is Questioned Early in the Care of Patients with Cervical-Level Quadriplegia, 328 New Eng. J. Med. 506 (1993); J.H. Hess, Looking for Traction on the Slippery Slope: A Discussion of the Michael Martin Case, 11 Issues in Law & Med. 105 (1995). See also R. Fenigsen, Euthanasia and Moral Reflection, in The Dignityofthe Dying Person: Proceedings ofthe Fifth Assembly of the Pontifical Academyfor Life 212-18 (J. de D.V. Correa & E. Sgreccia, eds., Vatican City 2000).

283 Fagerlin & Schnedier, supra note 280, at 30.

284 Dorfman, supra note 278.

285 Lecture delivered in 1996 at the Catholic University of Lublin, Poland.

286 John Stuart Mill, Bentham, in John Stuart Mill and Jeremy Bentham 148-55 (A. Ryan, ed. 1987) (hereinafter Mill & Bentham).

287 Charles Taylor, Sources of the Self: The Making of the Modern Identity 328 (1989) (quoting Helvetius, De l'Homme).

288 Jeremy Bentham, An Introduction to the Principles of Morals and Legislation, in Mill & Bentham, supra note 286, at 65.

289 Id. at 70-83.

290 Mill, supra note 286, at 139.

291 Bernard Williams, A Critique of Utilitarianism, in J.J.C. Smart & B. Williams, Utilitarianism, For and Against yy (1993).

292 John Rawls, A Theory of Justice 167-75, 183-92 (1972).

293 John Stuart Mill, Utilitarianism, in Mill & Bentham, supra note 286, at 272-338; John Stuart Mill, A System of Logic, in Mill & Bentham, at 113-31; John Stuart Mill, Colereidge, in Mill & Bentham, at 177-227; and John Stuart Mill, Whewell on Moral Philosophy, in Mill & Bentham, at 228-71.

294 John Stuart Mill, On Liberty (Penguin Books, London, 1988).

295 pETER Singer, Practical Ethics 94-96, 99-100, 110, 126-29, 153, 194-95 (2nd ed· 1993).

296 J.J.C. Smart, An Outline of a System of Utilitarian Ethics, in Smart & Williams, supra note 291, at 9-12.

297 Id. at 12-27.

298 R.N. Smart, Negative Utilitarianism, 67 Mind 542 (1958).

299 Helga Kuhse & Peter Singer, Should the Baby Live? The Problem of Handicapped Infants (1985).



302 PETER SINGER, PRACTICAL ETHICS (ist ed. 1979; 2nd ed. 1993) (Unless otherwise indicated, the page numbers cited are those of the second edition).

303 Singer, supra note 302, at 171; Singer, supra note 300, at 219.

304 Singer, supra note 302, at 60 (ist ed.).

305 Id. at 70 (2nd ed.).

306 Id. at 62-72.

307 Id. at 62.

308 Id. at 111-17.

309 Id. at 88, 173.

310 Gen. 4: 10-13; Ex. 20:13; and Lev. 20:1-6.

311 Singer, supra note 302, at 215.

312 Id. at 199.

313 Id. at 179, 196-97.


315 Id. at 194 ("life is terminated without explicit request of the patient ... in somewhat more than one thousand cases annually"). Fourteen percent of these patients (140 persons) were "able to assess the situation and [m]ake a decision adequately." Id. at 61 (Tbl. 6.4).

316 Id. In 1990, 22,500 patients died of an overdose of painkillers. Id. at 183. In 36 percent of these cases (8,100 persons) causing the patient's death was one of the purposes or the only purpose of doctors who administered excessive doses of painkillers. Id. at 73 (Tbl. 7.2). In 61 percent of these 8,100 cases (4,941 persons), the decision was not discussed with the patient. Id. at 75 (Tbl. 7.7). Twenty-seven percent of patients who died of an overdose of painkillers administered without their consent (1,334 persons) were "totally able to [m]ake a decision." Id.

317 Id. at 73 (ist ed.).

318 Id. at 75 (ist ed.).

319 Id. at 122 (ist ed.).

320 Id. at 124 (ist ed.).


322 Id. at 163.


324 BURLEIGH, supra note 321, at 147; FRIEDLANDER, supra note 323, at 97.

325 BURLEIGH, supra note 321, at 150; FRIEDLANDER, supra note 323, at 295-302.

326 SINGER, supra note 302, at 188.

327 Id. at 199-200

328 Id. at 193-200

329 Id. at 194-95.

330 Id. at 246.

331 Id. at 222-24.

332 Id. at 179

333 Mill, supra note 294, at 173.

334 Bentham, supra note 28 8, at 65.

335 Singer, supra note 302, at 92-93.

336 Id. at 2.

337 C. Innemee, Commissie Remmelink krijgt zes gevallen voorgelegd: NPV geeft voorbeelden van ongevraagde levensbeeingdiging [Six Cases Presented to the Remmelink Committee: Dutch Patients' Association Presents Examples of Termination of Life Without Request], in Zorg (Veenendaal), Vol. 8, No. 4, 1990, at 4-5.

338 R. Fenigsen, Euthanasie, een weldaad? [Charitable Euthanasia?] 69-72, 83-84 (Van Loghum Slaterus, Deventer 1987).

339 See subsec. entitled Healer of Mankind's Afflictions, in Ch. XXI V (to be published in a future edition oí Issues in Law & Medicine).

340 I. van der Sluis, Mal-informed non-consent en andere medische gevaren van euthanasie [Mal-informed Non-consent and Other Dangers of Euthanasia], 128 Ned. Tijdschriftv. Geneeskunde 1247 (1984); D. L. Jackson & S. Younger, Patient Autonomy and <(Death With Dignity": Some Clinical Caveats, 301 New Eng. J. Med. 404 (1979).

341 Medische beslissingen rond het levenseinde. I. Rapport van de Commissie ONDERZOEK MEDISCHE PRAKTIJK INZAKE EUTHANASIE. II. HET ONDERZOEK VOOR DE COMMISSIE medische PRAKTiJK inzake euthanasie [Medical Decisions About the End of Life. I. Report of the Committee to Study the Medical practice Concernign Euthanasia. II. The Study for the Committee on Medical Practice Concerning Euthanasia] (State Publishing House SDU, The Hague 1991) [hereinafter "Report I" and "Report II," respectively]. Volume I has not been translated. Volume II appeared in English translation in P. J. van der Maas, J. J. M. van DELDEN, &L. PlJNENBORG, EUTHANASIAAND OTHER MEDICAL DECISIONS CONCERNING THE END of Life: An Investigation Performed Uponthe Request ofthe Commission of Inquiryinto the Medical Practice Concerning Euthanasia (Elsevier, Amsterdam-London-New YorkTokyo 1992). [The page numbers quoted in the present chapter refer to the Dutch original.]

342 Report II, supra note 341, at 45 (Table 5.7), & 62 (Table 6.5); G. van der Wal & P. J. van der Maas, Euthanasie en andere medische beslissingen rond het levens einde [Euthanasia and Other Medical Decisions Concerning the End of Life] 56 (Table 5.5) (Sdu Publishing House, The Hague 1996).

343 Report II, supra note 341, at 85-86, & 86 (Table 8.8).

344 This case was previously reported in Richard Fenigsen, Physician-Assisted Death in the Netherlands: Impact on Long-Term Care, 11 Issues in Law & Med. 283, 296-97 (1995).

345 M.C. Beach & R.S. Morrison, The Effect ofDo-Not-Resuscitate Orders on Physician Decision-Making, 50 J. Am. Geriatric Soc. 2057 (2002).

346 Innemmee, supra note 337.

347 Bedoeling en arts waren good: Voorwaardelijke celstrafvoor " slor dig e" euthanasie [The Doctor Had Good Intentions: Probation for "Sloppy" Euthanasia], Brabants Dagblad, Oct. 22, 1995; F. Abrahams, De huisarts die hetnietzo nauw nam [The Family Physician Who Did Not Take It Too Scrupulously], NRC Handelsblad, May 23, 1995.

348 Ver zor ging shuizen in opspraak: Het onnodig sterven [Rumors About Nursing Homes: The Unnecessary Deaths], Elzeviers Mag., Apr. 20, 1995; "Euthanasie" vertaald in viervoudig moord ["Euthanasia" Turns Out to be Murder of Four People], Brabants Dagblad, July 24, 1985; Arts bekent vijfmaal euthanasie [Physician Admits Having Performed Euthanasia on Five Persons], Brabants Dagblad, Apr. 17, 1985.

349 Report II, supra note 341, at 64 (Table 6.7).

350 F.T. Diemen-Lindeboom, in De dood, uitkomst voor het leven? [Death as Deliverance From Life?] 109-110 (Bueten & Schipperheyn, Amsterdam 1987); G. van der Wal étal., Medische besluitvorming aan het einde van het leven: De praktijk en de toetsing procedure [Medical Decisionmaking at the End of Life: The Practice and the Checking and Verifying Procedure] 52-53 (De Tijdstroom, Utrecht 2003).

351 Geen straf arts voor euthanasie: van Ooijen wel schuldig van moord [No Punishment for the Doctor Who Performed Euthanasia: But the Court Did Find (Dr.) Van Ooijen Guilty of Murder], Brabants Dagblad, Feb. 22, 2001. The seemingly paradoxical ruling (doctor guilty of murder, no punishment) is typical of the Dutch legal situation. See also the case of the "young patient who clung to life" and was, nevertheless, killed by the chest physician. See subsec. entitled Impatient Chest Physician, in Ch. XXIV (to be published in a future edition of Issues in Law & Medicine).

352 W. van den Linden, Zu moest eerst . . . Het dossier van Bommelen: een geval van euthanasie? [She Had to go First . . . The Van Bommelen File: A Case of Euthanasia?] (Strengholt Pub. Naarden 1984); Waarom heeft Wibo niet ingegrepen? [Why (the TV journalist) Wibo (van den Linden) Did Not Intervene? Zondag (Beusichem), Jan. 22, 1984; G.A. Lindeboom, Een ?. g. euthanasie-drama [The Drama of the So-Called Euthanasia], 11 Vita Humana 100 (1984); H. Ten Have & G. Kimsma, Geneeskunde tussen drrom en drama [Medicine Between Dream and Drama] 83-87 (Kik-Agora Pub., Kampen 1987); G.F. Koerselman, Hoe mondig zijn moderne patienten? [How Mature are the Modern Patients?], 130 Ned. Tijdschrift v. Geneeskunde 2017 (1986).

353 See supra Ch. XX, 26 Issues in Law & Med. 33, 69 (2010).

354 Fenigsen, supra note 344, at 294-95. The case of Mrs. P was cited at the U.S. Congressional hearings on "physician-assisted suicide and euthanasia in the Netherlands" in Sept., 1996. Report of Chairman Charles T. Canady to the Subcommittee on the Constitution of the Committee on the Judiciary, House of Representatives, 104th Cong., 2 Sess., U.S. Government Printing Office, Washington, D.C, 1996.

Author affiliation:

Richard Fenigsen, M.D., Ph.D.*

Author affiliation:

* Chapters XXI through XXIII of Other People's Lives: Reflections on Medicine, Ethics, and Euthanasia by Richard Fenigsen, also published sub. nom. Przy siega Hipokratesa [The Hippocratic Oath] by Ryszard Fenigsen (Polish, 2010). Dr. Fenigsen is a retired cardiologist, Willem-Alexander Hospital, 's-Hertogenbosch, the Netherlands; M. D., University of Lodz Medical School (Poland), 1951; Ph.D., Medical Academy, Lodz, 1959. Chapters I and II were published in the Spring 2008 edition, 23 Issues in Law &Med. 281 (2008); Chapters III, IV, and V were published in the Fall 2008 edition, 24 Issues in Law &Med. 149 (2008); Chapters VI, VII, and VHI were published in the Spring 2009 edition, 24 Issues in Law & Med. 221 (2009); Chapters IX - XII were published in the Summer 2009 edition, 25 Issues in Law & Med. 45 (2009); Chapters XIII and XIV were published in the Fall 2009 edition, 25 Issues in Law & Med. 169 (2009); and Chapters XV - XX were published in the Summer 2010 edition, 26 Issues in Law & Med. 33 (2010).

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