To the Editor:

A confusion occurs at a pivotal point in Sonya Rudikoff’s otherwise very informative article, “The Problem of Euthanasia” [February]. In discussing a subject which lies at the threshold of an analysis of euthanasia, namely the definition of death itself, Miss Rudikoff suggests that “brain death” has been found to provide more reliable criteria than heart and breathing cessation. This much is true, as the clinical application of the so-called “Harvard criteria” has demonstrated over the past five years. But Miss Rudikoff may mislead some readers by equating persons who have experienced “brain death” with “patients, often called ‘vegetables’ [who] are alive and yet not living as human beings.” The confusion is that many patients who are dependent to some degree on mechanical and pharmacological support, are comatose or noncommunicative, and are reduced to the “vegetative” life functions, are nevertheless “alive” with greater or lesser prospect of recovering their capacity to participate again in human interaction.

Although some of these patients may have suffered “death” of the higher functions of their brains, they can survive (albeit sometimes in a coma) for long periods without extraordinary medical care. These people have not experienced “brain death” because they have not suffered irreversible cessation of the integrated functioning of their heart, lungs, and brain (including its lower faculties). Part of the confusion is due to the term “brain death” itself, which may not only give the erroneous impression of measuring only the capacity for mentation but also suggests that there is more than one kind of death (“brain death” and “heart/lung death”). In fact, as Dr. Leon Kass and I try to reflect in the proposed statutory definition of death, the traditional standards (permanent cessation of heartbeat and respiration) measure the same phenomenon as the newer, neurologically-based standards, which are appropriately employed when medical intervention, such as a mechanical respirator, has rendered the older tests unreliable. The legal disarray recently brought on by heart transplants from assault victims in California argues all the more strongly for the prompt enactment of legislation which would put to rest the uncertainty that now plagues physicians as well as patients and their relatives.

Being clear about the definition of death, whether “brain” or otherwise, leads us directly to the sort of questions Miss Rudikoff addresses, because if we must admit that some of the patients who are “vegetables” are nonetheless not dead (in any sense of that word as it is usually employed), we will have to decide at what point, if ever, it becomes proper to withdraw treatment or give a lethal drug to bring on death. At the moment it seems to me we have neither the medical certainty about the reversibility of many conditions nor the common agreement about what are the essential capacities for human beings in modern society that would be needed for a collective decision about when to engage in euthanasia. We are faced then with the alternative, which is really more arduous, of developing means of medical and lay education as well as legal reform to permit the effectuation of informed and humane choice by individuals.

Alexander Morgan Capron
University of Pennsylvania
Philadelphia, Pennsylvania

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To the Editor:

. . . In the several surveys that my colleagues and I have conducted among various groups of physicians and non-physicians, we have found that approximately 80 per cent or more favor negative (passive) euthanasia. Yet my own observations in dealing with patients is that euthanasia is actually practiced with much less frequency and with much greater delay than is desired by patients, their families, and others. This procrastination is related to many factors, most prominent of which are: 1) the long tradition of attempting to do essentially everything possible to keep each person existing as long as possible, irrespective of the relative advantages and disadvantages to the patient, his family, and others; 2) laws forbidding euthanasia (strictly speaking, there are laws against it in each of the fifty states); and 3) church policies and canons. However, I am glad to say that I have witnessed in the last eight years a rapid increase in the number of people with understanding and approval of the principles of negative euthanasia. There remains a very strong opposition in the minds of some, especially among those who claim that such approaches constitute usurpation of the role of God. I am struck by the high degree of incongruity in thinking exercised by those who claim that the patient himself, his family, his physicians, and others have no right to make such a decision even about negative euthanasia, at the same time they claim that the propagation of life is the business only of the individuals involved. This applies even when we can predict in many instances that the progeny will have more than a 75-per-cent chance of having gross mental or physical difficulties throughout life. Such actions may produce unnecessary suffering for the individual, his family, and others.

The interrelationship of the mind, soul, and body is one that is very perplexing to many people. In my book, To Live and to Die: When, Why and How (Springer-Verlag), I outline the reasons why some people visualize the soul as a mysterious entity, superimposed on the body, with characteristics that are very poorly comprehended. Others, however, view the soul as a specialized aspect of mentation (thinking) and maintain that when there is no longer any thinking, there is no longer any activity of the soul, at least insofar as the person himself is aware. Thus, when mentation is permanently gone, it appears that of the body-mind-soul triad only the body remains, and it does not serve any very useful purpose as such. This principle is applied in speaking of “brain death” and the application of positive euthanasia, permitting the use of the heart for transplantation.

(Dr.) Robert H. Williams
Department of Medicine
University of Washington
Seattle, Washington

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To the Editor:

Sonya Rudikoff’s article on euthanasia is filled with insight and sensitivity, . . . and I agree with Miss Rudikoff’s analysis of the dangers to human freedom, democratic society, and respect for human rights inherent in proposed euthanasia bills and the “living will” concept.

I must, however, dispute the statement that no one in the medical profession is seeking to exterminate people who may be considered unwanted or undesirable or to create a climate similar to the society of Nazi Germany. The New England Journal of Medicine carried an article only last fall indicating that about 14 per cent of all children’s deaths in the area were caused by deliberate neglect on the part of doctors who felt these patients unworthy to live. The article proposed that laws should be changed to permit the doctors to make such judgments on who should die with legal impunity. . . .

There have also been reports of dangerous, involuntary human experimentation in inner-city hospitals, and some advocates of such practices indicate that there are definite racial overtones involved.

It is not enough to say, “It can’t happen here.” United Community Ombudsman strongly supports the adoption of legislation on all levels, and a constitutional amendment when feasible, making it a crime for doctors or hospitals to discriminate or deny medical care to any person because of race, creed, sex, color, physical handicap, or medical condition. . . .

Ronald Seigel
United Community Ombudsman
Detroit, Michigan

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To the Editor:

We would like to assure Sonya Rudikoff that no one opposing the promotion of euthanasia takes its advocates frivolously. If one reads the writings of Robert H. Williams, Joseph Fletcher, Glanville Williams, Arval Morris, Cyril Means, and others in the euthanasia movement, the Nazi analogy is quite accurate.

Dr. and Mrs. Robert K. Nixon
Birmingham, Michigan

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Sonya Rudikoff writes:

“Brain death” is distinctly different from a vegetative existence, as I believe my discussion indicated. Confusion arises in the public mind because the interest in this relatively new concept has developed at the same time as the refined, sophisticated techniques of organ transplantation. Concurrently, many people have become aware of the increasing number of patients who are maintained in life by mechanical supports at a minimal level of human functioning. The use of the “Harvard criteria,” in the precise determination of death when technology obscures the traditional criteria, is actually irrelevant to the morality of euthanasia, but there remains widespread confusion about the meaning and usefulness of the technology, and about the point at which the criteria do become relevant.

Behind all the confusion lies an impatience with illness. Many people, when asked, express a preference for swift, painless death, for themselves as well as for others. There is also a certain intolerance for states of being which are not active, articulate, energetic, expressive, or animated; the vegetative existence becomes horrifying then. Elderly people are urged to be active, babies are stimulated to come out of their infant somnolence, the appearance of activity becomes evidence of being. We do not need the wisdom of the East to recognize that this may be an extremely harsh view of life.

Impatience with illness may provoke the desire to intervene, correct, or transform conditions previously regarded as given, however, and the results are sometimes heroic and noble, but sometimes not. As Ronald Seigel suggests, the rights of those subject to experiment and research are not always insured. Medical procedures, research designs, experimental conditions can all result in neglect, indifference, danger, or even in monstrosities. The Tuskegee syphilis study deprived some of the subjects of proper medical treatment; the notorious participant-observer study of homosexual pick-ups incurred serious civil-liberties problems, and so on. Such research may involve errors and difficulties, but it is clearly not to be equated with barbaric monstrous genetic or eugenic experimentation, although the concern of Mr. Seigel and of Dr. and Mrs. Nixon is understandable.

We ought to be scrupulous in insuring humane and legal procedures and at the same time extremely parsimonious in the use of that Nazi analogy. The vocabularies of social and genetic engineering or of demography or of behavior modification are susceptible of great misinterpretation; the vocabulary of psychology is notoriously misleading. Irate critics sometimes forget that the vocabularies of physics, of biology, of chemistry are equally offensive in their indifference to the human person. The language of economics, too, reveals its capacity for offense in the recent discussions of inflation, for example. And whose back are they talking about when they “break the back of the energy crisis”?