Terminal Illness … and a Doctor Aided Suicide

THE OPEN MIND
Host: Richard D. Heffner
Guest: Peter Steinfels
Title: “Terminal Illness…and Physician Aided Suicide”
VTR: 11/17/91

Heffner: I’m Richard Heffner, your host on THE OPEN MIND. And I would suggest that before us in the public arena today no issue cries out more pointedly for open-mindedness in its analysis and determination than doctor-assisted suicide…an issue decided upon (though only in one place and only for this moment) by voters at the ballot box in the State of Washington just two weeks before we record this program in mid-November, 1991.

By a 54% to 46% margin, those Americans voted down State Initiative 119 that would have permitted doctors to help terminally ill patients who ask to die to do so. Just a month earlier an opinion survey showed that 61% of Washington’s likely voters at that time approved of the physician-assisted suicide initiative…a statistic reflected in national opinion surveys as well, but one whose reversal on election day let THE OPEN MIND’s journalist guest to write that: “The prospect of hanging, Samuel Johnson pointed out after visiting a condemned prisoner, concentrates the mind wonderfully. It seems that the same thing can be said of lethal injections”…of euthanasia.

Well, his New York Times column, “Beliefs” enables Peter Steinfels, the former editor of Commonweal, to bring a religious perspective to the news…and I would first ask him today what role such a perspective will likely play in Americans’ developing judgments on physician-aided suicide. What do you think, Mr. Steinfels?

Steinfels: Undoubtedly the religious convictions and backgrounds of Americans will have a great deal to do with the way they decide on this very important issue. It’s one of the things that distinguishes this country from most other advanced, industrial nations, the deep religiosity of the American people. That doesn’t necessarily mean, however, that their positions will be clearly determined by any religious precept or by any specific position taken by their religious leaders. It will just mean that in a very general way they’ll approach this question with some religious views in the backgrounds of their minds, such as the old Commandment…”Thou shalt not kill”. That will make them think a lot, I think. They will also approach the question with a concern for the kind of compassion that they think that dying people should have. And that will lead some, I think, to move one way in regard to this issue and it will move others to go the other way.

Heffner: The Commandment and the compassion both have in their origins in…let’s call it a religious thought, a religious concern. But you know, it seemed to me from what you had written and the quotation that it offered from your column, that it was fear that was the spur less than religiosity or religion. Because after all, 61% of the people surveyed had said that they were in approval of the proposition put before them.

Steinfels: Well, I think fear does have a lot to do with the way people are reacting on this issue. But it’s more complicated than simply fear in one direction. It’s fear in two directions. I think there’s a fear of being caught up in a kind of medical machinery, a technological medicine that today people often feel doesn’t help the dying, but prolongs dying when it needn’t. So, I think that’s one fear that was working early on in support then…at early and less later. But then I do think you’re right in saying that there was a fear working against it. In this case I think it was the fear of crossing a line, that they didn’t feel had been sufficiently examined. Let me point out something about this decision that was made. The citizens of the State of Washington faced a measure that had several very different times all wrapped into one. One item, for example, had to do with whether you could guarantee by a Living Will ahead of time that artificially provided nutrition and hydration, that is feeding and liquid provided by tubes would be withdrawn in the case of you ending up as a permanently vegetative or comatose patient. Now, to many people that’s a different question. Then the other item on the measure which was to give doctors permission, in effect, when requested in writing by patients, to actually give them a lethal injection. Now this difference between withdrawing a technological medical care and actually, actively doing something to bring about a person’s death, I think was something that as Samuel Johnson said, “concentrated the mind”, and made people think “maybe we better take a little longer about this”.

Heffner: Do you think if the issues were separately presented to the public that the resolution would be different?

Steinfels: I think that the earlier surveys of opinion in Washington would have been a lot closer if they had simply been facing the question of lethal injections and active euthanasia, rather than a set of measures which broadly could be seen as assuring dignity in dying and making sure that technology was not prolonging life. We’ll see in some of the other states now…in California, in Oregon…probably and maybe in other states, we’ll see these measures sorted out and then we’ll get the answer to that. I might add that there are other issues about caring for the dying that were not addressed in the Washington State…such as a question that the country saw before it in the case of Nancy Cruzan in the State of Missouri. A case that went to the Supreme Court. Where you had someone who had been comatose for seven years, and the question was, since she was not competent to make a decision, could her parents, on her behalf, in the feeding that was keeping her alive…that case wasn’t really addressed in the Washington State initiative, but that kind of case won’t go away either. So there’ll have to be moral, religious, philosophical efforts to address that as well.

Heffner: Was there any indication that that kind of case was, if not uppermost in the minds of the people who voted in Washington State, that at least that was clouding the issue right before them?

Steinfels: I think you point to something very important. I think that image of a person who’s dying, in effect, or whose life has continued in a kind of suspended state for long time, I think that image, indeed, was very much uppermost in the minds of people. I think the kinds of cases that occurred in the State of Michigan, where several women took advantage of a suicide machine constructed by Dr. jack Kevorkian, those cases in which people were not about to die, but faced long periods of perhaps drastic decline, physical and mental, those kinds of cases, although also not addressed in Washington State, are very much in the mind of the public and the kinds of things that people are struggling with some kind of answer for.

Heffner: Let me go back to what I characterized as a religious perspective. If you were to separate out these issues how would you see the religious community in America addressing itself to the respective issues at hand?

Steinfels: Well, generally, I think there has been a strong position on the part of most religious bodies that one should not actively take another’s life, except in the cases of the state doing it for capital punishment, or in cases of self-defense. Therefore, the kind of measure that would be tolerated by the Washington State ballot was at least formally opposed by most of the religious groups, with certain exceptions. On the other end of the spectrum, the question of whether you should always do everything to preserve human life, use every technological means at your disposal, most religious groups have reached the conclusion that “no”, there comes a point where such efforts are simply counter-humane, they no longer serve life, but are in effect, “counter-life”.

Heffner: How do you define that moment?

Steinfels: Well, this has been a difficult question. There are…they…religious traditions have drawn upon ancient teachings, trying to…to distinguish between what they consider ordinary care and what they consider “extraordinary” care that either burden the patient of the family in such a way that one was no longer under an obligation to accept that kind of medical treatment. And they’ve also had to face the question of what to do when the patient can no longer decide, but someone else has to decide for the patient. Now the most trying instance at the moment is in the case of, whether you can, as I mentioned before, withdraw food and liquid to a person who is in a coma, irreversibly in a coma, or vegetative, or in some way under a condition where it would be questionable that that “keeping alive” through those methods might indeed by serving that patient’s real benefit. And here the religious groups have divided, sometimes among themselves. For example, most of the Orthodox Jewish position is very reluctant to see that state…step taken. On the other hand, many, many other religious groups have compared that to turning off a respirator when it’s no longer helpful to a person. They say “You’re not really killing this individual, you are simply stopping an unhelpful medical procedure, so that the underlying condition can take its course”. The Catholic Church has been divided…the Catholic Bishops certainly have been divided among themselves over this issue, with some Bishops in some states actually having statements issued by their Conferences saying one thing “yes, you can discontinue this kind of feeding and providing of liquids artificially” under a wide set of circumstances where it might not be helpful. Others have said “no, you can only do that in the most narrow circumstances”. And I think the, the uncertainly about that question is one of the things that’s going to intersect with the debate about whether you can actually say, “Give someone a lethal injection”.

Heffner: When the intersection, or where the intersection takes place, what’s your own guess as to what we shall be doing as we move into the future?

Steinfels: Well, I think there are certain things working besides the fear that we have, on the one hand of permitting people to take actions that could threaten the lives of many of those who are vulnerable or not valued by society if we give permission, generally, to actually do away with people. And on the other hand, the fear we mentioned before of being caught up in a medical technology where you lose all control. I think that word I just mentioned is very important. I think that Americans have a great sense of wanting to control things. Wanting to control their life, make decisions over what they’re going to do, make their own choices. A kind of individual…individualism that we have in our culture. And I think this culture of control, this ethos, it’s very hard for anyone to feel that “well, if I have control over the other important things in my life, why shouldn’t I have control over this most important thing in some way…my death”. And I think that that’s a question, if the religious traditions who are opposed to this development wish to speak to it effectively, they have to talk not only to this legal question, but they have to talk to this wider question of how much control we can rightfully expect to hold over our own lives, and our own deaths.

Heffner: It’s interesting that you talk about this almost as if it were an American phenomenon. You talk about a cultural pattern. Do you think of it as an American phenomenon?

Steinfels: Well, I think we, we know that, for example, the Netherlands is a nation which has, in fact, practiced this kind of active euthanasia…where patients were able to request and receive lethal injections, for over a decade. In a kind of twilight zone of legality. Strictly speaking it’s still against the criminal code. In practice, it’s been accepted by the courts and the medical professions. So we have their experience, increasingly now to turn to. It hasn’t been well studied until recently because of this twilight zone in which it’s existed. But more and more we’re finding out things about Netherlands experience. I think other European nations, other advanced nations will face this question as well. I think Americans will probably face it and debate it in a specifically American way. We talk the language of the individual’s rights. We talk the language of making decisions for ourselves. I think other countries will discuss it in different ways. Maybe with more deference to the medical profession, or more, more simply talking in humanitarian terms about suffering and its meaning or its relief.

Heffner: More reasonably, is that what you’re suggesting?

Steinfels: I’m not sure that it’s more reasonably. I feel that in some ways the open discussion of this in the State of Washington and now in other states, is actually a healthier phenomenon than the kind of quite, and I think, publicly unexamined development in a country like Netherlands. I think that, especially once the issues got focused out, or separated out in the State of Washington, so that voters could focus in on what I think was the critical question in this, this, this issue, which was the question of actually allowing people to give lethal injections or to bring a bout a death. And I think the debate was probably a healthy one, to have it this way.

Heffner: Of course, we think of ourselves as sovereign unto each other, unto ourselves, individualistic, that’s the individualistic tradition. But certainly Americans are coming more and more to realize that the hipbone is connected to the thighbone, and that we live in a way, cheek-to-jowl, that we don’t have in any area as much of that self-determination, self-sovereignty, independence, that we once thought we had. As we become more crowded, in on each other, don’t you think that this will impact upon these decisions?

Steinfels: I think that this is an important…this was an important development in the discussion in Washington. I think that there are people in many cases who began thinking of this only in terms of an individual fate. As the debate went on, I think they became more conscious that this decision was one that would affect a whole practice, a whole way in which the practice of medicine, for example, would look on death and dying. The way in which family members would think about the decisions they had to make and their relations with others and what was expected of them and what they could expect of others by way of help and assistance. And I think there is a, a way in which this does force the question from simply the individual rights, to the larger social network of expectations, duties, obligations and how we want to treat each other as we face death.

Heffner: Of course, you mentioned before the impact of a certain kind of suffering upon the individual herself or himself, and upon the family. Was it this concern that others, perhaps close others, clearly closely associated others might take advantage for their own purposes of someone’s situation that participated in the decision to reject the amendment.

Steinfels: I think there was a general concern that this is not yet thought through well enough so that there can’t be abuses. I think that there’s less concern about a kind of outright fraud and manipulation than there is a concern about two things. One that one will shift the focus of providing death, in a sense, form those who so explicitly request it to those whom society feels it does not want to provide with expensive care anymore.

Heffner: But that’s the fearful thing, isn’t it?

Steinfels: That’s certainly one of them. And, and we know that this decision will take place in a medical system that on one has the best opinion of at the moment. And where it’s felt that there are a lot of inequities and therefore there is the possibility that those who are poorest and most vulnerable, least able to have advocates on their behalf, might eventually become the victims of a, an accepted practice if people were going to be provided with death. So I think that’s one real fear. Now those who advocate taking this step, who say that the ability to, to obtain a doctor’s help or it’s simply the doctor’s actual action in, in dying, is a fundamental right, those people of course, say that there are ways of preventing these abuses and we shouldn’t, we shouldn’t prevent people from having this fundamental right because of possible risks along the way.

Heffner: But, of course, you’ve suggested that there are still others who maintain that the potential for abuse, and perhaps the subjective necessity for this avenue out of this veil of tears could e diminished if we took the proper social role, if we cared for people sufficiently to relieve them of the pain. Working on the assumption that medicine can do this today, that medical technology can do this, and that there needn’t be burdens upon themselves and their families, just upon society at large.

Steinfels: Well, I think that that is at least one thing that most people should be able to agree about after this kind of debate. That the very least we could do is to try and reform our medical care, to try and develop practices of hospices, hospice care for those who are dying. Try and have real dissemination of the medical knowledge about controlling pain. So at least the kind of hard cases that we will continue to have to debate about will be reduced to a minimum, and they won’t be the looming fear that so many people have in their minds right now.

Heffner: But now the question must come up…as to the nature of the resources that we devote to, to this care-fullness, instead of being careless about the ill, the terminally ill, the dying…those who for all practical purposes are…are not living today. And do you suspect, as you look around this nation today that we are voluntarily going to offer up the resources…that we’re going to tax ourselves more and more to provide this caring attitude?

Steinfels: Well, those are questions that I feel a little unable to address because they’re…some of them are technical questions about medical economics and the question of whether perhaps a medical system which is so oriented toward cure, that it doesn’t really know what to do with people for whom cure is no longer a real possibility, but what they need is care. Whether that system might not, in fact, have within it the resources if it would be able to switch some of those from high-technology cure in cases where the benefit is questionable to simple human care and compassion and communication. I’m not sure that such things as adequate pain control, which I think the profession can give if it would, if it would put its mind to spreading around to the local level the knowledge which the good medical centers now have. I’m not sure that that would be necessarily more expensive than what’s happening now. But it would take a re-focusing of concern and I think here something where again there should be a lot of agreement on from people on both sides of this debate.

Heffner: The religious community, getting back to it, has it put its emphasis upon accepting death, accepting the end, because as you suggest, contemporary medicine is focused on avoiding the end, instead of embracing it. Now those who would be perhaps best suited to teach us to embrace it would be those in the religious community. Do you find that happening?

Steinfels: I can’t say that the religious community has done an outstanding job in preparing people or preparing the society to face and discuss death. I don’t think any one of us have done such a good job. But it’s true that death is something that the United…it doesn’t fit our optimistic, forward looking culture in some way, and I don’t think American religion has been an exception there. It’s probably done as much as others, and it still has at its disposal a, a lot of traditions that would be of great importance here.

Heffner: When you say “as others…as much as others”, you mean the religious community as much as others in our community…

Steinfels: That’s right…

Heffner: …not as other nations.

Steinfels: …other cultural forces. No, I can’t really speak for other nations but I, I suspect that our culture may tend to be even more a death-denying one than those cultures which have accepted in a way, into their thinking and into their histories a greater sense of tragedy.

Heffner: Do you think that that may be because, despite what we talk about, we say about the religious community, that in fact the religious tradition in this country does not loom very large today?

Steinfels: You raise a question that is, is very basic and very difficult to answer. We now that people say they are very religious when they speak of what they believe in and how they feel. We’re not at all sure what that means at critical moments of their lives. My sense though, is that in this country, much more than in most others, certainly around something like death, religion and the representatives of religion, the clergy, or others still plays a very, very important role in the way that people respond and the way that they come to help one another, or the ways that they fail.

Heffner: Well, you know I, I told you when you came to the studio today that I had been so impressed with still another piece in your “Beliefs” column, the one that you call “In Search of the Spirituality of Conflicting Cultures Through Motion Pictures” could be anything our society…not just motion pictures. And you seemed to be saying here, writing here that we’re…if not ignorant of, we have very little to do with the sense of the role that religion has played in the past. That we’re, we’re ignorant of it. Now, is there a conflict there?

Steinfels: Well, I think that we have a thinner view of our own religious background than we ought to. In that case I was writing about a film in which it seemed easier for a least a well-educated cultured audience to make a connection with a shamanistic religion of the 18th century Native Americans than with the religion of 18th century French missionaries to the Native Americans. And certainly I was arguing there that we needed a kind of multi-culturalism that, that looked at our own…at our own past cultures from which we are cut off, to some extent. And I would argue that that was true about religion as well. We need a thicker, more historically sensitive and richer notion of our religious traditions. But I think that probably is less a failure again specifically of religion in the United States than it is of an American culture which is not historically minded.

Heffner: It’s so interesting to me that here you use the concept of multi-culturalism to include our own.

Steinfels: That’s right.

Heffner: Not others.

Steinfels: That’s right. I was think about how, in some senses, this 18th century culture was, was as much a different culture to the well-educated American viewer of 1991, as a culture from another part of the world.

Heffner: Peter Steinfels, thank you so much for joining me today in our discussion…

Steinfels: Thank you so much.

Heffner: …on THE OPEN MIND. And thanks, too, to you in the audience. I hope you join us again next time. And if you’d like to share your thoughts about our program today, our program, please write THE OPEN MIND, P.O. Box 7977, F.D.R. Station, New York, NY 10150. For transcripts, send $2.00 in check or money order. In the meantime, as an old friend used to say, “Good night, and good luck”.

Continuing production of THE OPEN MIND has been made possible by grants from The Rosalind P. Walter Foundation; The M. Weiner Foundation of New Jersey; The Edythe and Dean Dowling Foundation; The Thomas and Theresa Mullarkey Foundation; The New York Times Company Foundation; The Richard Lounsbery Foundation; and from the corporate community, Mutual of America.