Other People’s Lives- Reflections on Medicine, Ethics, and Euthanasi

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Other People’s Lives:Reflections on Medicine,Ethics, and Euthanasia

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

Part Two: Medicine Versus Euthanasia

Chapter XXI. The Philosophy of Euthanasia

“Use logic to overcome the scruple.”245

Francois Mauriac

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

• Hopelessly ill people who in the end will have to die in unbearable pain,wish to be freed from a life that has become a burden to them. Theyshould not be compelled against their will to endure their meaninglesssuffering. Medical progress can now extend the lives of the gravely ill;in doing so, the doctors are guided by technical considerations, withoutregard for the human aspect of such interventions. As a result, peopleare condemned to an unbearable life and to a death unworthy of humanbeings.

• Another important factor is the aging of the population, the prevalenceof disabling infirmities inherent in old age, and the proliferation of

Chapters XXI through XXIII of Other People’s Lives: Reflections on Medicine, Ethics,*

and Euthanasia by Richard Fenigsen, also published sub. nom. Przysiega Hipokratesa [TheHippocratic Oath] by Ryszard Fenigsen (Polish, 2010). Dr. Fenigsen is a retired cardiologist,Willem-Alexander Hospital, ‘s-Hertogenbosch, the Netherlands; M.D., University of LodzMedical School (Poland), 1951; Ph.D., Medical Academy, Lodz, 1959. Chapters I and II werepublished in the Spring 2008 edition, 23 ISSUES IN LAW & MED. 281 (2008); Chapters III, IV,and V were published in the Fall 2008 edition, 24 ISSUES IN LAW & MED. 149 (2008); ChaptersVI, VII, and VIII were published in the Spring 2009 edition, 24 ISSUES IN LAW & MED. 221(2009); Chapters IX - XII were published in the Summer 2009 edition, 25 ISSUES IN LAW &MED. 45 (2009); Chapters XIII and XIV were published in the Fall 2009 edition, 25 ISSUES IN

LAW & MED. 169 (2009); and Chapters XV - XX were published in the Summer 2010 edition,26 ISSUES IN LAW & MED. 33 (2010).

FRANCOIS MAURIAC, LA PHARISIENNE 112 (Grasset, Paris 1972).245

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Issues in Law & Medicine, Volume 26, Number 3, 2011240

nursing homes and institutions for chronically ill residents, who are cutoff from their families, isolated from the rest of society, and who havelost faith in the meaning of their lives.

• And let’s not forget the terrible scourge of Alzheimer’s disease. “Do anyof us want to end out lives with the paralyzing fear and anxiety and thecomplete loss of one’s mental faculties? Do any of us want our spouseto spend ten long, lonely years after losing all real contact with a lifetimepartner?” asks a proponent of death by own choice.246

• Like every important social problem, this one can and should be solvedby society. We have achieved freedom of belief and expression. Allproblems can now be discussed, all taboos can be shaken and outdateddogmas doubted. The old taboo on killing is at odds with compassionand a truly humane attitude. Suffering people desire to put an end totheir lives. The rational autonomous beings’ right to make such adecision should be recognized as a fundamental human right.

• However, the extremely painful problem of unnecessary humansuffering cannot always be solved by the victims’ conscious andvoluntary decision. By rigidly adhering to the voluntary principle wedeprive infants who are severely disabled and people who are dementedor comatose of the chance for a painless death. A number of247

comatose persons are being kept alive by artificial means, at great effortand expense, and to the despair of their families. Caregivers do not dareto make a decision and cut short these lives. But to keep a comatoseperson alive is also a decision and the one who makes such decisionshould be obliged to justify it.248

• Steps should be taken to avoid errors and abuses. The patient’s familiesshould be involved in the decision. The carrying out of euthanasia andassisting patients in suicides must be entrusted to doctors. Theconclusion that the patient’s condition is hopeless should be confirmed

G. Bachrach, Death with Dignity, BOSTON GLOBE, June 14, 2004.246

J. Fletcher, Ethics and Euthanasia, in TO LIVE AND TO DIE: WHEN, WHY, AND HOW247

113-22, and in particular 118 (R.H. Williams, ed., Springer Verlag, New York, Heidelberg,&Berlin 1973);The “Right” to Live and the “Right” to Die, in BENEFICENT EUTHANASIA 44-53 (M.Kohl, ed., 1975); G. Tindall, It’s My Life and I’ll Die If I Want To, THE INDEPENDENT (London),Sept. 18, 1987; and Hoofdbestuur KNMG, Reactie op vragen van de StaatscommissieEuthanasie [The Board of the Royal Dutch Society of Medicine, Answers to the QuestionsAsked by the State Committee on Euthanasia], MEDISCH CONTACT (Official Sec.), Aug. 3, 1984,at 1002.

A. van den Akker, Hoe lang moet sterven duren [How Long Must It Take to Die?],248

BRABANTS DAGBLAD, Feb. 25, 1985 (Interview of Gerard Stinissen, the husband of a comatosewoman).

Other People’s Lives: Reflections on Medicine, Ethics, and Euthanasia 241

by a committee or at least another doctor. Physicians who carry outeuthanasia or assist their patients in committing suicide should proceedwith due care.

While appealing to noble emotions, the argument of the proponents ofeuthanasia also makes a logical, cogent impression. But assertions that entailirreversible consequences for human life must be supported by irrefutableproof. Thus, all elements in the narrative and all assumptions in thereasoning of the advocates of euthanasia, or assisted suicide, ought to bemeticulously examined.

The Abolition of All Taboos. The overthrowing of taboos occursselectively. Perhaps it is worth reflecting on the fact that society offered littleresistance in defending the inviolability of human life while still defendingwith great force the taboo on private property. Not only have we maintainedcertain old taboos, but we also have created new ones, like the inviolate rightof growing and grown children to live their own lives without the restrainingintervention of parents and without concern for them. When Dr. P killed hermother at her request in a home for the chronically ill (the Leeuwaardentrial, 1973), she was reproached in a letter to the editor of Time Magazine:“probably taking the mother home would have solved the problem, but thisdid not occur to Mrs. P.” Indeed it did not. Killing her mother was anacceptable solution, but disturbing her own well-ordered life was not. In Dr.P’s eyes, the taboo on killing had already been abolished, but the taboo onprivacy was binding. The issue of abolition of taboos would not seem torequire further commentary.

All Problems Are Solvable and Every Important Problem Should BeSolved by Society. This is the basic idea and point of departure for the pro-euthanasia movement. It is an expression of the triumphant self-confidenceof Western industrialized society which has succeeded in solving so manyproblems. We produce great wealth, we have created a government of lawand order and a pluralistic, tolerant community; we are approaching theideal of peaceful and free life for all citizens. If there are problems, they canalways be solved providing there is a genuine will to solve them. If someminority is being discriminated against, we will enforce the appropriate lawsand launch an educational campaign. We will set up special classes forchildren having difficulties with learning. When ice damages the highways,we will repair them. There are no unsolvable problems, only problemsawaiting a solution, for example, that people must suffer and then die. Thetime has come to solve this problem, and it can be done.

But it cannot be done. The notion that all problems are solvable is quiteobviously at variance with the truth. It denies the sad reality and man’sinevitable tragedy. It is man’s fate on this earth to be born, to strive, tostruggle, to hope, and in the end, to be disappointed in all he sought, tosuffer defeat in every battle, to lose those he loved, to be conscious of the



nursing homes and institutions for chronically ill residents, who are cutoff from their families, isolated from the rest of society, and who havelost faith in the meaning of their lives.

• And let’s not forget the terrible scourge of Alzheimer’s disease. “Do anyof us want to end out lives with the paralyzing fear and anxiety and thecomplete loss of one’s mental faculties? Do any of us want our spouseto spend ten long, lonely years after losing all real contact with a lifetimepartner?” asks a proponent of death by own choice.246

• Like every important social problem, this one can and should be solvedby society. We have achieved freedom of belief and expression. Allproblems can now be discussed, all taboos can be shaken and outdateddogmas doubted. The old taboo on killing is at odds with compassionand a truly humane attitude. Suffering people desire to put an end totheir lives. The rational autonomous beings’ right to make such adecision should be recognized as a fundamental human right.

• However, the extremely painful problem of unnecessary humansuffering cannot always be solved by the victims’ conscious andvoluntary decision. By rigidly adhering to the voluntary principle wedeprive infants who are severely disabled and people who are dementedor comatose of the chance for a painless death. A number of247

comatose persons are being kept alive by artificial means, at great effortand expense, and to the despair of their families. Caregivers do not dareto make a decision and cut short these lives. But to keep a comatoseperson alive is also a decision and the one who makes such decisionshould be obliged to justify it.248

• Steps should be taken to avoid errors and abuses. The patient’s familiesshould be involved in the decision. The carrying out of euthanasia andassisting patients in suicides must be entrusted to doctors. Theconclusion that the patient’s condition is hopeless should be confirmed

G. Bachrach, Death with Dignity, BOSTON GLOBE, June 14, 2004.246

J. Fletcher, Ethics and Euthanasia, in TO LIVE AND TO DIE: WHEN, WHY, AND HOW247

113-22, and in particular 118 (R.H. Williams, ed., Springer Verlag, New York, Heidelberg,&Berlin 1973);The “Right” to Live and the “Right” to Die, in BENEFICENT EUTHANASIA 44-53 (M.Kohl, ed., 1975); G. Tindall, It’s My Life and I’ll Die If I Want To, THE INDEPENDENT (London),Sept. 18, 1987; and Hoofdbestuur KNMG, Reactie op vragen van de StaatscommissieEuthanasie [The Board of the Royal Dutch Society of Medicine, Answers to the QuestionsAsked by the State Committee on Euthanasia], MEDISCH CONTACT (Official Sec.), Aug. 3, 1984,at 1002.

A. van den Akker, Hoe lang moet sterven duren [How Long Must It Take to Die?],248

BRABANTS DAGBLAD, Feb. 25, 1985 (Interview of Gerard Stinissen, the husband of a comatosewoman).


by a committee or at least another doctor. Physicians who carry outeuthanasia or assist their patients in committing suicide should proceedwith due care.

While appealing to noble emotions, the argument of the proponents ofeuthanasia also makes a logical, cogent impression. But assertions that entailirreversible consequences for human life must be supported by irrefutableproof. Thus, all elements in the narrative and all assumptions in thereasoning of the advocates of euthanasia, or assisted suicide, ought to bemeticulously examined.

The Abolition of All Taboos. The overthrowing of taboos occursselectively. Perhaps it is worth reflecting on the fact that society offered littleresistance in defending the inviolability of human life while still defendingwith great force the taboo on private property. Not only have we maintainedcertain old taboos, but we also have created new ones, like the inviolate rightof growing and grown children to live their own lives without the restrainingintervention of parents and without concern for them. When Dr. P killed hermother at her request in a home for the chronically ill (the Leeuwaardentrial, 1973), she was reproached in a letter to the editor of Time Magazine:“probably taking the mother home would have solved the problem, but thisdid not occur to Mrs. P.” Indeed it did not. Killing her mother was anacceptable solution, but disturbing her own well-ordered life was not. In Dr.P’s eyes, the taboo on killing had already been abolished, but the taboo onprivacy was binding. The issue of abolition of taboos would not seem torequire further commentary.

All Problems Are Solvable and Every Important Problem Should BeSolved by Society. This is the basic idea and point of departure for the pro-euthanasia movement. It is an expression of the triumphant self-confidenceof Western industrialized society which has succeeded in solving so manyproblems. We produce great wealth, we have created a government of lawand order and a pluralistic, tolerant community; we are approaching theideal of peaceful and free life for all citizens. If there are problems, they canalways be solved providing there is a genuine will to solve them. If someminority is being discriminated against, we will enforce the appropriate lawsand launch an educational campaign. We will set up special classes forchildren having difficulties with learning. When ice damages the highways,we will repair them. There are no unsolvable problems, only problemsawaiting a solution, for example, that people must suffer and then die. Thetime has come to solve this problem, and it can be done.

But it cannot be done. The notion that all problems are solvable is quiteobviously at variance with the truth. It denies the sad reality and man’sinevitable tragedy. It is man’s fate on this earth to be born, to strive, tostruggle, to hope, and in the end, to be disappointed in all he sought, tosuffer defeat in every battle, to lose those he loved, to be conscious of the



inevitability of death, to suffer and to die; this is a tragic fate and onewithout a solution. We can solve many problems, but not the ultimate ones.

The “solution” proposed by the pro-euthanasia movement is obviouslya sham. We can blow up a ship that is taking on water, but we cannot assertthat thereby we have solved the problem of leakage. No problem is solved bydestroying the thing involved.

Institutions for the Elderly and the Chronically Ill. These institutionshave been created due to a great demand, are maintained at high financialcost, and perform a very useful function. On the other hand, the negativeaspects of these institutions are also evident. Some people, isolated in aninstitution, lapse into depression and may even think of hastening their owndeath. But to use this argument to justify euthanasia is logically (not tomention morally) inadmissable. Institutions for the ill and aged are notnatural disasters to which, with all their consequences, we must resignourselves. These institutions are the result of our own deliberate actions. They were created as places where the elderly can live. Had our effortsproduced only the opposite result, leading to people asking for death, thenthe logical conclusion would have been to close the institutions, not to killthe residents.

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

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

Keeping the Sick Artificially Alive with Modern Technology. Theallegation that it is modern technology that produces the demand forvoluntary euthanasia can hardly be substantiated. In Holland, in themajority of cases, euthanasia is performed by family physicians, at patients’homes, on patients treated without any special techniques. Hospital patientswho are conscious and tired of treatment and all the machines, have theright to refuse treatment, and have always had this right and exerted it. If thepatient is unconscious there in no question of “voluntary” euthanasia.

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

And let’s note that the allegations of senseless prolonging life throughuse of modern technology were already made in 19 century: In 1875, Ernstth

Haeckel wrote about “improved modern medicine” which supposedly was


not permitting “those unworthy of life” to die, and in 1899, Baldwin249

accused “subcutaneous injections, transfusions and intravenous infusions”of allowing medicine “to keep us from the grave in a state of constantstruggle for life.” And yet at that time the ability of medicine to prolong250

human life was almost nil. Thus, to use the “modern technology” argumentit is not necessary for somebody’s life to be prolonged, or even for any suchtechnology to exist.

Death Unworthy of a Human Being. The fate of people who die afterlong suffering is decried as “unworthy of a human being.” A value judgment,of course, but one worth reflecting on. Death, after a short, long, or veryprotracted illness and suffering, is not an invention of modern medicine, itwas always the sad fate of many people. Victims of plague pneumonia diedin few days, but patients in congestive heart failure dragged on for a coupleof years, breathless and on swollen legs, and soldiers with abdominalwounds sometimes took months to die. To believe the advocates ofeuthanasia, the majority of our predecessors on this planet, hundreds ofmillions of human beings, Mozart, Goethe, and Einstein, my grandfatherand your grandmother, all died a death unworthy of a human being. It wasnot their privilege to die in a way worthy of a human being, that is ourdiscovery alone: to be put to death by a professional. The use of the “deathunworthy of a human being” argument is a display of considerable arro-gance, and an insult to our ancestors, and to mankind’s entire past.

Meaningless Suffering. Does suffering have meaning? Various answerscan be given that question depending on the way the issue is formulated. Towit, it may be formulated from the point of view of religion, biology, or froman anthropocentric standpoint. Dualistic religions consider evil (and humansuffering) to be on an equal footing with the good in the universe, whereasmonotheistic religions assume that evil and suffering have a meaning whichcannot be understood by man, but is clear to God. The latter construct isnecessary to reconcile the existence of evil and suffering with a beneficentand omnipotent God, and thus is useful to those who have the good fortuneto believe in such God. The theorists of euthanasia leave both of thesereligious concepts of suffering out of consideration, for which the presentauthor will not reproach them.

From the biological standpoint, the suffering and the pain are meaning-ful in so far as they elicit reactions that tend to reduce the injury, i.e.,favoring a broken limb, the reflex to raise from supine posture when thereis congestion of the lungs, etc. These reactions are expressions of adaptationto the external world, an adaptation of a high degree, formed during theevolution of the species. The biological role of pain is demonstrated by

ERNST HAECKEL, NATÜRLICHE SCHÖPFUNGSGESCHICHTE 154 [The Natural History of249

Creation] (6 ed., Georg Reimer Verlag, Berlin 1875).th

E. Baldwin, The Natural Right to a Natural Death, 1 ST. PAUL MED. J. 877 (1899). 250



inevitability of death, to suffer and to die; this is a tragic fate and onewithout a solution. We can solve many problems, but not the ultimate ones.

The “solution” proposed by the pro-euthanasia movement is obviouslya sham. We can blow up a ship that is taking on water, but we cannot assertthat thereby we have solved the problem of leakage. No problem is solved bydestroying the thing involved.

Institutions for the Elderly and the Chronically Ill. These institutionshave been created due to a great demand, are maintained at high financialcost, and perform a very useful function. On the other hand, the negativeaspects of these institutions are also evident. Some people, isolated in aninstitution, lapse into depression and may even think of hastening their owndeath. But to use this argument to justify euthanasia is logically (not tomention morally) inadmissable. Institutions for the ill and aged are notnatural disasters to which, with all their consequences, we must resignourselves. These institutions are the result of our own deliberate actions. They were created as places where the elderly can live. Had our effortsproduced only the opposite result, leading to people asking for death, thenthe logical conclusion would have been to close the institutions, not to killthe residents.

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

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

Keeping the Sick Artificially Alive with Modern Technology. Theallegation that it is modern technology that produces the demand forvoluntary euthanasia can hardly be substantiated. In Holland, in themajority of cases, euthanasia is performed by family physicians, at patients’homes, on patients treated without any special techniques. Hospital patientswho are conscious and tired of treatment and all the machines, have theright to refuse treatment, and have always had this right and exerted it. If thepatient is unconscious there in no question of “voluntary” euthanasia.

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

And let’s note that the allegations of senseless prolonging life throughuse of modern technology were already made in 19 century: In 1875, Ernstth

Haeckel wrote about “improved modern medicine” which supposedly was


not permitting “those unworthy of life” to die, and in 1899, Baldwin249

accused “subcutaneous injections, transfusions and intravenous infusions”of allowing medicine “to keep us from the grave in a state of constantstruggle for life.” And yet at that time the ability of medicine to prolong250

human life was almost nil. Thus, to use the “modern technology” argumentit is not necessary for somebody’s life to be prolonged, or even for any suchtechnology to exist.

Death Unworthy of a Human Being. The fate of people who die afterlong suffering is decried as “unworthy of a human being.” A value judgment,of course, but one worth reflecting on. Death, after a short, long, or veryprotracted illness and suffering, is not an invention of modern medicine, itwas always the sad fate of many people. Victims of plague pneumonia diedin few days, but patients in congestive heart failure dragged on for a coupleof years, breathless and on swollen legs, and soldiers with abdominalwounds sometimes took months to die. To believe the advocates ofeuthanasia, the majority of our predecessors on this planet, hundreds ofmillions of human beings, Mozart, Goethe, and Einstein, my grandfatherand your grandmother, all died a death unworthy of a human being. It wasnot their privilege to die in a way worthy of a human being, that is ourdiscovery alone: to be put to death by a professional. The use of the “deathunworthy of a human being” argument is a display of considerable arro-gance, and an insult to our ancestors, and to mankind’s entire past.

Meaningless Suffering. Does suffering have meaning? Various answerscan be given that question depending on the way the issue is formulated. Towit, it may be formulated from the point of view of religion, biology, or froman anthropocentric standpoint. Dualistic religions consider evil (and humansuffering) to be on an equal footing with the good in the universe, whereasmonotheistic religions assume that evil and suffering have a meaning whichcannot be understood by man, but is clear to God. The latter construct isnecessary to reconcile the existence of evil and suffering with a beneficentand omnipotent God, and thus is useful to those who have the good fortuneto believe in such God. The theorists of euthanasia leave both of thesereligious concepts of suffering out of consideration, for which the presentauthor will not reproach them.

From the biological standpoint, the suffering and the pain are meaning-ful in so far as they elicit reactions that tend to reduce the injury, i.e.,favoring a broken limb, the reflex to raise from supine posture when thereis congestion of the lungs, etc. These reactions are expressions of adaptationto the external world, an adaptation of a high degree, formed during theevolution of the species. The biological role of pain is demonstrated by

ERNST HAECKEL, NATÜRLICHE SCHÖPFUNGSGESCHICHTE 154 [The Natural History of249

Creation] (6 ed., Georg Reimer Verlag, Berlin 1875).th

E. Baldwin, The Natural Right to a Natural Death, 1 ST. PAUL MED. J. 877 (1899). 250



pathological conditions that deprive the patient of pain sensation, as forexample, syringomyelia or leprous neuropathy: unprotected by the ability tofeel pain, these patients are prone to severe injuries and burns. From thebiological point of view, suffering and, in particular, pain, become “meaning-less” (cease to be of use to the organism) when they overstep their functionsof warning, correcting, and reducing injury.

The idea of “meaningless suffering” as used by advocates of euthanasiacannot be reduced to the biological concept because it leads to consequencesfarther reaching than a biological reaction to suffering. The biologicalreaction to suffering contains no impulse to self-destruction.251

From the anthropocentric point of view (which I share with theproponents of euthanasia, though not their conclusions) suffering thatexceeds its biological function has no greater “meaning” than an earthquakeor other natural phenomena. The “meaning” of such suffering depends onhow we deal with it. Some people find their suffering a stimulus to creativity;thus Dostoyevsky exploited his epilepsy, Pascal his headaches, and VanGogh his mental illness. Others have been spiritually enriched by suffering. The following truth applies to everyone: when it is no longer possible to livewithout suffering, one will suffer in order to live. And that is the “meaning”of suffering: the price we pay for preserving the higher, singular, and uniquevalue: our lives.

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

But let us return to the concept of “meaningless suffering.” This is avalue judgment derived from the principle of utilitarianism (“man desires asmuch happiness and as little suffering as possible, and nothing else is worthdesiring”). I shall discuss this principle in the next chapter. Let us bypassthat and examine the role of the concept of “meaningless suffering” in theargument in favor of euthanasia. Let us compare the standpoint of an old-

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


fashioned person O who has never heard of euthanasia, with that of the“modern” individual M, who considers euthanasia a possible solution. Osays, “I hope that my suffering will pass and I’ll live a while yet.” M replies,“But your suffering may not abate, what then?” O says, “That would be verybad, but what can I do—I’ll have to go on suffering.” M replies, “That’s nottrue, your suffering is meaningless, I mean unnecessary, so there is no needfor you to go on suffering at all; you can accept euthanasia and be immedi-ately freed of suffering.” Thus, the concept of “meaningless suffering” findsapplication only when an end can be put to suffering, and to life, througheuthanasia. The entire line of reasoning proves to be a vicious circle. Thepossibility of euthanasia makes the suffering meaningless; in turn, we usethe concept of “meaningless suffering” to justify euthanasia. This is the well-known logical fallacy called circulus in probando. One may use the conceptof “meaningless suffering” to express one’s personal feelings, but not toprove anything.

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

But progress in these good works in recent decades has been accompa-nied by changes in the way sick people are dealt with, changes that haveexerted a perverse influence and have caused sick people to feel that theirsufferings are unbearable. I have in mind, first of all, the new way ofinforming the patients. This is the result of a new role that the public hasimposed on doctors and that some doctors have imposed on themselves: thedoctor is no longer a person who brings people help and solace, but is nowan “impartial expert.” This is an unfortunate change because no one reallywants or needs to be brought before an impartial medical judge, nor is adoctor really able to perform that new function. Luckily, the majority ofphysicians have kept some common sense and empathy with the patient; themajority still remember what medicine is about. Without these qualities, the



pathological conditions that deprive the patient of pain sensation, as forexample, syringomyelia or leprous neuropathy: unprotected by the ability tofeel pain, these patients are prone to severe injuries and burns. From thebiological point of view, suffering and, in particular, pain, become “meaning-less” (cease to be of use to the organism) when they overstep their functionsof warning, correcting, and reducing injury.

The idea of “meaningless suffering” as used by advocates of euthanasiacannot be reduced to the biological concept because it leads to consequencesfarther reaching than a biological reaction to suffering. The biologicalreaction to suffering contains no impulse to self-destruction.251

From the anthropocentric point of view (which I share with theproponents of euthanasia, though not their conclusions) suffering thatexceeds its biological function has no greater “meaning” than an earthquakeor other natural phenomena. The “meaning” of such suffering depends onhow we deal with it. Some people find their suffering a stimulus to creativity;thus Dostoyevsky exploited his epilepsy, Pascal his headaches, and VanGogh his mental illness. Others have been spiritually enriched by suffering. The following truth applies to everyone: when it is no longer possible to livewithout suffering, one will suffer in order to live. And that is the “meaning”of suffering: the price we pay for preserving the higher, singular, and uniquevalue: our lives.

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

But let us return to the concept of “meaningless suffering.” This is avalue judgment derived from the principle of utilitarianism (“man desires asmuch happiness and as little suffering as possible, and nothing else is worthdesiring”). I shall discuss this principle in the next chapter. Let us bypassthat and examine the role of the concept of “meaningless suffering” in theargument in favor of euthanasia. Let us compare the standpoint of an old-

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


fashioned person O who has never heard of euthanasia, with that of the“modern” individual M, who considers euthanasia a possible solution. Osays, “I hope that my suffering will pass and I’ll live a while yet.” M replies,“But your suffering may not abate, what then?” O says, “That would be verybad, but what can I do—I’ll have to go on suffering.” M replies, “That’s nottrue, your suffering is meaningless, I mean unnecessary, so there is no needfor you to go on suffering at all; you can accept euthanasia and be immedi-ately freed of suffering.” Thus, the concept of “meaningless suffering” findsapplication only when an end can be put to suffering, and to life, througheuthanasia. The entire line of reasoning proves to be a vicious circle. Thepossibility of euthanasia makes the suffering meaningless; in turn, we usethe concept of “meaningless suffering” to justify euthanasia. This is the well-known logical fallacy called circulus in probando. One may use the conceptof “meaningless suffering” to express one’s personal feelings, but not toprove anything.

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

But progress in these good works in recent decades has been accompa-nied by changes in the way sick people are dealt with, changes that haveexerted a perverse influence and have caused sick people to feel that theirsufferings are unbearable. I have in mind, first of all, the new way ofinforming the patients. This is the result of a new role that the public hasimposed on doctors and that some doctors have imposed on themselves: thedoctor is no longer a person who brings people help and solace, but is nowan “impartial expert.” This is an unfortunate change because no one reallywants or needs to be brought before an impartial medical judge, nor is adoctor really able to perform that new function. Luckily, the majority ofphysicians have kept some common sense and empathy with the patient; themajority still remember what medicine is about. Without these qualities, the



“impartial expert” becomes a true sower of misery. With a morose expres-sion, he informs the patient of his gloomy suspicions. When a patient252

asked me, “Doctor, how long can I live with this?” I answered, “How can Iknow? I don’t even know what will happen to me this evening. Let’s all tryto live as long as we can.” And this is more or less the answer given by mycolleagues, the “traditionally” educated doctors. And in answering this waywe are faithful to the truth because the fate of each of us is uncertain, and Ireally don’t know who will die first, my patient, a sick person, or I, thoughI seem healthy. And in answering this way we make the patient feel that heshares the common human fate with all of us, the common hope, and thecommon uncertainty. We do not exclude him from the human community.But in recent years I have seen patients who have been given a deathsentence, they have “another two months” or “another two weeks” to live. Aprediction of this kind can never be true, it can only come about through253

pure chance; but how is a person supposed to live while awaiting a fixed datefor execution? Fortunately, the patient usually maintains a bit of healthyskepticism, but the more he believes in the doctor’s expertise, the moreunbearable his life and, of course, every symptom becomes to him.

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

• Don’t tell him anything you yourself don’t know;• It is not your task to make this world crueler than it is; and• Don’t let yourself think you know the future; many patients with a bad prognosis have lived to attend his or her doctor’s funeral.

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

Before one begins to legally kill patients “upon their own request,” itwould make sense first to put a stop to doctors’ actions which drive patientsto consider suicide.

To present a gravely ill person with the prospect of an “easy death” is anact which directly intends that the patient begin to view his suffering asunbearable. People have an admirable ability to reconcile themselves toprotracted suffering. Stroke victims, dependent for years on help fromothers, are able to enjoy all the little pleasures of daily life, and beam withhappiness when visited by a grandchild. Patients who twenty years beforehad part of their intestine removed because of cancer, and have an artificialanus created on their abdomen, bravely empty the plastic bag containing

See subsec. entitled The Lethal Avalanche, 24 ISSUES IN LAW & MED. at 223-27252

(2009). See subsec. entitled The Oregon Law, in Ch. XXVIII (to be published in a future253

edition of Issues in Law & Medicine).


their own excrement a few times a day, and work, attend concerts, and arehappy in their marriages. There are patients who have had their larynxremoved, but who work in their garden and take an interest in everythingthat is happening in the world; to be able to speak, they adroitly put a fingeron the tracheostomy opening on their throat. What will-power andendurance these people must have, and renew it each morning! I have forthem the greatest admiration and respect. Who would dare to shake theirwillpower, sow doubt in their mind, force them to wonder if all that effortwas worth it, and tempt them to give up? And yet that is precisely what weare doing today, showing these people euthanasia as a possibility, as adesirable solution, and a brave, wise decision. We justify the need foreuthanasia referring to unbearable human suffering, while at the same timethe prospect of euthanasia causes people to view their suffering as unbear-able and instills in them the desire to be freed of it by death. We are in avicious circle once again.

Doctors and all people of good will should seek to relieve suffering, notexterminate the sufferers.

The Decision to Leave a Person Alive. The case of Mr. and Mrs. Sbecame well known in Holland because of press reports and TVbroadcasts. As a result of an error in anesthesia, Mrs. S had been in a254

coma for years. Her husband did not abandon her, visited her every threemonths, and had been very involved on her behalf. He had devoted all thoseyears to intense reflection, and many times had requested the doctors to putan end on her life. “No one wanted to make this kind of decision.” But—soreasoned Mr. S—to keep a comatose patient alive is also a decision, and onethat needs to be justified.

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

A Higher Necessity: Euthanasia an as Act Performed Under Con-straint. The theorists of euthanasia maintain that under certain circum-stances a doctor may decide to kill a person. The Dutch Supreme Court wentfarther: the high-ranking justices have acknowledged that under certain

Van den Akker, supra note 248.254



“impartial expert” becomes a true sower of misery. With a morose expres-sion, he informs the patient of his gloomy suspicions. When a patient252

asked me, “Doctor, how long can I live with this?” I answered, “How can Iknow? I don’t even know what will happen to me this evening. Let’s all tryto live as long as we can.” And this is more or less the answer given by mycolleagues, the “traditionally” educated doctors. And in answering this waywe are faithful to the truth because the fate of each of us is uncertain, and Ireally don’t know who will die first, my patient, a sick person, or I, thoughI seem healthy. And in answering this way we make the patient feel that heshares the common human fate with all of us, the common hope, and thecommon uncertainty. We do not exclude him from the human community.But in recent years I have seen patients who have been given a deathsentence, they have “another two months” or “another two weeks” to live. Aprediction of this kind can never be true, it can only come about through253

pure chance; but how is a person supposed to live while awaiting a fixed datefor execution? Fortunately, the patient usually maintains a bit of healthyskepticism, but the more he believes in the doctor’s expertise, the moreunbearable his life and, of course, every symptom becomes to him.

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

• Don’t tell him anything you yourself don’t know;• It is not your task to make this world crueler than it is; and• Don’t let yourself think you know the future; many patients with a bad prognosis have lived to attend his or her doctor’s funeral.

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

Before one begins to legally kill patients “upon their own request,” itwould make sense first to put a stop to doctors’ actions which drive patientsto consider suicide.

To present a gravely ill person with the prospect of an “easy death” is anact which directly intends that the patient begin to view his suffering asunbearable. People have an admirable ability to reconcile themselves toprotracted suffering. Stroke victims, dependent for years on help fromothers, are able to enjoy all the little pleasures of daily life, and beam withhappiness when visited by a grandchild. Patients who twenty years beforehad part of their intestine removed because of cancer, and have an artificialanus created on their abdomen, bravely empty the plastic bag containing

See subsec. entitled The Lethal Avalanche, 24 ISSUES IN LAW & MED. at 223-27252

(2009). See subsec. entitled The Oregon Law, in Ch. XXVIII (to be published in a future253

edition of Issues in Law & Medicine).


their own excrement a few times a day, and work, attend concerts, and arehappy in their marriages. There are patients who have had their larynxremoved, but who work in their garden and take an interest in everythingthat is happening in the world; to be able to speak, they adroitly put a fingeron the tracheostomy opening on their throat. What will-power andendurance these people must have, and renew it each morning! I have forthem the greatest admiration and respect. Who would dare to shake theirwillpower, sow doubt in their mind, force them to wonder if all that effortwas worth it, and tempt them to give up? And yet that is precisely what weare doing today, showing these people euthanasia as a possibility, as adesirable solution, and a brave, wise decision. We justify the need foreuthanasia referring to unbearable human suffering, while at the same timethe prospect of euthanasia causes people to view their suffering as unbear-able and instills in them the desire to be freed of it by death. We are in avicious circle once again.

Doctors and all people of good will should seek to relieve suffering, notexterminate the sufferers.

The Decision to Leave a Person Alive. The case of Mr. and Mrs. Sbecame well known in Holland because of press reports and TVbroadcasts. As a result of an error in anesthesia, Mrs. S had been in a254

coma for years. Her husband did not abandon her, visited her every threemonths, and had been very involved on her behalf. He had devoted all thoseyears to intense reflection, and many times had requested the doctors to putan end on her life. “No one wanted to make this kind of decision.” But—soreasoned Mr. S—to keep a comatose patient alive is also a decision, and onethat needs to be justified.

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

A Higher Necessity: Euthanasia an as Act Performed Under Con-straint. The theorists of euthanasia maintain that under certain circum-stances a doctor may decide to kill a person. The Dutch Supreme Court wentfarther: the high-ranking justices have acknowledged that under certain

Van den Akker, supra note 248.254



circumstances a doctor must kill his patient. This is when a conflict of255

duties occurs: on one hand, there is the doctor’s duty always to preserve life,and the law (art. 293 of Dutch Penal Code), which prohibits euthanasia; but,on the other hand, there is doctor’s duty toward his desperate patient whobegs to be delivered of his misery. It is in such situation of higher necessitythat doctors decide to carry out euthanasia. After several such rulings by theSupreme Court, a provision providing for “acting out of higher necessity”has been included in the official guidelines instructing doctors how to avoidprosecution (i.e., the “rules of careful conduct”).256

Higher necessity is not an independent and separate concept, butdepends on the actions that are considered admissible in a certain situation;actually it is an offshoot of these actions. Someone who has robbed a bankwill find it fruitless to plead that he acted out of higher necessity (his family’spoverty, impending bankruptcy), fruitless because his act—theft, bankrobbery—is considered absolutely inadmissable under any circumstanceswhatsoever. A doctor who kills a patient can only appeal to higher necessityif his action is a priori considered as possibly permissible. It is only the apriori acceptance of euthanasia which creates the “higher necessity”stipulated by the Supreme Court. Once again we find the vicious circle. “Higher necessity” is an argument based on a logical fallacy, circulus inprobando, and cannot be used to prove anything.

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

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

The Right to Self-Determination. The demand to recognize a person’sright to decide about his own life and death reflects the change in the valuesystem accepted by society. Traditional society considered human life thevalue worthy of highest protection and the life of every individual a value inwhich all other people had a share. The death of each person was a loss to allpeople; when any individual’s life was in danger, the intervention of allpeople was required; all other values, including freedom, must be subordi-nate to the defense of a person’s life (at least in peacetime). Thus, not only

H.J.J. Leenen, Euthanasie voor de Hoge Raad [Euthanasia (heard) at the Supreme 255

Court], 129 NED. TIJDSCHRIFT V. GENEESKUNDE 414, 414-17 (1985). Regelen met betrekking tot de hulpverlening door een geneskunde die zich beroept256

op overmacht bij levensbeeindiging op uitdrukkelijk en ernstig verlangen van een patient[Rules Concerning Assistance Rendered by a Physician Who Pleads Higher Necessity WhenTerminating the Life of a Patient Upon His Explicit and Serious Request], in Tweede KAMER

DER STATEN-GENERAAL, VERGADERJAAR 1987-1988, at 383 (Nos. 1-2, 20).


could no one take the life of another, but there also must be a limit on thefreedom of anyone who would put an end to his own life: forcible hospital-ization was justified in cases of mental illness that posed a danger of suicide. That social attitude and practice has not only been codified in law but isconsistent with the deep belief we all share and which is a natural reaction:everybody rushes to help at the sight of a clothed person preparing to jumpfrom a bridge into a river. “No man is an Iland, intire of itselfe,” wrote JohnDonne four hundred years ago, “every man is a peece of a Continent, a partof the maine; if a Clod be washed away by the Sea, Europe is the lesse . . . anyman’s death diminishes me, because I am involved in Mankinde.” There isno argument to justify this stance, and no need for one; whoever believes itis true can appeal to “the evidence of his heart.”257

Thus, the traditional view of the value of human life cannot be logicallyproven true. One can, however, apply logical analysis to point out fallaciesin the opposite position. The “permissive” society makes of freedom anabsolute value, placing it higher than human life: everyone should be free tocommit suicide and no one should interfere; a person should also be free toaid others in committing suicide, or to kill them at their own request.

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

Moreover, in making freedom an absolute value and placing it abovelife, still another and basic error in thinking is committed. Suicide andvoluntary euthanasia are not the realization, but the destruction, of aperson’s freedom. Only the living have freedoms. A corpse is utterly andforever devoid of all freedom.

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

The latter assertion is, however, untrue. Those who recognize the rightto self-determination recognize the right of each individual to decide whatwill happen to his own body, his own life. But assisted suicide or voluntaryeuthanasia includes more than that. Other people take part in carrying outthese acts: a doctor, often a nurse, and sometimes others. The right toassisted suicide or voluntary euthanasia (were we to recognize such right)would thus include not only the right to exert control over one’s own person,

“Evidence of one’s heart” is the phrase used by Polish philosopher Tadeusz257

Kotarbiñski to denote moral intuition.



circumstances a doctor must kill his patient. This is when a conflict of255

duties occurs: on one hand, there is the doctor’s duty always to preserve life,and the law (art. 293 of Dutch Penal Code), which prohibits euthanasia; but,on the other hand, there is doctor’s duty toward his desperate patient whobegs to be delivered of his misery. It is in such situation of higher necessitythat doctors decide to carry out euthanasia. After several such rulings by theSupreme Court, a provision providing for “acting out of higher necessity”has been included in the official guidelines instructing doctors how to avoidprosecution (i.e., the “rules of careful conduct”).256

Higher necessity is not an independent and separate concept, butdepends on the actions that are considered admissible in a certain situation;actually it is an offshoot of these actions. Someone who has robbed a bankwill find it fruitless to plead that he acted out of higher necessity (his family’spoverty, impending bankruptcy), fruitless because his act—theft, bankrobbery—is considered absolutely inadmissable under any circumstanceswhatsoever. A doctor who kills a patient can only appeal to higher necessityif his action is a priori considered as possibly permissible. It is only the apriori acceptance of euthanasia which creates the “higher necessity”stipulated by the Supreme Court. Once again we find the vicious circle. “Higher necessity” is an argument based on a logical fallacy, circulus inprobando, and cannot be used to prove anything.

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

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

The Right to Self-Determination. The demand to recognize a person’sright to decide about his own life and death reflects the change in the valuesystem accepted by society. Traditional society considered human life thevalue worthy of highest protection and the life of every individual a value inwhich all other people had a share. The death of each person was a loss to allpeople; when any individual’s life was in danger, the intervention of allpeople was required; all other values, including freedom, must be subordi-nate to the defense of a person’s life (at least in peacetime). Thus, not only

H.J.J. Leenen, Euthanasie voor de Hoge Raad [Euthanasia (heard) at the Supreme 255

Court], 129 NED. TIJDSCHRIFT V. GENEESKUNDE 414, 414-17 (1985). Regelen met betrekking tot de hulpverlening door een geneskunde die zich beroept256

op overmacht bij levensbeeindiging op uitdrukkelijk en ernstig verlangen van een patient[Rules Concerning Assistance Rendered by a Physician Who Pleads Higher Necessity WhenTerminating the Life of a Patient Upon His Explicit and Serious Request], in Tweede KAMER

DER STATEN-GENERAAL, VERGADERJAAR 1987-1988, at 383 (Nos. 1-2, 20).


could no one take the life of another, but there also must be a limit on thefreedom of anyone who would put an end to his own life: forcible hospital-ization was justified in cases of mental illness that posed a danger of suicide. That social attitude and practice has not only been codified in law but isconsistent with the deep belief we all share and which is a natural reaction:everybody rushes to help at the sight of a clothed person preparing to jumpfrom a bridge into a river. “No man is an Iland, intire of itselfe,” wrote JohnDonne four hundred years ago, “every man is a peece of a Continent, a partof the maine; if a Clod be washed away by the Sea, Europe is the lesse . . . anyman’s death diminishes me, because I am involved in Mankinde.” There isno argument to justify this stance, and no need for one; whoever believes itis true can appeal to “the evidence of his heart.”257

Thus, the traditional view of the value of human life cannot be logicallyproven true. One can, however, apply logical analysis to point out fallaciesin the opposite position. The “permissive” society makes of freedom anabsolute value, placing it higher than human life: everyone should be free tocommit suicide and no one should interfere; a person should also be free toaid others in committing suicide, or to kill them at their own request.

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

Moreover, in making freedom an absolute value and placing it abovelife, still another and basic error in thinking is committed. Suicide andvoluntary euthanasia are not the realization, but the destruction, of aperson’s freedom. Only the living have freedoms. A corpse is utterly andforever devoid of all freedom.

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

The latter assertion is, however, untrue. Those who recognize the rightto self-determination recognize the right of each individual to decide whatwill happen to his own body, his own life. But assisted suicide or voluntaryeuthanasia includes more than that. Other people take part in carrying outthese acts: a doctor, often a nurse, and sometimes others. The right toassisted suicide or voluntary euthanasia (were we to recognize such right)would thus include not only the right to exert control over one’s own person,

“Evidence of one’s heart” is the phrase used by Polish philosopher Tadeusz257

Kotarbiñski to denote moral intuition.



but over other persons as well, their acts and their conscience. The persondeciding on his own death would also have the right to make killers of thedoctor and the nurse, and to make others accomplices to the killing. Hewould have the right to compel society to renounce the principle ofinviolability of human life, to destroy the barrier protecting the life of eachperson. The right to assisted suicide or voluntary euthanasia is thus notidentical with the right to self-determination, but is broader in content. It isnot true that anyone who accepts a person’s right to self-determination eoipso accepts the right to voluntary euthanasia. This is the first reason whythe pro-euthanasia movement cannot invoke the right to self-determinationas an argument.

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

On the other hand, no mention is made of targeted individuals’ right toself-determination when American and British proponents of mercy killingcall for compulsory non-voluntary “euthanasia” of people with dementia,258

children who are gravely ill, people who are mentally retarded, disabled259 260

newborns, people who are comatose, or when Dutch patients who never261 262

asked for death are given lethal injections.263

The Patient’s Own Request. From the point of view of pure logic, arequest to die is not valid because the person making it cannot fully knowthe meaning of that request, since “no one can imagine his own total

Tindall, supra note 247.258

D.C. MAGUIRE, DEATH BY CHOICE 173-79 (1977); G. Williams, Euthanasia and the259

Physician, in BENEFICENT EUTHANASIA 154-57 (M. Kohl, ed. 1975); and H.T. Engelhardt, Jr.,Ethical Issues in Aiding the Death of Young Children, in BENEFICENT EUTHANASIA 180-82.

E.W. Lusthaus, Involuntary Euthanasia and Current Attempts to Define Persons260

with Mental Retardation as Less Than Human, 23 MENTAL RETARDATION 148 (1985). J. Lachs, On Humane Treatment and the Treatment of Humans, 294 NEW ENG. J.261

MED. 838 (1976); J. Fletcher, Ethics and Euthanasia, in TO LIVE AND TO DIE: WHEN, WHY, AND

HOW 113-22 (H. Williams, ed., Springer Verlag, New York-Heidelberg-Berlin 1973). S. M. Wolf, Nancy Beth Cruzan: In No Voice At All, HASTINGS CENTER REP.,262

Jan./Feb., 1990, at 38; W.H. Colby, Missouri Stands Alone, HASTINGS CENTER REP., Jan./Feb.,1990, at 5; P. Busalacchi, How Can They? HASTINGS CENTER REP., Jan./Feb., 1990, at 6; R.E.Cranford, A Hostage to Technology, HASTINGS CENTER REP., Jan./Feb., 1990, at 9.

See Chs. XIX and XX, 26 ISSUES IN LAW & MED. 63 & 69 (2010) (respectively).263


absence, without that being a contradiction in terms.” But also other264

questions must be asked: Does such request always signify a death wish?And, to what degree is that request the patient’s own?

It is common knowledge that, in reality, a request to die very oftensignifies something else: it can be a cry for help, for understanding, or anattempt to dramatize the situation. Even when someone requests death265

repeatedly and emphatically, in writing or in the presence of witnesses, thisdoes not preclude the possibility that he is actually asking for help andattention. Many such cries for self-destruction have traits of hystericalbehavior, typically marked by theatricality and hyperbole. Such an hystericalcry for help may, indeed, prove effective if it is addressed to good and wisepeople who would understand its true significance and show the despairingperson that he is important to them, that they are staying at his side.However, the danger is now great that such a request will be taken literally,will be seized upon, and the person crying for help will be killed! Hystericalpersons most often survive suicide attempts; euthanasia does not give themthat chance.

The other important question is, to what degree a request for death isa genuine request of the person involved? In a widely publicized Dutch case,a retired professor of geology coerced his healthy 72-year-old wife intosubmitting to euthanasia, promising to take recourse to it himself in threedays, but instead he went off to Austria where he married another lady. 266

We will never know whether this was all planned as a cold-blooded murderin advance, or whether he changed his mind only after his wife’s death. Ifthat was so, I would not condemn him for shrinking from his own “euthana-sia”; it’s good that at least somebody survived this heinous affair (the onlypity is that he escaped punishment). What good would it have done if he hadalso bid life farewell three days after his wife had been killed by a doctor?Would it have annulled his wife’s death, her desperate struggle for life, herfutile entreaties for a postponement, one more weekend with friends? Wesaw all that on the TV, the proceedings had been filmed on husband’srequest! And who was the culprit here? Was it only this old man or wassociety which had created the atmosphere favorable to “euthanasia,” which

L. Kolakowski, Fabula mundi and Cleopatra’s nose, in: CZY DIABE£ MO¯E BYÆ264

ZBAWIONY? [Can the Devil be Redeemed?] 71 (Aneks Pub., London 1982). This is also the case in many attempted suicides. An attempt to kill oneself is by no265

means always a step taken out of despair and hopelessness; more often it is dictated by hopethat this will come as a shock to other people, attract their attention, and change their attitudeby arousing a feeling of guilt.

W. VAN DEN LINDEN, ZIJ MOEST EERST . . . HET DOSSIER VAN BOMMELEN: EEN GEVAL VAN266

EUTHANASIE? [She Had to go First . . . The Van Bommelen File: A Case of Euthanasia?](Strengholt Pub. Naarden 1984); Waarom heeft Wibo niet ingegrepen? [Why (the TVjournalist) Wibo (van den Linden) Did Not Intervene? ZONDAG (Beusichem), Jan. 22, 1984;G.A. Lindeboom, Een z.g. euthanasie-drama [The Drama of the So-Called Euthanasia], 11VITA HUMANA 100 (1984).



but over other persons as well, their acts and their conscience. The persondeciding on his own death would also have the right to make killers of thedoctor and the nurse, and to make others accomplices to the killing. Hewould have the right to compel society to renounce the principle ofinviolability of human life, to destroy the barrier protecting the life of eachperson. The right to assisted suicide or voluntary euthanasia is thus notidentical with the right to self-determination, but is broader in content. It isnot true that anyone who accepts a person’s right to self-determination eoipso accepts the right to voluntary euthanasia. This is the first reason whythe pro-euthanasia movement cannot invoke the right to self-determinationas an argument.

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

On the other hand, no mention is made of targeted individuals’ right toself-determination when American and British proponents of mercy killingcall for compulsory non-voluntary “euthanasia” of people with dementia,258

children who are gravely ill, people who are mentally retarded, disabled259 260

newborns, people who are comatose, or when Dutch patients who never261 262

asked for death are given lethal injections.263

The Patient’s Own Request. From the point of view of pure logic, arequest to die is not valid because the person making it cannot fully knowthe meaning of that request, since “no one can imagine his own total

Tindall, supra note 247.258

D.C. MAGUIRE, DEATH BY CHOICE 173-79 (1977); G. Williams, Euthanasia and the259

Physician, in BENEFICENT EUTHANASIA 154-57 (M. Kohl, ed. 1975); and H.T. Engelhardt, Jr.,Ethical Issues in Aiding the Death of Young Children, in BENEFICENT EUTHANASIA 180-82.

E.W. Lusthaus, Involuntary Euthanasia and Current Attempts to Define Persons260

with Mental Retardation as Less Than Human, 23 MENTAL RETARDATION 148 (1985). J. Lachs, On Humane Treatment and the Treatment of Humans, 294 NEW ENG. J.261

MED. 838 (1976); J. Fletcher, Ethics and Euthanasia, in TO LIVE AND TO DIE: WHEN, WHY, AND

HOW 113-22 (H. Williams, ed., Springer Verlag, New York-Heidelberg-Berlin 1973). S. M. Wolf, Nancy Beth Cruzan: In No Voice At All, HASTINGS CENTER REP.,262

Jan./Feb., 1990, at 38; W.H. Colby, Missouri Stands Alone, HASTINGS CENTER REP., Jan./Feb.,1990, at 5; P. Busalacchi, How Can They? HASTINGS CENTER REP., Jan./Feb., 1990, at 6; R.E.Cranford, A Hostage to Technology, HASTINGS CENTER REP., Jan./Feb., 1990, at 9.

See Chs. XIX and XX, 26 ISSUES IN LAW & MED. 63 & 69 (2010) (respectively).263


absence, without that being a contradiction in terms.” But also other264

questions must be asked: Does such request always signify a death wish?And, to what degree is that request the patient’s own?

It is common knowledge that, in reality, a request to die very oftensignifies something else: it can be a cry for help, for understanding, or anattempt to dramatize the situation. Even when someone requests death265

repeatedly and emphatically, in writing or in the presence of witnesses, thisdoes not preclude the possibility that he is actually asking for help andattention. Many such cries for self-destruction have traits of hystericalbehavior, typically marked by theatricality and hyperbole. Such an hystericalcry for help may, indeed, prove effective if it is addressed to good and wisepeople who would understand its true significance and show the despairingperson that he is important to them, that they are staying at his side.However, the danger is now great that such a request will be taken literally,will be seized upon, and the person crying for help will be killed! Hystericalpersons most often survive suicide attempts; euthanasia does not give themthat chance.

The other important question is, to what degree a request for death isa genuine request of the person involved? In a widely publicized Dutch case,a retired professor of geology coerced his healthy 72-year-old wife intosubmitting to euthanasia, promising to take recourse to it himself in threedays, but instead he went off to Austria where he married another lady. 266

We will never know whether this was all planned as a cold-blooded murderin advance, or whether he changed his mind only after his wife’s death. Ifthat was so, I would not condemn him for shrinking from his own “euthana-sia”; it’s good that at least somebody survived this heinous affair (the onlypity is that he escaped punishment). What good would it have done if he hadalso bid life farewell three days after his wife had been killed by a doctor?Would it have annulled his wife’s death, her desperate struggle for life, herfutile entreaties for a postponement, one more weekend with friends? Wesaw all that on the TV, the proceedings had been filmed on husband’srequest! And who was the culprit here? Was it only this old man or wassociety which had created the atmosphere favorable to “euthanasia,” which

L. Kolakowski, Fabula mundi and Cleopatra’s nose, in: CZY DIABE£ MO¯E BYÆ264

ZBAWIONY? [Can the Devil be Redeemed?] 71 (Aneks Pub., London 1982). This is also the case in many attempted suicides. An attempt to kill oneself is by no265

means always a step taken out of despair and hopelessness; more often it is dictated by hopethat this will come as a shock to other people, attract their attention, and change their attitudeby arousing a feeling of guilt.


EUTHANASIE? [She Had to go First . . . The Van Bommelen File: A Case of Euthanasia?](Strengholt Pub. Naarden 1984); Waarom heeft Wibo niet ingegrepen? [Why (the TVjournalist) Wibo (van den Linden) Did Not Intervene? ZONDAG (Beusichem), Jan. 22, 1984;G.A. Lindeboom, Een z.g. euthanasie-drama [The Drama of the So-Called Euthanasia], 11VITA HUMANA 100 (1984).



treated that man’s murderous plans as a respectable, trend-setting idea,which prompted a doctor to be a killer, and which so bewildered a TVjournalist that he wanted to turn this sordid affair into a morality play aboutthe leading figures of our time?

That woman did not want to die, but was in fact killed at her ownrequest. The dominating husband coerced her into asking for death.Sometimes it is not the husband but a wife who dominates in a marriage. Awife who no longer wished to care for her sick husband offered him a choicebetween euthanasia and admission to a nursing home. The man, afraid of267

being in unfamiliar surroundings and in the care of strangers, chose death.The family physician, though aware of the coercion, performed theeuthanasia. The patient’s daughter, a nurse by profession who took part incarrying out the euthanasia, developed a severe depression and for a longtime remained under psychiatric treatment.

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

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

Apart from fashion, there is almost always another important factoroperative in the request for death: the doctor. It is striking that some doctorspublish articles in which they boast of having already dispatched manypeople to the next world “at their own request” (Dr. K gave a figure ofseventeen ), while traditional physicians have never heard any such268

request from their patients. Evidently we, the traditional doctors, are notsuited for euthanasia; all we know is to treat sick people, bring them relief,encourage them, support their hope and will to live. But the euthanasia-

H. TEN HAVE & G. KIMSMA, GENEESKUNDE TUSSEN DRROM EN DRAMA [Medicine267

Between Dream and Drama] 83-87 (Kik-Agora Pub., Kampen 1987); G. F. Koerselman, Hoemondig zijn moderne patienten? [How Mature are the Modern Patients?], 130 NED.TIJDSCHRIFT V. GENEESKUNDE 2017 (1986).

E.G.H. Kenter, Euthanasie in de huisartspraktijk [Euthanasia in Family Physician’s268

Practice], 38 MEDISCH CONTACT 1179 (1983).


doctor knows what to do to fulfill his calling. He begins by acquainting thepatient with the situation, sparing him no description of the horriblecomplications which have already ensued or “may ensue” in the future. Heterms the patient’s condition hopeless (without mentioning that sooner orlater a hopeless fate awaits us all). He speaks with the full power of infalliblescience (and omits saying how many errors science has made). He predictsprecisely how long the patient has to live (predictions which never cometrue), and excommunicates the patient from the community of the livingwhile he is still alive. Such a harangue (and not the illness itself) plunges thepatient into depression, and, sometimes into reactive psychosis. And whenthe patient driven to despair requests death, that request will not be treatedas a call for help, or a complaint which escaped the patient’s lips at amoment of mental breakdown, no, that request will be seized upon, treatedas a possible solution, discussed in all seriousness, often in the presence offamily members or other persons, so that the sense of shame will prevent thepatient from retracting “his own decision.”

The Patient’s Own Request—A Case Report. As already mentionedabove, the patients of traditional doctors do not request to be put to death.Yet it did happen to me once. The patient was swollen all over and sufferingfrom such shortness of breath that he had not slept for three weeks and hadspent all those nights sitting in a chair, breathing heavily. Two hours afterhis transfer to my department he said to me: “Doctor, I cannot take itanymore, please give me that injection, you know what I mean.” Obviouslyhe had a fatal injection in mind. Had he chanced on a euthanasia-doctor,probably this request would have been granted. He was suffering horribly.His condition seemed to be an irreversible congestive heart failure with noprospect of improvement, and it could even be assumed that “the dyingprocess had already begun.” And the patient himself demanded that he be269

put to death, didn’t he?But he had addressed the request to the wrong person. I’m only an old-

fashioned doctor, I often doubt my diagnoses and never trust my prognoses.It never entered my mind to turn the words the patient spoke in a momentof despair against him. It also never entered my mind that I might killanyone and I don’t even know how it is done. Along with a curt letter, I hadsent back the Handbook of Responsible Euthanasia which, like all doctorsin Holland, I had once received from a society involved in such matters. So,I must admit that I did not pay due attention to the patient’s request. Myreply was: “Please don’t bother me with this kind of talk, you see I’m verybusy trying to give you some relief.” This patient survived his request formany years. His heart failure was linked to inordinately quick heart rate, and

This term is particularly “elastic,” and anyone may stretch it according to his own269

opinion. It may also be asserted on good grounds that every human being’s dying processbegins at birth.



treated that man’s murderous plans as a respectable, trend-setting idea,which prompted a doctor to be a killer, and which so bewildered a TVjournalist that he wanted to turn this sordid affair into a morality play aboutthe leading figures of our time?

That woman did not want to die, but was in fact killed at her ownrequest. The dominating husband coerced her into asking for death.Sometimes it is not the husband but a wife who dominates in a marriage. Awife who no longer wished to care for her sick husband offered him a choicebetween euthanasia and admission to a nursing home. The man, afraid of267

being in unfamiliar surroundings and in the care of strangers, chose death.The family physician, though aware of the coercion, performed theeuthanasia. The patient’s daughter, a nurse by profession who took part incarrying out the euthanasia, developed a severe depression and for a longtime remained under psychiatric treatment.

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

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

Apart from fashion, there is almost always another important factoroperative in the request for death: the doctor. It is striking that some doctorspublish articles in which they boast of having already dispatched manypeople to the next world “at their own request” (Dr. K gave a figure ofseventeen ), while traditional physicians have never heard any such268

request from their patients. Evidently we, the traditional doctors, are notsuited for euthanasia; all we know is to treat sick people, bring them relief,encourage them, support their hope and will to live. But the euthanasia-

H. TEN HAVE & G. KIMSMA, GENEESKUNDE TUSSEN DRROM EN DRAMA [Medicine267

Between Dream and Drama] 83-87 (Kik-Agora Pub., Kampen 1987); G. F. Koerselman, Hoemondig zijn moderne patienten? [How Mature are the Modern Patients?], 130 NED.TIJDSCHRIFT V. GENEESKUNDE 2017 (1986).

E.G.H. Kenter, Euthanasie in de huisartspraktijk [Euthanasia in Family Physician’s268

Practice], 38 MEDISCH CONTACT 1179 (1983).


doctor knows what to do to fulfill his calling. He begins by acquainting thepatient with the situation, sparing him no description of the horriblecomplications which have already ensued or “may ensue” in the future. Heterms the patient’s condition hopeless (without mentioning that sooner orlater a hopeless fate awaits us all). He speaks with the full power of infalliblescience (and omits saying how many errors science has made). He predictsprecisely how long the patient has to live (predictions which never cometrue), and excommunicates the patient from the community of the livingwhile he is still alive. Such a harangue (and not the illness itself) plunges thepatient into depression, and, sometimes into reactive psychosis. And whenthe patient driven to despair requests death, that request will not be treatedas a call for help, or a complaint which escaped the patient’s lips at amoment of mental breakdown, no, that request will be seized upon, treatedas a possible solution, discussed in all seriousness, often in the presence offamily members or other persons, so that the sense of shame will prevent thepatient from retracting “his own decision.”

The Patient’s Own Request—A Case Report. As already mentionedabove, the patients of traditional doctors do not request to be put to death.Yet it did happen to me once. The patient was swollen all over and sufferingfrom such shortness of breath that he had not slept for three weeks and hadspent all those nights sitting in a chair, breathing heavily. Two hours afterhis transfer to my department he said to me: “Doctor, I cannot take itanymore, please give me that injection, you know what I mean.” Obviouslyhe had a fatal injection in mind. Had he chanced on a euthanasia-doctor,probably this request would have been granted. He was suffering horribly.His condition seemed to be an irreversible congestive heart failure with noprospect of improvement, and it could even be assumed that “the dyingprocess had already begun.” And the patient himself demanded that he be269

put to death, didn’t he?But he had addressed the request to the wrong person. I’m only an old-

fashioned doctor, I often doubt my diagnoses and never trust my prognoses.It never entered my mind to turn the words the patient spoke in a momentof despair against him. It also never entered my mind that I might killanyone and I don’t even know how it is done. Along with a curt letter, I hadsent back the Handbook of Responsible Euthanasia which, like all doctorsin Holland, I had once received from a society involved in such matters. So,I must admit that I did not pay due attention to the patient’s request. Myreply was: “Please don’t bother me with this kind of talk, you see I’m verybusy trying to give you some relief.” This patient survived his request formany years. His heart failure was linked to inordinately quick heart rate, and

This term is particularly “elastic,” and anyone may stretch it according to his own269

opinion. It may also be asserted on good grounds that every human being’s dying processbegins at birth.



it occurred to me that this atrial flutter could have been caused by multiplepulmonary emboli; a diagnosis which I subsequently confirmed bypulmonary artery angiography. Step by step, I succeeded in expellingexcessive fluid from his body, restoring normal heart rhythm, and prevent-ing further embolization by anticoagulant treatment. The patient wasfollowed at the out-patient clinic for six years; he never again mentioned therequest he had made in a moment of despair, nor did I.

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

It is now demanded that the patient’s family take part in the decision oneuthanasia. This is indeed a logical demand in the eyes of those who hold itpermissible to put a person to death in the interest of other people,especially in the interest of his family. I will not discuss this “moral270

principle” or the actions resulting from it. Let’s confine ourselves to thosesituations in which a patient’s life is to be cut short “for his own good.”

The husband of a woman in coma requested her doctors to put his wife to death,270

arguing that he wished to marry another woman but as a Catholic could not divorce his wife. WERKGROEP EUTHANASIE VAN HET KATHOLIEK STUDIECENTRUM [Catholic Studies Center,Working Group on Euthanasia], VRAGEN OM DE DOOD: BESCHOUWINGEN OVER EUTHANASIE [Requesting Death: Reflections on Euthanasia] 172-73 (G. Dierick, ed., Amboboeken, Baarn1983).


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

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

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

These are, of course, quite exceptional cases; as a rule, the situation isotherwise. Family members request euthanasia “because the father cannottake it any longer” and they sincerely believe that this is what moves themto ask for euthanasia. They do not realize that it is themselves who can no271

longer bear this extremely trying situation, the enormous psychologicalburden, the sheer physical torment, the hours, days and nights spent in thehospital, nearly sleepless, unwashed, without clean clothes or regular meals;every few hours they hear that the patient’s condition has not improved. Weshould see and understand the relatives’ ordeal, support them in every way,but not kill the patient for their sake!

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

Granting a patient’s family the right to take part in the decision oneuthanasia has still another important aspect, to wit, the influence such rightmust have on the institution of the family. There are already reports of olderpeople overcome by fear of their own families in connection with thepossibility of euthanasia. And indeed, in a society that permits euthanasia,272

Tolstoy noted this form of self-deception a hundred and twenty years ago:271

“[Nekhludov] recalled how toward the end of [his mother’s] illness he frankly desired herdeath. He tried to tell himself that he wished her deliverance from suffering; actually hewished himself to be delivered from the sight of her suffering.” L.N. Tolstoy, Voskreseniye[Resurrection], in 11 SOBR. KHUD.PROIZVED. 88 (Pravda Pub., Moscow 1948).

M. Wagner, Stervenshulp: Wensen van patienten [Assisted Death: The Wishes of272

Patients], 49 MEDISCH CONTACT 1569 (1984).



it occurred to me that this atrial flutter could have been caused by multiplepulmonary emboli; a diagnosis which I subsequently confirmed bypulmonary artery angiography. Step by step, I succeeded in expellingexcessive fluid from his body, restoring normal heart rhythm, and prevent-ing further embolization by anticoagulant treatment. The patient wasfollowed at the out-patient clinic for six years; he never again mentioned therequest he had made in a moment of despair, nor did I.

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

It is now demanded that the patient’s family take part in the decision oneuthanasia. This is indeed a logical demand in the eyes of those who hold itpermissible to put a person to death in the interest of other people,especially in the interest of his family. I will not discuss this “moral270

principle” or the actions resulting from it. Let’s confine ourselves to thosesituations in which a patient’s life is to be cut short “for his own good.”

The husband of a woman in coma requested her doctors to put his wife to death,270

arguing that he wished to marry another woman but as a Catholic could not divorce his wife. WERKGROEP EUTHANASIE VAN HET KATHOLIEK STUDIECENTRUM [Catholic Studies Center,Working Group on Euthanasia], VRAGEN OM DE DOOD: BESCHOUWINGEN OVER EUTHANASIE [Requesting Death: Reflections on Euthanasia] 172-73 (G. Dierick, ed., Amboboeken, Baarn1983).


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

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

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

These are, of course, quite exceptional cases; as a rule, the situation isotherwise. Family members request euthanasia “because the father cannottake it any longer” and they sincerely believe that this is what moves themto ask for euthanasia. They do not realize that it is themselves who can no271

longer bear this extremely trying situation, the enormous psychologicalburden, the sheer physical torment, the hours, days and nights spent in thehospital, nearly sleepless, unwashed, without clean clothes or regular meals;every few hours they hear that the patient’s condition has not improved. Weshould see and understand the relatives’ ordeal, support them in every way,but not kill the patient for their sake!

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

Granting a patient’s family the right to take part in the decision oneuthanasia has still another important aspect, to wit, the influence such rightmust have on the institution of the family. There are already reports of olderpeople overcome by fear of their own families in connection with thepossibility of euthanasia. And indeed, in a society that permits euthanasia,272

Tolstoy noted this form of self-deception a hundred and twenty years ago:271

“[Nekhludov] recalled how toward the end of [his mother’s] illness he frankly desired herdeath. He tried to tell himself that he wished her deliverance from suffering; actually hewished himself to be delivered from the sight of her suffering.” L.N. Tolstoy, Voskreseniye[Resurrection], in 11 SOBR. KHUD.PROIZVED. 88 (Pravda Pub., Moscow 1948).

M. Wagner, Stervenshulp: Wensen van patienten [Assisted Death: The Wishes of272

Patients], 49 MEDISCH CONTACT 1569 (1984).



a person, even one young and healthy, will look with different eyes on hisown family; they will no longer be the persons who enrich lives, lend themscope, purpose, and meaning, but those who, at the decisive moment, willdecide whether or not to put an end to our lives. A person will always beaware of this, even when concluding marriage, if not before. Just as a worldharboring stockpiles of nuclear weapons is no longer the world it once was,so in an age of euthanasia a family will no longer be what it once was—norwill society be what we had hitherto known it to be.

Consultations, Coordination and Agreements. “I am appalled” said thepresident of the British Association of General Practitioners when he learnedthe sentence received by the doctor defendant in the Leeuwaarden trial (aweek in prison, suspended for a year, for killing her mother). But a differentreaction was expressed by a young woman, Dr. D, with whom I discussedthat case at the time: “Dr. P did indeed act improperly, she should have firstconsulted with another physician.” Thus, it’s O.K. to kill one’s mother, butremember to talk first to a colleague. The majority of the theorists ofeuthanasia recommend, or require, that there be some form of consultationor that decision be made by a committee.

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

The idea that the decision on euthanasia should be taken by a commit-tee belongs to “the founding father” of Dutch euthanasia, professor JanHendrik van den Berg. Is it true that errors may be avoided in this way?274

I doubt it. The outcome of deliberations will always be influenced by thecomposition of such bodies: the committee will only include people whoaccept euthanasia in principle; understandably, a person who entirely rejectseuthanasia cannot be a member. What role is such a committee supposed tofulfill? The doctor submitting a case will not want to act alone, but have agroup of people assume legal and moral responsibility for putting a patientto death. Everyone makes the decision and everyone shares the responsibil-ity, meaning no one does. And this is what the euthanasia committee’s rolewill in reality be: to dissolve, dilute, and destroy personal responsibility. Thisis not an especially praiseworthy role. And from the linguistic point of view,“committee meeting” is not the most accurate term for an agreement amongseveral people to act against the law and, in particular, to deprive someone

G. VAN DER WAL ET AL., MEDISCHE BESLUITVORMING AAN HET EINDE VAN HET LEVEN: DE273

PRAKTIJK EN DE TOETSING PROCEDURE [Medical Decisionmaking at the End of Life: The Practiceand the Checking and Verifying Procedure] 149, 188 (De Tijdstroom, Utrecht 2003).

J.H. VAN DEN BERG, MEDISCHE MACHT EN MEDISCHE ETHIEK [Medical Power and274

Medical Ethics] 41, 50 (G.V. Callenbach, Nijkerk 1969).


of his life. Language has more accurate terms to describe such behavior,such as “conspiracy” or “collusion.”

Moreover, can one on principle accept committee determination ofwhether or not a person is to be put to death? Meetings, debates, and votingare indeed the right path to take when various important human affairs areto be resolved, like the expenditure of money, sharing burdens among themembers, and so on. But no group or meeting has the right to decidewhether a person lives or dies—not by voting, and not by unanimousdecision. Speaking one’s mind about somebody’s life or death is a matter ofconscience. But there is no collective conscience, only the individual hasconscience. It is a meaningless act to assemble several people to decide aquestion of conscience.

Agreements Not to Resuscitate. When too broadly and indiscriminatelyapplied, and in particular, when issued without the patient’s consent orknowledge (as is often the case ), Do Not Resuscitate (“DNR”) orders275

create the danger of untimely and unnecessary deaths. The followingsituation is typical: a patient with hemiparesis due to an old clot in a brainartery is admitted to the hospital with a myocardial infarction and aneuthanasia-minded doctor orders “do not resuscitate.” A few hours later theCCU nurses allow the patient to die of a trivial ventricular fibrillation. Whatis the cause of that person’s death? Not the myocardial infarction and itscomplications because that ventricular fibrillation could be stopped with asingle discharge of the electrical defibrillator. Neither is it the old partialparalysis with which that person had lived for years and could continue to.This person died by agreement. Another feature of these agreements is thatthey are made in advance, in the false belief that those making them haveknowledge of future events. We know how deceptive such predictions are,e.g., a patient with severe emphysema can give the impression of having died—he lies there, dark blue-grayish, not reacting, not breathing—but a fewminutes later he sits up and lights a cigarette “because that helps him clearhis airways.” An agreement entered in advance also means that no one isresponsible any more, responsibility dissolves and vanishes. The “agree-ment” is made but nothing immediately happens, it will only happen later;one person issued the order, but does not directly cause the patient’s death,others just carry out the doctor’s order, that is, do nothing at a critical

MEDISCHE BESLISSINGEN ROND HET LEVENSEINDE. II. HET ONDERZOEK VOOR DE275

COMMISSIE MEDISCHE PRAKTIJK INZAKE EUTHANASIE [Medical Decisions About the End of Life. II. The Study for the Committee on Medical Practice Concerning Euthanasia] 75 (StatePublishing House SDU, The Hague 1991). Volume II appeared in English translation in P. J.VAN DER MAAS, J. J. M. VAN DELDEN, & L. PIJNENBORG, EUTHANASIA AND OTHER MEDICAL

DECISIONS CONCERNING THE END OF LIFE: AN INVESTIGATION PERFORMED UPON THE REQUEST

OF THE COMMISSION OF INQUIRY INTO THE MEDICAL PRACTICE CONCERNING EUTHANASIA

(Elsevier, Amsterdam-London-New York-Tokyo 1992). [The page number cited here refersto the Dutch original.]



a person, even one young and healthy, will look with different eyes on hisown family; they will no longer be the persons who enrich lives, lend themscope, purpose, and meaning, but those who, at the decisive moment, willdecide whether or not to put an end to our lives. A person will always beaware of this, even when concluding marriage, if not before. Just as a worldharboring stockpiles of nuclear weapons is no longer the world it once was,so in an age of euthanasia a family will no longer be what it once was—norwill society be what we had hitherto known it to be.

Consultations, Coordination and Agreements. “I am appalled” said thepresident of the British Association of General Practitioners when he learnedthe sentence received by the doctor defendant in the Leeuwaarden trial (aweek in prison, suspended for a year, for killing her mother). But a differentreaction was expressed by a young woman, Dr. D, with whom I discussedthat case at the time: “Dr. P did indeed act improperly, she should have firstconsulted with another physician.” Thus, it’s O.K. to kill one’s mother, butremember to talk first to a colleague. The majority of the theorists ofeuthanasia recommend, or require, that there be some form of consultationor that decision be made by a committee.

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

The idea that the decision on euthanasia should be taken by a commit-tee belongs to “the founding father” of Dutch euthanasia, professor JanHendrik van den Berg. Is it true that errors may be avoided in this way?274

I doubt it. The outcome of deliberations will always be influenced by thecomposition of such bodies: the committee will only include people whoaccept euthanasia in principle; understandably, a person who entirely rejectseuthanasia cannot be a member. What role is such a committee supposed tofulfill? The doctor submitting a case will not want to act alone, but have agroup of people assume legal and moral responsibility for putting a patientto death. Everyone makes the decision and everyone shares the responsibil-ity, meaning no one does. And this is what the euthanasia committee’s rolewill in reality be: to dissolve, dilute, and destroy personal responsibility. Thisis not an especially praiseworthy role. And from the linguistic point of view,“committee meeting” is not the most accurate term for an agreement amongseveral people to act against the law and, in particular, to deprive someone

G. VAN DER WAL ET AL., MEDISCHE BESLUITVORMING AAN HET EINDE VAN HET LEVEN: DE273

PRAKTIJK EN DE TOETSING PROCEDURE [Medical Decisionmaking at the End of Life: The Practiceand the Checking and Verifying Procedure] 149, 188 (De Tijdstroom, Utrecht 2003).

J.H. VAN DEN BERG, MEDISCHE MACHT EN MEDISCHE ETHIEK [Medical Power and274

Medical Ethics] 41, 50 (G.V. Callenbach, Nijkerk 1969).


of his life. Language has more accurate terms to describe such behavior,such as “conspiracy” or “collusion.”

Moreover, can one on principle accept committee determination ofwhether or not a person is to be put to death? Meetings, debates, and votingare indeed the right path to take when various important human affairs areto be resolved, like the expenditure of money, sharing burdens among themembers, and so on. But no group or meeting has the right to decidewhether a person lives or dies—not by voting, and not by unanimousdecision. Speaking one’s mind about somebody’s life or death is a matter ofconscience. But there is no collective conscience, only the individual hasconscience. It is a meaningless act to assemble several people to decide aquestion of conscience.

Agreements Not to Resuscitate. When too broadly and indiscriminatelyapplied, and in particular, when issued without the patient’s consent orknowledge (as is often the case ), Do Not Resuscitate (“DNR”) orders275

create the danger of untimely and unnecessary deaths. The followingsituation is typical: a patient with hemiparesis due to an old clot in a brainartery is admitted to the hospital with a myocardial infarction and aneuthanasia-minded doctor orders “do not resuscitate.” A few hours later theCCU nurses allow the patient to die of a trivial ventricular fibrillation. Whatis the cause of that person’s death? Not the myocardial infarction and itscomplications because that ventricular fibrillation could be stopped with asingle discharge of the electrical defibrillator. Neither is it the old partialparalysis with which that person had lived for years and could continue to.This person died by agreement. Another feature of these agreements is thatthey are made in advance, in the false belief that those making them haveknowledge of future events. We know how deceptive such predictions are,e.g., a patient with severe emphysema can give the impression of having died—he lies there, dark blue-grayish, not reacting, not breathing—but a fewminutes later he sits up and lights a cigarette “because that helps him clearhis airways.” An agreement entered in advance also means that no one isresponsible any more, responsibility dissolves and vanishes. The “agree-ment” is made but nothing immediately happens, it will only happen later;one person issued the order, but does not directly cause the patient’s death,others just carry out the doctor’s order, that is, do nothing at a critical

MEDISCHE BESLISSINGEN ROND HET LEVENSEINDE. II. HET ONDERZOEK VOOR DE275

COMMISSIE MEDISCHE PRAKTIJK INZAKE EUTHANASIE [Medical Decisions About the End of Life. II. The Study for the Committee on Medical Practice Concerning Euthanasia] 75 (StatePublishing House SDU, The Hague 1991). Volume II appeared in English translation in P. J.VAN DER MAAS, J. J. M. VAN DELDEN, & L. PIJNENBORG, EUTHANASIA AND OTHER MEDICAL

DECISIONS CONCERNING THE END OF LIFE: AN INVESTIGATION PERFORMED UPON THE REQUEST

OF THE COMMISSION OF INQUIRY INTO THE MEDICAL PRACTICE CONCERNING EUTHANASIA

(Elsevier, Amsterdam-London-New York-Tokyo 1992). [The page number cited here refersto the Dutch original.]



moment. . . . Of course, as in any field of human endeavor, mistakes canhappen in connection with such agreements; but these are macabremistakes. In a university hospital, I was witness to a conversation betweenDr. G, who had just finished duty, and his colleague, Dr. M. Dr. G said thathe had been summoned to Dr. M’s patient who had suffered a respiratoryarrest, but he had done nothing because the nurse had informed him that ithad been agreed not to resuscitate the patient. “What do you mean?” criedDr. M in genuine despair, “and she died? That can’t be! There never was anysuch agreement! I mean there was one, but it was for another patient!” Itried to explain to him that the point here was not the mistake, mistakes dohappen, the point was that such agreements are dangerous. He did notunderstand.

Of course, we cease treatment if there truly is nothing more to be done.We also cease attempts at resuscitation when after an hour and half’s battleno pulse can be detected. But that has to be your personal decision, madeafter losing the battle, hic et nunc, in a situation you have seen with yourown eyes. It should not be a decision made in advance, based on a predictionof a future that is unforeseeable, and never a decision imposed on others. Itcan only be a concession of our defeat, never a conspiracy.

The question arises how in a country where the “Protestant spirit” is sodeeply rooted that people reject all intermediary between their ownconscience and the One they consider the judge of their deeds, how nursesand doctors accept orders allowing another person to take charge of theirown conscience. The answer is simple—and frightening. The decision ofwhether someone else is to live or die is no longer considered a matter ofconscience. It has become an administrative matter to be handled throughthe channels.

Agreements Not to Resuscitate II. When one speaks of the dangersentailed in modern science, one usually has in mind nuclear fission orgenetic manipulation. But there is still another danger: the wreckagesuffered by weaker minds when they come in contact with Science. Yearsago, when I was working in one of the Scandinavian countries, I observed asad example of this in the person of Dr. S, head of a hospital department ofinternal medicine. A patient at the department had fallen into severehypoglycemic coma (loss of consciousness caused by low blood sugar),which reached the point of cardiac arrest; it became necessary to applyexternal heart massage and a ventilator. However, after intravenousinjection of glucose the heart resumed beating normally, and the patientregained consciousness. Dr. S protested against such medical action. “The276

guess diagnosis that it was hypoglycemia was brilliant,” he said, “but youhad no right to inject glucose until the lab report on blood glucose was

See case described in subsec. entitled Sudden Insights, in Ch. VII, 24 ISSUES IN LAW276

& MED. 229, 234 (2009).


known! I forbid such unscientific proceedings in my department!” The lab277

report came half an hour later and could not have been obtained earlier. Itwas impossible for a patient in such a deep coma that it had caused cardiacarrest to survive that long without intravenous glucose, as was entirelyobvious to Dr. S as well. But this doctor was not concerned with whethersomeone lived or died; his concern was Science. To die in accordance withthe rules of Science was just how it should be. To survive against the laws ofScience was forbidden.

Well, this eminent scientist also issued orders “not to resuscitate” and“not to treat” and also in doing so he was guided by strictly scientific criteria.A 55 year old woman had surgery for a brain tumor (non-malignant atmicroscopy), but the growth could not be totally removed. After theoperation the patient was in fair condition except for a moderate weaknessof one arm and one leg. She was entirely independent, walked a great deal,and devoted her time to reading and going to the movies and theatricalperformances. When she was admitted to the hospital with a severepneumonia, Dr. S “forbade” that she be treated! There are, however, otherdoctors who do not take such prohibitions to heart, the patient was givenpenicillin, and quickly recovered.

On another occasion, ambulance attendants brought to the hospital thebody of a 16 year old boy who had suddenly lost consciousness and had nopulse or breath. The paramedics had applied neither heart massage norventilation because the boy’s (well-trained) parents showed them a notefrom Dr. S written two years before, containing the words “do not resusci-tate.” The patient had a congenital heart defect, a so-called transposition ofthe great vessels, and the university hospital decided that surgery was notpossible (it is possible now). The boy was the best student in his class andintended to study law. Due to Dr. S’s note, the disturbance in heart rhythm,which could have been corrected had life-saving action commenced at once,put an end to the boy’s life.

By now we have gained sufficient insight into the mentality and valuesystem of Dr. S. He is a true servant of Science. For him Science is neithera means nor even an end, it is the Supreme Judge, empowered to pass deathsentences. There are people whose health Science was ready to improve—butlook what happened! They proved unfit! They were disqualified by Science!And, in their foolishness, these people feel well, run around, study at school,date girls, attend the theater, while according to the rules of Science, they areunfit for life! These rebels against Science do not have the right to live. Butthe necessary steps have already been taken, orders issued, and, sooner orlater, one of those rebels will get pneumonia, another a ventricular

In the opinion of Dr. S and those of like-mind, that which we see with our own eyes277

cannot be science. Scientific information comes written on forms from the laboratory signedby a technician.



moment. . . . Of course, as in any field of human endeavor, mistakes canhappen in connection with such agreements; but these are macabremistakes. In a university hospital, I was witness to a conversation betweenDr. G, who had just finished duty, and his colleague, Dr. M. Dr. G said thathe had been summoned to Dr. M’s patient who had suffered a respiratoryarrest, but he had done nothing because the nurse had informed him that ithad been agreed not to resuscitate the patient. “What do you mean?” criedDr. M in genuine despair, “and she died? That can’t be! There never was anysuch agreement! I mean there was one, but it was for another patient!” Itried to explain to him that the point here was not the mistake, mistakes dohappen, the point was that such agreements are dangerous. He did notunderstand.

Of course, we cease treatment if there truly is nothing more to be done.We also cease attempts at resuscitation when after an hour and half’s battleno pulse can be detected. But that has to be your personal decision, madeafter losing the battle, hic et nunc, in a situation you have seen with yourown eyes. It should not be a decision made in advance, based on a predictionof a future that is unforeseeable, and never a decision imposed on others. Itcan only be a concession of our defeat, never a conspiracy.

The question arises how in a country where the “Protestant spirit” is sodeeply rooted that people reject all intermediary between their ownconscience and the One they consider the judge of their deeds, how nursesand doctors accept orders allowing another person to take charge of theirown conscience. The answer is simple—and frightening. The decision ofwhether someone else is to live or die is no longer considered a matter ofconscience. It has become an administrative matter to be handled throughthe channels.

Agreements Not to Resuscitate II. When one speaks of the dangersentailed in modern science, one usually has in mind nuclear fission orgenetic manipulation. But there is still another danger: the wreckagesuffered by weaker minds when they come in contact with Science. Yearsago, when I was working in one of the Scandinavian countries, I observed asad example of this in the person of Dr. S, head of a hospital department ofinternal medicine. A patient at the department had fallen into severehypoglycemic coma (loss of consciousness caused by low blood sugar),which reached the point of cardiac arrest; it became necessary to applyexternal heart massage and a ventilator. However, after intravenousinjection of glucose the heart resumed beating normally, and the patientregained consciousness. Dr. S protested against such medical action. “The276

guess diagnosis that it was hypoglycemia was brilliant,” he said, “but youhad no right to inject glucose until the lab report on blood glucose was

See case described in subsec. entitled Sudden Insights, in Ch. VII, 24 ISSUES IN LAW276

& MED. 229, 234 (2009).


known! I forbid such unscientific proceedings in my department!” The lab277

report came half an hour later and could not have been obtained earlier. Itwas impossible for a patient in such a deep coma that it had caused cardiacarrest to survive that long without intravenous glucose, as was entirelyobvious to Dr. S as well. But this doctor was not concerned with whethersomeone lived or died; his concern was Science. To die in accordance withthe rules of Science was just how it should be. To survive against the laws ofScience was forbidden.

Well, this eminent scientist also issued orders “not to resuscitate” and“not to treat” and also in doing so he was guided by strictly scientific criteria.A 55 year old woman had surgery for a brain tumor (non-malignant atmicroscopy), but the growth could not be totally removed. After theoperation the patient was in fair condition except for a moderate weaknessof one arm and one leg. She was entirely independent, walked a great deal,and devoted her time to reading and going to the movies and theatricalperformances. When she was admitted to the hospital with a severepneumonia, Dr. S “forbade” that she be treated! There are, however, otherdoctors who do not take such prohibitions to heart, the patient was givenpenicillin, and quickly recovered.

On another occasion, ambulance attendants brought to the hospital thebody of a 16 year old boy who had suddenly lost consciousness and had nopulse or breath. The paramedics had applied neither heart massage norventilation because the boy’s (well-trained) parents showed them a notefrom Dr. S written two years before, containing the words “do not resusci-tate.” The patient had a congenital heart defect, a so-called transposition ofthe great vessels, and the university hospital decided that surgery was notpossible (it is possible now). The boy was the best student in his class andintended to study law. Due to Dr. S’s note, the disturbance in heart rhythm,which could have been corrected had life-saving action commenced at once,put an end to the boy’s life.

By now we have gained sufficient insight into the mentality and valuesystem of Dr. S. He is a true servant of Science. For him Science is neithera means nor even an end, it is the Supreme Judge, empowered to pass deathsentences. There are people whose health Science was ready to improve—butlook what happened! They proved unfit! They were disqualified by Science!And, in their foolishness, these people feel well, run around, study at school,date girls, attend the theater, while according to the rules of Science, they areunfit for life! These rebels against Science do not have the right to live. Butthe necessary steps have already been taken, orders issued, and, sooner orlater, one of those rebels will get pneumonia, another a ventricular

In the opinion of Dr. S and those of like-mind, that which we see with our own eyes277

cannot be science. Scientific information comes written on forms from the laboratory signedby a technician.



fibrillation, and we have already seen to it that when such occasions presentthemselves these people disappear from the face of the earth.

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

Prevention of Alzheimer’s Disease? All of us want to avoid this personaldisaster and spare our families the sorrow and the torment. The proponentsof death by one’s own choice point out that assisted suicide, or otherwisecaused death of the person involved, would prevent the misfortunes ofAlzheimer’s disease.278

But the concept of preemptive death as a way to escape Alzheimer’sdisease, logical as it may seem when considered in the abstract, makes usshudder when imagined as a reality. Moreover, in every case of suspected orpresumably diagnosed Alzheimer’s disease, and in any society abiding by lawand fairness, an attempt to put this idea into effect would present insur-mountable difficulties.

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

The Person. Please don’t let yourself be convinced by sophistries,assertions that “the person is gone,” that “what’s left is an empty shell.” Youknow very well this is your mother, your husband, the same person you’vealways loved, only afflicted by terrible disease.

Making the Decision. To avoid Alzheimer’s disease, says a proponent ofdeath by one’s own choice, “we must place securely in our own hands howwe end our life.” This seems to suggest that the patient himself should279

decide; thus, the issue is placed in the familiar context of autonomy andfreedom of choice.

But a patient with Alzheimer’s dementia, durable memory loss and deepcognitive disturbance, unable to fulfill simple functions, obviously cannotmake the decision to end his life; nor do these patients even utter suchwishes. A resolve to end such a life can only be other people’s decision, notthe patient’s.

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

Apparently, we are relegated to “living wills” or other directives issuedin advance by still sane, fully competent persons. But a substantial studyshowed that—in spite of all encouragement and tremendous pressure—most

Bachrach, supra note 246; A. Dorfman, Alzheimer’s and a Caring Society, BOSTON278

GLOBE, June 17, 2004. Bachrach, supra note 246.279


Americans avoid signing living wills; and rightly so. They are guided by280

caution, wisdom, and moral objections.Cautious people are reluctant to issue clear instructions about what to

do in the future, in always complex, often difficult to grasp, and neverentirely predictable situations. The textbooks list, besides Alzheimer’s, sixtyother possible causes of dementia, of which thirty are curable or otherwisereversible. In principle, all persons tentatively diagnosed with Alzheimer’s281

disease should first be tested for all thirty curable causes of dementia, but inpractice this is not always done. What if the patient were killed while herconfusion could have been cured with a shot of vitamin B12 or B6?

Wise people understand that what they feel and desire while healthy andunwilling to accept any limitations, is not the same as what they may desirewhen gravely ill. Morally sensitive people question whether their present282

selves have the right to bind their future, changed selves, in the wayscontemplated in living wills. 283

Putting the Decision to Die into Effect. Let’s suppose there is a “livingwill” stipulating to end the patient’s life when she no longer recognizes herdaughter; the fatal moment arrives; and we decide to break the law,overcome our instinctive repugnance, and grant the request the patient hadexpressed years ago.

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

Shall we cheat the unsuspecting patient, approach her with themilkshake into which nine grams of barbiturate had been mixed, and say“Mum, I brought you a drink”? Is this our idea of “patient taking firmly inher own hands how she ends her life”? What advocates of “prevention ofAlzheimer’s disease” propose would in reality boil down to is lethal

A. Fagerlin & C.E. Schnedier, Enough: The Failure of the Living Will, HASTINGS280

CENTER REP., Mar./Apr., 2004, at 30. M.M. Brown & V.C. Hachinski, Acute Confusional States, Amnesia, and Dementia,281

in HARRISON’S PRINCIPLES OF INTERNAL MEDICINE 183, 190 (12 ed., J.D. Wilson et al. eds.th

1991). People’s intuitive understanding that the wishes of the gravely ill are different from282

those of healthy persons has been confirmed by substantive studies. Cf., M.L. Slevin, Attitudesto Chemotherapy: Comparing Views of Patients with Cancer with Those of Doctors, Nurses,and General Public, 300 BRIT. MED. J. 1458 (1990); D.E. Patterson, When Life Support isQuestioned Early in the Care of Patients with Cervical-Level Quadriplegia, 328 NEW ENG.J. MED. 506 (1993); J.H. Hess, Looking for Traction on the Slippery Slope: A Discussion ofthe Michael Martin Case, 11 ISSUES IN LAW & MED. 105 (1995). See also R. Fenigsen,Euthanasia and Moral Reflection, in THE DIGNITY OF THE DYING PERSON: PROCEEDINGS OF THE

FIFTH ASSEMBLY OF THE PONTIFICAL ACADEMY FOR LIFE 212-18 (J. de D.V. Correa & E. Sgreccia,eds., Vatican City 2000).

Fagerlin & Schnedier, supra note 280, at 30.283



fibrillation, and we have already seen to it that when such occasions presentthemselves these people disappear from the face of the earth.

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

Prevention of Alzheimer’s Disease? All of us want to avoid this personaldisaster and spare our families the sorrow and the torment. The proponentsof death by one’s own choice point out that assisted suicide, or otherwisecaused death of the person involved, would prevent the misfortunes ofAlzheimer’s disease.278

But the concept of preemptive death as a way to escape Alzheimer’sdisease, logical as it may seem when considered in the abstract, makes usshudder when imagined as a reality. Moreover, in every case of suspected orpresumably diagnosed Alzheimer’s disease, and in any society abiding by lawand fairness, an attempt to put this idea into effect would present insur-mountable difficulties.

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

The Person. Please don’t let yourself be convinced by sophistries,assertions that “the person is gone,” that “what’s left is an empty shell.” Youknow very well this is your mother, your husband, the same person you’vealways loved, only afflicted by terrible disease.

Making the Decision. To avoid Alzheimer’s disease, says a proponent ofdeath by one’s own choice, “we must place securely in our own hands howwe end our life.” This seems to suggest that the patient himself should279

decide; thus, the issue is placed in the familiar context of autonomy andfreedom of choice.

But a patient with Alzheimer’s dementia, durable memory loss and deepcognitive disturbance, unable to fulfill simple functions, obviously cannotmake the decision to end his life; nor do these patients even utter suchwishes. A resolve to end such a life can only be other people’s decision, notthe patient’s.

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

Apparently, we are relegated to “living wills” or other directives issuedin advance by still sane, fully competent persons. But a substantial studyshowed that—in spite of all encouragement and tremendous pressure—most

Bachrach, supra note 246; A. Dorfman, Alzheimer’s and a Caring Society, BOSTON278

GLOBE, June 17, 2004. Bachrach, supra note 246.279


Americans avoid signing living wills; and rightly so. They are guided by280

caution, wisdom, and moral objections.Cautious people are reluctant to issue clear instructions about what to

do in the future, in always complex, often difficult to grasp, and neverentirely predictable situations. The textbooks list, besides Alzheimer’s, sixtyother possible causes of dementia, of which thirty are curable or otherwisereversible. In principle, all persons tentatively diagnosed with Alzheimer’s281

disease should first be tested for all thirty curable causes of dementia, but inpractice this is not always done. What if the patient were killed while herconfusion could have been cured with a shot of vitamin B12 or B6?

Wise people understand that what they feel and desire while healthy andunwilling to accept any limitations, is not the same as what they may desirewhen gravely ill. Morally sensitive people question whether their present282

selves have the right to bind their future, changed selves, in the wayscontemplated in living wills. 283

Putting the Decision to Die into Effect. Let’s suppose there is a “livingwill” stipulating to end the patient’s life when she no longer recognizes herdaughter; the fatal moment arrives; and we decide to break the law,overcome our instinctive repugnance, and grant the request the patient hadexpressed years ago.

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

Shall we cheat the unsuspecting patient, approach her with themilkshake into which nine grams of barbiturate had been mixed, and say“Mum, I brought you a drink”? Is this our idea of “patient taking firmly inher own hands how she ends her life”? What advocates of “prevention ofAlzheimer’s disease” propose would in reality boil down to is lethal

A. Fagerlin & C.E. Schnedier, Enough: The Failure of the Living Will, HASTINGS280

CENTER REP., Mar./Apr., 2004, at 30. M.M. Brown & V.C. Hachinski, Acute Confusional States, Amnesia, and Dementia,281

in HARRISON’S PRINCIPLES OF INTERNAL MEDICINE 183, 190 (12 ed., J.D. Wilson et al. eds.th

1991). People’s intuitive understanding that the wishes of the gravely ill are different from282

those of healthy persons has been confirmed by substantive studies. Cf., M.L. Slevin, Attitudesto Chemotherapy: Comparing Views of Patients with Cancer with Those of Doctors, Nurses,and General Public, 300 BRIT. MED. J. 1458 (1990); D.E. Patterson, When Life Support isQuestioned Early in the Care of Patients with Cervical-Level Quadriplegia, 328 NEW ENG.J. MED. 506 (1993); J.H. Hess, Looking for Traction on the Slippery Slope: A Discussion ofthe Michael Martin Case, 11 ISSUES IN LAW & MED. 105 (1995). See also R. Fenigsen,Euthanasia and Moral Reflection, in THE DIGNITY OF THE DYING PERSON: PROCEEDINGS OF THE

FIFTH ASSEMBLY OF THE PONTIFICAL ACADEMY FOR LIFE 212-18 (J. de D.V. Correa & E. Sgreccia,eds., Vatican City 2000).

Fagerlin & Schnedier, supra note 280, at 30.283



injections administered to patients without their knowledge. That’s how the“compassionate society” will prevent the tragedy of Alzheimer’s.284

Chapter XXII. Utilitarianism of Bentham-Mill-Singer and thePhilosophy of Euthanasia285

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

But Bentham had at least one very human trait: he was particularlysensitive to suffering both in people and in animals. That’s why he readilyadopted Helvetius’ opinion that living beings are governed by the search287

for pleasure and the desire to avoid pain. Bentham elevated this hypothesisto the position of natural law. He also assumed, on less certain grounds,288

that these are the only motives of animal and human behavior. He thereforeproclaimed the principle of utility as the only criterion of moral evaluation:good deeds are those that increase the sum of happiness, the acts thatincrease the sum of sufferings are morally bad. All other criteria Benthamnot only rejected, but sharply condemned. Having grounded the whole of289

ethics on a single principle, allowing only one criterion of evaluation,Bentham was able to build an exceptionally consistent system. Moreover, inthe true spirit of the Enlightenment, Bentham tended to see ethics as ascience, a branch of natural sciences; he demanded rigorous reasoning anddid not take anything for granted. He was not willing to admit that murder,robbery, or arson were bad acts, until convincing proof was presented.290

Premises had to be verifiable; appealing to privileged information, such asintuition, or revelation, was prohibited. It is owing to these scientificqualities that Bentham’s ethical system—utilitarianism—became so popularamong the philosophers of our time. Utilitarianism is still sharply criticized,

Dorfman, supra note 278.284

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

John Stuart Mill, Bentham, in JOHN STUART MILL AND JEREMY BENTHAM 148-55 (A.286

Ryan, ed. 1987) (hereinafter MILL & BENTHAM). CHARLES TAYLOR, SOURCES OF THE SELF: THE MAKING OF THE MODERN IDENTITY 328287

(1989) (quoting HELVETIUS, DE L’HOMME). Jeremy Bentham, An Introduction to the Principles of Morals and Legislation, in288

MILL & BENTHAM, supra note 286, at 65. Id. at 70-83.289

Mill, supra note 286, at 139.290


for instance by Bernard Williams and John Rawls, but in the English-291 292

speaking countries it is generally regarded as the most serious attempt tocreate a reasoned system of ethics.

John Stuart Mill, raised since his childhood in an atmosphere ofadoration of Bentham, as a young man suffered a nervous breakdown andrebelled against the Master’s stiff doctrine, but later did a great deal to makeit more humane. Mill’s original contribution (in many ways linked to the293

subject of our interest, euthanasia), is his excellent treatise On Liberty. In294

this book Mill asserted that neither the state, society, nor neighbors shouldinterfere with what an individual is doing as long as his actions are notinjurious to anybody but himself. The modern intellectual current directedagainst paternalism in social relations and in medicine traces its origin backto that treatise On Liberty first published by Mill in 1859.

Several variants of utilitarianism have been developed, which showsthat their originators have been aware of certain faults in Bentham’s classicdoctrine; but it also means that these authors wished to maintain theutilitarian tradition. “Preferential” utilitarianism recommends making295

people happy not after some universal pattern, but in accordance to eachindividual’s preferences. The utilitarianism of rules postulates that not somuch our acts but rather the rules we follow should aim at increasing thegeneral happiness. Further, the “non-hedonistic” and the so-called296 297

“negative utilitarianism” are worth mentioning, but we now turn to a more298

detailed discussion of the views of professor Singer.Peter Singer, formerly a lecturer at Monash University in Melbourne,

at present Ira W. DeCamp professor of bioethics at Princeton, is a brilliantand undoubtedly the most influential utilitarian philosopher living. AmongSinger’s publications, his monograph with co-author Helga Kuhse, Shouldthe Baby Live? (1985),” Rethinking Life and Death: The Collapse of Our299

Bernard Williams, A Critique of Utilitarianism, in J.J.C. SMART & B. WILLIAMS,291

UTILITARIANISM, FOR AND AGAINST 77 (1993). JOHN RAWLS, A THEORY OF JUSTICE 167-75, 183-92 (1972).292

John Stuart Mill, Utilitarianism, in MILL & BENTHAM, supra note 286, at 272-338;293

John Stuart Mill, A System of Logic, in MILL & BENTHAM, at 113-31; John Stuart Mill,Colereidge, in MILL & BENTHAM, at 177-227; and John Stuart Mill, Whewell on MoralPhilosophy, in MILL & BENTHAM, at 228-71.

JOHN STUART MILL, ON LIBERTY (Penguin Books, London, 1988).294

PETER SINGER, PRACTICAL ETHICS 94-96, 99-100, 110, 126-29, 153, 194-95 (2nd ed.295

1993). J.J.C. Smart, An Outline of a System of Utilitarian Ethics, in SMART & WILLIAMS,296

supra note 291, at 9-12. Id. at 12-27.297

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

HELGA KUHSE & PETER SINGER, SHOULD THE BABY LIVE? THE PROBLEM OF HANDICAPPED299

INFANTS (1985).



injections administered to patients without their knowledge. That’s how the“compassionate society” will prevent the tragedy of Alzheimer’s.284

Chapter XXII. Utilitarianism of Bentham-Mill-Singer and thePhilosophy of Euthanasia285

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

But Bentham had at least one very human trait: he was particularlysensitive to suffering both in people and in animals. That’s why he readilyadopted Helvetius’ opinion that living beings are governed by the search287

for pleasure and the desire to avoid pain. Bentham elevated this hypothesisto the position of natural law. He also assumed, on less certain grounds,288

that these are the only motives of animal and human behavior. He thereforeproclaimed the principle of utility as the only criterion of moral evaluation:good deeds are those that increase the sum of happiness, the acts thatincrease the sum of sufferings are morally bad. All other criteria Benthamnot only rejected, but sharply condemned. Having grounded the whole of289

ethics on a single principle, allowing only one criterion of evaluation,Bentham was able to build an exceptionally consistent system. Moreover, inthe true spirit of the Enlightenment, Bentham tended to see ethics as ascience, a branch of natural sciences; he demanded rigorous reasoning anddid not take anything for granted. He was not willing to admit that murder,robbery, or arson were bad acts, until convincing proof was presented.290

Premises had to be verifiable; appealing to privileged information, such asintuition, or revelation, was prohibited. It is owing to these scientificqualities that Bentham’s ethical system—utilitarianism—became so popularamong the philosophers of our time. Utilitarianism is still sharply criticized,

Dorfman, supra note 278.284

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

John Stuart Mill, Bentham, in JOHN STUART MILL AND JEREMY BENTHAM 148-55 (A.286

Ryan, ed. 1987) (hereinafter MILL & BENTHAM). CHARLES TAYLOR, SOURCES OF THE SELF: THE MAKING OF THE MODERN IDENTITY 328287

(1989) (quoting HELVETIUS, DE L’HOMME). Jeremy Bentham, An Introduction to the Principles of Morals and Legislation, in288

MILL & BENTHAM, supra note 286, at 65. Id. at 70-83.289

Mill, supra note 286, at 139.290


for instance by Bernard Williams and John Rawls, but in the English-291 292

speaking countries it is generally regarded as the most serious attempt tocreate a reasoned system of ethics.

John Stuart Mill, raised since his childhood in an atmosphere ofadoration of Bentham, as a young man suffered a nervous breakdown andrebelled against the Master’s stiff doctrine, but later did a great deal to makeit more humane. Mill’s original contribution (in many ways linked to the293

subject of our interest, euthanasia), is his excellent treatise On Liberty. In294

this book Mill asserted that neither the state, society, nor neighbors shouldinterfere with what an individual is doing as long as his actions are notinjurious to anybody but himself. The modern intellectual current directedagainst paternalism in social relations and in medicine traces its origin backto that treatise On Liberty first published by Mill in 1859.

Several variants of utilitarianism have been developed, which showsthat their originators have been aware of certain faults in Bentham’s classicdoctrine; but it also means that these authors wished to maintain theutilitarian tradition. “Preferential” utilitarianism recommends making295

people happy not after some universal pattern, but in accordance to eachindividual’s preferences. The utilitarianism of rules postulates that not somuch our acts but rather the rules we follow should aim at increasing thegeneral happiness. Further, the “non-hedonistic” and the so-called296 297

“negative utilitarianism” are worth mentioning, but we now turn to a more298

detailed discussion of the views of professor Singer.Peter Singer, formerly a lecturer at Monash University in Melbourne,

at present Ira W. DeCamp professor of bioethics at Princeton, is a brilliantand undoubtedly the most influential utilitarian philosopher living. AmongSinger’s publications, his monograph with co-author Helga Kuhse, Shouldthe Baby Live? (1985),” Rethinking Life and Death: The Collapse of Our299

Bernard Williams, A Critique of Utilitarianism, in J.J.C. SMART & B. WILLIAMS,291

UTILITARIANISM, FOR AND AGAINST 77 (1993). JOHN RAWLS, A THEORY OF JUSTICE 167-75, 183-92 (1972).292

John Stuart Mill, Utilitarianism, in MILL & BENTHAM, supra note 286, at 272-338;293

John Stuart Mill, A System of Logic, in MILL & BENTHAM, at 113-31; John Stuart Mill,Colereidge, in MILL & BENTHAM, at 177-227; and John Stuart Mill, Whewell on MoralPhilosophy, in MILL & BENTHAM, at 228-71.

JOHN STUART MILL, ON LIBERTY (Penguin Books, London, 1988).294

PETER SINGER, PRACTICAL ETHICS 94-96, 99-100, 110, 126-29, 153, 194-95 (2nd ed.295

1993). J.J.C. Smart, An Outline of a System of Utilitarian Ethics, in SMART & WILLIAMS,296

supra note 291, at 9-12. Id. at 12-27.297

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

HELGA KUHSE & PETER SINGER, SHOULD THE BABY LIVE? THE PROBLEM OF HANDICAPPED299

INFANTS (1985).



Traditional Ethics (1995), and Animal Liberation (1975) are pertinent300 301

to the issues here, but I’ll focus on Singer’s Practical Ethics, which302

contains a full exposition of his views.Always quite readable and usually sharply reasoned, this book first

appeared in 1979 and has since been widely acclaimed as the conceptualframework of the New Morality. The second edition (1993) was expandedand revised, but the core of the doctrine was preserved in its pure form:

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

• Murder is usually wrong because the pleasure of the killer is outweighedby the suffering of the victim, the loss of his future pleasures, the griefof his family, and the anxiety caused to others who knew him. However,if somebody who could expect only further suffering is killed instantlyin his sleep, in complete secrecy, the classical utilitarian would find noreasons to condemn the act. Mistaken as they may be, some personswish to stay alive even when they cannot expect anything pleasant in thefuture, and a “preference utilitarian” (but not the classical utilitarian)would respect their preferences.

• Animals, in particular those with a nervous system similar to ours, arecapable of suffering and feeling pleasure. Therefore, their interests mustbe considered in the same way as our own. Partiality to the interests ofthose of one’s own species (speciesism) is as unfounded and morallyuntenable as tribalism, racism or sexism. Killing animals in order to usetheir bodies as food is morally wrong because important interests ofthose killed (all pleasures of their continued existence) are sacrificed forthe negligible and unnecessary pleasure of human consumers.

PETER SINGER, RETHINKING LIFE AND DEATH: THE COLLAPSE OF OUR TRADITIONAL300

ETHICS (1995). PETER SINGER, ANIMAL LIBERATION (2nd ed. 1990).301

PETER SINGER, PRACTICAL ETHICS (1st ed. 1979; 2nd ed. 1993) (Unless otherwise302

indicated, the page numbers cited are those of the second edition).


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

• Morally praiseworthy results can be achieved not only by increasing thehappiness, or diminishing the suffering, of already existing beings, butalso by increasing the number of happy beings, or reducing the numberof unhappy ones. This means that some beings, in particular fetuses andinfants, are replaceable. If a couple intends to have two children, andone of these turns out to be a hemophiliac, it is right to kill this baby asit will enable the mother to conceive again, and, it is to be hoped, givebirth to a healthy child who will have a longer and happier life than theone killed would have had.

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

• Causing death by omission is discussed in connection with euthanasiaand also a broader context. We are guilty of murder if we fail to donatea sufficient part of our income to aid the Third World where millions dieprematurely.

A surprisingly large part of Practical Ethics is concerned with killing.One only refrains from killing if the prospective victim truly desires tocontinue living, and is able to express such wish. A peculiar image of the303

world ensues. Killing seems to become not a transgression but the regularcourse of action. Living beings seem to be constantly preoccupied withdecisions whether to put an end to their lives or to go on living.

Practical Ethics makes intellectually stimulating reading right to thevery last chapter. In the appendix to the second edition, the author, whosegrandparents perished in the Holocaust, tells the story of his troubled visit

SINGER, supra note 302, at 171; SINGER, supra note 300, at 219.303



Traditional Ethics (1995), and Animal Liberation (1975) are pertinent300 301

to the issues here, but I’ll focus on Singer’s Practical Ethics, which302

contains a full exposition of his views.Always quite readable and usually sharply reasoned, this book first

appeared in 1979 and has since been widely acclaimed as the conceptualframework of the New Morality. The second edition (1993) was expandedand revised, but the core of the doctrine was preserved in its pure form:

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

• Murder is usually wrong because the pleasure of the killer is outweighedby the suffering of the victim, the loss of his future pleasures, the griefof his family, and the anxiety caused to others who knew him. However,if somebody who could expect only further suffering is killed instantlyin his sleep, in complete secrecy, the classical utilitarian would find noreasons to condemn the act. Mistaken as they may be, some personswish to stay alive even when they cannot expect anything pleasant in thefuture, and a “preference utilitarian” (but not the classical utilitarian)would respect their preferences.

• Animals, in particular those with a nervous system similar to ours, arecapable of suffering and feeling pleasure. Therefore, their interests mustbe considered in the same way as our own. Partiality to the interests ofthose of one’s own species (speciesism) is as unfounded and morallyuntenable as tribalism, racism or sexism. Killing animals in order to usetheir bodies as food is morally wrong because important interests ofthose killed (all pleasures of their continued existence) are sacrificed forthe negligible and unnecessary pleasure of human consumers.

PETER SINGER, RETHINKING LIFE AND DEATH: THE COLLAPSE OF OUR TRADITIONAL300

ETHICS (1995). PETER SINGER, ANIMAL LIBERATION (2nd ed. 1990).301

PETER SINGER, PRACTICAL ETHICS (1st ed. 1979; 2nd ed. 1993) (Unless otherwise302

indicated, the page numbers cited are those of the second edition).


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

• Morally praiseworthy results can be achieved not only by increasing thehappiness, or diminishing the suffering, of already existing beings, butalso by increasing the number of happy beings, or reducing the numberof unhappy ones. This means that some beings, in particular fetuses andinfants, are replaceable. If a couple intends to have two children, andone of these turns out to be a hemophiliac, it is right to kill this baby asit will enable the mother to conceive again, and, it is to be hoped, givebirth to a healthy child who will have a longer and happier life than theone killed would have had.

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

• Causing death by omission is discussed in connection with euthanasiaand also a broader context. We are guilty of murder if we fail to donatea sufficient part of our income to aid the Third World where millions dieprematurely.

A surprisingly large part of Practical Ethics is concerned with killing.One only refrains from killing if the prospective victim truly desires tocontinue living, and is able to express such wish. A peculiar image of the303

world ensues. Killing seems to become not a transgression but the regularcourse of action. Living beings seem to be constantly preoccupied withdecisions whether to put an end to their lives or to go on living.

Practical Ethics makes intellectually stimulating reading right to thevery last chapter. In the appendix to the second edition, the author, whosegrandparents perished in the Holocaust, tells the story of his troubled visit

SINGER, supra note 302, at 171; SINGER, supra note 300, at 219.303



to Germany: the association of people with disabilities accused him ofreviving the Nazi program of extermination and barred him from lecturing.

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

The strength of Singer’s convictions, and the impressive logic of hiswritings keep his readers under the spell. All the more is it important toverify what he writes.

The Facts. In the New York Review of Books, H.L.A. Hart praisedPractical Ethics as a book “packed with admirably marshaled and detailedinformation, social, medical, and economic.” I do not share this favorableopinion. In reality, Singer’s command of the biological, medical, andhistorical information he quotes is rather sketchy. When writing the firstedition, Singer believed that no animals had a cerebral cortex! In the304

second edition this blunder had been only partially corrected.305

The author condemns using animals for food, and can well hold his306

ground as long as his arguments are moral. But he also contends that eatingmeat is an entirely unnecessary luxury. However, the meat of animals,307

birds, or fish, is the fullest and easiest accessible source of the nine “essen-tial” amino acids which we need to build our bodies’ proteins. Thus,consumption of meat does serve a biological purpose. The fact that it can bereplaced by (duly supplemented) vegetarian diet does not make it athoughtless fancy.

Singer presents as conclusive the few experiments with teaching signlanguage to apes. The interpretation and reproducibility of these studies308

are still quite uncertain. On these shaky grounds Singer projects humanmental states onto animals, anthropomorphizing them in the best pre-behaviorist, pre-Pavlovian, and even pre-Cartesian tradition.

Singer incorrectly makes Christianity solely responsible for proclaim-ing the sanctity of human life. In fact, the foundations of this doctrine had309

been already laid in the Old Testament, and the Hippocratic ethics.310

Singer uncritically accepts the Nazi’s claim that their euthanasiaprogram was aimed at the “elimination of useless eaters.” All evidence311

indicates that the supposed “savings” were not more than rationalizationsof what was on its face a hate crime, just as the mountains of eyeglasses,

SINGER, supra note 302, at 60 (1st ed.).304

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

Id. at 62-72.306

Id. at 62.307

Id. at 111-17.308

Id. at 88, 173.309

Gen. 4: 10-13; Ex. 20:13; and Lev. 20:1-6.310

SINGER, supra note 302, at 215.311


children’s shoes, and human hair amassed in the death camps were macabrerationalizations, and not the aim, of the genocide.

“Perhaps one day,” writes Singer, “it will be possible to treat allterminally ill and incurable patients in such a way that no one requestseuthanasia . . ., but this is now just a utopian ideal.” The statement is a312

curious distortion of truth. For hundreds of years, and until the present pro-euthanasia campaign, sick and dying people rarely requested euthanasia,and in most countries of the world, still never do.

Singer derides the idea that euthanasia could ever be performed withouta competent patient’s consent, and denies that such practice exists in theNetherlands. But the official report of the Dutch government’s Committee313

on Euthanasia, available to Singer in English translation since 1992, states314

that in 1990 the lives of 1,000 patients who did not request or consent toeuthanasia were “actively terminated” by doctors, and that 140 of thesepatients were fully competent. Moreover, doctors intentionally caused the315

deaths of patients without their request, consent, or knowledge, by givingthem lethal overdoses of morphine; among 4,941 patients who underwentthis form of involuntary active euthanasia, 27 percent (1,334 persons) werefully competent.316

The Corrections. Statements which irritated the readers of the firstedition of Practical Ethics: demeaning people with Down syndrome,317

calling retarded people “vegetables,” and assessing the mind of a one-year318

old child as below that of many animals were excised in 1993, and do not319

appear in the second edition.Ironically, these corrections have also drawn attention to Singer’s

original, apparently more genuine views. Among statements that wereexpurgated from the second edition of Singer’s Practical Ethics were his

Id. at 199.312

Id. at 179, 196-97.313

P.J. VAN DER MAAS, J.J.M. VAN DELDEN, & L. PIJNENBORG, EUTHANASIA AND OTHER314

MEDICAL DECISIONS CONCERNING THE END OF LIFE: AN INVESTIGATION PERFORMED UPON THE

REQUEST OF THE COMMISSION OF INQUIRY INTO THE MEDICAL PRACTICE CONCERNING EUTHANASIA

(Elsevier, Amsterdam-London-New York-Tokyo 1992). Id. at 194 (“life is terminated without explicit request of the patient . . . in somewhat315

more than one thousand cases annually”). Fourteen percent of these patients (140 persons)were “able to assess the situation and [m]ake a decision adequately.” Id. at 61 (Tbl. 6.4).

Id. In 1990, 22,500 patients died of an overdose of painkillers. Id. at 183. In 36316

percent of these cases (8,100 persons) causing the patient’s death was one of the purposes orthe only purpose of doctors who administered excessive doses of painkillers. Id. at 73 (Tbl.7.2). In 61 percent of these 8,100 cases (4,941 persons), the decision was not discussed withthe patient. Id. at 75 (Tbl. 7.7). Twenty-seven percent of patients who died of an overdose ofpainkillers administered without their consent (1,334 persons) were “totally able to [m]akea decision.” Id.

Id. at 73 (1st ed.).317

Id. at 75 (1st ed.).318

Id. at 122 (1st ed.).319



to Germany: the association of people with disabilities accused him ofreviving the Nazi program of extermination and barred him from lecturing.

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

The strength of Singer’s convictions, and the impressive logic of hiswritings keep his readers under the spell. All the more is it important toverify what he writes.

The Facts. In the New York Review of Books, H.L.A. Hart praisedPractical Ethics as a book “packed with admirably marshaled and detailedinformation, social, medical, and economic.” I do not share this favorableopinion. In reality, Singer’s command of the biological, medical, andhistorical information he quotes is rather sketchy. When writing the firstedition, Singer believed that no animals had a cerebral cortex! In the304

second edition this blunder had been only partially corrected.305

The author condemns using animals for food, and can well hold his306

ground as long as his arguments are moral. But he also contends that eatingmeat is an entirely unnecessary luxury. However, the meat of animals,307

birds, or fish, is the fullest and easiest accessible source of the nine “essen-tial” amino acids which we need to build our bodies’ proteins. Thus,consumption of meat does serve a biological purpose. The fact that it can bereplaced by (duly supplemented) vegetarian diet does not make it athoughtless fancy.

Singer presents as conclusive the few experiments with teaching signlanguage to apes. The interpretation and reproducibility of these studies308

are still quite uncertain. On these shaky grounds Singer projects humanmental states onto animals, anthropomorphizing them in the best pre-behaviorist, pre-Pavlovian, and even pre-Cartesian tradition.

Singer incorrectly makes Christianity solely responsible for proclaim-ing the sanctity of human life. In fact, the foundations of this doctrine had309

been already laid in the Old Testament, and the Hippocratic ethics.310

Singer uncritically accepts the Nazi’s claim that their euthanasiaprogram was aimed at the “elimination of useless eaters.” All evidence311

indicates that the supposed “savings” were not more than rationalizationsof what was on its face a hate crime, just as the mountains of eyeglasses,

SINGER, supra note 302, at 60 (1st ed.).304

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

Id. at 62-72.306

Id. at 62.307

Id. at 111-17.308

Id. at 88, 173.309

Gen. 4: 10-13; Ex. 20:13; and Lev. 20:1-6.310



children’s shoes, and human hair amassed in the death camps were macabrerationalizations, and not the aim, of the genocide.

“Perhaps one day,” writes Singer, “it will be possible to treat allterminally ill and incurable patients in such a way that no one requestseuthanasia . . ., but this is now just a utopian ideal.” The statement is a312

curious distortion of truth. For hundreds of years, and until the present pro-euthanasia campaign, sick and dying people rarely requested euthanasia,and in most countries of the world, still never do.

Singer derides the idea that euthanasia could ever be performed withouta competent patient’s consent, and denies that such practice exists in theNetherlands. But the official report of the Dutch government’s Committee313

on Euthanasia, available to Singer in English translation since 1992, states314

that in 1990 the lives of 1,000 patients who did not request or consent toeuthanasia were “actively terminated” by doctors, and that 140 of thesepatients were fully competent. Moreover, doctors intentionally caused the315

deaths of patients without their request, consent, or knowledge, by givingthem lethal overdoses of morphine; among 4,941 patients who underwentthis form of involuntary active euthanasia, 27 percent (1,334 persons) werefully competent.316

The Corrections. Statements which irritated the readers of the firstedition of Practical Ethics: demeaning people with Down syndrome,317

calling retarded people “vegetables,” and assessing the mind of a one-year318

old child as below that of many animals were excised in 1993, and do not319

appear in the second edition.Ironically, these corrections have also drawn attention to Singer’s

original, apparently more genuine views. Among statements that wereexpurgated from the second edition of Singer’s Practical Ethics were his

Id. at 199.312

Id. at 179, 196-97.313

P.J. VAN DER MAAS, J.J.M. VAN DELDEN, & L. PIJNENBORG, EUTHANASIA AND OTHER314

MEDICAL DECISIONS CONCERNING THE END OF LIFE: AN INVESTIGATION PERFORMED UPON THE

REQUEST OF THE COMMISSION OF INQUIRY INTO THE MEDICAL PRACTICE CONCERNING EUTHANASIA

(Elsevier, Amsterdam-London-New York-Tokyo 1992). Id. at 194 (“life is terminated without explicit request of the patient . . . in somewhat315

more than one thousand cases annually”). Fourteen percent of these patients (140 persons)were “able to assess the situation and [m]ake a decision adequately.” Id. at 61 (Tbl. 6.4).

Id. In 1990, 22,500 patients died of an overdose of painkillers. Id. at 183. In 36316

percent of these cases (8,100 persons) causing the patient’s death was one of the purposes orthe only purpose of doctors who administered excessive doses of painkillers. Id. at 73 (Tbl.7.2). In 61 percent of these 8,100 cases (4,941 persons), the decision was not discussed withthe patient. Id. at 75 (Tbl. 7.7). Twenty-seven percent of patients who died of an overdose ofpainkillers administered without their consent (1,334 persons) were “totally able to [m]akea decision.” Id.

Id. at 73 (1st ed.).317

Id. at 75 (1st ed.).318

Id. at 122 (1st ed.).319



remarks on Nazi euthanasia. In the first edition of Practical Ethics, Singerwrote that “[t]he Nazis committed horrendous crimes, but this does notmean that everything the Nazis did was horrendous. We cannot condemneuthanasia just because the Nazis did it, anymore than we can condemn thebuilding of new roads for this reason.”320

Thus, in 1979, Singer did not see anything horrendous in the Nazieuthanasia program. Yet Nazi euthanasia (“Aktion T4") was horrendous.Psychiatric patients who guessed or, due to indiscretions of the personnel,knew what awaited them, loudly protested, begged not to go, tried to defendthemselves, fled and hid themselves, screamed at transport personnel “ourblood cries out for revenge,” clung to their hospital beds and had to bedragged from the building. In Absberg, a hundred “feebleminded” persons321

resisted and had to be loaded with physical force into busses whichtransported them to the euthanasia center. At these centers (Grafeneck,322

Brandenburg on the Havel, Hartheim, Sonnenstein, Bernburg, andHadamar) the patients were gassed with carbon monoxide. It took about anhour to cause death in this way; the victims, crowded into closed chambers,experienced extreme terror and visibly suffered before dying. Doctors and323

other attendants liked to watch the scene through a reinforced glassaperture. The atrocities provoked a widespread indignation in Germany,324

and not only among the families of the victims and the general public, butin the Wehrmacht and in the Nazi party; on August 28, 1941, Hitler had toorder a halt on “Aktion T4.” A number of doctors, nurses and otherpersonnel who gained experience in the Nazi euthanasia program were latertransferred to death camps and were also involved in gassing the Jews.325

I’m not suggesting that Singer was cynical when he exonerated the Nazieuthanasia in 1979. I think he was biased due to his general preference foreuthanasia and ignored the true facts.

Singer’s Reasoning is superb most of the time but not all the time.Contrary to his assertion, the presence of a disability only allows one to326

conclude that a person’s life is more difficult, not that it is less worth living.The latter is a value judgment reflecting the author’s bias against people withdisabilities.

Singer explains why, on paternalistic grounds, we may prohibit the useof heroin but not voluntary euthanasia: the choice for euthanasia should not

Id. at 124 (1st ed.).320

M. BURLEIGH, DEATH AND DELIVERANCE: “EUTHANASIA” IN GERMANY 1900-1945 140,321

142 (1994). Id. at 163.322

Id. at 149; H. FRIEDLANDER, THE ORIGINS OF NAZI GENOCIDE: FROM EUTHANASIA TO323

THE FINAL SOLUTION 97 (1995). BURLEIGH, supra note 321, at 147; FRIEDLANDER, supra note 323, at 97.324

BURLEIGH, supra note 321, at 150; FRIEDLANDER, supra note 323, at 295-302.325



be prohibited because it is a rational choice. Value judgment again, this327

time on what is rational. Yet it can be argued, and on firmer grounds, thatthe choice to use heroin is less irrational than the decision to have oneselfkilled. An addict is very much a living person with many choices open tohim, including the choice to undergo detoxicating treatment; a dead man hasno choices.

Singer’s argument in favor of voluntary euthanasia for the incurably illand suffering persons is inconsistent. If respect for a person’s autonomy328

is the reason to kill him upon his request, why must this person be329

incurable, suffering, or even sick? Aren’t healthy people autonomouspersons? Since Singer does not recognize the autonomy of healthy individu-als, he does not recognize the autonomy of human beings in general. He has,therefore, no right to put forward personal autonomy as an argument foreuthanasia.

Drawing hard conclusions from soft premises is Singer’s frequent error.If we aid the Third World by donating the ten percent of our income,arbitrarily proposed by Singer, we are righteous men, but if we give less,330

we are murderers. Singer approves of killing “someone who has not331

consented to being killed, but if asked would have consented.” What332

someone would have said “if asked” is an uncertain premise, but if we killhim based on that uncertain premise, the resulting death is certain.

Singer argues that one may waive the right to life because “it is anessential feature of a right that one can waive [it].” The utilitarian tradition,which Singer here abandons, used to offer a sounder logic. “Over himself,over his body and mind, the individual is sovereign,” wrote John Stuart Mill,but “an engagement by which a person should sell himself . . . as a slavewould be null and void . . . . The reason for not interfering . . . with a person’svoluntary acts is consideration for his liberty . . . . But by selling himself fora slave, he abdicated his liberty . . . He therefore defeats . . . the very purposewhich is justification of allowing him to dispose of himself.” Mill’s333

objection is a fortiori valid against the freedom to have oneself killed, as thiswould abolish the person’s freedom once and for all.

All Criticism On Principle, to which utilitarianism has been subjectedfor almost two centuries, and which utilitarians never were able to refute,applies to Singer’s philosophy. Is it true that “Nature has placed mankindunder the governance of two sovereign masters, pain and pleasure”? No,334

Id. at 199-200.327

Id. at 193-200.328

Id. at 194-95.329

Id. at 246.330

Id. at 222-24.331

Id. at 179.332

MILL, supra note 294, at 173.333

Bentham, supra note 288,at 65.334



remarks on Nazi euthanasia. In the first edition of Practical Ethics, Singerwrote that “[t]he Nazis committed horrendous crimes, but this does notmean that everything the Nazis did was horrendous. We cannot condemneuthanasia just because the Nazis did it, anymore than we can condemn thebuilding of new roads for this reason.”320

Thus, in 1979, Singer did not see anything horrendous in the Nazieuthanasia program. Yet Nazi euthanasia (“Aktion T4") was horrendous.Psychiatric patients who guessed or, due to indiscretions of the personnel,knew what awaited them, loudly protested, begged not to go, tried to defendthemselves, fled and hid themselves, screamed at transport personnel “ourblood cries out for revenge,” clung to their hospital beds and had to bedragged from the building. In Absberg, a hundred “feebleminded” persons321

resisted and had to be loaded with physical force into busses whichtransported them to the euthanasia center. At these centers (Grafeneck,322

Brandenburg on the Havel, Hartheim, Sonnenstein, Bernburg, andHadamar) the patients were gassed with carbon monoxide. It took about anhour to cause death in this way; the victims, crowded into closed chambers,experienced extreme terror and visibly suffered before dying. Doctors and323

other attendants liked to watch the scene through a reinforced glassaperture. The atrocities provoked a widespread indignation in Germany,324

and not only among the families of the victims and the general public, butin the Wehrmacht and in the Nazi party; on August 28, 1941, Hitler had toorder a halt on “Aktion T4.” A number of doctors, nurses and otherpersonnel who gained experience in the Nazi euthanasia program were latertransferred to death camps and were also involved in gassing the Jews.325

I’m not suggesting that Singer was cynical when he exonerated the Nazieuthanasia in 1979. I think he was biased due to his general preference foreuthanasia and ignored the true facts.

Singer’s Reasoning is superb most of the time but not all the time.Contrary to his assertion, the presence of a disability only allows one to326

conclude that a person’s life is more difficult, not that it is less worth living.The latter is a value judgment reflecting the author’s bias against people withdisabilities.

Singer explains why, on paternalistic grounds, we may prohibit the useof heroin but not voluntary euthanasia: the choice for euthanasia should not

Id. at 124 (1st ed.).320

M. BURLEIGH, DEATH AND DELIVERANCE: “EUTHANASIA” IN GERMANY 1900-1945 140,321

142 (1994). Id. at 163.322

Id. at 149; H. FRIEDLANDER, THE ORIGINS OF NAZI GENOCIDE: FROM EUTHANASIA TO323

THE FINAL SOLUTION 97 (1995). BURLEIGH, supra note 321, at 147; FRIEDLANDER, supra note 323, at 97.324

BURLEIGH, supra note 321, at 150; FRIEDLANDER, supra note 323, at 295-302.325



be prohibited because it is a rational choice. Value judgment again, this327

time on what is rational. Yet it can be argued, and on firmer grounds, thatthe choice to use heroin is less irrational than the decision to have oneselfkilled. An addict is very much a living person with many choices open tohim, including the choice to undergo detoxicating treatment; a dead man hasno choices.

Singer’s argument in favor of voluntary euthanasia for the incurably illand suffering persons is inconsistent. If respect for a person’s autonomy328

is the reason to kill him upon his request, why must this person be329

incurable, suffering, or even sick? Aren’t healthy people autonomouspersons? Since Singer does not recognize the autonomy of healthy individu-als, he does not recognize the autonomy of human beings in general. He has,therefore, no right to put forward personal autonomy as an argument foreuthanasia.

Drawing hard conclusions from soft premises is Singer’s frequent error.If we aid the Third World by donating the ten percent of our income,arbitrarily proposed by Singer, we are righteous men, but if we give less,330

we are murderers. Singer approves of killing “someone who has not331

consented to being killed, but if asked would have consented.” What332

someone would have said “if asked” is an uncertain premise, but if we killhim based on that uncertain premise, the resulting death is certain.

Singer argues that one may waive the right to life because “it is anessential feature of a right that one can waive [it].” The utilitarian tradition,which Singer here abandons, used to offer a sounder logic. “Over himself,over his body and mind, the individual is sovereign,” wrote John Stuart Mill,but “an engagement by which a person should sell himself . . . as a slavewould be null and void . . . . The reason for not interfering . . . with a person’svoluntary acts is consideration for his liberty . . . . But by selling himself fora slave, he abdicated his liberty . . . He therefore defeats . . . the very purposewhich is justification of allowing him to dispose of himself.” Mill’s333

objection is a fortiori valid against the freedom to have oneself killed, as thiswould abolish the person’s freedom once and for all.

All Criticism On Principle, to which utilitarianism has been subjectedfor almost two centuries, and which utilitarians never were able to refute,applies to Singer’s philosophy. Is it true that “Nature has placed mankindunder the governance of two sovereign masters, pain and pleasure”? No,334

Id. at 199-200.327

Id. at 193-200.328

Id. at 194-95.329

Id. at 246.330

Id. at 222-24.331

Id. at 179.332

MILL, supra note 294, at 173.333

Bentham, supra note 288,at 65.334



it is not true, and even the very dichotomy of pain versus pleasure is false.Everything that is important in a human being’s life, growing up, learning,love, marriage, giving birth, parenthood, work and creativity, ambition andstruggle—all this brings about happiness and sorrow, pain and pleasureinseparably tied together, and people by no means shun these happeningsand strivings, they seek them passionately.

People act out of a sense of duty, stand up against injustice, risk theirown lives for the sake of others, toil and mortify themselves in search ofperfection, and none of these endeavors fits the utilitarian description ofman’s aim.

The utilitarian doctrine completely disregards the real contents of aperson’s life. Gradation of values, the source of all diversity and richness inour lives, does not exist for a utilitarian: eating a freshly baked roll andmaking a scientific discovery are converted to a common currency and addedup.

The utilitarian seeks the balance of general happiness by adding up allpeople’s pleasures and subtracting all pains. The fallacy of this moralarithmetic is evident. Mankind only exists as individual human beings. Onlyindividuals suffer or are happy. There is no intermediate moral substancebetween individuals, no common pool of happiness. The pleasures orsufferings of an individual cannot be added to or subtracted from those ofother people’s. Wrongs done to a human being cannot be compensated,outweighed, or justified by increased happiness of other persons: theyremain wrongs.

John Rawls correctly pointed out that in pursuit of greater happiness ofthe greatest numbers utilitarianism justifies the sacrifice of innocent personsfor the general welfare. Let’s note that this principle can even justify acts ofextreme violence if perpetrated by large crowds to their full satisfaction, atthe expense of a few victims, for example, pogroms, lynching, or cannibal-ism, which allows all the villagers to enjoy the nutritive and magic propertiesof the organs of the one person sacrificed. Not so, reassure us John S. Milland Peter Singer: justice takes precedence. Not that justice derives from anysource other than utility: it provides the sense of security people so muchneed. However, if justice is not an independent moral principle, but onefounded on utility, the protection it lends in unreliable. Other utilitarianconsiderations may prevail. Exterminating a hated minority may bring thepopulace a stronger feeling of security than justice ever would.

It is his defense of animals that has originally helped Singer to win somany followers; but he is not a reliable defender of our biological brethren.In fact, some of Singer’s views can be used to justify the extermination ofwhole animal species. Singer’s doctrine that the wrongfulness of killingdepends on the degree of consciousness of the prospective victim isparticularly dangerous in this respect. At present, some frogs are threatenedwith extinction, but why should we protect them since their level of


consciousness is rather low? And why shouldn’t we exterminate some fish,or burrowing rodents, which have hardly a memory of their past, noawareness of their own identity, no conceivable will to continue theirexistence, and distinct plans for the future? We are free to do that, evenmore so if the removal of that species will create more space for another one,blessed with a higher degree of consciousness.

It has often been argued that utilitarianism is a “parasitic” philosophybecause it subsists on criticism of other systems. Singer excels in pointingout the inconsistencies of intuitive and deontological ethics. We proclaim thesanctity of all life but do not hesitate to pull up a cabbage. And would weattempt indefinitely to keep alive a child born without brains and missingmost of his skull? But Singer’s claim to victory is mistaken. Intuitive andduty-based ethical systems can live with some inconsistencies. These ethicalsystems have never claimed full consistency, perhaps because it was felt thatman, life, and the universe did not seem to exist or operate in a fullyconsistent way. It is the reasoned utilitarian ethics that stands or falls withits consistency. It falls. Why is “happiness of the greatest number” thestandard? Reason can also justify opposite aims, for example, “happiness formyself and misery for everybody else.” The choice of the “happiness for thegreatest number” was Bentham’s moral intuition. It turns out the utilitarianethics flow from a source utilitarianism has forsworn and condemned.

But it is not only this original sin of inconsistency, there is more. Thereader of Practical Ethics has accompanied Dr. Singer on the vertiginousadventure of that book, construing with him consequentialist ethics free ofmoral intuitions, only to be told that “[i]n real life . . . it is simply notpractical to try to calculate the consequences . . . of every choice we make .. . . It would be better if, for our everyday ethical life, we adopt . . . soundlychosen intuitive moral principles.” The view is Richard M. Hare’s, but335

Singer concurs. This is not just a pragmatic concession, this is a capitulationon principle. Singer has himself admitted that “an ethical judgment that isno good in practice must suffer from a theoretical defect as well, for thewhole point of ethical judgment is to guide practice.”336

I wholeheartedly respond to Singer’s appeal never to torment animals,and, if possible, to avoid killing them. But we don’t owe it to them, we oweit to ourselves. Animals are objects of our moral order; a moral order theyhaven’t created and cannot obey. Only Man has attempted that. Abandoningthe human point of view and adopting that of the universe, Singer tries tocreate a scientific system of ethics that is not partial to Man. We are throwninto a nightmarish moral moonscape where the strong and the “normal” stayalive, but the weak and “different” are killed, where murdering children is nocrime, and the pleasures of a sadistic killer are a positive moral value to be

SINGER, supra note 302, at 92-93.335

Id. at 2.336



it is not true, and even the very dichotomy of pain versus pleasure is false.Everything that is important in a human being’s life, growing up, learning,love, marriage, giving birth, parenthood, work and creativity, ambition andstruggle—all this brings about happiness and sorrow, pain and pleasureinseparably tied together, and people by no means shun these happeningsand strivings, they seek them passionately.

People act out of a sense of duty, stand up against injustice, risk theirown lives for the sake of others, toil and mortify themselves in search ofperfection, and none of these endeavors fits the utilitarian description ofman’s aim.

The utilitarian doctrine completely disregards the real contents of aperson’s life. Gradation of values, the source of all diversity and richness inour lives, does not exist for a utilitarian: eating a freshly baked roll andmaking a scientific discovery are converted to a common currency and addedup.

The utilitarian seeks the balance of general happiness by adding up allpeople’s pleasures and subtracting all pains. The fallacy of this moralarithmetic is evident. Mankind only exists as individual human beings. Onlyindividuals suffer or are happy. There is no intermediate moral substancebetween individuals, no common pool of happiness. The pleasures orsufferings of an individual cannot be added to or subtracted from those ofother people’s. Wrongs done to a human being cannot be compensated,outweighed, or justified by increased happiness of other persons: theyremain wrongs.

John Rawls correctly pointed out that in pursuit of greater happiness ofthe greatest numbers utilitarianism justifies the sacrifice of innocent personsfor the general welfare. Let’s note that this principle can even justify acts ofextreme violence if perpetrated by large crowds to their full satisfaction, atthe expense of a few victims, for example, pogroms, lynching, or cannibal-ism, which allows all the villagers to enjoy the nutritive and magic propertiesof the organs of the one person sacrificed. Not so, reassure us John S. Milland Peter Singer: justice takes precedence. Not that justice derives from anysource other than utility: it provides the sense of security people so muchneed. However, if justice is not an independent moral principle, but onefounded on utility, the protection it lends in unreliable. Other utilitarianconsiderations may prevail. Exterminating a hated minority may bring thepopulace a stronger feeling of security than justice ever would.

It is his defense of animals that has originally helped Singer to win somany followers; but he is not a reliable defender of our biological brethren.In fact, some of Singer’s views can be used to justify the extermination ofwhole animal species. Singer’s doctrine that the wrongfulness of killingdepends on the degree of consciousness of the prospective victim isparticularly dangerous in this respect. At present, some frogs are threatenedwith extinction, but why should we protect them since their level of


consciousness is rather low? And why shouldn’t we exterminate some fish,or burrowing rodents, which have hardly a memory of their past, noawareness of their own identity, no conceivable will to continue theirexistence, and distinct plans for the future? We are free to do that, evenmore so if the removal of that species will create more space for another one,blessed with a higher degree of consciousness.

It has often been argued that utilitarianism is a “parasitic” philosophybecause it subsists on criticism of other systems. Singer excels in pointingout the inconsistencies of intuitive and deontological ethics. We proclaim thesanctity of all life but do not hesitate to pull up a cabbage. And would weattempt indefinitely to keep alive a child born without brains and missingmost of his skull? But Singer’s claim to victory is mistaken. Intuitive andduty-based ethical systems can live with some inconsistencies. These ethicalsystems have never claimed full consistency, perhaps because it was felt thatman, life, and the universe did not seem to exist or operate in a fullyconsistent way. It is the reasoned utilitarian ethics that stands or falls withits consistency. It falls. Why is “happiness of the greatest number” thestandard? Reason can also justify opposite aims, for example, “happiness formyself and misery for everybody else.” The choice of the “happiness for thegreatest number” was Bentham’s moral intuition. It turns out the utilitarianethics flow from a source utilitarianism has forsworn and condemned.

But it is not only this original sin of inconsistency, there is more. Thereader of Practical Ethics has accompanied Dr. Singer on the vertiginousadventure of that book, construing with him consequentialist ethics free ofmoral intuitions, only to be told that “[i]n real life . . . it is simply notpractical to try to calculate the consequences . . . of every choice we make .. . . It would be better if, for our everyday ethical life, we adopt . . . soundlychosen intuitive moral principles.” The view is Richard M. Hare’s, but335

Singer concurs. This is not just a pragmatic concession, this is a capitulationon principle. Singer has himself admitted that “an ethical judgment that isno good in practice must suffer from a theoretical defect as well, for thewhole point of ethical judgment is to guide practice.”336

I wholeheartedly respond to Singer’s appeal never to torment animals,and, if possible, to avoid killing them. But we don’t owe it to them, we oweit to ourselves. Animals are objects of our moral order; a moral order theyhaven’t created and cannot obey. Only Man has attempted that. Abandoningthe human point of view and adopting that of the universe, Singer tries tocreate a scientific system of ethics that is not partial to Man. We are throwninto a nightmarish moral moonscape where the strong and the “normal” stayalive, but the weak and “different” are killed, where murdering children is nocrime, and the pleasures of a sadistic killer are a positive moral value to be

SINGER, supra note 302, at 92-93.335

Id. at 2.336



weighed in the balance of general happiness. We are told this is the NewMorality, but in fact it is quite ancient. I am sure it prevailed in theNeanderthal.

Chapter XXIII. Doctors Who Practice EuthanasiaEven in the early days some observers warned that euthanasia was not

just another procedure added to the medical practice but would change thephysician’s whole attitude and also their professional performance. Thepredictions proved right.

Handling the Facts of the Case. Dutch doctors are excellently trainedprofessionals and many of them are strikingly talented individuals. Familyphysicians impress the specialists by their ability to report from memoryevery patient’s medical history in every detail. And yet two series of caseshave been published, one by Innemee from the Dutch Patients’Association, and the other by myself, showing factual errors, misrepre-337 338

sentation of the facts, and negligence on the part of doctors in their attemptsto justify euthanasia.

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

When transferring to me an acutely ill patient with myocardialinfarction and pulmonary edema, an internist colleague of mine tried topersuade me to let the patient die “because he was a widower without family,entirely alone in the world.” Of course, that argument had no influence onmy actions and also proved untrue. This patient, Mr. T, was under my carefor the next eight years and always came to the outpatient clinic accompa-nied by his loving sons, daughters, and in-laws.

After examining a woman patient of mine, the consulting neurologistwrote in his opinion: “this elderly man is deeply comatose and, in my view,should not be resuscitated again.” Having examined the patient, this doctor

C. Innemee, Commissie Remmelink krijgt zes gevallen voorgelegd: NPV geeft337

voorbeelden van ongevraagde levensbeeingdiging [Six Cases Presented to the RemmelinkCommittee: Dutch Patients’ Association Presents Examples of Termination of Life WithoutRequest], in ZORG (Veenendaal), Vol. 8, No. 4, 1990, at 4-5.

R. FENIGSEN, EUTHANASIE, EEN WELDAAD? [Charitable Euthanasia?] 69-72, 83-84338

(Van Loghum Slaterus, Deventer 1987).


still did not know whether the patient was a man or woman, but he did knowthat this person’s life should not be prolonged. To be sure, the patient’s sexhad no bearing on the conclusion; but the incident showed that decisionsabout life and death could be made in a distracted state of mind.

The actions of Dr. W were not marked by scrupulousness, to put it339

mildly. This doctor, who routinely put patients to death without theirconsent or knowledge, considered it unnecessary personally to examine thepatient before making such a decision. If, when making his (quick) wardrounds, he had the impression that a patient was in critical condition, hewould ask the nurse: “Is hij euthanasieachtig?” [“Is he suitable for euthana-sia?”] The nurse’s answer would decide the patients fate. In the case cited inChapter XXIV, Dr. W ordered that the patient be given a lethal injectionthough nobody knew what was wrong with the patient (if anything). Thepatient was in a dimmed state during the ward round because he had beenstupefied by valium (diazepam), which that same Dr. W had prescribed a fewdays before. Dr. W had forgotten that he had prescribed valium and it didnot occur to him that this might have been the cause of the patient’sstupefaction. He did not even glance at the patient’s chart which would showthat the patient was receiving the drug.

That’s how scrupulously the doctors proceeded who attempted tosubject patients to euthanasia. In my entire medical career I have neverencountered such a series of crude errors and transgressions as thosecommitted by doctors in their rush to euthanasia: lies, distortion of fact,impaired powers of observation and concentration (to mistake a woman fora man!), and, finally, complete negligence and carelessness as displayed byDr. W.

Such wholesale departure from the rules of professional conduct cannotbe accidental, it must have definite causes. In part, this has a simpleexplanation. In fact, it is not surprising that the “euthanasia doctors”overlook, distort, or disregard facts; rather it is surprising that “ordinary”doctors are able to master and remember such an immense number of factsconcerning their patients. There are dozens of patients from 10, 20, or even40 years back whom I and my colleagues still recall with all the details of thecourse their illness ran. Practicing doctors keep in their memory innumera-ble points of information concerning all their hospital patients andoutpatients. I set myself the task of analyzing the case history of one gravelyill elderly man; he was in congestive heart failure due to aortic and mitralvalvular heart disease. Six thousand two hundred pieces of information weregathered on him in four years of outpatient treatment and during his threestays in the hospital. In my daily work during this patient’s third hospitaliza-tion I used the data arranged in more than 130 complex information sets

See subsec. entitled Healer of Mankind’s Afflictions, in Ch. XXIV (to be published in339

a future edition of Issues in Law & Medicine).



weighed in the balance of general happiness. We are told this is the NewMorality, but in fact it is quite ancient. I am sure it prevailed in theNeanderthal.

Chapter XXIII. Doctors Who Practice EuthanasiaEven in the early days some observers warned that euthanasia was not

just another procedure added to the medical practice but would change thephysician’s whole attitude and also their professional performance. Thepredictions proved right.

Handling the Facts of the Case. Dutch doctors are excellently trainedprofessionals and many of them are strikingly talented individuals. Familyphysicians impress the specialists by their ability to report from memoryevery patient’s medical history in every detail. And yet two series of caseshave been published, one by Innemee from the Dutch Patients’Association, and the other by myself, showing factual errors, misrepre-337 338

sentation of the facts, and negligence on the part of doctors in their attemptsto justify euthanasia.

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

When transferring to me an acutely ill patient with myocardialinfarction and pulmonary edema, an internist colleague of mine tried topersuade me to let the patient die “because he was a widower without family,entirely alone in the world.” Of course, that argument had no influence onmy actions and also proved untrue. This patient, Mr. T, was under my carefor the next eight years and always came to the outpatient clinic accompa-nied by his loving sons, daughters, and in-laws.

After examining a woman patient of mine, the consulting neurologistwrote in his opinion: “this elderly man is deeply comatose and, in my view,should not be resuscitated again.” Having examined the patient, this doctor

C. Innemee, Commissie Remmelink krijgt zes gevallen voorgelegd: NPV geeft337

voorbeelden van ongevraagde levensbeeingdiging [Six Cases Presented to the RemmelinkCommittee: Dutch Patients’ Association Presents Examples of Termination of Life WithoutRequest], in ZORG (Veenendaal), Vol. 8, No. 4, 1990, at 4-5.

R. FENIGSEN, EUTHANASIE, EEN WELDAAD? [Charitable Euthanasia?] 69-72, 83-84338

(Van Loghum Slaterus, Deventer 1987).


still did not know whether the patient was a man or woman, but he did knowthat this person’s life should not be prolonged. To be sure, the patient’s sexhad no bearing on the conclusion; but the incident showed that decisionsabout life and death could be made in a distracted state of mind.

The actions of Dr. W were not marked by scrupulousness, to put it339

mildly. This doctor, who routinely put patients to death without theirconsent or knowledge, considered it unnecessary personally to examine thepatient before making such a decision. If, when making his (quick) wardrounds, he had the impression that a patient was in critical condition, hewould ask the nurse: “Is hij euthanasieachtig?” [“Is he suitable for euthana-sia?”] The nurse’s answer would decide the patients fate. In the case cited inChapter XXIV, Dr. W ordered that the patient be given a lethal injectionthough nobody knew what was wrong with the patient (if anything). Thepatient was in a dimmed state during the ward round because he had beenstupefied by valium (diazepam), which that same Dr. W had prescribed a fewdays before. Dr. W had forgotten that he had prescribed valium and it didnot occur to him that this might have been the cause of the patient’sstupefaction. He did not even glance at the patient’s chart which would showthat the patient was receiving the drug.

That’s how scrupulously the doctors proceeded who attempted tosubject patients to euthanasia. In my entire medical career I have neverencountered such a series of crude errors and transgressions as thosecommitted by doctors in their rush to euthanasia: lies, distortion of fact,impaired powers of observation and concentration (to mistake a woman fora man!), and, finally, complete negligence and carelessness as displayed byDr. W.

Such wholesale departure from the rules of professional conduct cannotbe accidental, it must have definite causes. In part, this has a simpleexplanation. In fact, it is not surprising that the “euthanasia doctors”overlook, distort, or disregard facts; rather it is surprising that “ordinary”doctors are able to master and remember such an immense number of factsconcerning their patients. There are dozens of patients from 10, 20, or even40 years back whom I and my colleagues still recall with all the details of thecourse their illness ran. Practicing doctors keep in their memory innumera-ble points of information concerning all their hospital patients andoutpatients. I set myself the task of analyzing the case history of one gravelyill elderly man; he was in congestive heart failure due to aortic and mitralvalvular heart disease. Six thousand two hundred pieces of information weregathered on him in four years of outpatient treatment and during his threestays in the hospital. In my daily work during this patient’s third hospitaliza-tion I used the data arranged in more than 130 complex information sets

See subsec. entitled Healer of Mankind’s Afflictions, in Ch. XXIV (to be published in339

a future edition of Issues in Law & Medicine).



I vividly recall a 14 year old girl who two years before the event heredescribed had been examined for fainting spells. At that time the pediatri-cian found nothing and declared her in good health. Now she fell uncon-scious on the school’s sports field. Those on the scene began heart massageand mouth-to-mouth ventilation. When the ambulance arrived, it turned outthat the girl had ventricular fibrillation (a fatal disturbance in the heart’selectrical activity, which can, however, be reversed by a shock from anelectric defibrillator). The attendants defibrillated the girl and she wasbrought to our emergency room, breathing and with a normally beatingheart, but still unconscious. I found a young pediatrician with her and askedhim why he was not moving the patient to the intensive care unit whichoffered optimal facilities for resuscitation; after all, she might relapse inventricular fibrillation! “Oh, in that case I wouldn’t do anything further,”said the pediatrician—that is, he would allow the girl to die.

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

My voice hasn’t been the only one to warn that euthanasia, or even itsmental acceptance by doctors, leads to abandonment of viable treatmentoptions. Similar observations had been reported early on by other Dutch andAmerican authors. Then, the nationwide surveys, ordered by the Dutch340

government in 1990 and 1995, indicated that the trend was significantly341

I. van der Sluis, Mal-informed non-consent en andere medische gevaren van340

euthanasie [Mal-informed Non-consent and Other Dangers of Euthanasia], 128 NED.TIJDSCHRIFT V. GENEESKUNDE 1247 (1984); D. L. Jackson & S. Younger, Patient Autonomy and“Death With Dignity”: Some Clinical Caveats, 301 NEW ENG. J. MED. 404 (1979).

MEDISCHE BESLISSINGEN ROND HET LEVENSEINDE. I. RAPPORT VAN DE COMMISSIE341

ONDERZOEK MEDISCHE PRAKTIJK INZAKE EUTHANASIE. II. HET ONDERZOEK VOOR DE COMMISSIE

MEDISCHE PRAKTIJK INZAKE EUTHANASIE [Medical Decisions About the End of Life. I. Report ofthe Committee to Study the Medical practice Concernign Euthanasia. II. The Study for theCommittee on Medical Practice Concerning Euthanasia] (State Publishing House SDU, TheHague 1991) [hereinafter “REPORT I” and “REPORT II,” respectively]. Volume I has not beentranslated. Volume II appeared in English translation in P. J. VAN DER MAAS, J. J. M. VAN

DELDEN, & L. PIJNENBORG, EUTHANASIA AND OTHER MEDICAL DECISIONS CONCERNING THE END

OF LIFE: AN INVESTIGATION PERFORMED UPON THE REQUEST OF THE COMMISSION OF INQUIRY INTO

THE MEDICAL PRACTICE CONCERNING EUTHANASIA (Elsevier, Amsterdam-London-New York-


such as “the kidney function gets but moderately impaired under diuretictreatment,” “pleural effusion recurs with three days after each tapping,” “therelative tricuspid incompetence had disappeared,” etc. To retain this amountof complex data and use it all effectively requires a considerable mentaleffort which is only possible when the doctor is constantly, strongly, andunambiguously motivated. Why should a doctor make such extraordinaryeffort if he has already written off the patient?

But that only explains the carelessness of “euthanasia doctors” in part.To put someone to death with impunity, with a clear conscience, in the beliefthat one is doing the right thing, excites certain people. This could be seenin the days of the death penalty in England: before each execution excitedcrowds would gather at the prison gate. The instances cited in this chaptershow that some of the doctors who practice euthanasia are no strangers tothis kind of excitement. They make their great decision, are powerfullydriven to put it into effect, and will not allow any minor, inconvenient factsto stand in their way.

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

“Oh, that’s good,” said the doctors, “uremic patients who developpericarditis soon die of hyperkalemia (excess of potassium in blood), andthat’s an easy death.

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

On his first day at work in Nakskov Hospital’s coronary care unit, ayoung doctor told me that his primary interest was “scientifically basedcontraindications to resuscitation, a precise definition of cases in which oneshould not reanimate.” He had come to work in a unit that had been createdto resuscitate people, to reactivate “hearts that are too good to die.” He hadnot yet taken part in any resuscitation, still did not know the practical sideof the procedure, the difficulties entailed, and how to avoid these; but thatdid not interest him. What interested him was the “scientific basis” for doingnothing and waiting for patients to die. In the mind of this young maneuthanasia was replacing medicine!



I vividly recall a 14 year old girl who two years before the event heredescribed had been examined for fainting spells. At that time the pediatri-cian found nothing and declared her in good health. Now she fell uncon-scious on the school’s sports field. Those on the scene began heart massageand mouth-to-mouth ventilation. When the ambulance arrived, it turned outthat the girl had ventricular fibrillation (a fatal disturbance in the heart’selectrical activity, which can, however, be reversed by a shock from anelectric defibrillator). The attendants defibrillated the girl and she wasbrought to our emergency room, breathing and with a normally beatingheart, but still unconscious. I found a young pediatrician with her and askedhim why he was not moving the patient to the intensive care unit whichoffered optimal facilities for resuscitation; after all, she might relapse inventricular fibrillation! “Oh, in that case I wouldn’t do anything further,”said the pediatrician—that is, he would allow the girl to die.

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

My voice hasn’t been the only one to warn that euthanasia, or even itsmental acceptance by doctors, leads to abandonment of viable treatmentoptions. Similar observations had been reported early on by other Dutch andAmerican authors. Then, the nationwide surveys, ordered by the Dutch340

government in 1990 and 1995, indicated that the trend was significantly341

I. van der Sluis, Mal-informed non-consent en andere medische gevaren van340

euthanasie [Mal-informed Non-consent and Other Dangers of Euthanasia], 128 NED.TIJDSCHRIFT V. GENEESKUNDE 1247 (1984); D. L. Jackson & S. Younger, Patient Autonomy and“Death With Dignity”: Some Clinical Caveats, 301 NEW ENG. J. MED. 404 (1979).

MEDISCHE BESLISSINGEN ROND HET LEVENSEINDE. I. RAPPORT VAN DE COMMISSIE341

ONDERZOEK MEDISCHE PRAKTIJK INZAKE EUTHANASIE. II. HET ONDERZOEK VOOR DE COMMISSIE

MEDISCHE PRAKTIJK INZAKE EUTHANASIE [Medical Decisions About the End of Life. I. Report ofthe Committee to Study the Medical practice Concernign Euthanasia. II. The Study for theCommittee on Medical Practice Concerning Euthanasia] (State Publishing House SDU, TheHague 1991) [hereinafter “REPORT I” and “REPORT II,” respectively]. Volume I has not beentranslated. Volume II appeared in English translation in P. J. VAN DER MAAS, J. J. M. VAN

DELDEN, & L. PIJNENBORG, EUTHANASIA AND OTHER MEDICAL DECISIONS CONCERNING THE END

OF LIFE: AN INVESTIGATION PERFORMED UPON THE REQUEST OF THE COMMISSION OF INQUIRY INTO

THE MEDICAL PRACTICE CONCERNING EUTHANASIA (Elsevier, Amsterdam-London-New York-


such as “the kidney function gets but moderately impaired under diuretictreatment,” “pleural effusion recurs with three days after each tapping,” “therelative tricuspid incompetence had disappeared,” etc. To retain this amountof complex data and use it all effectively requires a considerable mentaleffort which is only possible when the doctor is constantly, strongly, andunambiguously motivated. Why should a doctor make such extraordinaryeffort if he has already written off the patient?

But that only explains the carelessness of “euthanasia doctors” in part.To put someone to death with impunity, with a clear conscience, in the beliefthat one is doing the right thing, excites certain people. This could be seenin the days of the death penalty in England: before each execution excitedcrowds would gather at the prison gate. The instances cited in this chaptershow that some of the doctors who practice euthanasia are no strangers tothis kind of excitement. They make their great decision, are powerfullydriven to put it into effect, and will not allow any minor, inconvenient factsto stand in their way.

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

“Oh, that’s good,” said the doctors, “uremic patients who developpericarditis soon die of hyperkalemia (excess of potassium in blood), andthat’s an easy death.

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

On his first day at work in Nakskov Hospital’s coronary care unit, ayoung doctor told me that his primary interest was “scientifically basedcontraindications to resuscitation, a precise definition of cases in which oneshould not reanimate.” He had come to work in a unit that had been createdto resuscitate people, to reactivate “hearts that are too good to die.” He hadnot yet taken part in any resuscitation, still did not know the practical sideof the procedure, the difficulties entailed, and how to avoid these; but thatdid not interest him. What interested him was the “scientific basis” for doingnothing and waiting for patients to die. In the mind of this young maneuthanasia was replacing medicine!



narrowing the range of therapeutic interventions. It showed that in manycases doctors proceeded to active euthanasia and disregarded the existingtreatment options. When “passive euthanasia” was intended (25,000 cases342

in 1990), doctors arbitrarily withheld or withdrew potentially effectivetreatments.343

How Do We Treat a Cardiac Emergency. The following example will344

illustrate how the acceptance of euthanasia is influencing the performanceof highly skilled nurses at an intensive care unit.

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

The internist, however, had ordered “NR” (not to resuscitate) thispatient (Fig 3). Therefore, the nurses had not reacted in any way to theemergency seen on the monitor ECG. Moreover, the medicines whichworsen (and probably had caused) the patient’s slow heart rhythm, the beta-blocker sotacor and the digoxin, were not stopped! (Fig. 3). Medicine’s basicrule—“Whether or not you can help, first of all, do no harm!”—was no longervalid.

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

A substantial study showed that “Do Not Resuscitate” (DNR) ordersinhibit doctors’ readiness to administer other treatments, those unrelatedto resuscitation. If the patient had a DNR order, the doctors were signifi-

Tokyo 1992). [The page numbers quoted in the present chapter refer to the Dutch original.] REPORT II, supra note 341, at 45 (Table 5.7), & 62 (Table 6.5); G. VAN DER WAL & P.342

J. VAN DER MAAS, EUTHANASIE EN ANDERE MEDISCHE BESLISSINGEN ROND HET LEVENS EINDE

[Euthanasia and Other Medical Decisions Concerning the End of Life] 56 (Table 5.5) (SduPublishing House, The Hague 1996).

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

This case was previously reported in Richard Fenigsen, Physician-Assisted Death in344

the Netherlands: Impact on Long-Term Care, 11 ISSUES IN LAW & MED. 283, 296-97 (1995).


[Insert Fig. 2 here]




narrowing the range of therapeutic interventions. It showed that in manycases doctors proceeded to active euthanasia and disregarded the existingtreatment options. When “passive euthanasia” was intended (25,000 cases342

in 1990), doctors arbitrarily withheld or withdrew potentially effectivetreatments.343

How Do We Treat a Cardiac Emergency. The following example will344

illustrate how the acceptance of euthanasia is influencing the performanceof highly skilled nurses at an intensive care unit.

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

The internist, however, had ordered “NR” (not to resuscitate) thispatient (Fig 3). Therefore, the nurses had not reacted in any way to theemergency seen on the monitor ECG. Moreover, the medicines whichworsen (and probably had caused) the patient’s slow heart rhythm, the beta-blocker sotacor and the digoxin, were not stopped! (Fig. 3). Medicine’s basicrule—“Whether or not you can help, first of all, do no harm!”—was no longervalid.

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

A substantial study showed that “Do Not Resuscitate” (DNR) ordersinhibit doctors’ readiness to administer other treatments, those unrelatedto resuscitation. If the patient had a DNR order, the doctors were signifi-

Tokyo 1992). [The page numbers quoted in the present chapter refer to the Dutch original.] REPORT II, supra note 341, at 45 (Table 5.7), & 62 (Table 6.5); G. VAN DER WAL & P.342

J. VAN DER MAAS, EUTHANASIE EN ANDERE MEDISCHE BESLISSINGEN ROND HET LEVENS EINDE

[Euthanasia and Other Medical Decisions Concerning the End of Life] 56 (Table 5.5) (SduPublishing House, The Hague 1996).

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

This case was previously reported in Richard Fenigsen, Physician-Assisted Death in344

the Netherlands: Impact on Long-Term Care, 11 ISSUES IN LAW & MED. 283, 296-97 (1995).




Figure 2

Figure 3



cantly less willing to order blood cultures, place a central line, or give bloodtransfusions.345

Carefulness and Professional Integrity. It has been repeatedly stated inthe Dutch euthanasia debate that doctors should act with due care. This is,indeed, a legitimate demand to make of any person and any action andespecially of a doctor. But need a doctor who decides to terminate a person’slife also act with such scrupulousness? A number of reports from Hollandindicate that he need not. Published cases and studies revealed graveerrors and criminal negligence on the part of doctors carrying out346 347

euthanasia, lethal injections administered to get rid of troublesomepatients, or to free a needed hospital bed, decisions taken and euthana-348 349

sia carried out in unseemly haste, lethal injections given to patients who350

had clearly stated they did not want euthanasia, euthanasia carried out by351

doctors aware that the patients had been coerced to ask for death.352

M.C. Beach & R.S. Morrison, The Effect of Do-Not-Resuscitate Orders on Physician345

Decision-Making, 50 J. AM. GERIATRIC SOC. 2057 (2002). Innemmee, supra note 337.346

Bedoelingen arts waren good: Voorwaardelijke celstraf voor “slordige” euthanasie347

[The Doctor Had Good Intentions: Probation for “Sloppy” Euthanasia], BRABANTS DAGBLAD,Oct. 22, 1995; F. Abrahams, De huisarts die het niet zo nauw nam [The Family Physician WhoDid Not Take It Too Scrupulously], NRC HANDELSBLAD, May 23, 1995.

Verzorgingshuizen in opspraak: Het onnodig sterven [Rumors About Nursing348

Homes: The Unnecessary Deaths], ELZEVIERS MAG., Apr. 20, 1995; “Euthanasie” vertaald inviervoudig moord [“Euthanasia” Turns Out to be Murder of Four People], BRABANTS

DAGBLAD, July 24, 1985; Arts bekent vijfmaal euthanasie [Physician Admits HavingPerformed Euthanasia on Five Persons], BRABANTS DAGBLAD, Apr. 17, 1985.

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

F.T. Diemen-Lindeboom, in DE DOOD, UITKOMST VOOR HET LEVEN? [Death as350

Deliverance From Life?] 109-110 (Bueten & Schipperheyn, Amsterdam 1987); G. VAN DER WAL

ET AL., MEDISCHE BESLUITVORMING AAN HET EINDE VAN HET LEVEN: DE PRAKTIJK EN DE TOETSING

PROCEDURE [Medical Decisionmaking at the End of Life: The Practice and the Checking andVerifying Procedure] 52-53 (De Tijdstroom, Utrecht 2003).

Geen straf arts voor euthanasie: van Ooijen wel schuldig van moord [No351

Punishment for the Doctor Who Performed Euthanasia: But the Court Did Find (Dr.) VanOoijen Guilty of Murder], BRABANTS DAGBLAD, Feb. 22, 2001. The seemingly paradoxicalruling (doctor guilty of murder, no punishment) is typical of the Dutch legal situation. See alsothe case of the “young patient who clung to life” and was, nevertheless, killed by the chestphysician. See subsec. entitled Impatient Chest Physician, in Ch. XXIV (to be published in afuture edition of Issues in Law & Medicine).


EUTHANASIE? [She Had to go First . . . The Van Bommelen File: A Case of Euthanasia?](Strengholt Pub. Naarden 1984); Waarom heeft Wibo niet ingegrepen? [Why (the TVjournalist) Wibo (van den Linden) Did Not Intervene? ZONDAG (Beusichem), Jan. 22, 1984;G.A. Lindeboom, Een z.g. euthanasie-drama [The Drama of the So-Called Euthanasia], 11VITA HUMANA 100 (1984); H. TEN HAVE & G. KIMSMA, GENEESKUNDE TUSSEN DRROM EN DRAMA

[Medicine Between Dream and Drama] 83-87 (Kik-Agora Pub., Kampen 1987); G.F.Koerselman, Hoe mondig zijn moderne patienten? [How Mature are the Modern Patients?],130 NED. TIJDSCHRIFT V. GENEESKUNDE 2017 (1986).


Are these exceptional deviations from an otherwise orderly andconscientious practice? Alas, this is not so. The nationwide surveys of thepractice of euthanasia ordered by the Dutch government in 1990 and againin 1995 revealed that the doctors practicing euthanasia, that is, the majorityof the Dutch medical profession, in an exceedingly high percentage of casestransgressed the “rules of careful conduct” established by the authorities.353

Should Doctors Promote Death? The New Role of the Physician. Facinga patient with a chronic and incapacitating illness the “traditional” doctortried to improve her condition, relieve her symptoms, avoid side effects, andgive her some encouragement. But now we are witnessing a completereversal of the aims of medicine. The following case history, perhaps the354

saddest in my experience, illustrates the physician’s “new role.”Mrs. P was a seventy-two year old widow who after a bad myocardial

infarction was left with a grossly dilated heart and congestive heart failure.She was treated with digoxin, an aldosterone antagonist, a diuretic, and ananticoagulant, and for a whole year had almost no symptoms at rest. True,she needed help with cleaning her house, and her only exercise was walkinga few blocks. One night her breathlessness recurred; this required adding athird pillow and an increased dosage of the diuretic. Another time shecomplained of dizziness, which turned out to be due to a fall in bloodpressure in upright posture; she was taught the necessary precautions. Mrs.P was an extremely nice, mild-tempered lady who never showed anyimpatience and complied with the doctor’s every order and advice. Barringsome clot or a sudden disturbance in heart rhythm (both of which could ofcourse occur), she might have survived for years in that condition. When shefailed to appear at the outpatient clinic, I was very much worried. Respond-ing to my inquiry, her family physician, Dr. K, paid me a visit. He had hada talk with Mrs. P, he said, and explained the situation to her: This wasn’tgoing to get any better, and living such a limited life, with all those pills,made no sense at all. Mrs. P accepted everything he said. He stopped herpills, and three days later she died. My only answer was to nod. I couldn’temit a sound. I was overcome by deep sorrow. It returns every time I thinkof Mrs. P.

See supra Ch. XX, 26 ISSUES IN LAW & MED. 33, 69 (2010).353

Fenigsen, supra note 344, at 294-95. The case of Mrs. P was cited at the U.S.354

Congressional hearings on “physician-assisted suicide and euthanasia in the Netherlands” inSept., 1996. Report of Chairman Charles T. Canady to the Subcommittee on the Constitutionof the Committee on the Judiciary, House of Representatives, 104 Cong., 2 Sess., U.S.th

Government Printing Office, Washington, D.C., 1996.



cantly less willing to order blood cultures, place a central line, or give bloodtransfusions.345

Carefulness and Professional Integrity. It has been repeatedly stated inthe Dutch euthanasia debate that doctors should act with due care. This is,indeed, a legitimate demand to make of any person and any action andespecially of a doctor. But need a doctor who decides to terminate a person’slife also act with such scrupulousness? A number of reports from Hollandindicate that he need not. Published cases and studies revealed graveerrors and criminal negligence on the part of doctors carrying out346 347

euthanasia, lethal injections administered to get rid of troublesomepatients, or to free a needed hospital bed, decisions taken and euthana-348 349

sia carried out in unseemly haste, lethal injections given to patients who350

had clearly stated they did not want euthanasia, euthanasia carried out by351

doctors aware that the patients had been coerced to ask for death.352

M.C. Beach & R.S. Morrison, The Effect of Do-Not-Resuscitate Orders on Physician345

Decision-Making, 50 J. AM. GERIATRIC SOC. 2057 (2002). Innemmee, supra note 337.346

Bedoelingen arts waren good: Voorwaardelijke celstraf voor “slordige” euthanasie347

[The Doctor Had Good Intentions: Probation for “Sloppy” Euthanasia], BRABANTS DAGBLAD,Oct. 22, 1995; F. Abrahams, De huisarts die het niet zo nauw nam [The Family Physician WhoDid Not Take It Too Scrupulously], NRC HANDELSBLAD, May 23, 1995.

Verzorgingshuizen in opspraak: Het onnodig sterven [Rumors About Nursing348

Homes: The Unnecessary Deaths], ELZEVIERS MAG., Apr. 20, 1995; “Euthanasie” vertaald inviervoudig moord [“Euthanasia” Turns Out to be Murder of Four People], BRABANTS

DAGBLAD, July 24, 1985; Arts bekent vijfmaal euthanasie [Physician Admits HavingPerformed Euthanasia on Five Persons], BRABANTS DAGBLAD, Apr. 17, 1985.

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

F.T. Diemen-Lindeboom, in DE DOOD, UITKOMST VOOR HET LEVEN? [Death as350

Deliverance From Life?] 109-110 (Bueten & Schipperheyn, Amsterdam 1987); G. VAN DER WAL

ET AL., MEDISCHE BESLUITVORMING AAN HET EINDE VAN HET LEVEN: DE PRAKTIJK EN DE TOETSING

PROCEDURE [Medical Decisionmaking at the End of Life: The Practice and the Checking andVerifying Procedure] 52-53 (De Tijdstroom, Utrecht 2003).

Geen straf arts voor euthanasie: van Ooijen wel schuldig van moord [No351

Punishment for the Doctor Who Performed Euthanasia: But the Court Did Find (Dr.) VanOoijen Guilty of Murder], BRABANTS DAGBLAD, Feb. 22, 2001. The seemingly paradoxicalruling (doctor guilty of murder, no punishment) is typical of the Dutch legal situation. See alsothe case of the “young patient who clung to life” and was, nevertheless, killed by the chestphysician. See subsec. entitled Impatient Chest Physician, in Ch. XXIV (to be published in afuture edition of Issues in Law & Medicine).


EUTHANASIE? [She Had to go First . . . The Van Bommelen File: A Case of Euthanasia?](Strengholt Pub. Naarden 1984); Waarom heeft Wibo niet ingegrepen? [Why (the TVjournalist) Wibo (van den Linden) Did Not Intervene? ZONDAG (Beusichem), Jan. 22, 1984;G.A. Lindeboom, Een z.g. euthanasie-drama [The Drama of the So-Called Euthanasia], 11VITA HUMANA 100 (1984); H. TEN HAVE & G. KIMSMA, GENEESKUNDE TUSSEN DRROM EN DRAMA

[Medicine Between Dream and Drama] 83-87 (Kik-Agora Pub., Kampen 1987); G.F.Koerselman, Hoe mondig zijn moderne patienten? [How Mature are the Modern Patients?],130 NED. TIJDSCHRIFT V. GENEESKUNDE 2017 (1986).


Are these exceptional deviations from an otherwise orderly andconscientious practice? Alas, this is not so. The nationwide surveys of thepractice of euthanasia ordered by the Dutch government in 1990 and againin 1995 revealed that the doctors practicing euthanasia, that is, the majorityof the Dutch medical profession, in an exceedingly high percentage of casestransgressed the “rules of careful conduct” established by the authorities.353

Should Doctors Promote Death? The New Role of the Physician. Facinga patient with a chronic and incapacitating illness the “traditional” doctortried to improve her condition, relieve her symptoms, avoid side effects, andgive her some encouragement. But now we are witnessing a completereversal of the aims of medicine. The following case history, perhaps the354

saddest in my experience, illustrates the physician’s “new role.”Mrs. P was a seventy-two year old widow who after a bad myocardial

infarction was left with a grossly dilated heart and congestive heart failure.She was treated with digoxin, an aldosterone antagonist, a diuretic, and ananticoagulant, and for a whole year had almost no symptoms at rest. True,she needed help with cleaning her house, and her only exercise was walkinga few blocks. One night her breathlessness recurred; this required adding athird pillow and an increased dosage of the diuretic. Another time shecomplained of dizziness, which turned out to be due to a fall in bloodpressure in upright posture; she was taught the necessary precautions. Mrs.P was an extremely nice, mild-tempered lady who never showed anyimpatience and complied with the doctor’s every order and advice. Barringsome clot or a sudden disturbance in heart rhythm (both of which could ofcourse occur), she might have survived for years in that condition. When shefailed to appear at the outpatient clinic, I was very much worried. Respond-ing to my inquiry, her family physician, Dr. K, paid me a visit. He had hada talk with Mrs. P, he said, and explained the situation to her: This wasn’tgoing to get any better, and living such a limited life, with all those pills,made no sense at all. Mrs. P accepted everything he said. He stopped herpills, and three days later she died. My only answer was to nod. I couldn’temit a sound. I was overcome by deep sorrow. It returns every time I thinkof Mrs. P.

See supra Ch. XX, 26 ISSUES IN LAW & MED. 33, 69 (2010).353

Fenigsen, supra note 344, at 294-95. The case of Mrs. P was cited at the U.S.354

Congressional hearings on “physician-assisted suicide and euthanasia in the Netherlands” inSept., 1996. Report of Chairman Charles T. Canady to the Subcommittee on the Constitutionof the Committee on the Judiciary, House of Representatives, 104 Cong., 2 Sess., U.S.th

Government Printing Office, Washington, D.C., 1996.


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Other People’s Lives- Reflections on Medicine, Ethics, and Euthanasi