Line, Please

To the Editor: From the moment that contemporary medicine began to acquire the ability to stave off death almost indefinitely, the question arose as to whether there could be too much of a good thing. This question is debated to this day, as is evidenced by the essay set featured in the September-October 2008 issue of the Hastings Center Report.

Just three decades ago, the morality, legality, and practicality of knowing when to resign ourselves to the inevitability of death began to be openly debated. Over the ensuing years, a consensus about forgoing life-sustaining treatment gradually emerged and became reasonably well accepted, though resistance to it continues and probably will for a long time to come.

The consensus has taken root only because of the insistence that there is a bright line between "passive" means of hastening death and "active" means—that is, between withholding and withdrawing medical treatment on the one hand, and active euthanasia and assisting suicide on the other. To have failed to draw this line would have meant either accepting all means of hastening death or none, and it is highly unlikely that the former could have prevailed; that would have meant keeping everyone alive until they died even with the administration of maximal life-sustaining medical treatment. The line never was as bright as its proponents claimed—hence the accuracy of Margaret Battin's calling it a "false bright line" in her essay ("Terminal Sedation: Pulling the Sheet over Our Eyes")—but practical and political purposes made insisting that it was a bright line necessary. For if we had acknowledged how blurry the line really is, it is unlikely that a consensus about forgoing life-sustaining treatment could have been hammered out at all.

Unfortunately, the consensus about forgoing life-sustaining medical treatment is not a panacea that resolves all end-of-life dilemmas. For some, merely stopping medical miracles cannot provide relief from pain, from suffering, from loss of control. Is there a more eloquent penned example than Susan Wolf provides us about her father's death ("Confronting Physician-Assisted Suicide and Euthanasia: My Father's Death")? Hospice—and, for that matter, palliative care in all its manifestations—has provided much, if not most, of that needed relief. But not all.

There is still a group of people near the end of life, no matter how small, for whom forgoing treatment is not an option because there is no life-sustaining treatment to forgo, and for whom palliative care has failed to provide adequate relief from pain, from suffering, or from both. As Timothy Quill points out (in "Physician-Assisted Death in the United States: Are the Existing 'Last Resorts' Enough?"), for these people, only more aggressive action will provide relief. The only way for them to end their pain, their suffering, their loss of control is for them to end their lives, or to obtain assistance in doing so.

In 1997, the voters of Oregon stood in roughly the same position as the New Jersey Supreme Court did two decades earlier in the Quinlan case. And like the New Jersey Supreme Court, they chose to embark on an experiment. The voters of Washington have now decided to replicate that experiment. Like the courts before them, the voters in these two states have opted for an incrementalist approach that will help us draw lines and figure out how to make physician aid-in-dying work, just as the courts did with withholding and withdrawing life-sustaining treatment. One important difference between the judicial process and the legislative/regulatory process is that the latter provides a clearer idea in advance of what is legally permissible.

Acceptance of physician-assisted suicide is going to happen. In fact, it's already happening. As Battin reminds us, although the Supreme Court refused to declare it a constitutional right, it did announce a right to terminal sedation, which, in effect, legalizes the even more controversial practice of active euthanasia. Although some (and perhaps many) will continue to adhere to the belief that Daniel Callahan espouses in "Organized Obfuscation...