To the Editor:

In “Death With Dignity and the Sanctity of Life” [March], Leon R. Kass addresses the serious and growing problem of when and how a human life should end in these times. We are faced with a medical technology becoming able to preserve a bodily shell of human life almost indefinitely, and a society devoting a hugely disproportionate and growing share of its resources to the final weeks of a person’s life. Unfortunately, Mr. Kass only succeeds in confusing and obscuring the difficult problems he addresses.

For example, he states: “It is now fashionable, in many aspects of public life, to demand what one wants or needs as a matter of rights,” a statement few readers of COMMENTARY would question, but he uses this in an attempt to discredit those who believe that a person has a right to end his own life. . . . He goes on to say that it is then only a “small step” from the claimed right to die to claim the right to have others assist the dying process if one cannot do the job oneself. Further, it is then, according to Mr. Kass, an easy step to have proxies empowered to claim another’s right to die on behalf of one incapable of understanding and deciding the issue.

These “small” and “easy” steps are great and difficult steps morally, as Mr. Kass surely knows. And he must also know that people claiming the right to choose to die are not trendy liberal inventors of a new sociopolitical right. They are, instead, supporters of an honorable belief system as old as human civilization itself that holds that a man’s life belongs to him by right, that once born into this world, it is a man’s right to live, to seek fulfillment, and, by his free choice, to cease to live. One may disagree with this position as one may disagree on the quite different questions as to when, if ever, a second party has the right to prolong another’s life against his will or to end it without his consent. What Mr. Kass fails to do is to discuss these issues on their own merits. Instead, he dismisses all possibility of thoughtful discourse: “No one bothers very much about where these putative rights come from or what makes them right, and simple reflection will show that many of them are incoherent.”

My own impression is that the existence and nature of the putative right is the central issue in the problem we face, and that it is at the very heart of serious discussions we hear everywhere concerning the right of physicians or relatives to “pull the plug” on life-support equipment under certain circumstances; the use of “living wills” to prevent being kept alive artificially under circumstances where one would want death; the rights and wrongs of “mercy killing”; and many related issues. What I found incoherent was Mr. Kass’s convoluted demonstration to prove that murder is wrong through biblical references, and then his proceeding to why he thinks the assisting of death is murder. Are those struggling with these problems really helped by being told that “moral notions trace back to biblical religion”? (Many of us would say that biblical religion traces back to the evolution of human morality.) And are we helped by being told that the Sixth Commandment heads the second table; or that the human prohibition against murder traces back to God’s announcement after the Flood that “Whoso sheddeth man’s blood, by man shall his blood be shed . . . [Genesis 9.6]”? Is COMMENTARY now into giving Bible lessons?

Few would deny Leon Kass’s right as a physician to refuse to be a party to euthanasia. To do so would violate his moral and religious convictions. Further, it is surely difficult to specify who should have a right to euthanize and under what safeguards. At the same time, it seems very wrong to me to continue forced interventions by others to sustain artificially a life that lacks evidence of, and shows little prospect of gaining, or gaining back, the human qualities of thought, volition, or symbolic communication. If medical science becomes able to preserve such lives for a hundred years, would Mr. Kass favor doing so? If not, exactly where would he draw the line, and why?

It is time we accepted the responsibility for deciding when to end some lives. Our debate needs to focus on when, how, and by whom the responsibility should be exercised. The Bible doesn’t tell us.

Charles R. Kelley
Vancouver, Washington

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To the Editor:

Leon R. Kass emphasizes the distinction between “letting die” and deliberate killing. Those who equate the two, he says, “polarize” the debate over euthanasia and assisted suicide. Let us put this to the test of an example. A, in the heart of a desert, comes upon B, who is dying of thirst. A gives B no share of his own plentiful supply of water, and watches passively until B is dead. A’s defense: “I did not murder B, but merely let nature take its course. There is no law requiring one to provide treatment in such a case.” Whatever the legal status of this claim may be, I fail to see any moral distinction between A’s inaction and the alternate course of killing B by shooting him.

Mr. Kass notes that even pagans and atheists believe that murder is wrong, and he asks, “Why is murder wrong?” He answers in a footnote: “. . . murder, which is, by definition, unjust or wrongful killing.” His next assertion thus reduces to the statement that everyone knows wrongful killing to be wrong, immediately and without argument. This is true, but we need not ask ourselves why. We have equally true, and equally trivial, knowledge of every tautology.

Substantial questions, not resolvable by mere definition, can be raised. Why are some killings classified as murder while others are not? Why should they be thus classified? Mr. Kass does, in effect, pose such questions. In doing so, he says that capital punishment and killing in war or for self-defense are not instances of murder, but declines to argue about these exceptions. This abstention is tactically expedient because the exceptions are embarrassing when placed beside his other claims. Each human life, he tells us, is in itself respectable; all persons have an equal humanity, an equal worth, and a divine-like status, so that any man’s very being requires that we respect his life. How, then, do we justify wholesale slaughter carried out in the name of patriotism or national sovereignty? (“Respect the godlike; do not shed its blood!” says Mr. Kass.) This is a mystery incomprehensible to Philistines like me. Incongruities and outright contradictions, it seems, become mere “difficulties,” or vanish entirely, when one’s thinking is supernaturally inspired.

Concerning the treatment of dying patients, Mr. Kass affirms “the primacy of easing pain and suffering.” This implies, presumably, that he regards as permissible the administration of pain-relieving drugs. Their use, however (when it succeeds), removes the opportunity for an edifying display of courage, endurance, dignity, and self-command, traits which he commends as the best indicators of what a man is made of. One who is in a drugged stupor cannot “preserve and reaffirm his humanity by seeing clearly and without illusion.” Anesthesia, when first introduced, was opposed by some divines for essentially the same reasons. Whatever one may think of them, they were consistent.

David A. Shotwell
Alpine, Texas

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To the Editor:

Leon R. Kass rightly states that the taking of human life by society or an indivdual is moral in some situations. He then argues that under no circumstances does euthanasia meet the morality criterion. One of his major objections is that choosing death is not consonant with the concept of human freedom because it is an option to end all options and thus constrains human choices.

When Patrick Henry said, “Give me liberty or give me death!” was he constraining his choices? Does a soldier who chooses to die to save his comrades constrain his choices? What of the person who willingly jumps off an overloaded lifeboat to allow others to survive? Mr. Kass may argue that in these examples the overriding social and humanitarian benefits outweigh the individual loss of freedom. Does he not recognize that there surely are circumstances in which the scales of morality similarly favor euthanasia?

Sylven Gollin
Claremont, California

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To the Editor:

I was very moved by Leon R. Kass’s concern for the dignity of the dying, . . . but the question of dignity has a number of other facets. . . . For example, there is a certain lack of dignity involved in bed-panning brain-dead individuals over a period of years. . . . What about the dignity of the person asked to perform such duties for someone abandoned by family and friends, who is no longer even being visited, as is often the case? If ever there was a hopeless task, this is it. Is it dignified to expect a human being to perform acts that have no real purpose? . . . Is there dignity in a physician’s spending time and energy serving the inanimate animate, . . . converting hospitals into living mortuaries warehousing the almost dead?

It is not a pleasant thought, but modern technology has made living past a certain point unbearable for the dying as well as for their survivors. This is a fact we must deal with. There is a limit to how much society can afford to provide, . . . especially when there is so much need in other areas.

Jerome Greenblatt
Laguna Hills, California

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To the Editor:

Leon R. Kass eloquently discusses the tension inherent in the two concepts of “death with dignity” and “the sanctity of life.” Mr. Kass correctly notes that the push to legalize assisted suicide and euthanasia springs, at least in part, from two key aspects of contemporary culture: denial of death and illness, and a desire to control everything by technical means. One may speculate that these twin characteristics betray a fear of being out of control, resulting in attempts to retain (or at least appear to retain) control even in the face of death, the final proof that we are not in control. In a secular society, life and health become ends in themselves, so that feeling good comes to replace (and to be mistaken for) doing good. If life has no meaning beyond itself, then loss of life or health becomes terrifying indeed, and this fear tends to be projected onto the patient. It then becomes difficult to discern whether we wish to hasten his death in order to relieve his suffering or our own.

Some time ago, I attended a seminar at which assisted suicide and euthanasia were discussed. Present were faculty physicians, medical students, nurses, social workers, administrators, and a professor of bioethics. Various opinions were expressed, but those who spoke in opposition voiced only practical objections. Not one speaker mentioned any source of ethical principles, such as the Ten Commandments or the Hippocratic Oath (“I will give no deadly medicine to anyone if asked, nor suggest any such counsel”). Recently, assisted suicide and euthanasia were discussed in two prestigious medical journals. The authors referred to no external source of ethical principles, although a public-opinion poll was mentioned. Apparently neither the authors nor the editors found anything amiss in basing life-and-death ethical decisions on a public-opinion poll.

What can be expected from a society that combines denial of death and illness with ethical illiteracy? Before the end of this decade, barring a therapeutic miracle, AIDS will have increased to the point where all available hospital beds will be occupied. What will happen when Mr. and Mrs. Moral Relativist try to admit their favorite uncle to the hospital because of chest pains, only to be told that there is a three-month waiting list? What will happen when Mr. and Mrs. Secular Humanist need to admit their young child to the hospital because of a high fever, but fear to do so because most of the pediatrics beds are occupied by children with AIDS?

I predict that assisted suicide will be “encouraged” for AIDS patients at earlier and earlier stages of the disease; when this proves insufficient, involuntary euthanasia will be proposed. This proposal will be favored by “mainline” religious denominations and liberals (for compassionate reasons), by conservatives (for fiscal reasons), by civil libertarians and loose interpreters of the Constitution (for privacy reasons), and by proponents of New Age theology (for whatever reasons). However, I predict that the proposal will be strongly opposed by fundamentalist Protestants, devout Catholics, observant Jews, and strict interpreters of the Constitution—in short, by those whom gays and AIDS patients now perceive as enemies, but whose beliefs are founded on something more permanent and substantial than public opinion.

[Dr.] David C. Stolinsky
Los Angeles, California

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To the Editor:

Thank the Lord for the sweet reasonableness, patience, and wisdom of Leon R. Kass. I have not read elsewhere so winning a defense against euthanasia.

There seems to be no more important work right now than stemming the grim advance of the choose-death crowd against both of life’s flanks. Mr. Kass is a mighty defender.

At the unborn flank, at least, few argue that babies would be “better off dead,” . . . but when it comes to the senior flank practically all “view with alarm” how “unpleasant” old age is (shades of the Buddhal), not crediting that most of us senior parties will continue to view it as better than the alternative right up to the red-hot end.

Tom White
Odessa, Texas

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Leon R. Kass writes:

It was not my intent, in “Death With Dignity and the Sanctity of Life” to help anyone try to solve the terribly difficult, complicated, and distressing practical problems so many of us face regarding the care of the terminally or hopelessly ill. On the contrary, I wanted to show why we should oppose those who offer to “simplify” matters by euthanizing them away, especially when they defend this final technical solution for our enfeeblement in the name of human dignity. My argument did indeed reach firm opposition to the practice of so-called active euthanasia, the direct and intentional killing of patients who request death themselves or who are declared euthanizable by others because their lives are said to be “no longer worth living.” But the article was mainly an exploration of our thinking and of two powerful notions—death with dignity; sanctity of life—notions which, in their putative opposition, now frame much of the debate about end-of-life decisions. It was motivated by my concern that sloganeering and sloppy thinking (about these notions and others) are doing great harm in this vexed and highly emotional matter. This concern, I regret to say, is thoroughly vindicated by the tone and reasoning of most of the letters printed above. They also show, alas, how little I have succeeded in producing clarification and in encouraging deeper reflection. Perhaps the following words of summary can ground more specific responses and even encourage a rereading of the original.

It is now fashionable to pit “sanctity of life” versus “quality of life” or versus “human dignity.” As one learned commentator has put it: “The belief in the sanctity of life is the belief that each moment of biological life of every member of our species is of infinite value. . . . It stands in opposition . . . to most discussions of death with dignity which emphasize patient autonomy and quality of life rather than the sanctity of human life.” But this view of “sanctity” seems to me too rigid and too shallow, and this view of a dignified death too narrow and abstract; accordingly, the polarized opposition between sanctity and dignity strikes me as spurious. My analysis sought to show that human dignity and the sanctity of life are not only compatible, but, if rightly understood, interdependent. Through a lengthy discussion of the reasons why murder is wrong—drawing in part on a philosophical reading of Genesis—I argued that the so-called sanctity of human life rests absolutely on the dignity—the god-like-ness—of human beings; but respect for that dignity requires also respect for the precarious bodily vessel upon which everything humanly high depends. The reason restraining the taking of innocent life lies not in the needs of society nor in our autonomous wills, but in being itself. Thus, human dignity—which, I argued, has largely to do with how we exercise the humanity that life makes possible and very little to do with pulling plugs or interrupting treatment—can in no way be enhanced by the practice of euthanasia. If euthanasia is to be defended, it must be on other grounds.

Charles R. Kelley makes a great deal of my very brief discussion of a so-called “right to die,” not the subject of my essay. He claims that “the right to die” is supported by “an honorable belief system as old as human civilization itself that holds that a man’s life belongs to him by right, that . . . it is a man’s right to live . . . and, by his free choice, to cease to live.” This is just not true. There may be very old views that defend the rightness or justness of suicide—though the view that I own my life by right is certainly not ancient—but they do not speak of “rights.” “Rights”—certain permitted liberties—are an invention (or discovery) only of modern philosophy (since Hobbes). All natural rights trace home to the primary right-to-life, or better, the right of self-preservation, itself rooted in the powerful self-loving impulses and passions that seek our own continuance, and asserted first against those who might insist that morality requires me to turn the other cheek when my life is threatened. All the so-called natural or human rights presuppose our self-interested attachment to our own lives; for this reason, one cannot derive there from any “right to die” or a right to be made dead. Neither is there any constitutional basis for such a right. If it is to exist, it will have to be legislated, as a matter of positive law. To be sure, we can defend, on the ground of natural rights, a right to refuse treatment, to justify our wishes to escape from the clutches of those physicians who constrain our liberty, but a “right to become dead” or to be mercifully killed is a non sequitur—and incoherent. Argue if you must that it is good to allow someone the option of committing suicide or obtaining euthanasia, but do not say it is because he has a right to do so.

David A. Shotwell questions the distinction between “letting die” and “deliberately killing,” and seeks to overturn it with his contrived example of the two men in the desert. But I am not persuaded. I agree that refusal to give water to a man dying of thirst is morally reprehensible, but not therefore morally identical to shooting him. The distinction turns in part on an analysis of causation, in part on a consideration of intention—both of which are relevant to moral no less than to legal judgment. More to the point, the desert example does not capture the medical situation. The dying patient cannot be restored to health (by water or penicillin or anything else), though his dying can be aggravated by burdensome or useless or unwelcome interventions. To cease from these interventions, in the name of the patient’s good, is utterly different from intentionally putting an end to the patient altogether.

Mr. Shotwell (and Mr. Kelley) misunderstand why and how I explore the question of murder and how I use the Bible. If one seeks to understand the notion “sanctity of life”—and to rescue it from the reductionist view that would have us treat every heartbeat in the permanently comatose as having “infinite value”—one looks properly at reasons why we are enjoined from violating human life. We do so not because, having discovered why murder is wrong, we can more easily condemn euthanasia, but because we can more readily evaluate any alleged reasons for ignoring the prima-facie case against bloodshed. (Please, Mr. Shotwell, do not try to pin on me a defense of “wholesale slaughter,” in the name of patriotism or anything else. Just-war theorists have wrestled for years with the difficult task of justifying any such exception to the respect owed equally to all human life, including that of one’s “enemies.”) As it happens, the Bible read philosophically can help us to understand why and how human beings come to protect and respect human life—and great thinkers, such as Rousseau and Kant, have drawn on the book of Genesis for identical arguments. To treat this repository of wisdom as “religious” and hence as purely sectarian, and to claim (mockingly) that thinking with the Bible must be “supernaturally inspired” is indeed Philistinism. I continue to insist that arguments I made with the Bible’s help do not rest on biblical or divine authority, and I invite my critics to try to show the arguments wrong, by counter-argument, not insult.

I am grateful to Mr. Shotwell for his last comment, showing the tension between the desire to relieve pain and suffering and the desire to uphold the prospects for dignity and self-command, possibilities that not only pain but also drugs can undermine. But whereas Mr. Shotwell wants consistency, I would rather acknowledge the dilemma and insist on the need for prudent judgment of the man-on-the-spot. How bad is the pain? What is its cause? How strong is the soul? What is the prognosis? What does the patient himself want? Only answers to these and other concrete questions can help decide how much medication to give, and how often. Yet even if, sadly, extensive narcosis is called for, it is done with the patient’s good in view. In contrast, one cannot serve the patient’s good by deliberately eliminating the patient. No benefits without a beneficiary.

This leads me to Sylvan Gollin’s concern about choice. I share with him an admiration for noble self-sacrifice, and can easily conceive of someone removing himself from life for someone else’s benefit-say, to spare my children the anguish of years of attending my demented self and the horrible likelihood that they will come, hatefully to themselves, to resent my continued existence. But noble self-sacrifice is rare, ignoble “other-sacrifice” is common. For this reason, the legal alternative of euthanasia will not, in the aggregate, enhance choice but will constrain it—especially regarding the care and attention given to the elderly, the seriously ill, the vulnerable. Precisely because we now know that we cannot kill them, we are able to search out the best possible ways to relate to them, humanly speaking. What would happen, any time the going gets tough, were death to be a “viable treatment option”? Will this really increase the freedom-and hence the dignity—of these vulnerable folks?

Jerome Greenblatt sees the point but rejects it. Instead, he worries about the “dignity” of family and physicians and nurses and hospitals having to attend to “inanimate animates.” I share his concern for the trend toward “warehousing the living dead,” but reject the implication that killing them off is the solution. His rather casual extension, without argument, of the notion of “dignity” has at least this virtue: he makes it crystal clear who is to be benefited by any move to euthanasia. His rather frank appeal to the interests of others should warn us of the danger of self-deception. I repeat a major conclusion: “We must never seek to relieve our own frustrations and bitterness over the lingering deaths of others by pretending that we can kill them to sustain their dignity.”

I thank David C. Stolinsky and Tom White for their support.