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Christian Ethics

Instructor: Dr. David Jones

Audio Transcription for Lesson 22: Respect for Human Life, II

As we begin this session, I would like to read the first question and answer from the Heidelberg Catechism. The question is, "What is your only comfort in life and in death?" And the answer says, "That I am not my own, but belong body and soul, in life and in death, to my faithful Savior Jesus Christ. He has fully paid for all of my sins with His precious blood, and has set me free from the tyranny of the devil. He also watches over me in such a way that not a hair can fall from my head without the will of my Father in heaven. In fact, all things must work together for my salvation. Because I belong to Him, Christ by His Holy Spirit assures me of eternal life and makes me wholeheartedly willing and ready from now on to live for Him."

Let us pray together.

Lord, we thank You for the great comfort that the Gospel brings to us, the Gospel of life and salvation. And we pray we may live in the light of this truth, that we may have the same respect for physical life that You do, and that we may have the same motivation to spread Your Gospel that motivated the Reformers who wrote this wonderful catechism. Be with us in our generation, we pray, to uphold Your Word. We ask for Jesus' sake. Amen.

The issue that we have left under "Respect for Human Life" is human embryo research. This seems to always be in the news in America. For example, the senate held hearings on federal funding for human embryo stem cell research, and I will explain a little bit about what that means. The current law on federal funding of human embryo research says, "None of the funds available in this act may be used for the creation of a human embryo or embryos for research purposes. And research in which a human embryo or embryos are destroyed, discarded, or knowingly subject to risk or injury or death greater than that allowed for research on fetuses in utero is forbidden." They define human embryo or embryos as "any organism not protected as a human subject" and so forth, "that is derived by fertilization, parthenogenesis, cloning, or any other means from one or more human gametes" -- that is the sperm and egg -- "or human diploid cells," -- that is the union of the sperm and the egg cell.

In Bevington's "Stem Cell Research and 'Therapeutic' Cloning: a Christian Analysis," she asks, "How were scientists able to retain these cells?" and gives two means by which they were obtained. The Wisconsin team obtained its cells from surplus embryos donated by fertility clinics. We have frozen embryos accumulating at a rate of 10,000 a year that are not wanted by those who conceive them and so the last time I checked several years ago, we had 50,000 of these that are simply being maintained in frozen form. So these were donated by the clinics for research. The other research team at John Hopkins derived their stem cells from aborted fetal tissue. There is now a third means by which human stem cells are derived. Michael West, who is the head of a company called Advance Cell Research, has cloned human embryos by removing the genetic material from cows' eggs and inserting human cell tissue. And so that is the third area from which these stem cells are derived. A human embryo has now been created by cloning. In Great Britain there was a recommendation from the agency that is responsible for ethics in these things to allow cloning as a source of embryos for stem cell research in Britain. So this is where the current issue is, and there are all sorts of advantages that come from stem cells that have great potential. In a very moving and emotional testimony by Christopher Reeve to Congress, you get the idea that you can replace a spinal cord as well as treat Parkinson's disease and a number of these things, so the potential of good that could be done from embryo stem cell research is great.

In the way in which this is reported, typically you get a dismissive phrase that this is all affected by abortion politics, and if we did not have abortion politics then there would not be any question about this research going forward. Well, I say, "Thank God for abortion politics." Let me explain what I mean by that. There are at least some people who are trying to hold the line in terms of federal funding that would further institutionalize abortion in America. It has been going on for some years since the 1970s. Since Roe versus Wade, there has been the one area where the pro-life movement has been able to hold the line, and it regards the federal funding of abortion or federal funding of the research that involves abortion. The idea is that Roe versus Wade established the right of a woman to choose abortion, but that is different from approval of abortion, which would be the case if we get into federal funding that goes beyond tolerance to sanction. Beginning in the 1970s, there was a strong movement to resist, even with the abortion on demand, taking that at face value as the right to choose abortion. The right to choose abortion does not mean that the state may not express its non-complicity in abortion by refusing federal funding. It is just the one small hold that has been in effect for the last years.

It begins with fetal tissue research. There is a distinction between fetal tissue research and live fetal research. Research on human beings in the womb from implantation to birth has been denied federal funding since 1975. Even if that fetus is going to be aborted, you cannot experiment on it. So federal funding of live fetal research is permitted only if the experiment is therapeutic for that particular child. The experimental surgery for spina bifida, for example, is therapeutic for that particular child or somehow necessary for gathering information that poses no risk to the child. Now, it is still on the books that you may not experiment on a fetus in the womb even though it is scheduled for abortion. Even though a woman has a legal right to choose abortion, the living fetus is still treated as a subject with human dignity. That is the value of having that law denying federal funding. Of course, in private clinics that are not federally funded, that may be done. But at least it does not have public support through taxation. Fetal tissue research, on the other hand, involves the use of tissue following the death of a fetus, and those have been going on in the early part of the century without much success, and the use of such tissue from spontaneous abortions, miscarriages, or indirect abortion is not the issue. The issue is whether we should allow such research, in terms of federal funding for tissue research, of using fetuses from induced abortion.

There is an interesting development here I want to just share with you. In America in 1988 the Bush administration banned the federal funding of fetal tissue research using aborted fetuses for transplant. That was by an administrative order. That ban was rescinded by President Clinton on January 22, 1993. That was his first act upon assuming office. He did this as the pro-life movement was gathered there on the anniversary of Roe versus Wade to protest abortion. By administrative fiat, he removed that ban. Now, what gets glossed over is that later in that year, on June 10th, 1993, the president signed into law a bill passed by Congress that permitted fetal tissue research on aborted fetuses. It passed overwhelmingly. It is the National Institutes of Health Reauthorization Act. The Senate vote was 96 to 4; the House of Representatives voted 283 to 13. It was not just President Clinton. There is strong congressional support of this. And as one person who is sympathetic to this move has said, "The irresistible pull of progress in the end trumps moral concerns." I fear that is true, but we should recognize that there was overwhelming support of that in Congress. And the argument shifted this way. Of course, we may not do evil that good may come, but the argument was "Can we not at least bring good out of evil?" Granted that abortion is evil, can we not at least do some good with this fetal tissue that otherwise would be incinerated?

The act included a number of safeguards that helped gain congressional support. "Doctors performing the abortion must certify that the women specifically consented to the abortion before being asked to donate fetal tissue." The decision has to be made, and then you ask. It also banned departures from standard abortion procedures. The woman had to certify that she does not know who the recipient is. So there were these safeguards, including making it a felony to purchase or sell the tissue for profit. It did allow reasonable charges to be paid to companies that extract and transfer the tissue to researchers. Pro-life activists at the time said, to quote one, "How long before we have an unregulated fetus industry in which the organs of unborn babies are bought and sold as commonly as pints of blood?" And the answer to that is "About five years." This was the story that broke. There was a good report in World Magazine a few years ago on the sale of fetal tissue for transplant, fetal body parts with price tags attached: brain, foot, or whatever you want. It is a grotesque industry, and it was featured on one of the evening news programs when the congressional hearings were held. But as so often happens, the pro-research forces attacked the witness. They attacked the person who drew attention to the practice, and his motivation, and nothing came of it. There is all this big noise that body parts from aborted babies are being sold for profit, and that is a felony, but no one is really interested in pursuing that and going to the trouble of finding out how it is done. But you know, there is a symbiotic relationship between researchers and abortion clinics in which it is to the advantage of abortion clinics to have these folks on sight where they can have access to the body parts, and it is clear that the law is being circumvented. All parties claim no one is buying or selling fetal tissue. It is just one of those areas where even those who had supported the idea of abortion were shocked by the buying and selling of fetal tissue. The spokesperson from Planned Parenthood said it was inappropriate. That is not a strong moral critique, but the subject was changed in the House hearings and so a moral dilemma is obscured. There is a very great hardness of heart on this issue. Any question of what it would take to enforce the law shows that. We ought not to be so easily distracted by safeguards. We have to ask, are the safeguards enforceable? Is there the will to enforce the safeguards? And an astute pro-life activist at the time predicted that it would be not likely.

Now, the progress overcame the scruples. Embryonic stem cell research is at the same place in the debate. I think that it is very courageous for people to oppose this on principle grounds, but it is a living human embryo. I will not take time to go into the details of stem cell research. You can look at an analysis. But those who are on the other side, Michael West of Advanced Cell Technology, for example, is quoted in Nature Medicine, and he asks the question this way. "Does a blastocyst" -- that is the one cell embryo that begins developing, the zygote that develops to a blastocyst over a few days. -- "Does a blastocyst want the same right and reverence as that accorded a living soul, a parent, a child, or a partner, who might die because we fail to move the moral line?" Now, I think that my response to that would be that we do not draw the moral line. If we move the moral line, it can be moved anywhere. Indeed as Arthur Kaplan, University of Pennsylvania, said before the committee, "We do not live in a world of moral absolutes." Well, what that means is if there are no moral absolutes, then nothing is forbidden. We use the saying, "If God is dead, everything is permitted." Well, you can state it the other way, too. If we do not live in a world of moral absolutes, then nothing is forbidden. Is the moral line something that is under our control, or is the moral line something that we discover?

The other question involves a great resistance to the idea that an embryo is a living human being. It begs the question. If you use that term, saying, does a blastocyst have the same rights as a person whose life we might save, then of course you feel the pull of that argument. The question is what is the status of the blastocyst? Is that a living human being? There was an exchange between Senator Specter and the opponent of stem cell research, who raised the issue of experimentation on human beings in Nazi Germany. And Senator Specter said, "But those were living human beings." And the answer came right back, "This is a living human embryo. This is a living human being." I think that there is a line from Paul Ramsey that is so much to the point. This goes back several years, when cloning was first on the horizon as a theoretical possibility. He said this, "The good things that men do can be made complete only by the things they refuse to do." I think that is a great line. There are some moral lines. It is not for us to move the moral line in terms of the good consequences that we can get out of it. Consequentialism is a principle for tyrants, and it is tyrants over embryos and fetuses as well as born human beings. If you draw the line, then nothing is forbidden. The good things that men do can be made complete only by the things they refuse to do. So is it abortion politics? Well, I do not dismiss that. It is trying to hold onto the dignity of the human being from its beginning. The life of every human being begins at conception.

Now, there are alternatives to embryo stem cell research that have the same results. In Nature Magazine there was a feature article on stem cell research where both the ethical issues and the scientific issues were drawn up. There is more possibility or as much possibility from using adult stem cells as there is from embryonic stem cells. And in the case of a particular adult, there is no rejection possible in terms of cells from his or her own body. Well, we really need to not think we are shut into all these horrors of nobody will be able to help; it is moving the research in another direction, putting federal funding into adult stem cell research. I think it is a significant issue. You might say, if we allow abortion on demand, is there any point in trying to hold on to the dignity of the embryo and not using human embryos for research purposes? Well, I think that there is. I think that there is a great deal of interest in that.

Especially disturbing is the consequentialist ethic that the end justifies the means, in which all of this progress and all of this good that can be done overcomes any scruples. You feel the pull of that, do you not? But if God has forbidden it, there are other ways to approach doing good in these same areas. Well, not to make it dependent upon this research, but how murky it becomes in future times because it is hard to separate out in the future what has come from where. So we may face some hard questions later on.

You might ask about moral reservations with using the knowledge that is attained from embryonic stem cell research. It is troubling. I am not sure what to do with it. Once it is there and is common knowledge, the source of it was evil, but knowledge is knowledge, and I am not sure what to think about that. So it is a good question. Resist participating in it while it is still in its experimental stage, which in effect encourages it being done. At some point the question may become moot. How can you separate out what went into research? That may be impossible to do, and so I do not really have a firm position on that.

My topic was respect for nascent human life. That is the rationale for keeping abreast of where we are going as a society with experimentation on human beings, for now at the embryonic stage. If we can move the line, then we can move the line further along. Is the line ours to move, and what is the status of that living being in the womb, or now in vitro?

We need to move on to what is the sixth major heading, which I am going to call "Respect for the Natural End of Human Life." And I am underscoring natural there on the basis of biblical passages such as Psalm 90:10. "Days of his years are three score and ten; if they be 80 years, it is with sorrow." Not many people at present live past a hundred. Now there is another area of research developing that promises open-ended aging. We need to look at that, too. Ecclesiastes 3:2 is another one of those texts. In a fallen world, "there is a time to be born and a time to die." And I think we may paraphrase that, there is a time to resist death and there is a time to cease resisting. And what that time is is a matter for discernment. So this subject deals with respect for the natural end of human life, knowing when to resist death, and knowing when it is time to cease resisting.

The PCA Heroic Measures report lists five biblical principles. I just want to list them. The first is God is sovereign over human life. You would expect us to begin there as Presbyterians, but it is an important point. Interact with it. Second, physical death is a relative evil. It is spiritual death that is the absolute evil. Physical death is a relative evil. We may give up our lives for the sake of the Gospel, for example. Third, life is to be lived to its full extent to the glory of God. We use Philippians there where Paul, even with the passage where it says, "to depart and be with Christ is far better," yet lives to the full in terms of his calling before God. Number four says life is not to be abandoned on account of suffering. Our text there is Jesus' word to Peter at the end of the Gospel of John. And Jesus says to him, "Follow me." When you are old, Jesus says to Peter, somebody else will dress you and take you where you do not want to go, and you follow me. He was talking about the kind of death Peter would die. Now, what people fear is not so much pain as it is loss of control. That comes out again and again in these studies, but pain we know can be controlled. People do not fear pain so much as they fear being dependent on somebody else. Nobody wants other people to change their diapers at the end of life. That is what people do not like: to have that loss of autonomy, to be dependent. Especially in the United States, we have that strong independence that works against us. We do not want to suffer in being a burden on anybody. And Jesus says, "Follow me." He determines how we may glorify God through our death. And being recipients of the service of others, as well as the will in giving of it in terms of our ministry here, is part of God's plan. It is part of God's purpose in a fallen world. Then the fifth point is that eminent death is to be met with realism and readiness, and we use the patriarchs there. They are ages from us and technology, but the recognition that death is near, with final ministry to family and so forth, is appropriate. Frances Schaeffer is our model there. In the last stages of his life, he made that tour to promote the film How Shall We Then Live, and the Mayo Clinic told Edith that he was going to have to come in and have more radical treatment in the hospital. And Schaeffer said, "Let me go home. It is time for me to die. Do not intervene." So he forewent the equipment that would have maintained him for a few more days in order to be at home in the circle of his family and friends, ministering and being ministered to. It is a legitimate decision biblically to say, "Do not intervene; it is time for me to die," and to recognize when that time comes that life is not just a mere length of days that we must extend as long as we possibly can using every technology and means that is available. Eminent death is to be met with realism and readiness.

Now, we need a definition of euthanasia. I am using a definition of euthanasia that was put out by the U.S. Roman Catholic bishops in 1996. Euthanasia is "an action or omission which of itself or by intention causes death in order to relieve suffering." Euthanasia comes from the Greek; it means "good death." It means easy death, relatively painless death. "Mercy killing" is what it really means, but the bishops are including in their definition an act of omission as morally culpable. So it is not simply mercy killing, but it is neglect, supposedly out of mercy, that would also fall under that definition. It is "an action or omission which of itself or by intention causes death in order to relieve suffering," or that is at least the ostensible reason.

We need to remember the Larger Catechism, questions 135 and 136, on the sixth commandment. The Larger Catechism treats it in terms of sins of commission and sins of omission. The sixth commandment is violated by sins of commission. You have heard these before: "All taking away of life of ourselves, or of others, except in case of public justice," -- rigorously controlled capital punishment -- "lawful war," -- just in both cause and conduct, as we expanded on that -- "or necessary defense," -- that is, eminent threat to innocent life. The sixth commandment is violated by all taking away of life of ourselves, or of others, except under those limited conditions, and sins of omission, which they defined as "neglecting or withdrawing the lawful and necessary means of preservation of life." That is a very carefully crafted phrase, and it is highly relevant to this moment in our thinking through of ethical issues. "Neglecting or withdrawing the lawful and necessary means of preservation of life" is a good phrase. All taking away is the sin of commission, but also there is neglecting or withdrawing the lawful and necessary means of preservation of life; that is the sin of omission.

When we come to terminal decision-making, that is, when death is eminent, I think we should distinguish three categories of decision. We should distinguish killing and neglect; both of those are morally wrong. The sin of commission is killing; the sin of omission, as the Larger Catechism defines it, is neglect. I think that there is a third category of non-intervention in the dying process that ought not to be confused with neglect, which is morally culpable omission. We need three categories of distinction between killing, an act of commission, neglect, which is a sin of omission, and a morally right decision not to intervene in the dying process. Putting to death is killing. The phrase "allowing to die" is not specific enough to make this distinction. "Allowing to die" could be culpable neglect. But "allowing to die" could mean non-intervention in the dying process as futile. I will talk about the criteria for non-intervention later, but it is a great advantage to the proponents of euthanasia to blur these distinctions and to talk about killing as active euthanasia and to bracket these other two as passive euthanasia. So morally just, morally appropriate non-intervention gets blurred in with culpable neglect. And the argument goes, since you approve non-intervention, passive euthanasia, why do you not approve active euthanasia? There is a very great rhetorical issue involved in how these terms are used, so be on guard and try to sort that out.

We need three categories, and the term "passive euthanasia" tends to blur that distinction when it is applied to non-intervention to create a favorable attitude toward euthanasia. That is my concern anyway. Take it and see what you can do with it. I am going to treat this under three major headings. The first heading is "Neonatal Neglect." Neonatal neglect refers to newborns. The neglect of handicapped newborns is what this is talking about. And there is a case on record that I think that is worth recalling, which is the case of Baby Doe. This was a case that goes back to 1982 in Bloomington, Indiana. A child born with Down syndrome and a deformed esophagus was allowed to die of starvation and dehydration. She was allowed to die of neglect. The esophagus could have been corrected by routine surgery. Had it not been for the Down syndrome, it would have been corrected. But the parents decided against treatment. They did not want a retarded child, and so Baby Doe was allowed to die only because she was a Down syndrome baby. Now, it turned out at that time that this was not that uncommon. We are not talking about situations with babies who are born dying, in which heroic measures are futile. An anencephalic baby, a baby who is born without a brain, is going to die after a few days. A baby with only a brain stem is not going to live, and so you make that child comfortable. We had a case in Florida, Baby Theresa, in which folks wanted her to be killed in order to provide organs for transplant. She is going to die anyway, so why not salvage these organs? You wait for her to die, they will deteriorate, and they will not be available for transplant. The consequentialist ethic was used. In that case, Florida held the line and would not allow her to be killed for body parts.

But we are talking about lives that can be saved and would be saved were there no handicap such as Down syndrome or spina bifida. But we learned at the time that it was common in the United States to withhold routine surgery and medical care from infants with Down syndrome for the explicit purpose of hastening death. That is a form of omission; that is euthanasia by omission. And it turned out that this was more common than we really noted. There was even a quality of life formula that was applied to infants to decide whether to treat them or not based on the idea of little or no hope for achieving meaningful humanhood. And Down syndrome is the classic case, although it is clear that Down syndrome babies grow up to be adults with great interaction, a blessing to their family for those who have had them. There was a program of neonatal neglect at Yale. They called it "management option." In the coverage of the Yale Medical School management option, Newsweek used the term "vegetables" in describing certain handicapped newborns who were allowed to die. They are just vegetables. That was not their intention, but that is how they characterized them. Well, this produced a response from Sandra Diamond. I will read you her response. "I will wager my entire root system and as much fertilizer as it would take to fill Yale University that you have never received a letter from a 'vegetable' before this one. But as much as I resent the term, I must confess that I fit the description of a 'vegetable' as defined in the article. Due to severe brain damage incurred at birth, I am unable to dress myself, toilet myself, or write. My secretary is writing this letter. Many thousands of dollars had to be spent on my rehabilitation and education in order for me to reach my present professional status as a counseling psychologist. My parents were also told 35 years ago that there was little or no hope of achieving meaningful humanhood for their daughter. She was afflicted with cerebral palsy. Have I reached humanhood? Compared with Drs. Duff and Campbell, I think I have surpassed it. Instead of changing the laws to make it legal to weed out us 'vegetables,' let us change the laws so we may receive quality medical care, education, and freedom to live as full and productive lives as our potentials allow." Now, that is a great letter, and you admire her spirit.

In 1995 the American College of ObGyn recommended Down syndrome screening for all pregnant women. Now, there is no cure for Down syndrome. Maybe they will soon find the gene like they have done for genetic screening in terms of the immune deficiency. They finally found that and two kids have been set free from the bubble. But that is the only one so far. But what this screening means usually is a death sentence for the Down syndrome fetus. Amniocentesis is $1000, and a Down syndrome baby in the first year of life is $100,000. Now you can see how HMOs regard this. We have a problem. We have to think about what we have to do with healthcare.

Following the publicity of the Baby Doe case, President Reagan ordered the Secretary of the Department of Health and Human Services to apply section 504 of the Rehabilitation Act of 1973 to handicapped infants. The Act prohibits discrimination against the handicapped under any program receiving federal aid. Well, that got contested in the courts. The Second Circuit Court decided against the administration, and I quote from the dissent: "A judgment not to perform certain surgery because a person is black is not a bona fide medical judgment; so too, as not to correct a life-threatening digestive problem because an infant has Down syndrome is not a bona fide medical judgment." So Congress then amended the Child Abuse Prevention and Treatment Act to make explicit that withholding medically indicated treatment from disabled infants with life threatening conditions is included in the definition of child abuse and neglect. This is the way to get it. There is all this uproar about child abuse. I am not depreciating that, but this is a form of child abuse.

I really bring this out because of the opposition that that move received from Peter Singer, now at Princeton University. He opposed bringing newborns under the Child Abuse Prevention and Treatment Act. He wrote this at the time, "Society cannot coherently hold that it is all right to kill a fetus a week before birth, but as soon as the baby is born, everything must be done to keep it alive." Well, that is true. That is incoherent, although we do not exactly say it is all right to kill a fetus. We say that a woman may make that choice, so I think you know practically that we are saying it is all right. So according to Singer, since we cannot coherently hold that it is all right to kill a fetus before birth and as soon as the baby is born we do everything to keep it alive, the solution is to abandon the idea that all human life is of equal worth. The reasoning behind that is that the equal worth of human life is sectarian. It is a Christian conviction that you are imposing upon the society at large. You see how his argument moves? You have separation of church and state. You get all the big guns in on an issue like this and claim that it is a sectarian view. "Well, that view has been influenced by Christianity." The question is whether it is right, but it is true that the equal worth of human beings is Judeo-Christian tradition. But the question is not whether it is sectarian, but whether it is true, whether that is the way human lives ought to be taught.

I use this neonatal neglect issue because Singer is now going beyond what he said then. At the time, it was to allow them to die. But actually, would it not be more merciful to painlessly kill them? Letting them just starve to death does not seem to be merciful. Would it not be more merciful just to kill them? Well, if you agree that they can be neglected to death, how much difference is there between it being a sin of omission and a sin of commission? It is the same murderous assault on innocent human life. But I would hope that we would rethink neglect and that we would rethink abortion. What is the difference one week before birth and a week after birth? The infant is breathing on his own. Is the key significant event when the baby takes air into its lungs? Oxygen has been doing all those other things via the blood of the mother. What is it that makes the difference there? But as I mentioned before, in terms of the way in which the human being is not regarded as a person in the womb, it is the same after birth as before. If we define human beings in terms of functioning humanhood, then we lose protection for innocent infant life as well as in the womb.

You might ask if non-intervention is not just another form of medical neglect. The most controversial question in that area is giving food as assisted nutrition and hydration in medical intervention. I may have to delay this until the next session, but for factual information you can read the article "Do Dying Patients Really Need I.V. Fluids." It is written by a nurse who has the technical information on what actually goes on in the dying process and what we need. When I served on the Heroic Measures committee of the PCA, I went in with a different view. But there were ruling elders on the committee who were medical doctors and they had the facts. And sometimes, it is counter-productive to try to feed a dying person. The body shuts down, it cannot metabolize, and you are hurting them by trying to force feed them. The same is true with hydration. There is a reason to turn off machines, and that is why I say we need three categories of decision-making, and non-intervention is the third. So we are coming to that. I feel concern because in this area that is the thing that I have most been asked, in terms of pastoral questions. People in our circles are not contemplating assisted suicide. I think that is a social issue. But they do want to know whether it is a sin of omission, whether the Larger Catechism's "withholding the necessary means of the preservation of life" means turning off that respirator. Is air not necessary? Is oxygen not necessary? That is a good question.

My second main heading is "Physician-Assisted Suicide." There is an article from the Hastings Center report promoting autonomy, or medicalizing suicide. I think it is a very good analysis of a cultural trend that affects this question. Let me just highlight a couple of things, and then you can work through this. It says, "Incontestably from a certain perspective, physician-assisted suicide is a dramatic expression of autonomy, empowerment, self-determination, and the like. The contemporary debate about death and dying has shifted focus from medical norms to individual rights, choices, and desires" -- a shift from outer codes to inner individuals. Then it says, "Yet there is a paradox underlying physician-assisted suicide. It is conceived of as an intimate existential act, indeed, a response to modern medicine. But at the same time, it is a request for the complicity of physicians and society." This is not just an individual's choice, this is asking for complicity of the medical profession and society, so that "in contemporary Western society the decision to take death in one's own hands is construed as an act that is not simply personal, private, and solitary, but contrary to social norms and expectations. From a societal perspective, the individual who commits or attempts suicide is in this sense an outsider. What seems unusual in the debate about aid and dying is the request for public endorsement and legitimization of the act of suicide." The cultural trend for autonomy has overridden the right of society, or has overridden social norms. So we are in a total individualistic frame of mind. Whose life is it anyway? Well, it is my life. Society has an interest in the life of all of its citizens. I think that first of all what we think about suicide is the key issue. The civil law does not make suicide a crime in the United States, and that is also true in Great Britain. The Suicide Act of 1961 in Britain decriminalized suicide -- in Britain you can do this all at once; in the United States it is state by state -- but at the same time it made aiding or abetting the suicide of another a crime punishable by up to 14 years.

Let me give you some figures on where we are in terms of the United States and assisted suicide. By the way, to decriminalize suicide was not approval of suicide; it was only recognition that it only penalizes the family. And because most suicides are so shaded with depression, it was a criminal approach to what the medical and psychological problems are. So it was not an appropriate area for the civil law to try to criminalize. But with assisted suicide, 35 states explicitly criminalized assisted suicide. The latest of those is Michigan, trying to get Dr. Kevorkian. In 1999 they finally passed the assisted-suicide law. Nine states criminalize it through common law, not with an explicit statute, but through common law. So that is 35 plus 9. Of the rest of the states, there is only one that explicitly permits physician-assisted suicide, and that is Oregon, since 1977. So you have ambiguity in about five states and one state with explicit permission.

If you follow the Oregon reports, it is distressing. The safeguards just do not work. What you get is doctor shopping. This example was reported in the Weekly Standard, and it comes out of Oregon. A daughter took her mother to get permission for physician-assisted suicide. They went first to a psychiatrist, and he would not give permission, because it was not so clear to him that it was really what her mother wanted. So she shopped for another doctor and went this time to a psychologist. And after he did not at first feel that it warranted assisted suicide either, it ended up that someone in his office made the final decision. The final decision was left to an ethicist administrator, and he interviewed Katie who told him she wanted the pills not because she was in irremediable pain, but because she feared not being able to attend to her personal hygiene. And he gave the okay for assisted killing. Once you have this in the law, you create permission for it. You even create an expectation for it. In a culture where people do not want to be a burden on somebody else, here is a law that is safe and legal. We should not think that this enhances patient autonomy; this is putting pressure on folks to take that option. Once you have the option in law, you create a situation in which it becomes an expectation.

Derek Humphrey is the Hemlock Society head who wrote The Final Exit. He writes in his more recent book, Freedom to Die, and asks the question thus: "Is there in fact a duty to die, a responsibility within the family unit that should remain voluntary but expected nevertheless?" Now, just let that sink into your brain. "Voluntary but expected nevertheless." How voluntary is it? You do not want to be a burden. The safeguards do not work. I think that assisted suicide is the first step in an inevitable process toward voluntary euthanasia. I think it is inevitable for this reason. If you concede that a person has the right to physician-assisted death, then it actually makes more sense and it is more humane to let the physician do the injection. If you are relying on pills, you can spill the pills, you can vomit them up, it takes time, and it is stressful on all concerned. In fact, I think physician-assisted suicide is a stop-gap measure, because voluntary euthanasia would not pass the referendum. But it is inevitable. It is an inevitable next step, and it happened in the Netherlands. But it is inherent in creating the problem. It is actually more pro-life to have voluntary euthanasia, because you have to take those pills before you get too sick to take them yourself. Why not wait until I lapse into a coma and then have the doctor inject me? I have expressed my wishes. I cannot argue against that, if I have argued for physician-assisted suicide, so I think it is all the more reason for us to oppose it. And I will have to say something more about that in the next session and not get it confused with the third area, which is non-treatment, when it is right to reject or refuse medical intervention.

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