In one sense, dying is the most personal and private of all events. Each of us comes to the end of a unique life and dies his or her own death. Along with birth, death sets the natural boundaries of a particular life's trajectory. But unlike birth, the consciousness of death can define a person's plan of life. In existential terms, the consciousness of an inevitable person death provokes an anxiety that is radically individuating. The fact of my death makes this my life.(1)
Yet no aspect of human experiences is wholly personal and private. Like birth, our knowledge of death comes from others. The way we die--when, under what circumstance, and from what cause or reason--is shaped in profound ways by relationships with others and by large social and institutional forces. The symbolic significance attached to death is derived from religious and cultural realities that precede and survive individuals. And it is precisely because death is such as intensely personal and private event, so defining of the individual, that the social arrangements that attend death are so important. What could be more important for society than events that shape individuals?
The character of dying and how th dying are cared for has changed in profound ways in the last several decades.(2) In all of our prior history, death for those who reached adulthood came generally in what is now mildlife. It came swiftly, "a thief in the night." It came without significant resistance from medicine; little could be done to ward off impending death. Now death is generally an event of old age. It typically follows a long pattern of chronic illness and decline. It comes only after exhaustive medical interventions, some of which plainly increase the length and intensity of suffering and all of which increase costs to the health care system.
This change in dying, and especially its impact on the deaths of individuals, has produced a social consensus over the last two generations on a patient's or proxy's right to refuse life-sustaining medical measures, a hospice movement designed to improve the quality of life in dying, and a growing debate over legalization of doctor-assisted suicide and active euthanasia. What are the social dimensions of these developments, especially the third, since it stands before us as a social choice? Aside from real and projected impacts on individuals, how does our treatment of the terminally ill effect society as a whole? How might changes in social arrangements surrounding dying affect the common good?
These issues are taken up here under three headings. First, some general observations are offered about the notion of the common good. Second, some changes are proposed designed to better serve the common good in the way dying patients are cared for. Finally, some reasons are developed to show why legalization of doctor-assisted suicide and active euthanasia cannot serve the common good.
The Common Good
Traditionally, the common good has been the key term of articulating and assessing the implications for society as a whole of changes in social practice or public policies.(3) But the notion of the common good is problematic in our society. The idea comes to us from ancient Greco-Roman civilizations and from medieval Europe. Thus, the birth and development of the notion of the common good is derived from civilizations far more homogeneous than contemporary American. The diversity in our society--of races, ethnic groups, religions, languages, culture, and lifestyle--makes it more difficult for us to understand and assent to the idea that there is some good or goods that are of value to us as members of society irrespective of our many differences.
American politics, especially in the twentieth century, work against generation of a practical consensus on the common good. The checks and balances built into our Constitution hobble attempts to develop unitary policy visions. Moreover, interest group politics encourage the perception that the public interest is merely the balance struck among competing, highly organized, and well-financed private interests. In other words, Americans tend to think of the common good in descriptive terms instead of normative terms: how the political agenda is set and carried out by the influential few rather than what is best for the nation taken as a whole.(4)
Also, our excessive American individualism has enshrined such a thoroughgoing relativism in our cultural affairs and our intellectual life that we have become deeply skeptical about assertions of ethical goodness or badness that move beyond what any person takes to be good or bad in his or her own experience.(5) Even the most homogenous societies--say the Athens of pericles or the Florence of Machiavelli--can have deep disagreements about which choices serve the common good. American is not distinctive in his sense. Our distinctiveness lies in a dogmatic normative relativism pervading our public life: Nop one has the right to tell anyone else what is good, not only for him or her, but for us. This disposition regards claims about the common good, no matter how modest in substance and style, as arrogant and oppressive.
As a result, surprisingly little has been published on the common good in contemporary scholarly literature.(6) In John Rawls's influential Theory of Justice, for example, there are only two brief references to the notion of the common good, in spite of considerable attention to the theories of the good.(7) Thus, there is no contemporary consensus on the meaning of the notion and little explicit discussion of it.
In spite of these daunting challenges, discussion of the common good is imperative if public policy is to reflect anything more than money, opinion pools, and assertions of individuals' rights. There must be some moment in public life where this question is engaged in its simplest ethical terms: What course of action is best for us? This is especially true when the arena in question--dying and care for dying--is so important to individuals and therefore to society, the context in which individuals are made. The following brief reflections on the common good are offered in hopes of advancing such a discussion.
The common good is a good for all, not a good for each. The common good is something collective, not simply the sum of what is good for each member of the society in a distributive sense. It is a good that pertains to the general social realationships in which individuals seek specific goods. Because the common good is a general good, it may frustrate acquisition of specific goods for individuals.
Traffic lights, for example, plainly serve the common good because they allow for orderly movement through dangerous intersections. They structure social relationships in a way that serves everyone's interests generally. Yet any number of inidividuals can be frustrated by the order traffic lights impos. It plainly serves the common good to prevent environmntal destruction of rivers. The beneficiaries of this application of the common good include generations into the future. But the measures necessary to protect rivers from environmental destruction may thwart goods for others, including the creation of jobs and other economic opportunities. It serves the common good to ban romantic relationships between psychiatrists and their patients because of the emotional vulnerability of psychiatric patients. Yet this ban may frustrate many mature and conflict-free romances between some psychiatrists and patients.
In each of these cases an important public good is at stake--safety in transportation, the integrity of our natural environment, protection of the vulnerability of patients--even though other goods legitimately sought by individuals may be frustrated b y each of these. Thus, discussion of the common good cannot begin and end with what serves the good of each and every person in society. Nor can it be left an open question morally whether it is better or not to save lives at intersections, better or not ot preserve the environment, better or not to protect the valnerable from exploitation.
On the other hand, measures that serve the common good must serve the interests of individual persons in general and in the long run. It must, as the words themselves suggest, provide a mutual benefit that all can share. So the common good must include goods that serve the interest of individual persons. It cannot be use to violate an individual's basic human rights. This is an especially demanding standard in a society with strong traditions of respect for persons ans autonomy. So although the common good is not equivalent to the good of each, no good can be part of the commonm good if it does not serve the good of most individuals over time.
The tension between serving all, but not each, and yet respecting individuals can be located more precisely in the social relationships that fulfill or frustrate individual persons. The idea of the common good assumes a social realims: Society is real. It has real effects on the development and particular fates of individual persons. Changes in society can change the development and fates of individuals. These may seem modest and obvious truimsms, but they are ignored when exclusive emphasis is palced on individual autonomy. Persons can be considered autonomous ends in themselves from an ethical point of view. From this perspective, they ought to be. But empirically, persons are born into, shaped by, and satisfied or frustrated in networks of concrete means-to-end relationships: people doing things with, for, and to one another. These relationships are themselves configured by social roles and institutional forms. Autonomous agents can be killed at poorly regulated intersections. Individuals who are ends in themselves can be poisoned and denied natural beauty by pollution. Persons with incalculably great individual worth can be psychologically damaged by manipulations in unequal romantic relationships. To know and affirm these truths is to accept the reality of the social context of individual persons.
Two conclusions about the common good can be drawn from these brief observations. First, the common good must be motivated by a dual vision of persons in society. It must assess, on the one hand, what is good for persons considered as individuals. Yet, on the other hand, it must assess what is good for society--including future societies--because social relationships can build or destroy individual persons. Thus, a working definition of the common good might be as follows. The common good is constituted by those general conditions that tend to support the fulfillment of individual persons in real and anticipated socities. The second conclusion follows. Because the common good presumes a social realism and moral concern for relationships and institutional arrangements beyond the individual, claims about the common good will inevitably create tensions in a culture marked by ethical relativism and extreme individualism.
The Common Good and the Terminally Ill
If the common good is composed of the social conditions that tend to fulfill human persons, then assessment of what measures serve the common good must have two features. It must be contextual and related to the real social conditions of its time and place. But it must also make reference to certain general goods that must be conceived as desiderata of the human condition itself: e.g., health, freedom from pain, public order, productive activity, a range of liberty, and support for the pursuit of excellence.
The concerns at stake here are universal: minimizing pain and suffering and increasing the chances of dying in a humane and dignified fashion. But the specific social circumstances of late twentieth century America often frustrate achievement of these goals. Walter Bortz crytallizes the matter: "Dying takes too long and it costs too much."(8) Because it takes too long, excess pain and suffering are created around an already difficult and often tragic set of circumstances. It can take too long because patient wishes to avoid extraordinary or heroic measures are unknown, unsolicited, or disregarded. Providers feel morally (and legally) obliged to "do everything" to delay death. And dying may take too long in human time when effective pain control measures are withheld and appropriate psychosocial support is unavailable.
Dying costs too much. It is now a significant factor in America's unrestrained health care spending. Up to twenty-eight percent of Medicare spending is devoted to the care of the six percent of program enrollees who die each year. Seventy-seven percent of total health care expenses in an individual's life occur in the last 180 days of life.(9) Because so much is spent on the dying, basic health care coverage for the uninsured is made increasingly difficult to obtain, and the package of benefits for those in the Medicaird program more difficult to defend. Moreover, as health care costs escalate, achievement of other social goods in education, transportation, and economic development become jeopardized. These are the opportunity costs of spending nearly a trillion dollars annually on health care in America.
Against this background, the common good can be served by measures that add simplicity and dignity to the process of dying and contain unnecessary spending. The following are some practical measures that might serve to enhance the common good in the care for the terminally ill.
First, the use of home hospice care should be increased dramatically. In spite of significant strides over the last decade, home hospice still serves too few terminally ill Americans. There are many factors that account for this. They include a cultural denial of death, poor physician education, medial ideology about fighting death to the last, lack of clear protocols for determining when an illness is terminal, the social logic of referral to specialists in tertiary care centers, and certain federal regulations that make application for Medicare certification unattractive to many hospice organizations. It is also clear that, given the dimensions of the need there should be for home hospice, expanded care in the future will have to rely on wider use of nonprofessional volunteers than ever before. In short, dying should be brought home and put in the hands of family and friends. It should be deinstitutionalized and deprofessionalized.(10)
Second, more aggressive pain management strategies are needed. Dying patients should have access to all drugs, including heroin and marijuana, that show any promise for relieving their pain. Moreover, drugs should be used liberally without fatuous concerns about addiction. Health care providers should be made more aware of the traditional double-effect analysis that permits increasing doses of pain relief even if these measures hasten death, so long as the direct intention is the easing of suffering and not the killing of the patient.
Third, practice protocols and refined use of diagnostic tools such as APACHE scores must be developed in greater detail and used more widely. This will allow for earlier diagnosis of terminal illness and timely referral to hospice care. Such professional guidelines will help to restrain the use of inappropriate, wasteful, and often unwanted technologies in the care of the dying.
Fourth, the right to refuse extraordinary care must be made universal. The federal Patient Self-Determination Act is a good start in promoting the use of advance directives, but it does not go far enough. The next reasonable step is to require by law that all individuals entering hospitals or nursing homes file a living will or name a health care proxy. Society should no longer tolerate individual desire and who is empowered to choose for them when what dying patients desire and who is empowered to choose for them when they cannot choose for themselves. Chances are good that more patient control will mean fewer aggressive measures and lower costs. One speculative account put the savings of universal deference to terminally ill patients' wishes about withholding life-sustaining measures at $55 billion for 1990.(11)
Fifth, policies and practices should be developed to expand the significance of a DNR order beyond its literal translation of withholding frantic attempts to resusciate a dying patient in crisis. A DNR order should be understood to symbolize acceptance of an inevitable and proximate death. It should trigger withdrawal of all measures not directly related to patient comfort. DNR should mean CMO--comfort measures only--or should be replaced by that new order. Patients with DNR orders should not be kept in ICU beds, where dying is prolonged, expenses multiplied, and loved ones held at arm's lenght.(12) When DNR orders are written, patients should be sent home for hospice care. If transfer home is not feasible or death is imminent, dying patients should be moved to hospice beds in the hospital, where they can be served by professionals trained in comfort care and where visiting family and friends can have ready and welcoming access.
Sixth, it should be part of the social contract in an advanced soceity that everyone has access to an appropriate combination of home care, inpatient care, nursing home care, and hospice care, both at home and in nursing homes. To many of our present long-gterm care decisions are driven by reimbursement and funding considerations with insufficient attention to the most appropriate locus of care for each patient. Terminally ill patients in nursing homes should be sent to hospitals in a crisis unless it is to obtain comfort measures. All nursing homes should have hospice beds and clear protocols, including use of DNH (do not hospitalize) orders, to control pointless hospitalization of dying patients.(13)
Finally, America needs a universal health insurance system that creates enrollment for all Americans in primary, managed care networks. Such networks should have a primary care coordinator whose job it is to see that enrollees enter the health care system when necessary at the most appropriate site for their care and for the patient use of health care dollars.(14)
These measures will not insure that everyone's dying is serene and dignified. But they could significantly improve the current state of affairs and thus serve the common good. They could help create the general social conditions that would support the fulfillment of persons in the dying process. If Americans were assured that every known drug is available to control their pain, that they will be cared for in their homes or in the most appropriate site of care, and that their dying will not be pointlessly extended--if Americans could be assured of this, there would be considerably less energy behind the political movement to legalize the direct killing of dying patients.
The Common Good and Killing the Dying
Most of those who oppose legalization of doctor-assisted suicide and active voluntary euthanasia ground their argument explicitly or implicitly in a simple deontic foundation: It is wrong to directly intend the death of an innocent human being, included oneself. If it is wrong to kill directly, it is wrong to assit in direct killing, even in the voluntary suicide of a terminally ill patient. For most opponents of euthanasia, these claims have a self-evidence difficult to articulate without throwing into question the very fundamentals of morality. They involve a deep respect for the mystery or sanctity of human life. They entail a commitment to a metaphysical acceptance of fate or of God's will. They express a conviction that it overreaches the human estate to seek to control destiny in such an ultimate fashion.
It these asseertions seem too prosaic for such a weighty ethical issue, it is useful to recall the metaethical insight of the intuitionist tradition from Aristotle to the twentieth century Oxford philosophers.(15) On this account, not everthing in ethics can be argued for completely or fully justified on the grounds of reason. There cannot be a reason for every ethical conviction and a reason for that reason and so on, since this would initiate an invidious infinite regress. Instead, there must be some ethical first premises, some moral data, that are simply seen or given in experience. What more obvious candidate for the role of first premise in ethics than a commitment to human life that refuses to accept the directly intended killing of innocent human beings?
But concern for the common good can prescind from this important but difficult element of the debate. A common good perspective must focus on social realities and questions of the public interest. In that light, the following considerations constitute the main elements of the common good argument against legalizing the killing or assisting in the killing of the dying. These are not new arguments, but they are at the heart of the public policy debate.
First, consider the political and cultureal difficulties that stand in the way of achieving the short but ambitious list of changes recommended above to make dying more dignified, humane, and cost-worthy. Now add a new reality: widely available and socially acceptable killing of terminally ill patients. Why bother with raising taxes for insuring appropriate hospice care for all? Why increase research dollars to develop more effective pain management? Why stuggle to improve practice protocols, advance directives, medical orders, and the long-term care system? In short, why take the more difficult road to make the dying process more humane when there is social shortcut that terminates the dying process itself?(16)
This is a serious matter of public policy in the political and economic sense, that is, a matter of sapping the wil to invest in the resources necessary to improve the care of dying patients. This surely would happen were assisted suicide and euthanasia to become widely used. Proponents often claim or intimate that recourse to killing would be rare even under the most permissibe laws, but there is no good reason to suppose that this would be so. A change in law would change private practice and public expectations. This, in turn, would change our collective moral psychology, making what was previously prohibited more and more socially acceptable, even expected. No doubt it will be part of the future agenda of many of those who favor legalization to remove whatever social stigma may attach to killing the dying so that it is no only permissible but often the right or obligatory thing to do. Our therapy-oriented culture would not want anyone to feel guilty for assisting in or practicing euthanasia. Thus acceptance and recourse to euthanasia would likely grow over time. The first generation after legalization might still feel some powerful moral sentiments against killing in this context; they were raised to think so. This might tend to hold the numbers down at first. But three or four generations later, Americans might come to see this as the way to die. Certainly nothing in the proponents' case for legalization is inconsistent with this future.
Financial pressures may also lead to incentives for active killing by limiting funding for terminal care. Legislators considering the cost of terminal care in the Medicare and Medicaid programs, or private insurers representing premium payers, may well take it as an obligation to encourage a more cost-effective way of dying. Nearly all observers agree that cost pressures will force future adoption of practice protocols based on patient condition, likely outcome, and cost of alternative treatments. If legal and widely acceptable euthanasia is added to this economic pressure, it is hard to imaging a future without practice protocols, a package of basic benefits, reimbursement restrictions, or cost-sharing arrangements that provide de facto incentives for the active killing of terminally ill patients. If this future should come to pass, the freedom to choose that many proponents of legalization champion will set the stage for not-so-subtle financial coercions that will determine how many of us die, especially the poor and uninsured or underinsured.
The general point that the will to improve dying will be comprised if active killing is legalized is relevant not only to public policy in the broad sense, but also to the social relationships that will be affected by legalized euthanasia. Why should an adult child struggle to support and care for a declining parent when such a facile alternative exists? And why should an aging parent continue to struggle--in fact, how can he or she justify what may come to be seen as the selfishness of continuing to struggle--when others do the "right thing" by their children by having themselves killed? In short, legalization will seriously erode efforts to humanize the dying process and will create its own new coercions. The hard work needed to humanize dying will simply become less and less worth it at the national and familial levels.
It might be said in response that this argument presumes that legalized killing would create new ethical realities but that contemporary medical practice has already sanctioned direct killing in the guise of the removal of ventilators and feeding tubed. There are philosophers aplenty prepared to argue that there is no longer a tenable distinction between allowing to die and direct killing.(17) Although there are serious intellectual challenges here and contemporary medical practice has certainly entered a difficult gray zone, the distinction still has merit. The facts of dawn and dusk do not erase the distinction between night and day. There is still at the heart of the matter a profoundly important distinction in moral intention. This distinction is intuitively obvious to many families of dying patients, families prone to say things like: "We don't want prolong Grandpa's suffering, but we cannot kill him."
Replacement of efforts to make dying more humane with a practice of killing the dying also has a broad cultural significance. It is plainly part of the common good that we should seek moral balance in our public practices, social relationships, and institutions. Virtue or moral excellence lies between excess and deficiency; extremes should be avoided.(18) But there is one extreme in our health care system that has been decried by ethicists and social critics throughout the late twentieth century, namely, fixation on cure to the detriment of care. Euthanasia is the apotheosis of this tendency. Instead of enhancing care for the dying patient, the condition is cured by killing the patient. Legalization will exacerbate this excess and move the health care system further away from balance and moral excellence.
A second common good consideration that counts against legalization of doctor-assisted suicide and euthanasia is the slippery slope concern. There are two moral arguments central to the proponents' case.(19) First is the humanitarian or beneficence-based argument that a doctor-assisted or -caused death will reduce human suffering. There may be cases where the pain experienced in the dying process is simply intractable, though this is a contended claim in the debate.(20) Suffering, of course, is inherently part of the dying process. It can be reduced by care measures typically part of hospice--psychosocial support, maximum family involvement, and spiritual counseling. But suffering in dying can only be eleminated by eliminating death or the dying. It is certainly true that pain and suffering could be lessened in total if the terminally ill died earlier and more quickly. Killing could be timed to locate the optimal mix of pleasure and pain, happiness and suffering. In theory, legalization could create a world with less pain and suffering than would be the case with contined prohibition of killing.
The second argument is based on autonomy. Competent individuals should have control over their dying as a matter of self-determination. Respect for persons entails the right to be free of paternalistic interference with one's own interpretation and pursuit of the good. In short, whose life is it anyway? Competent adults ought to be free to determine when and how they will die.
Taken together, the beneficence and autonomy arguments ground the claim the terminally ill and competent persons ought to be able to choose doctor-assisted suicide or euthanasia. But note that these two arguments are easily separable. When they are separated, the conceptual slippery slope becomes clear. Development of the pain and suffering argument along justifies involuntary euthanasia. Why should someone be left in pain and suffering simply because he is not competent to choose death for himself? In fact, isn't it discrimination against persons who are mentally disabled to restrict access to a quick and painless death to persons who are competent?
The slide from voluntary to involuntary euthanasia is not merely a theoretically possibility. At present, Dutch pediatricians are debating proposed guidelines, written by a committee of the Dutch Pediatric Association, that would immunize doctors for performing euthanasia on disabled newborns. "The proposed guidelines recommend that the attending physician decide whether to end the child's life, with approval from the parents and other physicians."(21) The head of the committee estimated that, even without the proposed guidelines, Dutch doctors, who have the most permissive voluntary euthanasia policies in the world, give lethal injections to ten newborns a year.(22) Plainly, legalizing lethal injections for infants would be a step down on the slippery slope from voluntary to involuntary euthanasia. If it is taken, the slide to include other suffering children and incompentent adults would be both small and that much more likely.
On the other hand, the autonomy argument has no inherent link to pain and suffering or even to terminal illness. Suffering or not, terminally ill or not, a person has a right to self-determination. When a competent adult--regardless of somatic health or illness--understands the consequences and feely chooses them, shouldn't he or she have the right to choose death? In other words, is it not insufferably paternalistic to condition the right to choose death on certification of terminal illness, on a requirement of a doctor's consent and cooperation, before an individual can exercise this or her ultimate autonomy? The slope of this argument is a slick, steep grade. At the bottom is an unqualified right to suicide on demand.
Two rejoinders are generally raised against such slippery slope concerns. First, such a moral decline is dismissed as far-fetched. People will not become moral monsters overnight because an ethical prohibition, even a long-standing one, is rejected. But nothing in the slippery slope argument requires that these changes happen quickly, only that they shall happen as a consequence of rejecting the ethical prohibition. Perhaps it will take a generation or two before practice protocols determine when euthanasia is indicated, before third-party payers refuse reimbursement for the care of those who have not been euthanized in the "usual and customary" manner, before the link between suffering and autonomy is uncoupled to legalize both involuntary euthanasia and suicide for the healthy. But when these things happen is not the issue; that they are made likely to happen is the issue.
The second rejoinder brought frequently against the slippery slope is the Dutch example. In Holland, a democratic society has accepted euthanasia without leading to the kind of abuses anticipated in the slippery slope argument. But the Dutch retort is flawed for several reasons. First, as indicated above, Holland may well be moving down the slippers slope by accepting officially the euthanasia of incompetent persons. And there have been other abuses: numbers of acts of involuntary euthanasia and many unreported acts of what may or may not be voluntary euthanasia.(23) Second, there may not have been enough time, enough generations of Dutch citizens and physicians, to reveal the full effects of this policy choice. Physicians and patients have lived with the prohibition against killing, even if imperfectly, for all of the history of Western medicine. It may take longer than a generation before the full effects of losing this moral anchor are evident. Third, Holland has universal health care coverage. This blunts some of the financial incentives that surely would shape euthanasia in America. The gross inequities of our system would pressure America's millions of poor and uninsured toward euthanasia for financial reasons. Finally, Dutch society is significantly more homogeneous than America. Holland is less scarred by extremes of racial and ethnic divisions that would certainly skew patterns of euthanasia in the United States. Can anyone honestly believe that legal euthanasia would not make desired terminal care more difficult to secure for those already underserved in the American system--African-Americans, Hispanics, and Native Americans?
The third reason that legalization cannot serve the common good is the negative impact on the doctor-patient relationship when the role of healer becomes conflated with the role of killer. This change would adversely affect the trust the public has in the medical profession. Because of cost pressrue and the demand for greater continuity of care, future relations with physicians will probably take place more and more within organized delivery networks not unlike today's HMOs. The structural arrangement responsible for the financial savings of HMOs--prepayment for a covered package of service--is the same arrangement that raises the central moral concern about HMOs, viz., the incentive they have to undertreat. If euthanasia becomes part of the doctor-patient relationship in this context, many patients will ask themselves this question: Is my doctor's advice that there is nothing left for me but euthanasia motivated by my best interest or his, by concern for my suffering or for her delivery network? And, conflicts of interest aside, there will inevitably be this worry: Is my doctor's advice that it is time for euthanasia an expression of concern for me, or of her exasperation with a condition that can't be cured, or of his desire to be done with a case that is no longer medically interesting?
The impact on doctors is worrisome too. Though ios may not be so for each doctor, medicine is motivated by a deep compassion for the sick and the dying. Some doctors who advocate legalization are plainly motivated by this compassion. In their practices, they experience the inhumane effects of contemporary dying. Their hope is that some hard cases can be dealt with more humanely by doctor-assisted suicide and active euthanasia. The political agenda of legalization is fostered by the evident professional virtues of these doctors.
But the doctors who advocate legalization today developed their admirable sympathies in a medical world that inherited a clear conviction that killing patients is professionally unethical. When it did occur, it was a private matter in which doctors who believed that killing patients is wrong in general struggled with exceptional cases--and with their own consciences. What of the generations of doctors, most of them quite ordinary men and women, who would be educated after legalization? They would be socialized into a professional ethic that says killing is an acceptable thing, perhaps the right thing, certainly the expected thing. Could they develop the same degree of compassion for suffering and for the dying as doctors of the past? Isn't it more reasonable to suppose that they would increasingly think of suffering as unnecessary, of the natural process of sying as an elective choice, of those who refuse euthanasia as curiosities or fanatics?
There have been multiple critiques of doctors' overly aggressive care for the terminally ill in the last several decades. Will critiques of the future say that doctors behave more appropriately and more compassionately when lethal injectiowsn are part of their practice? Or isn't it more reasonable to suppose that critiques of medicine after legalization would center on doctors who inappropriately dispatched their difficult cases, on doctors dulled to the moral drama of killing by its all too quotidian appearance?
One impatient defense against the indermining of patient trust and the hardening of doctors' attitudes is the personal dimension of the doctor-patient relatioinship. Patients trust the doctors they know; doctors care about the patients they know. Thus, it can be hoped that the personal core of the therapeutic relationship will safeguard both doctor and patient from the worst consequences of legalization. But how is medical killing most likely to occur? On potential scenario is that most doctors, at least in the first generation of legalized euthanasia, will refuse to accept this new role, will refuse to offer euthanasia as part of their professional care. Because of this and because of the general logic of medical services, the role will then specialize so that some doctors spend a great part or all of their practice as euthanasia experts. These "obitiatrists" may be called in as specialists in hospitals or may operate their own outpatient clinics. This means that euthanasia will occur outside the intimacy and safeguards of a primary care relationship with the same kind of impersonality that is such a widely criticized aspect of our present health care system. The doctor-patient relationship therefore will provide no defense against abuse.
A point often underscored by proponents of legalization in the context of the impact on the doctor-patient relationship is the novelty of contemporary dying. Death can be delayed as never before, resulting in prolongation of pain and suffering. Patients can be locked indefinitely in states of limbo. This is certainly true, and it motivates many of the reforms suggested above. But it is also true that doctors have dealth with dying patients from the beginnings of the profession and have long had at their disposal, an array of poisonse capable of killing their suffering patients quickly. In other words, while the character of modern dying has surely changed, the general structure of the moral problem of euthanasia is as old as the Hipppocratic Oath. Its traditional prohibition has shaped the doctor-patient relationship. Legalization of killing patients would create a profound change in medicine, a change that could bring many other unforeseen and adverse social consequences for the profession and the public it serves.
The common good must be assessed carefully in the debate over legalization of doctor-assisted suicide and euthanasia. This is not just an issue of individual rights or of the difficult deaths of a few. Respect for the common good demands creation and protection of social realities that serve all persons, though they may not serve each. Persons can be best served by adopting measures that make the process of dying more humane and dignified for all of us. In essence, this means adopting a hospice-inspired strategy of accepting death when it is inevitable, providing the best human support to ease suffering, and using evrey reasonable measure to control pain. But dying is not made more humane and dignified by killing. That "curative" shortcut would undermine efforts of care. Moreover, accepting killing in a few hard cases would set the stage for acceptance of widespread medical killing and would seriously undermine the doctor-patient relationship. In some terribly difficult circumstances, the killing of a dying patient may serve the good of some. But as a public policy, killing cannot serve the common good.
(1) Martin Heidegger, Being and Time, in EXISTENTIALISM 116 (Robert C. Solomon ed., 1974).
(2) See generally L. Tad Cowley et al., Care of the Dying: An Ethical and Historical Perspective, 20 CRITICAL CARE MED. 1473 (1990).
(3) See, e.g., JOHN OESTERLE, ETHICS 198 (1956_: MICHEAL NOVAK, FREE PERSONS AND THE COMMON GOOD (1989).
(4) Compared, e.g., to France, where L'Etat is thought to embody the common good and interest groups are viewed as self-serving. See D. WILSFORD, DOCTORS AND THE STATE: THE POLITICS OF HEALTH CARE IN FRANCE AND THE UNITED STATES 56 (1991).
(5) Charles J. Dougherty, The Excesses of Individualism, HEALTH PROGRESS, Jan.-Feb. 1992, at 22.
(6) Recent books include GARY DORRIEN, THE COMMON GOOD: THEOLOGY AND THE SOCIAL ORDER (1990); MICHAEL NOVAK, FREE PERSONS AND THE COMMON GOOD (1989); MARCUS RASKIN, THE COMMON GOOD: ITS POLITICS, POLICIES, AND PHILOSOPHY (1986).
(7) JOHN RAWLS, A THEORY OF JUSTICE 233, 246 (1971).
(8) Walter M. Bortz II, The Trajectory of Dying: Functional Status in the Last Year of Life, 38 J. AM. GERIATRIC SOC'Y 146, 146 (1990).
(9) James R. Webster and Celia Berdes, Ethics and Economic Realities: Goals and Strategies for Care Towards the End of Life, 150 ARCHIVES INTERNAL MED. 1795 (1990).
(10) On hospice care see C. Brooks, A Comparative Analysis of Medicare Home Care Cost Savings for the Terminally Ill, 10 HOME HEALTH CARE SERVICES Q. 79 (1989); Cathy C. Cutchins, Making Room for Hospice, GERIATRIC NURSING, May-June 1991, at 144; Olga Lechky, In a Greying Canada, Hospice Care Is the Wave of the Future, 145 CANADIAN MED. ASS'N J. 1152 (1991); Jill Rhymes, Hospice Care in America, 264 JAMA 369 (1992); Robert J. Miller, Hospice Care as an Alternative to Euthanasia, LAW, MED. & HEALTH CARE, Spring-Summer 1992, at 127; Robert J. Miller, Ethics and the Hos pice Physician, AM. J. HOSPICE & PALLIATIVE CARE, Jan.-Feb 1991, at 17.
(11) Peter A. Singer & Fredrick H. Lowy, Rationing, Patient Preferences, and the Cost of Care at the End of Life, 152 ARCHIVES INTERNAL MED. 478, 479 (1992).
(12) M. Campbell & B. Field, Management of the Patient with Do Not Resuscitate Status: Compassion and Cost Containment, 20 HEART & LUNG 345-48 (1991).
(13) For an example of nursing home-based hospice, see Cutchins, supra note 10. See also Kathleen Nolan, Do-Not-Hospitalize Orders: Whose Goals? What Purpose? 30 J. FAMILY PRAC. 31 (1990).
(14) See generally Chales J. Dougherty, Ethical Values at Stake in Health Care Reform, 265 JAMA 2409 (1992).
(15) See H. Pritchard, Does Moral Philosophy Rest on a Mistake, in READINGS IN ETHICAL THEORY 86 (W. Sellars & J. Hospers eds., 2d ed. 1970) (describing main insight of intuitionsim).
(16) American Geriatric Soc'y Pub. Policy Comm., Voluntary Active Euthanasia, 39 J. AM. GERIATRIC SOC'Y 826 (1991); Miller, Hospice Care an an Alternative to Euthanasia, supra note 10, at 131.
(17) See, e.g., James Rachels, Active and Passive Euthanasia, 292 New ENG. J. MED. 78 (1975), and the rejoinder in THOMAS L. BEAUCHAMP & JAMES F. CHILDRESS, PRINCIPLES OF BIOMEDICAL ETHICS 136-50 (3d ed. 1989).
(18) This is Aristotle's "Golden Mean." See ARISTOTLE, NICOMACHEAN ETHICS 471-52 (T. Irwin trans., 1985).
(19) See Danial J. Callahan, Aid-in-Dying: The Social Dimensions, COMMONWEAL, Supp., Sept. 1992, at 12.
(20) Miller, Hospice Care as an Alternative to Euthanasia, supra note 10, at 128.
(21) Dutch Pediatricians Move to Address Infant Euthanaia, AM. MED. NEWS, Sepot. 14, 1992, at 6.
(23) Carlos F. Gomez, Euthanasia: Consider the Dutch, COMMONWEAL, Supp., Sept. 1992, at 5.…