Deciding When Death Is Better Than Life

By Gilbert Cont

I am a broken piece of machinery. I am ready.

- Last words of Woodrow Wilson, Jan. 31,1924

George Zygmaniak, 26, lacked the former President's rhetorical skills, but as he lay in a hospital bed last month in Neptune, N.J., paralyzed from the neck down because of a motorcycle accident, he felt that he was a broken piece of machinery.

He was ready to go. He begged his brother Lester, 23, to kill him. According to police, Lester complied -using a sawed-off shotgun at close range. Lester, who had enjoyed an unusually close relationship with his brother, has been charged with first-degree murder.

Last December Eugene Bauer, 59, was admitted to Nassau County Medical Center on Long Island with cancer of the throat. Five days later he was in a coma and given only two days to live. Then, charges the district attorney, Dr. Vincent A. Montemarano, 33, injected an overdose of potassium chloride into Bauer's veins. Bauer died within five minutes. Montemarano listed the cause of death as cancer, but prosecutors now say that it was a "mercy killing" and have accused the doctor of murder.

The two cases underscore the growing emotional controversy over euthanasia ("mercy killing") and the so-called right to die -that is, the right to slip from life with a minimum of pain for both the patient and his family. No one seriously advocates the impulsive taking of life, as in the Zygmaniak shooting. A person suddenly crippled, no matter how severely, may yet show unpredictable improvement or regain at least a will to live. Whether or not to speed the passage of a fatally ill patient is a far subtler question. The headlong advances of medical science make the issue constantly more complex for patients and their families, for doctors and hospitals, for theologians and lawyers.

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The doctor's dilemma -how long to prolong life after all hope of recovery has gone -has some of its roots in half-legendary events of 2,400 years ago. When Hippocrates, the "Father of Medicine," sat under his giant plane tree on the Aegean island of Kos, euthanasia (from the Greek meaning "a good death") was widely practiced and took many different forms. But from beneath that plane tree came words that have been immortalized in the physician's Hippocratic oath, part of which reads: "I will neither give a deadly drug to anybody, if asked for, nor will I make a suggestion to this effect."

Down the centuries, this has been interpreted by most physicians to mean that they must not give a patient a fatal overdose, no matter how terrible his pain or how hopeless his prospects. Today many scholars contend that the origin of this item in the oath has been misinterpreted. Most likely it was designed to keep the physician from becoming an accomplice of palace poisoners or of a man seeking to get rid of a wife.

The most emphatic opponents of euthanasia have been clergymen, of nearly all denominations. Churchmen protest that if a doctor decides when a patient is to die, he is playing God. Many physicians still share this objection. However much they may enjoy a secret feeling of divinity when dispensing miraculous cures, to play the angel of death is understandably repugnant. Moreover, as psychoanalysts point out, they are chillingly reminded of their own mortality.

At a recent conference chaired by the Roman Catholic Archbishop of Westminster, Dr. W.F. Anderson of Glasgow University, a professor of geriatric medicine, called euthanasia "medicated manslaughter." Modern drugs, he argued, can keep a patient sufficiently pain-free to make mercy killing, in effect, obsolete. Perhaps. There is no doubt, however, that a panoply of new techniques and equipment can be and often are used to keep alive people who are both hopelessly ill and cruelly debilitated. Artificial respirators, blood-matching and transfusion systems, a variety of fluids that can safely be given intravenously to medicate, nourish and maintain electrolyte balance -these and many other lifesavers give doctors astonishing powers.

Until about 25 years ago, the alternatives facing a doctor treating a terminally ill patient were relatively clear. He could let nature take its sometimes harsh course, or he could administer a fatal dose of some normally beneficent drug. To resort to the drug would be to commit what is called active euthanasia. In virtually all Western countries, that act is still legally considered homicide (though juries rarely convict in such cases).

On the record, physicians are all but unanimous in insisting that they never perform active euthanasia, for to do so is a crime. Off the record, some will admit that they have sometimes hastened death by giving an overdose of the medicine they had been administering previously. How many such cases there are can never be known.

Now, with wondrous machines for prolonging a sort of life, there is another set of choices. Should the patient's heart or lung function be artificially sustained for weeks or months? Should he be kept technically alive by physicochemical legerdemain, even if he has become a mere collection of organs and tissues rather than a whole man? If a decision is made not to attempt extraordinary measures, or if, at some point, the life-preserving machinery is shut off, then a previously unknown act is being committed. It may properly be called passive euthanasia. The patient is allowed to die instead of being maintained as a laboratory specimen.

While legal purists complain that euthanasia and the right to die peacefully are separate issues, the fact is that they are converging. With the increasing use of extraordinary measures, the occasions for passive euthanasia are becoming more frequent. The question of whether terminal suffering can be shortened by active or passive means is often highly technical -depending on the type of ailment. Thus the distinctions are becoming blurred, particularly for laymen.

No dicta from ancient Greece can neatly fit the modern logistics of death. Until this century, death was a relatively common event in the household, particularly among farm families. Today more than 70% of deaths in American cities occur in hospitals or nursing homes. Both medical care and death have been institutionalized, made remote and impersonal. In major medical centers the family doctor is elbowed out by specialists and house physicians who have their elaborate and expensive gadgets. The tendency is to use them.

"The idea of not prolonging life unnecessarily has always been more widely accepted outside the medical profession than within it," says a leading Protestant (United Church of Christ) theologian, University of Chicago's Dr. James Gustafson. "Now a lot of physicians are rebelling against the triumphalism inherent in the medical profession, against this sustaining of life at all costs. But different doctors bring different considerations to bear. The research-oriented physician is more concerned with developing future treatments, while the patient-oriented physician is more willing to allow patients to make their own choices."

House-staff physicians, says Tufts University's Dr. Melvin J. Krant in Prism, an A.M.A. publication, "deal with the fatally ill as if they were entirely divorced from their own human ecology. The search for absolute biological knowledge precludes a search for existential or symbolic knowledge, and the patient is deprived of his own singular humanism." The house staff, Krant says, assumes "that the patient always prefers life over death at any cost, and a patient who balks at a procedure is often viewed as a psychiatric problem."

Technical wizardry has, in fact, necessitated a new definition of death. For thousands of years it had been accepted that death occurred when heart action and breathing ceased. This was essentially true, because the brain died minutes after the heart stopped. But with machines, it is now possible to keep the brain "alive" almost indefinitely. With the machines unplugged, it would soon die. In cases where the brain ceases to function first, heart and lung activity can be artificially maintained. While legal definitions of death lag far behind medical advances, today's criterion is, in most instances, the absence of brain activity for 24 hours.

The question then, in the words of Harvard Neurologist Robert Schwab, is "Who decides to pull the plug, and when?" Cutting off the machines -or avoiding their use at all -is indeed passive euthanasia. But it is an ethical decision -not murder, or any other crime, in any legal code. So stern a guardian of traditional morality as Pope Pius XII declared that life need not be prolonged by extraordinary means.

But Pius insisted, as have most other moralists, that life must be maintained if it is possible to do so by ordinary means that is, feeding, usual drug treatment, care and shelter. This attitude is supported by history. It would have been tragic, in 1922, to hasten the end of diabetics, for the medical use of insulin had just been discovered. Similar advances have lifted the death sentence for victims of hydrocephalus and acute childhood leukemia. But such breakthroughs are rare. For the aged and patients in severely deteriorated condition, the time for miracles has probably passed.

Faced with a painful and tenuous future and an all-too-tangible present crisis, how does the doctor decide what to do? Does he make the decision alone? Dr. Malcolm Todd, president elect of the American Medical Association, wants doctors to have help at least in formulating a general policy. He proposes a commission of laymen, clergy, lawyers and physicians. "Society has changed," says Todd. "It's up to society to decide." The desire to share the responsibility is reasonable, but it is unlikely that any commission could write guidelines to cover adequately all situations. In individual cases, of course, many doctors consult the patient's relatives. But the family is likely to be heavily influenced by the physician's prognosis. More often than not, it must be a lonely decision made by one or two doctors.

Some conscientious physicians may not even be certain when they have resorted to euthanasia. Says Dr. Richard Kessler, associate dean of Northwestern University Medical School: "There's no single rule you can apply. For me it is always an intensely personal, highly emotional, largely unconscious, quasi-religious battle. I have never said to myself in cold analytic fashion, 'Here are the factors, this is the way they add up, so now I'm going to pull the plug.' Yet I and most doctors I know have acted in ways which would possibly shorten certain illnesses -without ever verbalizing it to ourselves or anyone else."

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Kessler's ambivalence is shared by Father Richard McCormick of Loyola University's School of Theology. There are cases, McCormick observes, where the line is hard to draw. One example: a Baltimore couple who let their mongoloid baby die of starvation by refusing permission for an operation to open his digestive tract. The operation might have been considered an ordinary means of treatment, if the child had not been a mongoloid. "In cases like that," says McCormick, "you're passing judgment on what quality of life that person will have. And once you pass judgment that certain kinds of life are not worth living, the possible sequence is horrifying. In Nazi Germany they went from mental defectives to political enemies to whole races of people. This kind of judgment leads to the kind of mentality that makes such things possible."

For cases where the line is unclear between ordinary and extraordinary means, Roman Catholic theology offers an escape clause: the principle of double effect. If the physician's intention is to relieve pain, he may administer increasing doses of morphine, knowing full well that he will eventually reach a lethal dosage.

When Sigmund Freud was 83, he had suffered from cancer of the jaw for 16 years and undergone 33 operations. "Now it is nothing but torture," he concluded, "and makes no sense any more." He had a pact with Max Schur, his physician. "When he was again in agony," Schur reported, "I gave him two centigrams of morphine. I repeated this dose after about twelve hours. He lapsed into a coma and did not wake up again." Freud died with dignity at his chosen time.

Dr. Schur's decision was, in the end, relatively easy. More often, there are unavoidable uncertainties in both active and passive euthanasia. Doctors may disagree over a prognosis. A patient may be so depressed by pain that one day he wants out, while the next day, with some surcease, he has a renewed will to live. There is the problem of heirs who may be thinking more of the estate than of the patient when the time to pull the plug is discussed. Doctors will have to live with these gray areas, perhaps indefinitely. Attempts to legalize active euthanasia -under severe restrictions -have failed in the U.S. and Britain but will doubtless be revived. The fundamental question, however, is humane rather than legal. To die as Freud died should be the right Of Everyman.

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