Commentary Magazine


The Problem of Euthanasia

Although the death of close friends and relatives may have vanished as a vivid firsthand experience for most of us, almost everyone knows, or knows of, someone who is being kept alive by machines or tubes. It is quite common to hear people say that if they themselves should arrive at such a condition, they would hope for euthanasia. Thus, membership in the Euthanasia Society of America has jumped from 600 to over 50,000 in four years, and the society has been filling an unprecedented number of requests for copies of its “living will,” a declaration of the wish for euthanasia, which, although not legally binding, exerts a powerful demand on physician and family.

Euthanasia, from the Greek eu and thanatos, signifies a good or peaceful death. It conjures up images of dignity and repose, a calm, reconciled conclusion to a life whose meaning has been accorded its due. Euthanasia, often called “death with dignity,” also implies the necessary medical efforts to reduce pain without needlessly prolonging the agony of one who is going to die. Few in the past have been fortunate enough to die such a death, and not so many in the present. It is what used to be prayed for when dying people believed that death was a significant event to be followed by other unknown developments, and when the mortally ill were surrounded by those whose convictions were equally strong. It was not thought appropriate or desirable to hasten the onset of this event, which, in any case, was independent of human will and would come in its own time. The final weeks, days, or hours of the mortally ill were almost sacred, but perhaps only believers are still mindful of what everyone used to take thought for—the deathbed scene, perhaps a confession, the reconciliations, the promises made to the dying, the revelations, the assurances, the consolations and affirmations. To think of hastening the progress of this drama would have been unusual or even unconscionable. And, it should be added, the available pharmacopeia did not offer many alternatives, even for the rich and powerful: all were to encounter what used to be called “the Last Great Adventure” or, as Henry James greeted it, “the Distinguished Thing.”

Euthanasia means deliberate intervention in this process. It violates unmistakably the commandment against killing, and it is also therefore illegal. In spite of numerous attempts to introduce the idea of extenuating circumstances in what is often called “mercy killing,” euthanasia remains proscribed. Individual cases—as when a doctor gives a dying patient a fatal injection or when someone kills a dying relative—may be decided in favor of the killer, as recently happened in New Jersey, but the courts are reluctant to declare euthanasia acceptable. The Hippocratic Oath has always been interpreted as forbidding euthanasia, and the opinions of religious leaders have opposed it as a general practice, if with some qualifications. It is against the law to help a dying person to die quickly, although you can legally kill a healthy person if he seems about to kill you. And if you ask for lethal drugs with the intention of taking them yourself, that is suicide. Attempts to rationalize and clarify these seeming inconsistencies have not resulted in major reforms. England's Suicide Act of 1961 removes the illegality from suicide but still forbids assisting anyone else's suicide. Switzerland permits the doctor to put poison in the hand of the patient but not actually to administer it himself.

Some of the inconsistencies result from the complex conditions of modern medicine. It would be difficult to assert that the doctor who gives a humane overdose of drugs has “murdered” his patient. Obviously, when a patient has been receiving quite a lot of potentially lethal drugs, it is not always clear which or how much was the fatal dose. Prosecutors and juries have been and will continue to be reluctant to question the good faith of such doctors, or to demand precise proof whether death was hastened, induced, or merely not actively prevented. Doctors are of course most anxious to avoid anything remotely implying malpractice suits. At the same time, there are never unlimited resources, certainly not in personnel, and in every hospital there are unwritten customs to be followed in various cases, with coded notations on patients' charts indicating whether or not “heroic efforts” should be made at resuscitation in case of approaching death. Different emergencies demand different treatment, and the needs of patients, the exigencies of medical personnel, the availability of beds or operating rooms or other facilities are all factors which must be taken into account when sudden decisions are made.

So ambiguous is the matter that interested observers have developed distinctions between negative and positive, or active and passive, euthanasia, in order to account for some of the differences in the treatment of the mortally ill. Thus, doctors distinguish between the omission of certain drugs or mechanical supports at critical times, when the patient would proceed to die without them—this is negative euthanasia—and the more specific acts of administering an overdose of drugs, injecting an air bubble in the veins, or actually withdrawing drugs or intravenous feeding or the respirator with the intention of hastening the death of an already dying patient. If a doctor administers a drug with the intention of relieving suffering, and the drug is fatal, he has not committed murder because it was not his intention. Similarly, when a doctor performs a gall-bladder operation on an eighty-six-year-old man suffering from emphysema, heart trouble, and other ailments, and when the man has a stroke and dies after the operation, the operation is not murder, even though the patient died, because the doctor intended to relieve the gall-bladder condition and ease suffering. Even knowing the possibility of a patient's fatal reaction to a specific procedure does not make it murder without the explicit intention. The matter becomes more complex in the context of sophisticated medical alternatives, but euthanasia continues to mean not only the medical killing but the intent to accomplish it.

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Perhaps there are really only two important questions about euthanasia, and one is the same question that might be asked about suicide, or about many more commonplace forms of self-destruction such as alcoholism or smoking: Do our bodies and our selves belong to us so entirely, as private property, that we may dispose of them in any way we wish? All sorts of developments in the history of thought and faith have led many people to think so, and current ideas of individualism and self-determination and self-realization certainly underline it. Some people, however, continue to believe that they belong to God, or that their bodies, souls, and lives are as a gift or trust, rather than a private possession. Some believe that the breath of life in each of us is a part of a spirit of life, or a community of spirit over which we do not exert ultimate control; that life was given to us and we give it to others; that we may not extinguish life deliberately. Faced with the problem of balancing the two parts of that awful question, “Who shall live and who shall die?,” many people find themselves willing to grant and place their trust in the power of human intervention on the one side, while insisting that the latter half remain beyond the pale of human meddling. Indeed, anyone who has seen a victim of acute coronary attack returned to life in the intensive heart-care unit of a modern hospital must be vividly aware of the degree to which it is within our power to regulate significantly the number of living and dead.

The other question involves new knowledge and possibilities for legal reform. It is the question whether all death nowadays is not really euthanasia, in view of recent developments in the definition of death. It may come as something of a surprise that there should be any question of defining death—surely even the untutored have known for countless millennia, and before recorded time, the difference between life and death, and have not had to be instructed in the matter by savants and researchers! The news that this certainty as well has been called into question by modern science may be greeted by impatience or even fury. Preposterous as it may seem, however, the exact determination of death has never been quite so clear-cut as might be thought, and has always implied the possibility of mysterious occurrences and inexplicable recoveries. Indeed, death, its manner of occurrence, and its precise certification, became of political and administrative importance as soon as settled civilizations developed and rulers desired to know how many people were to be taxed. Humane societies were especially interested in rudimentary methods of mouth-to-mouth resuscitation, and the growing sophistication of medical knowledge aroused an interest in the causes of death and the manner of determining them, such as by means of autopsies. The development of death certificates, of mortuaries, of special burial practices, the use of cadavers for autopsy, the registering of births and deaths, all came about along with public rolls, coroners, poor laws, and other social and economic aspects of modern life.

Yet ideas about death and the way a whole society will deal with it have now become a subject of intense concern, full of implications for many other aspects of life, in a way that would surprise our ancestors. Thus, it would be hard to find a more contemporary title than that of David Hendin's book, Death as a Fact of Life,1 with its subtitle, “New Thinking about the Legal, Medical, and Psychological Aspects of Our Most Repressed Reality.” Certainly our ancestors would not or could not have considered death a “repressed” reality, and it probably would not have occurred to them that death was not a fact of life. And what conceivably could “new thinking” be? Equally up-to-date is the spectacle of a professor at a theological seminary, such as Robert Neale of Union, presenting The Art of Dying,2 a set of spiritual exercises for contemplating death and composing the entire mind for it; even though Montaigne said that to philosophize is to learn how to die, it was in a different context, and the means for spiritual self-examination hardly had to be learned as they do now. Ernest Becker's long discussion in The Denial of Death3 links the subject with contemporary psychoanalytic and existentialist thought in the most advanced fashion, and also with the theme of the absence of heroism in modern life, again one of the most contemporary of concerns. Arien Mack's interesting collection of essays, Death in American Experience,4 is another distinctly modern example, with its exploration of the death themes in American poetry, in the youth culture, anthropological thought, and in social relations. Other recent studies may be more traditional in focus, such as the essays collected by H. M. Ruitenbeek in Death: Interpretations5 which, although they deal with death and the pleasure principle, psychotherapy for the dying patient, mourning, and other related topics, are nevertheless more classically psychoanalytic in character. The observations of British psychoanalysts, such as Janice Norton, Hanna Segal, and Melanie Klein, and of others, although of superior quality, are not affected by the new knowledge about death, or the concept of “brain death,” or by recent developments in organ transplantation, or by techniques of resuscitation, and might have been written at any time in the past hundred years. In contrast, a collection of essays assembled by Robert H. Williams, professor of medicine at the University of Washington, To Live and to Die: When, Why, and How,6 could come into being only as a result of the new knowledge—as exemplified by advances in the areas of chemical and hormonal intervention, psychosurgery, population control, genetic engineering—which Dr. Williams and others believe has transformed all the old ethical and legal questions.

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What does death mean, when cardiac massage can make the dead live, or when heart-lung machines, electric shock, or chemicals perform easily the spontaneous recoveries witnessed in the past? Patients who “die” during operations can be instantly revived by the trained personnel in the modern operating room. If cardiac arrest and cessation of breathing no longer mean death, or if heart-beat and breathing no longer mean life, then death has become an event entirely incidental to medical technology, and always, then, an act of euthanasia. The number of patients maintained in biological life by mechanical supports has increased greatly in recent years, and the question of their survival has been raised at the same time that there has been an increased interest in the concept of “brain death” as providing more reliable criteria than heart and breathing cessation. Such patients, often called “vegetables,” are alive and yet not living as human beings. The interest in brain function has become more refined, but what has provided a special urgency requiring immediate attention has been the parallel development in highly complex techniques of organ transplantation. Not only does it become a matter of concern how long biological life should be maintained artificially if the brain has died, and at what social cost, but, more specifically, in order to proceed with organ transplants there must be absolute clarity about when the donor is to be considered legally dead. These recent developments are troubling, and they provide ample warrant for wondering whether anyone can die his own death anymore.

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Clinical death occurs in humans when the heart and lungs stop functioning and the brain is deprived of oxygen. Unless resuscitation begins immediately, brain death follows, because the brain cannot survive without oxygen, and brain tissues do not heal or regenerate as other tissues do. The brain dies in stages, beginning with the cerebral cortex, then the mid-brain, and the brain stem. Cellular death follows, with organs and tissues remaining alive a bit longer. It is this sequence in death which makes possible the transplantation of living organs from the newly dead and thus raises the difficult question, when does death occur and what is it? If a serious accident destroys a victim's brain, but his basic functions are maintained artificially, does he ever die? When should the respirator be turned off, and for what reason. At what point would organ transplants, often called the “gift of life,” be transformed unwittingly but unmistakably into the theft of life? Dr. Williams, throughout his collection, and especially in his own essays, emphasizes, as others do, the importance of mentation, of brain activity, as a sign of continued life. If cerebral functioning has virtually ceased, euthanasia is in a sense irrelevant. Death becomes an administrative matter: if the victim's organs are destined for use in transplants, the problem would be to synchronize the mechanically-supported life of the dying patient with the condition of the living patient awaiting a heart or kidney. Still, the question, “when?” remains.

As might be imagined, this subject has interested medical, legal, religious, and philosophical observers intensely ever since the first successful heart transplants in 1967 revealed the urgent need for immediate action, although the problem had been foreseen earlier. Legal and medical experts have been scrupulously concerned to set forth acceptable criteria for the cessation of cerebral function, and within the past five or six years, innumerable congresses and conferences have taken up the matter, legal scholars and theologians have explored it, and the courts have dealt with it. In 1968 an Ad Hoc Committee of the Harvard Medical School to Examine the Definition of Brain Death proposed four major criteria7 which would enable a doctor to pronounce a patient dead when the traditional signs of death—respiratory and circulatory failure—were obscured by the resuscitation machinery. The criteria would be: 1) irreversible coma; 2) complete absence of spontaneous breathing or muscular movement or response to pain; 3) complete absense of reflexes, or response to light, smells, heat, cold; fixed pupils; 4) a “flat” electroencephalogram, indicating no brain activity. Extreme care would be taken in administering such tests, and in insuring that they were not applied to patients suffering from hypothermia (temperature below 90° F.) or from central-nervous-system depressants. The tests would be repeated in twenty-four hours to ascertain any possible change, and some have suggested a longer waiting period. These tests have been used increasingly in the past five years and their usefulness has been confirmed.

The need of the medical profession for some clarity in the determination of death has become evident in a series of court cases in which the concept of “brain death” has been offered to jurors and judges. Indeed, two states have enacted statutes including “brain death” as an alternative to the traditional determination, Kansas in 1970 and Maryland in 1972, but the language of the statutes, and the attendant ambiguities, give cause for public and professional concern. An additional, perhaps a ghoulish, note is sounded by the seeming connection between new definitions of death and new techniques in organ transplantation, conjuring up an image of contemporary body-snatchers in the form of white-coated medical teams waiting to perform transplants. Are some people to be considered more dead than others if their organs are needed? All the possible abuses of this delicate situation may be imagined, when the death of a dying patient is not regarded as his own individual death but as an event contingent upon the needs of another patient with heart or kidney disease. The Uniform Anatomical Gift Act, which has been passed by fifty states in one version or another, specifies that time of death must be determined by a physician not involved in the transplant, but perhaps further efforts at separating these processes are required to allay inevitable disquiet and confusion.

In a careful examination of the problem, Alexander Morgan Capron, of the University of Pennsylvania Law School, and Leon R. Kass, of the National Research Council, have proposed refinements of the statutes and clarification of two important questions about the mortally ill, namely, “when to allow to die” and “when to declare dead.”8 (A further question, “when or whether to hasten death,” explicitly evokes the intentions of the euthanasia movement, but no useful purpose is served by uniting all these questions. Euthanasia is not the same thing as donating your body for scientific research, or donating your organs for transplant, or even dying in all but your biological functions.) The exact determination of death is relevant not only to the mortally ill but in cases of suicide, accidents, and slow expiration as well; criteria must be agreed upon no matter what caused the death. Even in a perspective entirely different from the medical, or legal, or social, namely, the religious perspective which regards as the most important thing about death the soul's departure from the body, some explicit criteria must be employed to determine whether this has in fact occurred. Thus, the concept of brain death may be introduced for accuracy so long as the limits of its usefulness are clearly understood.

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There may be some question whether mentation, cerebral activity, comprehends all that we mean by human existence, but it is clear that what really troubles us, behind the horror at becoming “vegetables,” with life mechanically maintained at its most minimal, is the quite reasonable fear of the fragility of life itself. The machines that maintain life with tubes and wires, the whole impressive battery of modern medical techniques, mock the very thing that is cherished, the human person. Indeed, it is, among other things, precisely the helpless surrender to medical technology and management which the euthanasia movement attempts to counteract, with its “living will” and its deliberate confrontation with irreversible illness. Advocates of euthanasia do not in fact urge it as public policy, but merely as a possible private alternative which should be removed from the criminal category. The Euthanasia Society believes that its “living will” insures the voluntary nature of the act. Like any other will, it is to be executed when the testator is of sound mind, and it instructs family and physician not to make extraordinary efforts to prolong his life if he should be so irreversibly ill that no recovery is possible. Obviously, the patient's initial act of consent is his visit to the doctor, and no subsequent medical procedures can be undertaken without further indications of consent. Even the sewing up of a wound in a hospital emergency room cannot be done without consent, nor can operations, transplants, autopsies, or other procedures. In the absence of a “living will,” the family of the mortally ill may in effect be asking the doctor to perform euthanasia by not using all possible means of resuscitation, and the family may thus be giving its informed consent, although the patient, if comatose, does not give his. (In this matter—the ambiguity of consent—there is a connection with the concern of large numbers of people over the question of consent in medical and psychological research in general, and those interested in euthanasia are not unaware of it.)

Obviously, it has been the wish of many people who ponder the end of life, as people have done for centuries, that they not live beyond a certain point of disability, pain, deterioration, or unconsciousness. A calm and soberly determined and desired suicide has often seemed an appropriate alternative. Those who retain scruples about actually committing suicide might view the possibility of the “living will” as more acceptable. It is no public policy of killing the undesirables or the weaklings, but rather a stoic individual decision, as individual as wanting to leave money to a person or a cause, or wishing to be buried in a certain place, or cremation. Of course, a bureaucracy might exact consent to euthanasia from its citizens in the same cruel manner the Russians have exacted “voluntary” vows and confessions; uncontrolled bureaucracies become capable of these things when they verge on totalitarianism. And there is the other undesirable Russian practice of regarding all bodies as belonging to the state and therefore subject to autopsies or organ transplants or any other procedure without consent of the next of kin or of the patient himself. Still, there is quite a large leap from legally permitting some people to request that their own lives not be unnecessarily prolonged by artificial means, to a public policy requiring all lives to be terminated according to certain external criteria. Fears of “the entering wedge” and “the slippery slope” may blur or eliminate these significant distinctions. But does it make sense to think that we would remain unaware of all other bureaucratic encroachment on our lives and privacy until euthanasia were made mandatory? Actually, euthanasia, like abortion and contraception, might become a private matter between the patient and his doctor. Large numbers of our citizens might continue to think euthanasia a sin, as they do contraception and abortion, but they could no longer insist that it was a crime as well.

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Euthanasia is not proclaimed frivolously by its advocates, or without thoughtful concern, and to speak of Nazis and ghoulish experiments in the same context is insulting. Nevertheless, instead of simplifying or clarifying a painful inevitable situation, there is reason to think that introducing euthanasia as a remedy for the travesty of death actually complicates it. To imagine euthanasia in practice, not as in a Nazi nightmare but as if it were working out in an ordinary system of medical care, is to provide more problems than cures, as the editors of a recent British book on the subject demonstrate.9 For instance, an examination of the system of safeguards reveals how much care must be taken to establish certain qualifications for euthanasia, to have the declaration certified by witnesses, to insure that the declarer is of sound mind, and to release attending medical personnel from the violation of their Hippocratic oath and of any criminal responsibility. Then, the declaration must provide for a waiting period, for the possibility of revocation, and must include punishment for anyone willfully concealing, destroying, falsifying, or forging such a document. As the other procedural implications undergo scrutiny, so does the usual notion of euthanasia as a calm, sober act recalling Socrates nobly ending his life, or Phèdre, in grandeur, par un chemin plus lent descendre chez les morts. The scene becomes, rather, an execution chamber, with witnesses and documents and official certification—how could it not?

What if the patient were of sound mind but had changed his mind since signing a declaration? Twenty-five per cent of requests received by the Euthanasia Society are from young people; what if such a declaration were signed long ago, in another place; could it be easily revoked? One out of five Americans moves every year, and loss of documents always attends such population mobility; would a doctor in California know that his paralyzed, comatose patient had signed a “living will” in Maine? And what if the patient had forgotten? Which is the sound mind and who attests to it? Would the very doctors and nurses dedicated to healing be the ones to perform euthanasia and if not, would a special class or caste or guild do it, and would their arrival in a ward or private room signify the approach of their dread responsibility? Is it conceivable that certain hospitals would become known as euthanasia mills? And would it be an improvement if the sense of anxiety and mistrust which many patients already feel on entering a hospital were to be confirmed by such practices and if the hospital were transformed back to what it was once thought to be, a place to die in, or rather a place in which to be made dead?

Other instances of the use of euthanasia may be beyond the reach of safeguards. Thus, if an elderly patient knows that the crowded family at home needs his room, will he be more likely to sign such a declaration, especially if family relations are not ideal, if his illness is a burden? How can doctors be sure that such situations are not exerting pressure on their patients, or that the nursing homes and geriatric hospitals, with their limited facilities and with an ever-increasing number of old people, do not exert such pressures? And what of the old or ill who have no relatives, who are not being cared for by a friendly family doctor, but are treated all unknown in the impersonal wards of modern hospitals? The soundness of their minds, their unknowable wishes and intentions, the unknown circumstances of their lives, all are hidden from the understanding and ministration of most medical personnel, and this very lack of knowledge might be a source of pressure.

It is often said that everyone has a right to a death with dignity, or even a right to death parallel to a right to life. Whether or not such a right can be reasonably derived is a difficult question, but as the editors of Your Death Warrant? point out, what it really means is a right to be put to death, and put to death by others, which in fact proposes the duty of others to kill. There are comparable difficulties with the argument that legalized euthanasia would mean an improvement in the quality of life. Clearly, the improvement is not experienced by those who are put to death, because their experience of life thereby ceases. Rather, it is the quality of other people's lives that may be improved when the dead forfeit their own. And there is a question whether the quality of life would in fact be improved at all. It is generally held that overcrowding, competition for scarce resources, the pollution and overpopulation and bureaucratic nightmares which face us everywhere, would all be modified if fewer resources were consumed by unproductive elderly people; more would then be available for the rest of society, for more productive purposes. The allocation of resources is indeed a problem, but those who advance theoretical arguments about the proper use of resources were themselves once unproductive as infants, and will one day become the unproductive geriatric instances they now decry. Surely it would not really improve the quality of one's life to know that others have been deliberately sacrificed for it, or that one's own life, so full of quality, would one day be readied for sacrifice. Would not the quality of life of the entire society conceivably be poisoned if it were knowingly nourished in this way?

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Death in dignity, significant death, is of course what we would all desire, and in a community of care and concern. No one likes to be thought of as a patient rather than a person, no one wants his body regarded as a mine of transplantable organs, or as a statistic in the tabulated death rates, or an item in the hospital budget or the mortician's accounting. An accumulating outrage has attended the development of modern medicine, which must reduce a person to a thing in order to return him to the status of a person once more. And yet to be treated as a thing may not be the worst that can befall a modern American patient; equally discomfiting is the pervasive habit of false personalization, such as having to endure fifteen or twenty minutes of a doctor's “relating” to you with all sorts of trivia about himself and his family in order to feel that he truly “cares” about you “as a person.” This is especially painful as it affects treatment of the elderly or dying, whose condition cannot be reached by wearing a smile button and saying, “Have a nice day.” When death is on the horizon there is need for a surrounding community of care, and it may be precisely the lack of such a community that as much as anything else has fostered the growing interest in euthanasia. Faced on the one hand with the antiseptic mechanical processes of efficiency which are the natural consequences of modern medical technology, and on the other with the feeble attempts to counteract these by a system of deception and false personalization, how much more acceptable becomes the wish to choose the time and circumstances of one's own death. And if one has already donated organs for transplant, one can even have a sense, not of immortality perhaps, but still of some meaning beyond one's self.

An interesting British development in this connection has been the establishment of the hospice as a kind of special half-way house for the dying. Those who are soon to die but are still alive, and for whom no further medical treatment is ordered or desired, are out of place in the modern hospital, with its dedication to cure and its efficient broad-scale response to emergencies. Nursing homes or old-age homes cannot provide the experienced medical care required by such patients, and of course have too many financial and administrative problems to take on other responsibilities. The hospice is intended to provide a community of care rather than a regimen of rehabilitation for patients who do not wish to commit suicide or have others perform euthanasia on them. Actually, the idea of the hospice is a very old one, it antedates the modern hospital, and even the old hospital, antedates advanced surgical knowledge, advanced pharmacopeia, and modern theories of disease and health. Before all of this, the hospice was an arm of the religious establishment, caring for the bodies and souls of the afflicted. Naturally there was little alternative then, and only the souls remained accessible to productive attention.

The treatment provided by a hospice, or similar programs at hospitals in this country, is a novel combination of psychotherapy and chemotherapy, along with what we can only call a decent human response to the dying person as a person. The number of those attending to these issues has grown remarkably in recent years. New groups like the Foundation of Thanatology or the Institute of Society, Ethics, and the Life Sciences, with their publications, research programs, seminars, and meetings as well as the traditional journals like the Journal of the American Medical Association, the Archives of Internal Medicine, the American Journal of Nursing, the New England Journal of Medicine, Proceedings of the Royal Society of Medicine, all report regularly on the state of research and on the ethical, legal, and practical aspects of treating the dying patient. Among recent studies of great interest is a discussion by Avery D. Weisman, a psychiatrist at the Harvard Medical School, on his own work with dying patients in On Dying and Denying,10 a book which explores with great sensitivity the implications of death for certain patients, their awareness of terminal illness, and their capacities for resolution and reconciliation. Elizabeth Kubler-Ross, of Chicago, and Albert Biel, of Jefferson Medical College, are engaged in similar work.

Despite what doctors and relatives want to believe, most terminal patients are aware of their illness and its prognosis, and apparently want someone to acknowledge it. The conspiracy of silence and denial, although intended to ease the patient, does not do so, but instead frightens those whose great need is for genuine candor. The dying patient dreams that he has died and is still in the hospital; when the nurse comes in, he asks whether he is dead or alive, and she replies, “Have you asked your doctor?” Dr. Kubler-Ross describes five stages of mental attitude in dying patients, from denial to resentment and anger, to a kind of bargaining and supplication of unknown forces, to depression, and perhaps, if the patient is fortunate, to a final stage of resolution, acceptance, integration of a sort. Dr. Weisman, with similar objectives, sees the progress somewhat differently, in terms of levels of awareness, levels of acceptance, illusion, and reconciliation. The responsibility of the hospice, or of any explicit program of care for the dying, is to assist and guide people in this final psychological and spiritual project, recognizing that healing of the body is no longer possible, accepting the very different goal of caring for the spirit.

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The requirement of significant death is perhaps even more compelling in our own day than in past ages with their shared beliefs in the stages along death's way, but it has never been more ignored. The entire culture is given over to other demands, and to a denial and dissimulation in which we all share, and there are few efforts or institutions, like the hospice, working to counteract the universal pattern In contrast to the people after the Black Death who, like Michelangelo, found themselves “thinking no grave thought which did not have Death engraved on it,” we are all able to think about death not at all if we so choose, despite the Holocaust, the wars of the past generation, despite the violence that greets us everywhere. James D. Watson and Sir Francis Crick do not contemplate a skull on their desks as they investigate the genetic code, and although recent existentialism played a part in recovering the subject of death for intellectual discussion, it has little practical significance in the organization of life. Everyone is quite familiar with the fear of death, and with its intricate permutations in conscious and unconscious mind, everyone knows about hostility and death wishes, not only in others but in oneself; but to what end?

Death is the most individual event in our lives, the most unique, its importance equaled only by the uniqueness of birth. Although euthanasia itself offers no solution to anything at all, the euthanasia movement may help to rouse a culture too long given over to a denial of the very reality of death, and, especially in view of the new medical technologies, may illuminate a subject that most urgently needs our thought and concern.


Footnotes

1 Norton, 255 pp., $750.

2 Harper & Row, 158 pp., $5.95.

3 The Free Press, 320 pp., f 7.95.

4 Schocken, 201 pp., $750.

5 Delta, 286 pp., $2.45.

6 Springer-Verlag (New York), 346 pp., $12.95.

7 Journal of the American Medical Association (July 3, 1972, Vol. 221, Number 1), “Report of Task Force on Death and Dying, Institute of Society, Ethics and the Life Sciences.” See also JAMA, Vol. 205, 1968, for the initial report of the Harvard Ad Hoc Committee.

8 “A Statutory Definition of the Standards for Determining Human Death: An Appraisal and a Proposal,” University of Pennsylvania Law Review, Volume 121, No. 1, November 1973.

9 Your Death Warrant? The Implications of Euthanasia, Edited by Jonathan Gould and Lord Craigmyle, Arlington House, 144 pp., $6.95.

10 Behavioral Publications, 247 pp.,$9.95.

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