Daniel Callahan is the director of the Hastings Center, an influential fount of advice on bioethical problems -- from organ transplants to when lifesaving treatment of patients should be withdrawn. Four years ago, writing in the Hastings Center Report, Callahan asked his readers: "Is it an extravagant exercise of the imagination to envision a time in the future" when it will be decided that "feeding does an irreversibly comatose patient no good; therefore it must be stopped?"
Callahan was fearful of that possibility. "The feeding of the hungry," he argued, "whether because they are poor or because they are physically unable to feed themselves, is the most fundamental of all human relationships. It is the perfect symbol of the fact that human life is inescapably social and communal . . . it is a most dangerous business to tamper with, or adulterate, so enduring and central a moral emotion."
No exercise of the imagination is any longer needed to envision the lawful ending of lives in America by dehydration and starvation. Courts in Massachusetts and New Jersey, among other states, have ruled that taking away food and water, under certain conditions, is legal. The issue has not yet been addressed by the Supreme Court, but it surely will be, for, as a member of the court told me recently, "There are important constitutional issues in this, and in other ways of withdrawing lifesaving treatment."
Is there, for instance, any fundamental difference between "active" and "passive" euthanasia? There are criminal penalties for "mercy" killing or assisted suicide. But if a patient is denied medical treatment, the patient will also die. Is that not also killing?
In an attempt to explore these and other questions about the permissible hastening of death, the Hastings Center has now published "Guidelines on the Termination of Life-Sustaining Treatment and the Care of the Dying." Daniel Callahan was a member of the project that is responsible for this report, which approves, under certain circumstances, the denial of nutrition and hydration to patients, including those who are not about to die.
This time, Callahan does not dissent. There is indeed a tidal pull in the direction of the majority, with many bioethicists throughout the country becoming ever more skilled at convincing physicians and courts that certain lives are no longer worth living.
It should be said that a patient with the capacity to make this decision for himself has a common-law right to ask that a feeding tube, for instance, be removed. A New Jersey court recently decided that a man frozen by a stroke but still possessed of a clear mind could have the tube removed. But most patients from whom lifesaving treatment is taken away are incompetent. Family members or other surrogates decide for them and then questions of cost may come into the decision. All the more so these days. Or, as the Hastings Center Report puts it, medical care should be measured as to whether it is "costworthy."
Some of the language of this new priesthood of death becomes Orwellian in such matters as removing food and water. For instance, the new guidelines say that when food and water are provided artificially, they should be considered as if they were respirators or some other highly invasive technological instrument for keeping people alive. Yet, it's still food and water -- that "perfect symbol" of the communality of human life.
To what purpose, then, is food and water equated with other "medical interventions that may be forgone in some cases"? The intent of the Hastings Center is to persuade physicians and judges that food and water are just another form of medical treatment. If a patient can be taken off dialysis, he can be taken off eating and drinking through a tube. So much for millennia of human priorities.
Of the 20 prestigious ethicists, professors and physicians directly responsible for the report, there were only two dissenters. One, Leslie Steven Rothenberg, a lawyer and a clinical ethicist in Los Angeles, objected to the broad scope of the report's denial of food and water. As for the broad guidelines as a whole, Rothenberg said he was fearful that some sections, "if widely endorsed, may be used to give a moral 'imprimatur' to undertreating or failing to treat persons with disabilities; unconscious persons for whom accurate prognoses are not yet obtainable . . . and others whose treatment is not believed . . . 'costworthy.' "
What also stays in my mind are these people sitting around a table deciding the limits of life. And most will never see those who may die through court adoptions of parts of these guidelines that they have designed.
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