To the Editor:
In “Dying Made Easy” [February], Paul R. McHugh attempts to be topical by juxtaposing the act of euthanasia committed by Jack Kevorkian on 60 Minutes with the book Tuesdays with Morrie. But these are bad takeoff points for analyzing end-of-life issues. It would have been better had he discussed a recent article in the New England Journal of Medicine in which the author—a physician and the executive editor of the journal—describes her father’s suicide and the suicide of a Nobel laureate with whom she was acquainted. Both men were terminally ill but cogent and lucid. They were boxed in, and chose suicide in preference to degradation.
By using amyotrophic lateral sclerosis (ALS) as the disease crystallizing the issue, Dr. McHugh ignores those with less attractive conditions. Dementia, for example, is not about idle talk and philosophizing, but about fear on the edge of a black hole. What the majority of intelligent people fear most is that a state of helplessness and a loss of dignity might sneak up on them, not allowing them the choice to end their lives before their families remember them only as empty shells. Dr. McHugh gives examples of patients who were rational to the end. But how does his discussion apply to patients overwhelmed with and completely disabled by the ravages of a more destructive disease?
There are honorable reasons for suicide. Jack Kevorkian is the problem here. He is an amoral, self-aggrandizing advocate, and distracts from the real issue, which is dignity.
John Dale Dunn, M.D.
Lake Brownwood, Texas
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To the Editor:
Libertarianism may underscore the primacy of the individual and of taking responsibility for one’s own life, Paul R. McHugh argues, but when it comes to terminally ill patients, “outside forces” are likely to “overwhelm the self, rendering it vulnerable to unreflective impulses.” This is his only comment in assessing the myriad circumstances surrounding an individual’s wish to depart this life.
Dr. McHugh believes that patients turn to physicians not only for medical attention but also because “their [own] capacities for thinking and planning have been compromised.” He goes on to claim that “the physician as a provider of reasoned guidance . . . helps a patient differentiate good from bad, right from wrong, responsible decisions from impulses.” It is only by submitting to this moral intrusion, according to Dr. McHugh, that suffering individuals can escape the disastrous “propositions advanced by [their own] unsettled and possibly unbalanced minds.”
This sort of certitude and rectitude has a menacing sound to anyone with a deep respect for human worth and dignity. For Dr. McHugh, it would seem that few of us are adequate to the task of living life, talking about it, or deciding to close it down.
John Fenner, M.D.
Carmel Valley, California
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To the Editor:
While Paul McHugh is certainly to be congratulated for his cogent criticisms of two extreme and poorly thought-out approaches to the issue of euthanasia, I cannot help feeling cheated by his essay. He accuses Jack Kevorkian, appropriately enough, of being a nihilist who misunderstands the true meaning of liberty and foolishly elevates the patient’s immediate feelings into inalienable rights. He dismisses the conversations of Mitch Albom and Morris Schwartz, as related in Tuesdays with Morrie, as empty rhetoric. But where is the reasoned middle ground between these two unreasonable (and unreasoned) extremes? Where is Dr. McHugh’s own position? Nowhere to be found.
Certainly Dr. McHugh has such a position. Why, then, does he so assiduously avoid any indication—let alone advocacy—of it? I hesitate to guess his motives, but I feel compelled to call him to task for leaving the central question of his essay unanswered, even unaddressed. Death is not easy, and those who give easy answers certainly deserve criticism—but only from someone willing to work toward the hard answers.
George M. Felis
Denver, Colorado
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To the Editor:
If Paul R. McHugh had done nothing more than correct the misconception that patients with ALS are destined to die a horrible death, his insightful article would have served a valuable purpose. Television programs that have used patients suffering with the distressing, paralyzing symptoms of ALS to argue for legalizing assisted suicide and euthanasia have fostered public misconceptions about the disease. The 60 Minutes program discussed by Dr. McHugh, in which Jack Kevorkian is shown giving a lethal injection to Thomas Youk, a patient with ALS, is but the most recent example.
Kevorkian never addressed what might have been done to relieve Youk’s distress. Youk was said to be afraid of choking from being unable to swallow his own saliva, for example, but there was no discussion of medications that can control this problem. Dame Cicely Saunders, the English physician who founded the hospice movement, has written that she has treated thousands of patients with ALS and none of them has choked or suffocated to death.
Although Youk’s case was treated by the media as the first showing of euthanasia on American television, in December 1994 ABC’s Prime Time Live played an excerpt from a Dutch documentary showing a physician ending the life of a patient who had recently been diagnosed with ALS. That program introduced the film as a story of “courage and love,” but enough detail was provided to make clear that the patient was decidedly ambivalent about dying and wanted to put off the date for his death. The doctor, who was supporting the desire of the patient’s wife to move forward quickly, ignored that ambivalence. The doctor never saw the patient alone, permitted the wife to answer all questions for the patient about whether he wanted to die, and presented a frightening and inaccurate picture of the death that awaited him without euthanasia.
Dr. McHugh understands that more than relief of distressing symptoms is involved in giving comfort and meaning to the last months of those who are terminally ill. His account of Morris Schwartz, the sociology professor dying from ALS, suggests the sense of purpose Schwartz achieved through sharing his thoughts with someone who valued him.
The producer of the Dutch television documentary was asked what role his filming the last months of the patient’s life might have played in the man’s decision for euthanasia. He replied that, if anything, it might have led the patient to postpone the date because he was enjoying the company of the producer and his staff. This is not surprising, since the filmmakers valued the patient and gave meaning to his life that he was not finding elsewhere.
The palliative-care specialist Robert Twycross has written, “where there is hope, there is life,” referring not to the hope of a cure but to the hope of doing something that gives meaning to life as long as it lasts. Without such purpose, terminally ill patients may be tortured by the feeling that they are only waiting to die—and may want to die at once.
Herbert Hendin, M.D.
American Foundation for
Suicide Prevention
New York City
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To the Editor:
Thank you for Paul R. McHugh’s remarkable article. His analysis of Jack Kevorkian’s euthanizing of Thomas Youk is the best kind of public ethical reasoning and all the better for his carrying it off without any trace of sermonizing in an area that naturally invites it. But the truly surprising part of this piece was his subtle exegesis of Tuesdays with Morrie. Dr. McHugh uncovers the moral poverty behind the spunky one-liners of an amusing and courageous stoic. Morrie’s will to live is admirable, but it is not sustained by a larger ethical vision, much less a religious one. And Youk’s will to die has only the one-dimensional Kevorkian as its interpreter. In both instances, Dr. McHugh shows how much language has failed us.
Poetry and testimony—the rich poetry of lament and the compelling stories of human survivors—are the communal and cultural resources people need to face extreme human situations. By contrast, the instinctive rhetoric of rights and the glib nostrums of popular psychology leave people victimized.
[Rev.] Robert F. Leavitt
St. Mary’s Seminary and
University
Baltimore, Maryland
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To the Editor:
Thank you for publishing “Dying Made Easy.” Bravo to COMMENTARY and Paul R. McHugh for excellent writing and reasoning.
Wesley J. Smith
Oakland, California
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To the Editor:
Paul R. McHugh’s “Dying Made Easy” is an extraordinary, wise statement. How reassuring to know this man is shaping the training of students of psychiatry.
Robert Pickus
Berkeley, California
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Paul R. McHugh writes:
In my essay I protested the moral collapse that enabled a national television program to feature the slaying of a man with amyotrophic lateral sclerosis (ALS). I also expressed disappointment with the book, Tuesdays with Morrie, because I expected but found no principles in it to thwart those who would prescribe medical killing for this disease.
John Dunn thinks I should have discussed terminal conditions that lack the “attractive” (his word) features of ALS because, he holds, there are honorable reasons for suicide, one of which he identifies as “fear,” particularly fear of the loss of dignity that occurs with dementia. This issue deserves an essay of its own. Let me just make a few points based on The Thirty-Six Hour Day, a book by my colleagues Peter Rabins and Nancy Mace devoted to providing life with dignity rather than death with dignity to patients with Alzheimer’s dementia. Basically, they argue that the aim of doctoring under difficult circumstances is to protect what is worth protecting. To this end, both patients and doctors must determine what is indispensable and what is not. The truth is that, as it is tough getting into life, it can be tough getting out, and on both occasions, what people generally call dignity ranks low on any list of what is vital. If you doubt this, ask the mother who bore you.
For the terminally ill, overwhelming catastrophic fear of the unknown is a cruel enemy whose grounds and features vary from person to person and from condition to condition. Doctors and nurses (particularly those experienced in such disorders as ALS and dementia), if given the opportunity and infused with the will, can allay these fears by providing information, guidance, treatment, and support. Their efforts can help patients believe in the significance, indeed the dignity, of their own existence and thus, despite the depredations of nature, avoid a despairing death—although I suppose this is what John Fenner would call “moral intrusion.”
In the New England Journal of Medicine article recommended by Dr. Dunn, the two suicidal patients were never examined psychiatrically. The author of that paper considered their likely and possibly treatable depression to be “beside the point.” Indeed, we know nothing of these patients’ actual mental states other than what the proponent of their deaths would have us know. Although, as can be seen in this example, supporters of patient suicide seem to prefer operating in a state of ignorance, it is dangerous to formulate policy from such a position.
George Felis complains that by not proposing a “middle ground” between Kevorkian’s homicides and Morrie’s empty rhetoric, I was being evasive and not stating my own position. But I see no middle ground between these two examples. As for my own position, I thought I had made it clear in my essay, but let me repeat it here.
To doctors I would say: choose life and deal with what flows from that decision in your practice, teaching, and research. That will keep you busy, and you will find yourself heartened by the company of many good people. One of them is Herbert Hendin, whose comments I appreciate and whose stalwart efforts include the careful study of the effects of “assisted-suicide” policies in Holland. Dr. Hendin’s recent book, Seduced by Death, exposes the coarsening of character among both doctors and citizens that the “Dutch cure” encourages; my correspondents should read it. Father Robert Leavitt, too, appears to be someone who knows where true solace and strength in adversity can be found. Finally, let me thank Wesley J. Smith and Robert Pickus for their kind words.
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