Barbara Wagner, a poor retired bus driver on the state health plan, made headlines in 2008 when she received a letter from the State of Oregon informing her that she was no longer eligible for the medication that would slow the growth of her cancer. The State would, however, pay for her physician-assisted suicide. Outraged, Wagner fought back. The State remained obstinate. A pharmaceutical company rallied to her side and provided her the drugs free of charge.
No one should be surprised by what happened to Barbara Wagner. Anti-life forces warred against the sanctity of life ethic for most of the 20th Century, a war that has continued into the 21st. In the name of reproductive freedom, many have abandoned the unborn. In the name of personal liberty, the sick and elderly have been forsaken through policies that allow doctors to withhold sustenance with impunity. Legalizing physician-assisted suicide (PAS) is simply the latest step in this century-long quest to extinguish the God-given inherent right to live.
This year, Massachusetts narrowly rejected a ballot initiative to legalize PAS by ballot initiative. Promoted under the banner of “patient autonomy” and “dignified dying,” it would have accomplished neither. Additionally, legalization of PAS in the Bay State would have further weakened the sanctity of life paving the way to involuntary euthanasia across the U.S. While this triumph for life is sweet, the razor-thin margin of victory underscores that this war against life is far from over.
The legalization of physician-assisted suicide and euthanasia affects everyone. History, at home and abroad, has taught us an invaluable lesson: Governments that abandon their primary obligation to protect innocent human life will eventually abandon their obligation to protect the inherent right to liberty and the freedoms citizens enjoy.
Physician-assisted suicide (or PAS) is defined as:
suicide by a patient facilitated by means (as a drug prescription) or by information (as an indication of a lethal dosage) provided by a physician aware of the patient’s intent.
Attempting to disguise its real purpose of degrading and destroying human life deemed no longer valuable to society, PAS has been retermed “death with dignity” and “aid in dying.” For many proponents, passage of PAS represents a necessary step toward the ultimate goal of active involuntary euthanasia.
“Euthanasia” means “good death.” By this, its proponents mean “the intentional killing by act or omission of a dependent human being for his or her alleged benefit.” There are several types, including passive where treatment is withdrawn and active where another person actively kills the patient. It can be voluntary where the patient consents, nonvoluntary where a representative consents to the killing, or involuntary where the physician violates the wishes of the patient or his representative.
Although euthanasia was allowed in Roman times, Christianity’s belief in the inherent dignity of the human person ended the practice in Western culture. Suicide was criminal as well, because it was an offense against God by His creature and an offense against the king by his subject. Assisting someone to commit suicide was considered murder. An 18th Century philosopher named Jeremy Bentham challenged the sanctity of life ethic and promoted, instead, a belief that man’s right to live must be weighed against his utility to society. Known as “utilitarianism,” it remained legally dormant worldwide until the end of the 19th Century. Euthanasia is grounded in utilitarianism.
A new movement called Progressivism ushered in the 20th Century. Progressivism emphasized science and humanitarian reform. On its coattails rode a renewed interest in euthanasia. The Ohio Legislature in 1906 considered, but resoundingly defeated, the legalization of euthanasia by a vote of 78-22. Euthanasia proponents learned that victories in the halls of legislatures would come only after victories in the court of public opinion.
The euthanasia movement advanced quietly. In 1938, Reverend Charles Potter founded the Euthanasia Society in America (ESA). Advocates favored involuntary euthanasia but saw voluntary euthanasia for terminally ill patients as a first step. “The immediate object [was] to get a bill passed as an entering wedge,” Potter said. During those years, some euthanasia proponents funded more popular euthanasia-related issues such as eugenics, birth control, and abortion.
The 1960s provided an opportunity the euthanasia movement had sought for years. The rise in medical technology and doctors’ refusal to remove patients from machines, juxtaposed with the newfound emphasis on patient autonomy set this country on an inevitable legal collision course that ended at the New Jersey Supreme Court. In the case, In re Quinlan, the court gave Karen Ann Quinlan’s parents the right to withdraw their daughter’s ventilator. Notably, Karen Ann Quinlan was not “terminally ill,” but unconscious, and in a “persistent vegetative state” (PVS) following the ingestion of narcotics and alcohol.
In re Quinlan opened a door for the legal “wedge” ESA President Charles Potter savored. Living wills became that “wedge.” Unbeknownst to the public, living wills had been invented in 1949 by the Euthanasia Society of America and the Euthanasia Educational Council but had been shelved for lack of support. Now, with the Quinlan decision, they gained support in state legislatures, beginning in 1976 in California. Health Care Powers of Attorney (HCPOAs) soon followed. By 1992, all 50 states and the District of Columbia had authorized living wills, HCPOAs, or both.
Euthanasia advocates understood the policy significance of medical directives. They represented far more than simply keeping dying people from being on machines against their will. Roe v. Wade had essentially destroyed government’s obligation to protect the unborn. Medical directives would soon cripple the government’s obligation to protect the elderly and handicapped. Proponents knew the eventual end would be an expansion of the “treatments” that could be withdrawn and the “patients” who would qualify.
Beginning in the 1980s, the American Medical Society (AMA) became a proficient ally of the euthanasia movement. In 1984, the AMA recommended expanding “treatments” which could be terminated or withdrawn by living wills or HCPOAs to include “mechanical ventilation, renal dialysis, chemotherapy, antibiotics, and artificial nutrition and hydration,” and, absent a living will or Health Care Power of Attorney, a surrogate could make the decision. In 1986, it expanded which “patients” could have treatment withdrawn to include patients for whom “death is not imminent.”
According to Wesley Smith, a pro-life bioethicist, until the 1984 AMA opinion, nutrition and hydration, including sustenance provided by a feeding tube, were considered humane care that could not be withdrawn. The 1984 opinion “deemed [it] a medical treatment that could be withdrawn ethically, the same as turning off a respirator or stopping kidney dialysis.”
Withdrawal of food and water, even when provided by a feeding tube, is distinctively different from withdrawal from a machine. Typically, when a machine is withdrawn, the person dies from an underlying condition that had facilitated the need for a machine. Assuming the body is capable of processing nutrition, removal of nutrition and hydration, on the other hand, causes the patient to die from starvation, not the underlying condition.
In May 1987, seemingly in lockstep with the AMA, in Cruzan v. Director of Missouri, the court struck the first legal blow to patient autonomy when it upheld “substituted judgment,” the right of someone other than the patient to consent to hastening the patient’s death. Nancy Cruzan had been involved in a serious car accident and suffered severe brain injuries, leaving her in a “vegetative state.” The court permitted Cruzan’s parents to remove their daughter’s feeding tube and she died twelve days later. Interestingly, the cause of death listed on Cruzan’s death certificate: dehydration.
The Cruzan case represented a “watershed moment.” Although the legal decision focused on “substituted judgment,” it legitimized the hastening of death of PVS patients by starvation and dehydration. Furthermore, it sanctioned the view of cognitively disabled individuals as non-humans who were better off dead than alive.
In 1994, the AMA struck again by recommending that life-sustaining treatments, including artificial food and water, could be withdrawn from conscious, cognitively disabled patients. In many states, at least in part, advance directives accommodate this recommendation.
In 2005, the morality of starving conscious, cognitively disabled patients moved front and center on the international stage. Terri Schindler Schiavo had been diagnosed with PVS for five years. Her estranged husband decided to authorize the withdrawal of her feeding tube, and her parents protested. After much wrangling in the courts, worldwide media coverage, and intervention by Congress and the President, her parents lost their battle to save their daughter. Terri Schiavo’s feeding tube was removed. She died 13 days later from starvation.
Although, every state has enacted laws authorizing living wills and health care powers of attorney allowing the withdrawal of food and hydration, many states’ laws have restrictions. Perhaps, to avoid these “limitations,” an Oregon pro-euthanasia organization pushed legislatures to enact POLST documents. POLST, an acronym for Physician Orders for Life-Sustaining Treatments, act as a doctor’s order. These documents dictate what care, including artificial food and hydration, can be withdrawn. In some states, POLSTs are not required to be signed by the patient or his representative and can override a patient’s living will or health care power of attorney. To date, at least 13 states, including North Carolina, use POLST programs and 20 states are developing programs.
As states grappled with living wills and HCPOAs, bioethicists began shifting the ethical foundation of medicine from a sanctity of life ethic to a quality of life morality. Promoted by Peter Singer, a utilitarian bioethicist and professor of bioethics at Princeton University, the right to live would be determined by a perceived quality of life. “Personhood” would be defined by mental cognizance. An ape, in Singer’s opinion, is a “person.” A newly born infant is not. Echoing Singer, in 1996, the AMA issued an opinion recommending the theory’s implementation in every U.S. hospital. A doctor’s duty to treat would not be based on what is physiologically beneficial to the patient but on the cognitive awareness of the patient and the quality of “personal interaction.” Doctors, according to the AMA, should make the decision to treat or not treat, rather than patients or their families.
In the 1940s and early 50s, only one-third of Americans favored the practice of PAS. Since that time, support has reached 75 percent. Despite popular support, 34 states have criminalized assisted suicide through statute and nine states through case law. Three states, including North Carolina have no laws on PAS. Only two states have legalized PAS, Oregon and Washington by ballot initiatives. The Washington law is modeled after Oregon’s. A 2009 Montana Supreme Court decision found nothing in Montana law which prohibits PAS, but left it up to the legislature to create a law regulating the practice. As of September 2012, the Montana State Legislature has remained silent. Every bill in state legislatures attempting to legalize PAS has failed, most recently an April 2012 Vermont bill failed by an 11-18 vote.
Massachusetts’ Question 2, which appeared on ballots this November and was entitled, “Prescribing Medication to End Life,” sought to legalize an Oregon-style PAS law. Massachusetts voters ultimately rejected Question 2, but had it passed, the law included several concerning aspects. It would have allowed a doctor to prescribe lethal doses of medication for a patient estimated to die within six months. Doctors would have had to make the request in writing and have it witnessed by two individuals, one who may be an heir. While Question 2 required reporting, it did not include any penalties for failure to do so. No one would have been required to witness the patient’s death to insure voluntariness. The prescribing doctor did not need to have a long-standing relationship with the patient to insure competency. Finally, the Department of Public Health had neither oversight nor investigative powers to insure compliance. The initiative was endorsed by two former editors of the New England Journal of Medicine and professors at local medical schools. Most of its in-kind contributions came from Oregon-based Death with Dignity National Center and Oregon’s Death with Dignity Political Action Committee. Opposition was funded by the Roman Catholic Church, the Massachusetts Medical Society, the American Family Association, and various right-to-life groups.
Compliance studies of Oregon’s PAS law should give Massachusetts residents pause. Legalized by ballot initiative in 1994, PAS went into effect in 1997. Almost identical to the proposed Massachusetts law, guidelines written into the statute restrict PAS to patients who are “terminally ill” and expected to die within six months. The guidelines assume that prescribing doctors have a long-standing relationship with the patient and can determine the patient’s mental competency. Patients, not doctors, must initiate physician-assisted suicide. The statute prohibits assistance in the administration of the lethal drugs and recommends a witness to the death. These restrictions have proven meaningless. According to Not Dead Yet, a disability advocacy group, abuse abounds. There have been at least five cases in Oregon where a nurse administered lethal dosages to a PAS patient, in direct violation of the law. Additional cases have been reported where the patient was provided assistance to “complete the job.” Because no oversight authority exists, there have been no investigations by the Department of Public Health to insure compliance with the law. Reports of abuse have been corroborated. In 2012, the Physicians for Compassionate Care Education Foundation reported that in 2011 some of the doctors who prescribed the lethal doses had known the patient for only one week. Prescriptions used for suicide were dated earlier than 6 months from the time of death, far longer than the law’s 6 month life-expectancy guidelines. Another euthanasia watch group has reported that despite a study in 2008 reporting that 25 percent of patients requesting assisted suicide suffer from depression, only one of the 71 PAS patients was referred for psychiatric evaluation in 2011. There has been at least one case where the doctor, not the patient, initiated discussions about PAS. In 1997, a doctor went beyond suggesting PAS. Clarietta Day, age 78, had suffered from a severe stroke. She instructed her doctor that she did not want extraordinary measures taken to keep her alive. Her doctor, James Gallant, took her off life support, gave her frequent large doses of painkillers and put a magnet over her pacemaker in an attempt to force her into cardiac arrest. Her heart continued to pump, and he injected her with a paralyzing drug. Mrs. Day died within 15 minutes. Amazingly, the prosecutor decided that “there was no useful purpose in prosecuting Dr. Gallant” and dropped the murder charges against him. Proponents of involuntary euthanasia have accomplished their ultimate goal through rationing in the State of Oregon. Over the past decade, Oregon has put into place a formal process of rationing medical services to individuals using the “public option.” Bureaucrats, not doctors, decide what health care the poor should receive. Cancer patients with less than a five percent chance of survival are ineligible to receive chemotherapy or surgery. Life-sustaining drugs are available only if they will prolong life for a “reasonable length of time.” As Barbara Wagner learned: the government may be willing to help you die, but not to help you live.