The Magazine


Jul 28, 1997, Vol. 2, No. 45 • By NELSON LUND
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If only the last few days or weeks in the lives of the dying elderly were at stake, the problem would be serious but limited. But this is only the beginning. Defining "terminal" illness and estimating its duration is a notoriously inexact exercise, and the label "terminal" is frequently applied to patients who prove to have many years to live. More profoundly, as Smith rightly stresses, there is simply no way to prevent physician-assisted suicide from leading physicians to kill not only those patients who have asked for it, but those who have not, as well. Once doctors begin deliberately hastening patients' deaths, they will be forced to make judgments about which patients' lives are worthy of continuation. Unless they adopt a policy of providing lethal poisons to anyone who asks -- including lovelorn college students and those temporarily deranged by recreational drugs -- doctors will immediately assume a role that conflicts with their responsibility as healers. And once they take on that role, nothing will stop them from succumbing to the temptation to decide that some patients who have not requested death deserve it.

This temptation will be most powerful in exactly those cases where the patient is incapable of giving consent -- not only the comatose, but also handicapped children and those suffering from a wide range of disorders involving senility, dementia, depression, and psychosis. And from here, it is only a short step to deciding that some competent patients who affirmatively wish to continue living simply fail to understand that death would really be for the best, especially when the doctor is aware that treating this individual may divert scarce medical resources from another, more promising patient.

This logic has already played itself out in other nations. The Netherlands' quick slide down the slippery slope during the last two decades has rightly been given considerable public attention. There is strong evidence that Dutch physicians engage in the widespread euthanizing of non-consenting victims, either for the benefit of the family or because the doctor decides that the quality of the victim's life is too poor. Smith's summary of the Dutch case is excellent, but even better is his discussion of Nazi Germany's earlier experience with euthanasia.

Although this example has received less attention, Ger man doctors eagerly went on a voluntary rampage against "useless eaters" the moment the government endorsed it, and they continued the pro gram even after Hitler withdrew his approval. The arguments for the program -- eerily similar to many we hear today -- had become e respectable well before the , Nazis came to power, and the same kind of thinking enjoyed a cachet in the United States during the '20s and '30s. Indeed, we might have gone down the slippery slope ourselves except that euthanasia acquired a bad name from its association with the Nazis' other programs for dealing with "unworthy" lives.

Smith's point is not that legalized euthanasia will lead to Nazism, but that legalized euthanasia is necessarily politicized euthanasia. This is especially alarming because American medicine itself is in any event becoming increasingly politicized. As Smith shows, euthanasia has a rapidly maturing first-cousin in the practice of granting and withholding health care (including food and water) on the basis of "quality of life" evaluations. In a world where doctors, HMO administrators, and politicians dole out medical care according to their own notions of who deserves it the most, politically favored groups like AIDS patients and pregnant women may do well, but only at the expense of those with less powerfill lobbyists and patrons: low- birthweight babies, advanced cancer patients, and maybe those, like cigarette smokers, who have engaged in politically incorrect behavior. In that world, the distinction between saving resources by withholding food, water, and medicine, and saving resources by the (more humane) expedient of a lethal injection is bound to become untenable.

What, then, should be done? If the slide down the slippery slope can be arrested by an intelligent and accessible explication of the route ahead, Smith's book could hardly be bettered. But as he himself recognizes, the economics of health care will probably ensure that this is not enough. Unfortunately, his recommendations for dealing with this problem tilt heavily toward more of the same policies that have created the current situation: more taxes and more government regulation, all ostensibly in the service of " compassion" and "community."