About 10 years ago, a home video of a young Dutch woman named Maria appeared in a PBS presentation called Choosing Death. Weighing 42 pounds, she was backed against a stark white wall, her sunken eyes searching, darting. She was 25 years old. For 14 of those years she had been suffering from anorexia.
I only punish myself. My entire life is a slow torture. And now I see the only way is death. It is an unbearable life. Her doctor, Nicholas Kors, a pediatrician, had started treating her at the age of 10. Over the years she accepted multiple treatments of tube feeding and psychiatric care, but each time, even though she eventually graduated from high school and held a job, she sank deeper into depression and anorexic emptiness.
The pediatrician, whom Maria called, my friend, my doctor, my second father, states that three times she had asked for death. As the camera backs away from her frightened, glaring eyes, we are told that five days later she was euthanized.
Dr. Kors was charged with murder. After the home video was shown in court, the judge acquitted him. The judge agreed with Maria. Her suffering had made her life unbearable.
I show this video to my undergraduate class in medical ethics because, among many more important reasons, I want them to see the strongest case made for the position opposed to my own: the absolute prohibition against the killing of persons.
It is excruciating to watch her. She is utterly convinced that it is better to be dead than to be who and what she is, than to endure such suffering. Her only will is that she exist no longer.
The video of the life and death of Maria was a prediction of the future. First in The Netherlands, and soon enough, in the United States.
The Netherlands, as Holy Week 2001 began, made legal, acceptable and legitimate what had been merely acceptable for quite some time. Even when it was illegal, Dutch physicians assisted in as many as 4,000 reported suicides a year. The new law, we are assured, has restrictionsall of which will in time evaporate into new acceptabilities. Children between 12 and 18 are required to have parental consent. No longer restricted to terminally ill and fully competent adults, patients must at least be chronically ill and in unbearable pain. Doctors will administer death only after an appropriate medical review. The Times of London reported that steps will be taken to prevent euthanasia-seeking tourists from traveling to The Netherlands to end their lives in dignity. Well! Such restraint.
But not for long. You see, it is difficult to restrain any autonomous individual’s demand for death. We are now assured by the high court of this land that our meaning, purpose and value is spun out of our very heads, troubled as they may be. And no one has the right to impose such private meaning on another, our cocoons of squirming choice having isolated us so.
As for restraints, Judge Miner, of the U.S. Court of Appeals for the Second Circuit, once offered the opinion that equal protection under the law, as articulated in the 14th Amendment, is violated when we allow people to refuse or withdraw treatment but not allow others to kill themselveswhich, in the judge’s estimate, amounts to the same thing. (It is interesting that in Quill v. Vacco, Miner appeals to Justice Scalia of the Supreme Court, of all people, who had rejected in the Nancy Cruzan case the irrelevance of the action-inaction distinction.... The cause of death in both cases is the suicide’s conscious decision to put an end to his own existence.)
Once we deny the principle of the double effect, that we may do a neutral or good act, like forgoing treatment, even if one of the results might be an earlier deathprovided the death is neither intended nor the direct means we take to achieve a desired end to sufferingMiner, of course, is right. If withdrawing treatment, now approved by law, is the same as intentionally killing oneself, then we cannot impede others who might want to kill themselves in other, more direct ways. And, come to think of it, by what right can we impede anyone who wants to be killed by a doctor? Why give access to suicidal liberty only to those who are terminally ill or in unbearable pain? And who is to say whose pain is worse? Why not prescribe death to minors, especially if they are intractably anguished? Why deny this precious right to the handicapped or those who are too senile to freely choose it?
The double effect, pace Judge Miner, is an ethically crucial distinction. Without it, not just medical ethics but all moral reflection is reduced to chaos. There are countless times when our actions have unintended, even if foreseen, effects that we do not choose or will. True, using the principle of double effect requires personal vigilance and honesty about motive and intention, but we all know the difference between intentional killing and letting die. Thousands of times, treatments have been forgone or withdrawn, and patients lived. Care was continued. That can never happen in intended physician suicide. If it doesn’t work the first time, you do it again and make sure the patient is dead.
As for frail Maria, so lost in despair and fear, it is harrowing to think that such sentiments were what her life amounted to. Killing her proclaimed as much, a final assent to self-rejection. And if there is, one day, no one left willing to enter the fear with love, or disarm despair with hope, despite the deepest wounds, we will not have euthanized only the hopeless. We will have killed frail life itself.
