Euthanasia in the past and in America today

Andrew Porter
October, 1997

In July, 1997, the Supreme Court declined to interfere with legislative acts to prohibit what has been called "physician-assisted suicide," in two cases, Quill v. Vacco and Washington v. Glucksberg, after hearing oral arguments on January 8, 1997. What is described as a "right" to die strikes me as a cover story, and what it will cover up is general encouragement for the disabled to avail themselves of this "right." Those who have a cognitive deficit (they need not be long-term unconsious) will simply be killed.

The logic of euthanasia cannot be limited, once it is allowed at all. The pivotal assumption is that it is better to be dead than sick or disabled, and once this is granted, then killing the disabled is a positive good, and a service to them. This assumption -- in older language, that some lives are not worthy of living, _Leben unlebenswert_ in the German usage of the 1920s to 1940s -- is what is being proposed by the euthanasia movement. Once legitimized, it effectively downgrades the lives of those it pretends to benefit.

The goal of the euthanasia movement is not just "assisted" suicide; it will mean doctors killing patients. It would be unfair to accuse the euthanasia movement of plotting directly to kill all the disabled in America, and they would be justly outraged if I were to do that. What they are doing is, however, more than what Karl Binding and Alfred Hoche did in Germany in the 1920s. Hoche and Binding merely laid the theoretical groundwork for euthanasia; many in America have gone well beyond that, though they are reluctant to acknowledge the logical import of their program.

The killing of patients without their consent or against their wishes is already happening now, right here in America. Michael Martin in Massachusetts and those working for him had to fight to prevent him from being starved (they won). Robert Wenlund in Stockton, California may yet be starved; a court hearing on October 21, will decide. This, despite the fact that he is conscious, can operate his own electric wheelchair, and is making slow progress recovering from the brain damage of a vehicle accident. Marjorie Nighbert was starved and dehydrated in Florida, despite her pleas for food.

Euthanasia has become debatable in America in the 1980s as it was not before. Richard John Neuhaus wrote about it in 1988, with extensive comment on the rationales offered. <"The Return of Eugenics," _Commentary_ 85#4 (1988/04) 15.> The term "eugenics" seems too narrow, but the larger movement of which it is emblematic has ambitions that are all-inclusive. The motive is to take control over human life rather than treating it with respect. Respect imposes some restrictions on what can be done to the living.

The project of control has been extended in America by gradual stages, pushing the limits of the acceptable, waiting for opposition to the formerly unacceptable to dissipate, and then pushing the limits again. This was not how it began. Euthanasia became an issue only after life-extending techniques became available in the 1950s and gave some measure of control over dying that was welcome in some cases, morally ambiguous or burdensome in others. At first, doctors gained some measure of control over the process of dying, and then patients (or more accurately, prospective patients) sought to gain for themselves some of that control. Carlos Gomez gives an account of the changing practices to 1991. See the first chapter for a history and a guide to other sources with more details than he gives. !endfootnote Lost in the technological changes was the ability to differentiate between allowing death and causing death.

The beginnings of the recent movement to legalize euthanasia were somewhat later, and at first not widely approved. Derek Humphry, an early and persistent advocate, founded the Hemlock Society in 1980 to promote euthanasia. The real changes, however, have not been made by people candid, systematic, or organized about what they sought, but rather by individuals facing painful choices and going to law to get what they wanted, without a long-range vision of the implications of their requests. A few hard cases have received extended national media coverage, but there has been slow and steady progress toward more and more killing through court cases that go unnoticed. It is by these that the defenses of life have been worn down and permission to kill extended by incremental rationalizations. One step often contains hidden implications that will be declared only after it has been consolidated, as grounds for the next step.

Since 1990, there have been several ballot initiatives in the Western states, thought to be the most liberal and most likely to approve them. These have been styled in variations of a "Death With Dignity" Act, and all would allow doctors to prescribe lethal drugs to terminal patients who requested them. Issues of constitutionality have not been resolved in the courts as of this writing (1996/06/01). What was not generally known even by voters who turned down two out of three of these initiatives was that previous court decisions give a conservator unlimited discretion in substituted judgement; thus an incompetent patient could "request" suicide through the judgement of his conservator. In plain English, of course, this means that the conservator can simply have an "incompetent" patient killed, as cases in America have begun to demonstrate.

Each ballot initiative has included elaborate assurances of safeguards against misuse, and the proposed safeguards have always been shown to be easily subverted. More importantly, the proponents of euthanasia have implicitly conceded that abuse is possible: the elderly and the ill could be encouraged to avail themselves of this "right," and thereby eliminated as a drain on other people's attention and resources. That would be only the beginning.

"Medicide," as Jack Kevorkian has called it, could become the treatment encouraged by insurance companies, simply by balking at any other treatments. Availability of easy suicide and euthanasia would make it permissible to neglect or abandon patients thought to have insufficient quality of life. There is today a widespread prejudice against people with major disabilities. When such people express an interest in suicide, that desire is viewed as rational, where it would not be in an able-bodied person in a similar situation. Their needs impose a burden on others' time and resources and on others' openness to co-suffering. The move to get rid of them is of course disguised as accomodation of their rights or mercy or compassion. Compassion is the most outragious cover-story, for compassion is exactly what encouraging suicide is not. Com-passion is just Latin for co-suffering, but it is unwillingness to enter co-suffering that leads people to call assisted suicide compassion.

Significant increase in killing has been effected by blurring the distinction between ordinary and extraordinary care. Starvation and dehydration have become morally permissible, construed as withdrawal of the extraordinary care that is implicit in feeding through a naso-gastric tube. (Why is this extraordinary, when it is easier than feeding by mouth?) But starvation and dehydration are ugly, especially when the patient is conscious. And so, once they are generally accepted, they will lead to active euthanasia when lesser means won't work. If death is desired, and action to achieve that end is permissible, the most efficient and painless way to achieve it will of course be sought. Once again, the governing motive is to relieve those in power of the burden of co-suffering that is imposed on them by the one being starved and dehydrated.

The Netherlands provides a window into what is ahead for America, for it has tolerated widespread euthanasia for some time. It began informally around 1973, and became widespread in the 1980s. It has never been legalized, but the Dutch courts have turned a benign eye to the practice, with the worst penalties being nominal; usually there have been no penalties at all. Indeed, prosecution has been extremely rare. Judicial precedents in the mid-1980s legitimized a general consensus in which euthanasia is tolerated. What is striking about the Dutch practice is the degree to which the act of killing has been subsumed under the language of healing, care for the patient. This was indeed a consequence of the way in which euthanasia was legitimized: through judicial opinions, which must, of necessity give a rationale for their decisions. Judges were still in some sense bound by the inherited Christian and covenantal ethic that forbade killing of the innocent, and so the practice had to be characterized in other ways. (Here again one can see the crucial import of H. L. A. Hart's distinctions in "The Ascription of Rights and Responsibilities.")

By the late 1980s, the Dutch practice of euthanasia had attracted misgivings and become generally known, if not openly acknowledged. The authorities wanted to ascertain the extent of the practice, and also to articulate a judicial rationale for it that could be openly acknowledged by the courts. An investigation was undertaken, published in 1991, surveying the activities of the year 1990. <_Report of the Committee to Study the Medical Practice Concerning Euthanasia_, I., and _The Study for the Committee on Medical Practice Concerning Euthanasia_, II., 2 vols., The Hague, 1991/09/10, also known as the Remmelink Report, for J. Remmelink, the Attorney General who chaired the committee.> An analysis in Engish has been made by Richard Fenigsen. <"The Report of the Dutch Government Committee on Euthanasia," _Issues in Law and Medicine_ 7#3 (1991) 339-344.> The Report in its conclusions gives assurances that are quite at variance with the numbers supplied in its body. It is clear to English-speaking readers of the Report that the incidence of euthanasia in the Netherlands has become quite significant, measured as a fraction of the total number of deaths, and especially as a fraction of those deaths that were leisurely enough to permit medical attention. What is more alarming is that it is commonly active rather than passive, and it is frequently non-voluntary (the patient is unable to request it), and even involuntary (the patient was competent and could request it, but was not even asked).

Now compare the German practice during World War II, in the project to simply eliminate all persons with disabilities or cognitive deficits. It makes a quite striking contrast with the later Dutch experience. There was not much historical attention to it from the end of the war until the 1980s, when euthanasia became a live issue in other countries. In the Netherlands, euthanasia has been informally pioneered by doctors and rationalized afterwards, but in Germany things were somewhat different. Though the German program was carried out by doctors, it had original involvement by the National Socialist party and received articulated justification beforehand. Among the recent accounts are those by Hugh Gregory Gallagher and Michael Burleigh. In September 1939, Hitler signed a secret order allowing doctors to "grant a merciful death" to those who were carefully certified to have incurable illnesses. A secret center for granting permission for euthanasia was set up at Tiergartenstrasse 4 in Berlin, and the program accordingly became known as "T-4." It continued formally, though still officially secret, until August of 1941. All manner of chronically ill were sent to six centers and usually killed promptly. Even wounded veterans were "granted a merciful death." Word got out, as was inevitable. Field Marshall Keitel complained to Hitler that T-4 was hurting morale on the Eastern Front. Clemens August von Galen, Bishop of Muenster, denounced the program from the pulpit in July of 1941, and Hitler verbally ordered the program halted. While it was officially in operation, it killed more than 120,000 disabled in Germany by its own count, though the real number may well over 200,000, inasmuch as the population of mental patients in 1939 (300,000) was reduced to 40,000 in 1946. More grotesque, T-4 pioneered the use of gas chambers disguised as showers, a tool scaled up for use on the Jews in Eastern Europe. Families were notified, but with a false cause of death, and an excuse for cremation. Ashes were sent to next of kin. Sometimes two sets. Sometimes to families with living relatives no longer in hospitals. No wonder word got out. What is perhaps most appalling is that, although the National Socialist party gave permission, encouragement, and administrative support, it was done entirely by the doctors. Though "formally" ended in 1941, the program continued informally. The last of the killing was not discovered and stopped until _three months after the end of the war_.

The biggest contrast between the T-4 program and the Netherlands in the 1980s is that the German doctors were centralized, methodical, and candid about what they were doing, at least among themselves. (They made every effort that the "patients" not realize what was happening to them, lest they "become excited.") In the Netherlands, as in America more recently, it has been decentralized, without government support, not in the least methodical (yet). But it bears some emphasis that it was the German doctors who did it, the National Socialist Party merely suspended the law of murder. There were fewer cover stories and more lies to protect the program. There was ideological preparation in eugenic theory, both in Europe and America. That preparation was no doubt greatly accelerated by the virtual hounding of Jewish doctors out of the profession early in the National Socialist years.

It is encouraging that protest worked some when it was tried, and discouraging that it was tried so seldom. The existence of the program was generally known within the profession; it is not as if the doctors were ignorant. Most doctors who were invited to send their patients to be killed or to participate in the killing did so. Had the doctors and the Churches protested more consistently, or protested on behalf of Jews, Gypsies, homosexuals, Seventh Day Adventists and others, much more killing might have been stopped. Evidently, once the groundwork was laid, the practice became unstoppable. That groundwork is being laid informally in America today by those who advocate legalizing euthanasia.

It is not hard to see the more radical motives for euthanasia. Richard Rubenstein traces what may be called functional genocide through the English-speaking world in an essay in _After Auschwitz_. <"Modernization and the Politics of Extermination; Genocide in Historical Context," in _After Auschwitz_, 2nd ed., Baltimore, Johns Hopkins University Press, 1992.> Economic changes devised and enforced by fiat in England in the sixteenth century (the enclosure of previously public grazing land) created an economically superfluous population which was managed locally to some extent. Mostly, it was eliminated by exporting it, some to America, more to Australia. In both places, the immigrants in turn displaced the aboriginal populations. The English establishment treated the Irish no better; the population of that oppressed island was reduced substantially by British policy in the nineteenth century. The signal contrast between the German and English-speaking examples is that the Germans knew what they were doing, whereas the English and their colonists were "self-deceived" in the sense of Herbert Fingarette: they did not spell out; the Germans spelled out.#f~ Rubenstein distinguishes between a genocidal society and a genocidal state; the difference is one of spelling out at the level of state policy. Euthanasia in America will not spell out what it is doing, at least not at first, and not so long as there is a sizeable Christian dissent. Rubenstein's lesson drawn repeatedly throughout his survey of many genocides is that those excluded from the community of moral obligation can simply be eliminated. When rights have no transcendant basis, they become only political, and membership in the community of moral obligation is not automatic, but may be lost or removed.

These observations should serve as ample warning that self-deception and cover-stories will abound in any killing programs in America, as indeed they have. Look again for a moment at the prerequisite for self-deception, the ability to conduct an engagement in life without spelling out what is going on. That is to say, without looking at the goals and motives. This is a very remarkable ability -- to get from here to there, never having been there before, without what one might have thought are "essential" features of _knowing_ what is there. It is an ability to size up a situation, even innocently, for what its next potential is, and to proceed on to the next, and the one after that. When initial choices have been covered up, or not recognized, they can carry implicit within them many of the later choices. One has then made moral commitments that are not obvious at first, and which seem benign or compassionate at first, but which nevertheless commit one later on to activities that were formerly thought to be evil. Or at least deprive one of a consistent reason to resist those formerly evil practices.

As a prospective victim of these practices, I would say they are still evil, and should be resisted in every possible way.