Wesley J. Smith

Forced Exit

The Slippery Slope from Assisted Suicide to Legalized Murder

Times Books, 304 pp., $ 25

While awaiting the Supreme Court's recent decision on assisted suicide, the pundits came to an unusual consensus. Without the usual left-right discord, most commentators agreed that this dangerous practice should not be constitutionalized. The Supreme Court has now agreed, unanimously refusing to create a broad new constitutional right to assisted suicide.

But the underlying issue is far from settled. Five justices were careful to signal that they might well create some kind of constitutional right in a future case involving different facts. More important, the court's decision did not even suggest that Congress or the states would be forbidden to legalize assisted suicide. And despite the current trend of elite thinking, there appears to be no genuine national consensus on the issue. Authorities in Michigan have been notoriously unsuccessful in persuading juries to convict Jack Kevorkian, the most extreme and flamboyant of the "assisters." And public-opinion polls consistently show large majorities favoring assisted suicide. One state, Oregon, has already voted to legalize the practice in a popular referendum.

Wesley J. Smith's Forced Exit shows why the public should reject Kevorkianism in all its forms. Laying out his case with clarity and restraint, Smith blends reasoned argument with blood-curdling anecdotes, proving beyond a reasonable doubt that legalizing assisted suicide would be a sure step on the road to bureaucratized euthanasia. Smith also recognizes that the current controversies over assisted suicide are just one manifestation of the forces pushing us toward legalized murder, and that avoiding the slippery slope may require a serious reorientation of our public policies and attitudes.

Smith's most straightforward and compelling argument is that legalizing assisted suicide would create terrible perverse incentives. Proponents of the practice emphasize the apparent injustice of denying fully competent people who are near death the opportunity to make a rational choice to avoid the expensive, painful, and degrading treatments that modern medicine offers many of us at the end of life. But the grim prospect of an over-medicalized death (which probably explains the popularity of assisted suicide in polls) is a demonstrably foolish basis for public policy. First, patients already have the legal right to refuse unwanted treatments. Second, and much more important, most real patients simply do not fit the abstract model of the rational, autonomous chooser. On the contrary, people near the end of fatal illnesses typically suffer from maladies ranging from clinical depression to terrifying loneliness to feelings of guilt about the burdens they impose on others. In these circumstances, patients are highly vulnerable to manipulation by their families and, especially, their doctors. Families and doctors will often have strong incentives to prefer that the patient die sooner rather than later and thus to become subtly manipulative, even without realizing it.

Anyone who doubts that such incentives operate on family members should read a few of Smith's well-documented horror stories. But even those who believe that families are generally immune to the low dictates of self- interest should at least acknowledge that physicians are not. Besides the fact that caring for the incurable is tough on a doctor's patience and pride, brute financial incentives created by our emerging system of managed care guarantee that physicians will increasingly be encouraged to promote the inexpensive alternative of a hastened death in place of more expensive life- prolonging options. Doctors have already perfected the art of offering " options" designed to ensure that the patient chooses what the physician wants.

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."

Consider for a moment, as Smith does not, that medicine does not have to be administered with the high level of government involvement we see today. Health care used to be allocated, like most other services, largely by the price mechanism. Patients bought what they were willing and able to pay for, and the indigent were taken care of (less well than the rich, no doubt) at public expense or, very significantly, by a substantial network of religious charities.

Three large changes, all attributable to government, have transformed that system. First, government funding has helped create a large new supply of expensive medical tools. Second, government has largely displaced the religious charities in caring for the indigent, along with many millions who are far from indigent. Third, wacky wage-control policies adopted in the 1940s caused employers to take evasive action by offering additional compensation in the form of health insurance, and the tax laws ensured that this would eventually become the dominant source of private funding for medical care.

Market forces now have hardly any direct effect on consumers, and patients have diminishing control over their doctors. Trying to repair the resulting mess with more government spending and more government regulation will only heighten the politicization of medicine and increase the pressure to choose beneficiaries and victims according to the perceived worth of their lives.

Apart from his naive preference for governmental over market mechanisms, Smith's principal prescription for the underlying disease is a call for moral reformation: the creation of "true community" based on the "equality-of-human- life ethic." Perhaps because he wants to persuade the widest possible audience, Smith advocates a pretty innocuous reformation that is limited in scope and secular in nature. The youngest and most vulnerable are left out, for Smith mentions unborn children only to note that one can make legal and logical distinctions between abortion and other forms of euthanasia (without noting that one could construct similar distinctions among all the other stages "down the slippery slope). And the closest he gets to endorsing anything like religion comes with his invocation of a Zulu word he picked up from a friend.

In the end, Smith's allegiance to secular rationalism leaves him with a mere assertion -- in the face of contrary claims that a "true community" is perfectly free to encourage or require the sacrifice of the community's most burdensome members. This does not detract from the persuasiveness of Smith's thoughtful and passionate argument against the legalization of assisted suicide. But it does suggest that the rationalization of murder will not stop in the face of his compelling contribution alone.

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