We live at a time of unusually intense activity with respect to the evolution of a new cultural paradigm (on which to base a new societal one): the store of values, attitudes, beliefs, commitments, and myths. This paradigm is the shared story – the shared culture – that informs both our collective and our individual lives. Societal phenomena that have given rise to the need for a new paradigm include mind-altering scientific and technological advances, especially genetics and reproductive technologies; a preoccupation with real as well as symbolic individual and communal death;² the technological reality of a global community that lacks an...

The question in my title – a deliberate inversion of the famous question asked by Helga Kuhse and Peter Singer: “Should the baby live?”¹ – is being asked more and more often. As Gerald Gruman has observed, “It is questionable if today the young comatose patient is the prototype for the discussion of issues of death and dying. A more probable crucial issue is that of the elderly: a reservoir of relatively defenceless persons, perceived, through bigoted ‘ageism,’ as unproductive and pejoratively dependent. In them, modernization has created a population stratum that, in a state of nature or conditions of scarcity economics,...

This chapter began as one lecture in a series on medical decisions at the end of life. In preparing what follows, two common but powerful and important insights were strongly reinforced. First, the debate about euthanasia concerns much more than that matter itself, for individuals and for society; second, the role of language is immensely important in formulating both the questions and the responses to them. Any consideration of euthanasia requires both thinking and feeling – and language affects not only how we think and feel but also whether these functions are integrated or separated.

To explore some of the complex...

In both literal and metaphorical senses, euthanasia is an end-of-a-millennium controversy. Some of the most complex and serious decisions we will face as individuals, families, communities, and society will be determined by how we approach, structure, analyze, and resolve the euthanasia debate. This debate can be regarded as the tip of an iceberg, an image that brings to mind the fact that the vast majority of the matters affected by the debate are submerged and hidden,¹ and the possibility that legalization of euthanasia could prove to be an icy (slippery) slope. Legalizing euthanasia can be seen also as a stone...

A paradoxical partnership has emerged concerning the definition of euthanasia. Both the pro-choice side (the death with dignity movements – those who believe that euthanasia should be available) and the anti-euthanasia side (which includes the pro-life movement) use a similarly broad definition, but with the aim of achieving exactly opposite effects. This very broad definition includes the following claims to rights: to refuse life-support treatment; to give “advance directives” while competent, in anticipation of incompetence, refusing such treatment through documents such as a “living will” or a durable power of attorney (which allows a person to choose a substitute decision-maker, or...

Until very recently, all countries prohibited euthanasia, although it had been legally tolerated – not legalized, but not prosecuted, provided it complied with various conditions – since the early 1970s in the much studied and cited case of the Netherlands, where it has just been formally legalized.¹ Many countries are now experiencing an unprecedented rise in calls to legalize euthanasia.² Some of these demands come from within the profession of medicine.³ Oregon law⁴ now authorizes physicians to prescribe lethal doses of medication for their patients.⁵ And the United States Second Circuit Court of Appeals⁶ and Ninth Circuit Court of Appeals⁷ struck down...

The euthanasia debate is beset by confusion – a condition caused both by accident and by design. One important way to promote the legalization of euthanasia is through various types of confusion. First, the examples of such confusion span the domain of semantics: confusion in definition; confusion created by choice of language; and confusion of association and analogy. Second, they span important areas of ethical and legal analysis: confusion of means and ends; confusion in the use of the legal concepts of intent and causation; and confusion in interpreting common-law precedents. We need to examine, understand, and, where possible, dispel these...

Arguments for liberty, mercy, and dignity support the legalization of euthanasia, but the possibility of undesirable social consequences present a problem. Accordingly, proposals for legalization must include suggestions to prevent involuntary euthanasia, to prevent unconscious coercion of the terminally ill to request euthanasia, to protect and enshrine the availability of first-class palliative care, to ensure documentation for purposes of enforcement and study, and to spell out enforceable consequences for violations.

Guidelines set by the Royal Dutch Medical Association for legalizing euthanasia have largely failed to meet these requirements. In North America, proposals for legalization, such as Oregon’s Measure 16 and...

The article by Torsten Nielsen, “Guidelines for Legalised Euthanasia in Canada,”¹ can be challenged on many bases, nine of which I will identify here.

First, good ethics depend on good facts. Good ethical and legal “facts” start with primary sources that are up to date and accurate. The 1990 Remmelink study, on which Dr Nielsen relies, was repeated in 1995 with different results in relevant and important respects.²

Second, the Australian studies on which Nielsen relies were part of a concurrent effort to support the legalization initiatives that were being considered by Australian state or territorial legislatures, most notably that...

Dr Somerville’s “Point of View” article raises several issues, perhaps the most important of which are the constitutionality of a euthanasia-committee approach, the underlying reasons motivating those who oppose euthanasia, and the fundamental conflicts inherent in arguments based on patients’ autonomy. First, however, I am compelled to respond to Somerville’s attacks on my sources, interpretations, and choice of language. Although her last paragraph makes it seem as though I describe euthanasia as “the final act of good palliative care,” at no point do these words appear in my article.

I was aware of the 1995 sequel to the Remmelink study...

Even if it is true that the 1995 Remmelink study “shows that practices in 1995 are not much different from those in 1990,” it is relevant to know that fact. But the 1995 study also provides additional important information about the practice of euthanasia in the Netherlands and, as outlined in chapter 7, has been the focus of in-depth and broad-based discussion and disagreement. The later study provides evidence of serious abuses of euthanasia, such as carrying it out on incompetent people and on competent people without obtaining their consent to its being administered to them.

Second, Nielsen is incorrect...

At the Twentieth International Congress of Chemotherapy (in Sydney, Australia in 1997), a session on physician-assisted suicide and euthanasia was included under the ambiguous title, “To Assist or Not to Assist? That Is the Question.” As I say elsewhere (for instance, in chapter 7 on “Euthanasia by Confusion”), speaking euphemistically of euthanasia as “physician-assisted death” causes serious confusion. Most of us want the assistance of physicians when we are dying, but that does not necessarily mean that we want physician-assisted suicide or euthanasia. The content of the session was well advertised on site, with a feature article in the congress...

Traditionally, consideration of “pain and suffering” by the law has been as a specific basis for recovery of damages under the general rubric of awards of damages for non-pecuniary loss. It is from this traditional perspective, the subject of the first part of this chapter, that a wider exploration of the law’s response to pain and suffering will be opened up. The second part deals with a more controversial, though by no means novel, problem – that of legal liability arising in relation to pain-relief treatment. Liability can be both civil and criminal. It can concern the contrasting situations of either...

Every word in the title of a working paper by the Law Reform Commission of Canada,Euthanasia, Aiding Suicide and Cessation of Treatment,¹ has a negative content – that of aiming to reduce suffering by eliminating suffering people or treatments that prolong their lives (and hence their suffering). One example of the latter would be when a competent patient has given an informed refusal of further treatment aimed at prolonging life. There is also an important correlative positive principle that pertains in these situations, however, and it must be clearly stated, understood, and applied. This principle is not new, but it...

This title refers to three major areas that have been a focus of conceptual and practical developments in late-twentieth-century societies: human rights, medicine, and the relief of suffering. What are our obligations in each of these contexts, and what is the relation among them?

What is the relation between contemporary concepts of human rights 1 and medicine? One way to explore this question is to ask three others: What is the relevance of human rights to governmental decision-making regarding medicine? What is the relevance of human rights in the context of decision-making by medical institutions? And what is the relevance...

The title “Death of Pain” can be interpreted in two ways: eitherpeople dieof pain or thepain dies, but not the people who had suffered from it.

Some people die of pain directly, because leaving them in pain could conceivably shorten their lives. All their physical and psychological resources are focused on dealing with the pain, and they become exhausted sooner than would otherwise have occurred. People can die of pain indirectly, too. For instance, they might commit suicide because of it. In one case an elderly man, who had been in chronic pain for a very long...

The double doors of the critical-care unit in the kidney ward of a prestigious New York hospital stood wide open. Visitors, nurses, and nurses’ aides walked in and out of the room, but I hardly noticed this busy traffic.

I stood near the elevator banks, where I had been ordered to wait. In my hands were plastic shopping bags from Gristede’s filled with cosmetic and medical paraphernalia, bottled water, and legal papers, but I was unaware of them as I stared at the woman on the raised bed in the northeast corner of the critical-care unit. Intense light illuminated her...

One statement is made by almost every person who enters my office to discuss a case of medical malpractice: “Even if nothing can be done for me, I want to make sure, as far as I am able, that this doesn’t happen to somebody else.” There is a good psychological reason for this attitude: converting a negative event, the consequences of which are often irreversible, into some positive value can help us to deal with the feelings of anger, loss, and outrage the event engenders. This transformation is therapeutic for the person. In addition, it might prove therapeutic for a...

“Death with dignity” has become the rallying cry of the assisted suicide and voluntary euthanasia movement. Its proponents assert that there is a right to prevent our dignity from being undermined by disability and suffering. Because the concept of human dignity carries strong rhetorical and moral force, we are obliged to examine any claims that our society is failing to act in accordance with it. This article examines and refutes the claim that human dignity is lost through disability, disease, dependency, or suffering. Human dignity is not a thing that can be lost, and the claim noted above involves an...

With her focus on the word “dignity,” Stolberg tries to answer the following question: Are we being manipulated by the use of special language in the euthanasia debate? In doing so, she raises as many questions as she answers. Warning that we should “respond cautiously to calls fordeath with dignity,” she rejects the claim that human dignity is lost through disability, disease, dependency, or suffering. As she points out, “dignity is not a thing that can be lost.”¹

Stolberg presents several problems: the relation between dignity and autonomy and between dignity and control, or power; the different effects of...

The steady spate of papers about euthanasia and physician-assisted suicide should remind us that death can be approached, as it were, from the opposite direction. Death (Gkthanatos, Lat.mors,mortis; Goth.dauthus) generally has been viewed as a “failure” (to survive); efforts to prevent – actually only to postpone – death have become a preoccupation of modem medicine, which indicates a widespread thanatophobia. Historically, in most societies, death has served as the ultimate penalty for evil and unlawful deeds, even though many have questioned both its deterrent and its ethical aspects. Ever since Diodotos’ address to the Athenian Assembly – recorded by...

Death is a complex issue for us, both as individuals and as a society. Constantine Falliers’s article, “Prothanasia: Personal Fulfilment and Readiness to Die,”¹ raises questions that add to our appreciation of this complexity. What would it mean in personal, practical, emotional, and societal terms to interpret Simeon’s words in St Luke’s Gospel as “convey[ing] the message that life is an obligation, or commitment to serve [and that] [w]hen this is achieved the person may be released – that is, free to die”?² Do we regard life as an obligation or as something else? Is it something we own (the materialist...

It is not enough, even as an academic, to engage in the euthanasia debate only in academia. This debate must take place primarily in the public square. The media are the messengers – and, as Marshall McLuhan showed us – they can be the message too. Consequently, the ethics adopted by the mass media, and that govern the content and mode of their communications, will have an important impact on the outcome of the euthanasia debate.

Canada, like other postmodern, secular, Western democracies, is often called a “media society.” People can have very disparate reactions to major controversies – such as euthanasia – depending...

Two high-profile news stories in early 1998, which centred on the infliction of death, raise questions about the relation between euthanasia and the death penalty: the dismissal of first-degree murder charges against Canadian physician Dr Nancy Morrison in relation to the death of her patient Paul Mills; and the execution of Karla Faye Tucker by the state of Texas. Although the death penalty has been abolished in Canada, there are people – including some members of the Canadian Alliance, the official opposition party – who promote its reintroduction. They claim that most Canadians support it. Many of these same people are also...

For some time now I have been hearing noises, ranging from rumblings to thunder claps, to the effect that the practice of psychiatry is becoming impossible owing to the application of law. One psychiatric resident told me that she was thinking of leaving psychiatry because it seemed too difficult – not the profession itself but the intervention of law.

I suggest that psychiatry and law are not only essential to each other but complementary; they can and must be integrated. Both have a common goal: the relief of suffering. But, in some circumstances, they see this goal as being best achieved...

The titles of colloquia, conferences, books or journals – for instance, “AIDS, Health and Human Rights,” “Health and Human Rights,” and “The Right to Health: A Human Rights Perspective” – and of academic centres for teaching and research reflect a relatively recent phenomenon. Human rights in relation to health (“rights to health,” “rights to health care,” or “rights to health protection”)¹ have for some time been articulated in international law and conventions² and found by courts to be part of national and domestic law.³ But the exploration of these rights – what is required to respect, protect, and fulfill them – is much more...