"Words, Words, Words"
RITA L. MARKER & WESLEY J. SMITH
success or failure of political or social revolutions often
depends on the terms used in the debate. But what if the
existing lexicon and traditional understanding of words and
phrases hurt the cause and bog down the movement? The answer is
simple: If the people don't want to follow where you want to
take them, make the destination appear more attractive. This is
precisely what proponents of the "right to die" have done.
"If thought corrupts language, language can also
corrupt thought." George Orwell1
"Sticks and stones may break my bones but words can never hurt me"
was a children's rhyme that was very common not many years ago. It was
also totally wrong. The deep emotional pain inflicted by words can often
hurt far more and for much longer than the physical pain of a broken
Today, as the debate over what has become known as the "right to die"
is taking place another type of harm can result from words. That harm
can be deadly.
Words that sound familiar like treatment, compassion, comfort care,
and terminal now may mean something far different than they did only a
few years ago. Those words, as they are currently used, may do more than
hurt. They may kill.
Take, for example, the seemingly clear statement "If I'm terminally
ill, the only medical treatment I want is comfort care." That statement
could now be interpreted as a request for a deadly drug overdose by a
person who has a life expectancy of months or even years.
Carbon Monoxide as "New Age Hospice Care"
Only a short time ago, any serious suggestion that administration of
carbon monoxide poisoning is a "procedure" that constitutes a "heroic
effort" to control suffering would have been met with incredulity.
Likewise, a reference to this "procedure" as "a kind of new age hospice
care," would have been beyond belief. Yet these very claims were made by
Stanley Levy, M.D., an internal medicine physician who specializes in
In few social movements has the interpretation of words been as
important as in the debate over euthanasia and assisted suicide. And in
few social movements have words ever been so effectively used to first
blur, then completely obliterate, the line between the acceptable and
Regardless of one's views about assisted suicide and euthanasia, an
understanding of the words used when they are discussed is vitally
important. This importance is underscored by a changing relationship
between patients and health care providers, a relationship increasingly
characterized less as a patient-physician relationship and more as a
consumer-provider transaction. In practice, the consumer/patient and the
doctor/provider are often placed in a position subordinate to that of
the managed care bureaucrat. Health care consumers deserve and
desperately need to know how definitions have changed, and they have a
right to know that these changes can affect them profoundly.
Transforming the Appalling into the
On January 27, 1939, in an article titled, "'Mercy' Death Law
proposed in State," the New York Times reported that the
Euthanasia Society of America had drafted a bill to "legalize painless
killing."3 Charles E. Nixdorff, the group's treasurer, took
issue with both the article's title and its reference to killing and, in
a letter to the editor, he wrote that the words "killing" and "death"
had sinister connotations. He suggested that it would be better to
describe euthanasia as "merciful release"4 so that the public
would not fear the Society's proposal.
However neither the newspaper, nor an official of Nixdorff's own
organization heeded his advice. Euthanasia continued to be described in
blunt terms. The public was horrified when Dr. Foster Kennedy, president
of the Euthanasia Society of America, explained that the primary purpose
of his group's legislative proposal was to eventually legalize
euthanasia for "born defectives who are doomed to remain defective,
rather than for normal persons who have become miserable through
Euthanasia proponents have learned a lot about public relations in
the six decades since the Euthanasia Society of America made that first
attempt to gain legislative approval for mercy killing. One lesson they
have heeded is that all social engineering is preceded by verbal
engineering. If words or their meaning can be changed, the quest to
change hearts and minds will be achieved.
Today when mercy killing is discussed, it is couched in euphemisms
words of gentleness or the language of rights. Titles of euthanasia
advocacy groups contain words like "compassion," "choice," and
"dignity." Even the Euthanasia Society of American has undergone name
changes to present a more positive image. (In l976 the Euthanasia
Society of America changed its name to the Society for the Right to Die
and, in l991, it became known as Choice in Dying.)
No longer does anyone but its strongest opponent refer to mercy
killing. The word "euthanasia" is generally avoided in proposals to
legalize it. Old words are replaced or given different, vague meanings.
Like a constantly changing kaleidoscope, meanings shift ever so
slightly, forming new patterns of thinking. Slowly, quietly but
inexorably the previously appalling is transformed into the presently
The manner in which words are defined is key to achieving this
This is something that Dutch euthanasia practitioner Dr. M.A.M.
Wachter, the ethicist/director for the Institute of Health in the
Netherlands, knows well. Speaking at a 1990 international euthanasia
gathering, he stated, "The definition builds the road for euthanasia."6
acknowledged that "euthanasia is the intentional ending of the life of
another....It is always a question of terminating human life," then went
on to urge that careful attention be paid to definitions.
"Definitions are not neutral," he said. "They are not just the
innocent tools that allow us to describe reality. Rather, they shape our
perceptions of reality. They select. They emphasize. They embody a bias.
Therefore definitions constantly need redefinition."7
Mercy Killing Called "Terminal Care"
So cognizant are the Dutch of this power of definitions that they
have managed to define euthanasia in such a way that it literally
precludes any finding of nonvoluntary euthanasia.
In l985 the Government Commission on Euthanasia defined "euthanasia"
as "the deliberate termination of another's life at his request."8
Since the definition requires that there is only euthanasia when the
patient requests death, any non-requested mercy killing that would
ordinarily be called "nonvoluntary euthanasia" cannot be referred to as
a euthanasia death. In effect, nonvoluntary euthanasia has been defined
out of existence.
This is particularly ironic since the practice of ending patients'
lives has given doctors such unprecedented power that it is primarily
Dutch doctors not patients who determine who will die at their
The first official confirmation of the prevalence of nonvoluntary
euthanasia in the Netherlands came on September 10, 1991, when the
long-awaited government report, Medical Decisions About the End of
Life9 was released. Popularly known as the Remmelink
Report (named after the chairman of the committee that issued it), the
study documents the degree to which doctors have taken over the decision
making questions of euthanasia.
The findings of the Remmelink Report indicated that, in one year,
Dutch physicians deliberately ended the lives of thousands of patients
by administering or providing lethal doses or fatal injections:
Twenty-three hundred people died as a result of doctors killing them
Four hundred people killed themselves with medication provided by
their doctors for that purpose.11
thousand people an average of three each day died when doctors
prescribed, provided, or administered a medication with the specific
purpose of causing death even though the patient had made no
explicit request for euthanasia.12 Of these, 14
percent were fully competent,13 while 72 percent of them
had never given any indication regarding termination of life.14
addition, 8,100 patients died as a result of doctors deliberately
giving them overdoses of pain medication with the specific intent of
hastening the patient's death.15 The decision to
administer the intentional overdose was not discussed with 4,941 (61
percent) patients, even though 2,187 (27 percent) of patients who
died in this manner were fully competent.16
As indicated by the above figures, 11,800 deaths were induced by
Dutch physicians in one year. Of greatest significance for this
discussion is the fact that more than one half of those deaths were
unrequested by the patients who died. This is clearly nonvoluntary
euthanasia. But, because of the way in which the Dutch define
euthanasia, those unrequested deaths are categorized as "deliberate
life-terminating actions without explicit request" and fall within a
classification of "terminal care."17
In November 1996, the Dutch government released a second report based
on two studies with findings strikingly similar to those of the earlier
Remmelink Report. Again, there were thousands of lives directly and
intentionally terminated by Dutch physicians. And, as in the previous
study, intentionally induced deaths in patients who had not requested
that their lives be ended were not referred to as euthanasia. Instead
such deaths were categorized as "ending of life without patient's
The Dutch ability to frame unrequested deaths as something other than
nonvoluntary euthanasia has been nothing short of a public relations
masterpiece masterful in keeping the true import and consequences of
legitimized euthanasia from being clearly acknowledged. It should be
noted, however, that euthanasia by any other name is still euthanasia.
Or, better stated: Killing is killing is killing.
A similar sleight of word has been employed in euthanasia and
assisted suicide proposals in the United States.
From 1988 through 1992, during campaigns to legalize euthanasia and
assisted suicide in California (1988 and 1992)19 and in
Washington (1991),20the phrase of choice among euthanasia
proponents was "aid-in-dying." The words conjured up images of plumping
the pillow, wiping the brow and holding the hand of a patient. But these
were not the types of aid that would have been legalized. "Aid-in-dying"
was defined in the measures' small print as "aid" that was to be
directly and intentionally provided to "end the life"21 or
"terminate the life"22 of a qualified patient.
Although the exact method for delivering the new death inducing
medical service was not specified, proponents acknowledged that it would
probably be accomplished by means of a lethal injection or drug
overdose. However, they went to great lengths to conceal this. "Try not
to go into methods of aid-in-dying such as lethal injections" was the
advice given in a speakers' packet formulated by the Friends of
Initiative 119, an umbrella group for the Washington state measure's
supporters. Instead speakers were advised to say that Initiative 119 was
needed to "protect our rights as patients." Audiences were to be told
that the measure was needed to correct flaws that had been discovered by
members of the medical community in the state's outdated Living Will
The measure was similarly described on national television when a
news program described the Initiative as a proposal "to clarify language
in Living Wills."24
Although the proposed laws in California and Washington would have
permitted euthanasia by lethal injection and assisted suicide by
prescribed drug overdoses, they each categorized such actions as
something other than mercy killing or suicide. California's proposal
stated : "Requesting and receiving aid-in-dying by a qualified patient
in accordance with this title shall not, for any purpose, constitute a
suicide"25 and "Nothing in this Act shall be construed to
condone, authorize, or approve mercy killing;"26
Washington's attempt to carve aid-in-dying out of the definitional
suicide and euthanasia niche read: "Nothing in this chapter shall be
construed to condone, authorize, or approve mercy killing, or to permit
any affirmative or deliberate act or omission to end life other than to
permit the natural process of dying and to permit death with dignity
through the provision of aid-in-dying.... "27
As in the Netherlands, these proposals would have permitted
euthanasia and assisted suicide while denying that either of those names
or the label of mercy killing applied.
However, voters in Washington and California did recognize that
"aid-in-dying" was merely a deceptively soothing term for the crime of
murder under those states' laws, and the proposals failed to gain public
approval. The public at large, it seems, did not favor turning the
specter of a lethal syringe-wielding physician into a reality, whether
called "aid-in-dying" or the more apt description, "killing."
Disguising the Brutal Facts
Following the abortive attempts in Washington and California
euthanasia advocates went back to the drawing board to reframe their
rhetoric. In preparation for a new initiative campaign then being
formulated for Oregon, a poll was commissioned in l993 by the newly
formed Euthanasia Research and Guidance Organization (ERGO!). The poll
which was ERGO!'s first activity was designed to determine "if
euphemisms allow people to come to grips with brutal facts which, stated
another way, would be repugnant to them."28
Not surprisingly, results indicated that people would be more
inclined to vote for laws that were couched in euphemisms. The poll
indicated that the greatest number of respondents (65 percent) would
favor a law using the terminology "to die with dignity."29 As
the drafting process of what would eventually be known as Measure 16,
Oregon's "Death with Dignity Act," went on, information from the poll
was incorporated to ensure the greatest possible chance of passage.
The first draft was written in September 1993 by attorney Cheryl K.
Smith, who served as a special counsel to the political action group,
Oregon Right to Die (ORD). Smith had previously served as the National
Hemlock Society's legal advisor from l989 to 1993 and as top aide to
then Hemlock director, Derek Humphry, until he resigned in 1992. While a
student at the University of Iowa College of Law in l989, Smith helped
draft a "Model Aid-in-Dying Act" which allowed for children's lives to
be terminated either at their request or, if under 6 years old, at the
request of their parents.30 Now working as Legal Services
Director for the Oregon Rehabilitation Association, she has also
authored Departing Drugs, a how-to-commit suicide manual that
is distributed by European euthanasia groups and is the author of
several chapters in the Art and Science of Suicide project, an
on-line "self-deliverance" instruction guide marketed by the Right to
Die Society of Canada through its DeathNET site on the Internet.31
Early drafts of Measure 16 (then titled, "A Bill for an Act
Relating to the Rights of Patients Who Are Terminally Ill to Receive
Aid-in-Dying") allowed doctors to directly end the lives of patients by
lethal injection. But this was considered a potential stumbling block
and was eventually omitted.32 Instead, the final draft
provided that a doctor could write a prescription for a patient "for
medication to end his or her life in a humane and dignified manner."33
As a means of placating those who wanted the wording to allow doctors to
actually administer the deadly dose, a compromise was reached by which
the physician as well as others were granted immunity if they were
"present when a qualified patient takes the prescribed medication to end
his or her life in a humane and dignified manner."34
As the measure was evolving, some words and phrases were sacrificed.
Others were carefully selected. "Aid-in-dying" which had become
identified with the failed California and Washington attempts was
totally eliminated from the title, the definition section, all
subheadings and even the body of the measure. The more soothing phrases,
"death with dignity," "to die a dignified death," and "humane and
dignified" were added.
Each word and phrase was meticulously examined for its potential
impact on voters. For example, the first five drafts had contained the
term "informed consent," a medical term meaning that the patient is
fully informed prior to consenting to surgery or treatment which his or
her doctor has recommended. When ORD members realized that the
established term, "informed consent," could pose some nuancing problems,
a new term, "informed decision"35 was used instead.
Since the polling done to prepare for the bill had shown that
"suicide" did not play well with the public (only 44 percent of voters
would have favored a law stating that it permitted physician assisted
suicide36), the Dutch solution to word problems was put into
use. Assisted suicide and euthanasia (which were, after all, the goals
of Measure 16) would not be called by their real names: "Nothing in this
Act shall be construed to authorize a physician or any other person to
end a patient's life by lethal injection, mercy killing or active
euthanasia. Actions taken in accordance with this Act shall not, for any
purpose, constitute suicide, assisted suicide, mercy killing or homicide
under the law."37
On November 8, 1994, Oregon voters approved Measure 16 by the
slimmest of margins (51-49 percent). As ERGO!'s Derek Humphry had said
when he viewed his poll's results, "The euphemisms won."38
While the very terms "euthanasia" and "assisted suicide" have been often
replaced by euphemisms such as "gentle landing" and "deliverance," there
are a number of words that are so universal to any and all so-called
right-to-die proposals and policies that they cannot be replaced.
Instead, their interpretations and definitions have blurred as well as
multiplied so that, in any one discussion, the same word can have as
many meanings as there are speakers and listeners.
Among these words are "terminal," "imminent, "treatment" and "care."
Such a breadth of interpretation can place caregivers and patients in a
position where they are speaking separate languages one in which the
listener interprets a word in a far different way than the speaker
To the lay person, "terminal" means that death is unavoidable and is
very close (meaning within days or weeks) no matter what treatments or
interventions are used.
Proponents of euthanasia and assisted suicide have, until recently,
stated or implied that only those whose conditions are considered
terminal would be candidates for accelerated death. At least this is the
framework within which most media coverage takes place.
This is certainly how the decisions in Compassion in Dying v.
Washington39 and Quill v. Vacco40
have been reported. Indeed, in his opinion declaring laws against
assisted suicide unconstitutional, Judge Stephen Reinhardt stated that
the Court was only deciding the issue of assisted suicide for the
terminally ill.41 At the same time he hedged by writing, "Our
conclusion is strongly influenced by, but not limited to, the plight of
mentally competent, terminally ill adults."42
What does Judge Reinhardt mean by "terminally ill"? He didn't say.
Nowhere in the lengthy opinion did he provide a definition. He did,
however, give some emotionally charged descriptions to portray
terminally ill people. He wrote that their fate will be one in which
they "can only be maintained in a debilitated and deteriorating state,
unable to enjoy the presence of family or friends"43 or one
in which they will end up in a "childlike state of helplessness,
diapered, sedated, incontinent."44
While such language might be useful in a euthanasia organization's
promotional material, it hardly provides guidance about the meaning of
"terminal," a word used by courts and in statutes to denote legal
categories. For example, if an incapacitated person is "terminal,"
medical treatment can be withheld or withdrawn, based either on the
patient's desires as expressed through an advance directive or in the
"best interests" of the patient through surrogate decision making. If
euthanasia or assisted suicide is legalized, the presence or absence of
a "terminal" condition would determine whether the state retains an
interest in protecting a patient's life or whether it stands aside
indifferently in the face of induced death. Thus, the applied definition
of the word would literally spell the difference between life and death.
E lsewhere, Judge Reinhart qualified the undefined "terminal" with the
word "imminent" when he wrote that the state has an almost negligible
interest in safeguarding the interests of third parties "when the
patient is terminally ill and his death is imminent....."45
Yet nowhere does his opinion give even a clue as to the meaning that
should be given to "imminent."
Likewise, the Second Circuit Court of Appeals, in its Quill v.
Vacco opinion, failed to give any specifics about what it meant by
"terminal." In finding that the state has no interest in preventing a
patient from obtaining drugs to end life "during the final stages of a
terminal illness,"46 the Court either couldn't find or
didn't look for any way to explain what it meant by "terminal
illness," let alone its "final stages."
Admittedly it is extremely difficult to clarify what is meant by
"terminal." Often the closest a physician can come to defining
"terminal" is to use Justice Stewart's words: "I know it when I see it."47
This difficulty has been acknowledged in the Netherlands and may be one
of the reasons that the Dutch made no attempt to even pay lip service to
requiring that one be "terminal" before being eligible for euthanasia.
The Dutch describe "terminal" as a "concrete expectancy of death."48
No attempt is made to predict when this concrete expectancy will be
fulfilled. Even a Dutch physician who has carried out euthanasia is
reluctant to say how long the patient might have lived otherwise since
"any estimate of the extent of shortening of life can only be very
general" and has no "absolute value."49
Even the most cursory look at advance directive laws in the United
States, which have attempted to define "terminal," reveals the evolving
nature of the word's meaning.
The first such law, passed in California in l976, referred to
"terminal" as a condition from which death would occur "regardless of
the application of life-sustaining procedures."50 Far broader
was the meaning given the word when the State of Idaho passed its
Natural Death Act the following year. According to the Idaho statute, a
terminal condition was "an incurable physical condition caused by
disease or illness which reasonable medical judgment determines
shortens the lifespan of the patient."51
Ironically, the early Idaho definition had great similarity to that
which is used by Jack Kevorkian. Kevorkian contends that a terminal
condition is "any disease that curtails life even for a day"52
or "any process that curtails natural life."53
While there is little doubt that Idaho legislators of the late 1970s
probably had such conditions as end stage cancer in mind, their
definition did lend itself to extremely broad interpretation. This is
illustrated by Jack Kevorkian's application of the similar definition to
his victims, many of whom had decades of life remaining but were
considered to fit within his definition of "terminal."
"Imminent" Eventual Death
Other states attempted to define the word more precisely. For
example, in l983 the state of Virginia declared that "terminal" was not
only a condition from which there could be no recovery but also that it
had to be a condition from which "death is imminent."54 One
year later, Wisconsin passed its Natural Death Act which stated that a
condition would be considered "terminal" if death was expected to occur
within 30 days regardless of the application of life-sustaining
Using "imminent" as a qualifier would seem to provide adequate
guidance as to the meaning of "terminal." But, in practice, "imminent"
also has been found to be open to extremely broad interpretation.
When some in Wisconsin thought that the state's 30 day life
expectancy requirement was too restrictive, the law was amended,
changing "would cause death within 30 days" to "would cause death
imminently."56 The change was intended to permit greater
flexibility in interpretation.57
Among examples of this flexibility are the following: A Virginia
court determined that death could be considered "imminent" if it was
expected to occur within several months;58 a Florida hospital
began interpreting "imminent" to mean that death would occur within one
year;59 and such statements as, "For death to be imminent,
the patient's life expectancy must be one year or less, according to
reasonable medical judgment," began to appear in law journals.60
As one physician testified before a legislative committee, "The word
'imminent' in medicine is just not useable"61 nor is it
In many cases, particularly when the concept of right-to-die laws was
relatively new, seemingly narrow definitions for the word "terminal" or
the addition of words like "imminent" were added to proposals to assure
that they would not be too broadly interpreted. Even today, many people
still maintain the belief that a diagnosis of a terminal condition has a
very specific meaning. Few realize that the same word can simultaneously
refer to a conditions that may not cause death for weeks, months or even
years, even if no treatment is provided. Nor are they aware that one can
fall within the category of being in a terminal condition even if the
condition could be controlled indefinitely by some type of medical
Such confusion was even evident on the part of Judge Reinhardt. In
his opinion, attempting to draw a distinction between a death resulting
from an underlying disease and a death occurring from the removal of
food and fluids, Judge Reinhardt referred to the death of Nancy Cruzan:
"Ms. Cruzan was not even terminally ill at the time, but had a life
expectancy of 30 years," he wrote.62
Judge Reinhardt apparently didn't know that in at least one state
within the 9th Circuit, those in conditions like that of Nancy Cruzan
are specifically defined, by statute, as "terminally ill." Arizona's
"Medical Treatment Termination of Life-Sustaining Procedures Act" is
but one example. It states: "Terminal condition includes a permanent
vegetative state and irreversible coma."63
If it is difficult for a Federal Appeals Court judge to keep up to
date on the many and changing legal meanings for "terminal," it is no
leap of the imagination to assume that others, not versed in the law,
may also lack understanding of the very words which could affect them
It is not only laws that have stretched the boundaries of definition
and interpretation. Some policies, as exemplified in guidelines for
Veterans Administration hospitals, have such great elasticity that even
individuals whose conditions are solely related to arthritis or mental
illness could fall within the category of the "terminally ill." Veterans
Administration hospital guidelines have defined "terminal illness" to
include "chronic debilitating conditions from which there is no
reasonable hope of recovery."64
Well meaning though they may be, individuals who believe that
assisted suicide and euthanasia can be limited to those who are in a
"terminal" condition are naοve. Their illusory safeguards will not
protect those in the ever-expanding group of candidates for the
"treatment" of death. Just as the word, "terminal," has become as hard
to pin down as jello to the wall, so too has the word "treatment" been
pulled and stretched out of shape. Euthanasia advocates have seized upon
this in furtherance of their political and social goals.
The Morphing of "Treatment"
Televised political advertising in the l990s has made effective use
of what is known as "morphing" (derived from the word metamorphosis).
With this technique, one image is smoothly transformed into another.
Even though it's happening before the viewers eyes, it creates the
illusion that the final image was always there making it difficult to
recall that the final image did not begin as it ended. The purpose is to
convey a powerful message and to influence attitudes, with powerful
visual symbolism replacing substantive discussion.
So, too, in the legal and public relations campaigns to gain
acceptance for assisted suicide and euthanasia, a form of linguistic
morphing has transpired. Like its first cousin, visual morphing, the
linguistic version is designed to change public perception and pave the
way for acceptance of previously unthinkable proposals all without in
depth or substantive analysis. For example, current attempts to
categorize intentionally prescribed fatal overdoses and lethal
injections as "treatment" are the culmination of a carefully constructed
bridge built from the traditional understanding of the term (i.e. an
attempt to cure or ameliorate a medical condition) to a new, deadly, and
very final "treatment" (i.e. killing).
As with the word, "terminal," the average person maintains a belief
that the word, "treatment," is simply and easily interpreted, referring
to medical interventions intended to cure or ameliorate a condition.
But, as with the understanding of terminal illness, the public
perception of what is meant by medical treatment is stalled stranded
in a time when a desire to forego life-sustaining treatment meant only
that one did not want to be tethered to machines, monitors, buzzers,
bells and whistles during the final days of life. Quite simply, the
debate about treatment has traveled so far beyond the original meaning
of the word that it almost begs for redefinition in Webster's. The
tracks have been switched moving no longer in the direction of natural
death but, instead, careening toward killing in the name of compassion.
Pivotal in this shift was what has become known as the "food and
fluids issue." No matter the view that one may maintain regarding the
removal of food and fluids from patients, there can be no legitimate
denial that nutrition and hydration cases have had significant impact on
the current status of the right-to-die debate.
Food and Fluids as Medical Treatment
The fundamental moral consensus that patients should receive care,
including food and fluids came under attack in the l980s. Debates
began to be waged in bioethics circles about the propriety of
withdrawing tube feeding from brain damaged or demented patients.
No one contended, even then, that a dying patient who could not
assimilate food and fluids or for whom the means of their provision was
a source of great discomfort should be given them anyway. To do so would
be futile or cruel. What did become a matter of debate was whether food
and fluids that were effectively sustaining life could be removed for
nonmedical reasons, with the intent of causing death.
The authors' discussion about the reclassification of food and fluids
from "care" to "treatment" is not intended to reargue the food and
fluids issue. Instead it is intended to provide a background of the
manner in which society and the courts have reached a point where
legitimizing the removal of food and fluids by calling this the "removal
of 'treatment'" has set the stage for the attempt to legitimize giving
intentionally lethal medications under the guise of "provision of
In l983, reflecting on the possible outcome of the debate, Daniel
Callahan, then director of the Hastings Center, wrote that "...a denial
of nutrition, may, in the long run, become the only effective way to
make certain that a large number of biologically tenacious patients
actually die."65 He further predicted, "Given the
increasingly large pool of superannuated, chronically ill, physically
marginal elderly, it could well become the nontreatment of
choice."66 He noted, however, that there still was a
"deep-seated revulsion"67 to withholding or withdrawing food
While many who, in the upcoming years, lent their support to the
concept of removing food and fluids saw little or no connection between
that and assisted suicide or euthanasia, leaders of the right-to-die
movement were quick to recognize that they could capitalize on its
acceptance. This was evident in the remarks of Helga Kuhse who is a long
time leader in the euthanasia movement. Speaking at a 1984 international
conference of euthanasia leaders, Kuhse, who is a philosophy professor
at Australia's Monash University, said that once people see how painful
death by starvation and dehydration is, then, "in the patient's best
interest," they will accept the lethal injection.68
Considerable verbal engineering was required to transform denial of
food and fluids into an appealing "removal of treatment." A series a
cases related to the removal of food and fluids provided by means of
tube was the starting point.69 And, in media accounts, the
very nature of providing nourishment by means of tube became distorted.
It was constantly depicted as a rare, exotic procedure of recent origin
that required constant monitoring by highly skilled medical
Tube Feeding: Neither New Nor Rare
In fact, food and water have been provided by means of gastrostomy
tube for over 100 years7 and, according to a government
report, at least 848,100 people per year receive food by means of a tube
in hospitals, nursing homes or in their own homes.71 A
gastrostomy tube, inserted through the abdominal wall directly into the
stomach, is a simple surgical procedure that can be performed under
local anesthesia. Once inserted, the small incision heals and its
presence causes essentially no discomfort to the majority of people.72
Yet, in the debate over food and fluids, this simple procedure has been
described as one which is highly invasive and highly risky.
The 1984 case of Mary Hier73 illustrates how the
classification of tube feeding as a "medical treatment" can to be used
when the intent was to withhold food and fluids.
Ninety-two-year-old Mary Hier had lived in a state hospital for more
that fifty- seven years. Elderly and demented, she thought she was the
Queen of England. She was not terminally ill. Because of a Zenkers
diverticulum in Mr. Hier's pharyngeal esophagus made it almost
impossible for adequate food and fluids to pass down her esophagus to
her stomach, she had received food by means of a gastrostomy tube for
many years. When, in an unexplained incident, Ms. Hier's gastrostomy
tube became dislodged, the care facility sought to replace the tube.
Although her guardian ad litem argued that nutrition should be
differentiated from treatment, the Court declared, "We do not agree that
such a distinction should be drawn as a matter of law."74 The
Court noted that the 1983 President's Commission for the Study of
Ethical Problems in Medicine had taken the position that "artificial
feeding" should be thought of as a "treatment" decision.75
Additionally the Court found that replacing Ms. Hier's gastrostomy tube
would entail a "major medical procedure" that was "highly intrusive" and
entailed a "relatively high risk to the patient due to her age."76
Permission to replace the tube was denied.
Mary Hier's story and her life might have ended there had it not been
for the fact that, just as her case was being reported, another story
appeared in the same newspaper. It concerned a ninety-four-year-old
woman who was doing well following "minor surgery to correct a
nutritional problem." The surgery had been performed on an outpatient
basis under local anesthesia. The woman's name was Rose Kennedy and the
"minor surgery to correct a nutritional problem" was insertion of a
gastrostomy tube.77 For ninety-four-year old Rose Kennedy,
matriarch of a rich and powerful family, tube feeding was a mere
correction of a nutritional problem. For ninety-two-year-old Mary Hier,
poor and mentally ill, it was termed "medical treatment" that was too
invasive and risky for a woman of her age.
Last minute intervention by a local physician and an attorney did
eventually lead to Mary Hier' s tube feeding being provided again, and
both Mary Hier and Rose Kennedy lived for many additional years.
The choice of words to describe the method of providing food and
fluids, as illustrated in the case of Mary Hier, depends upon whether
the discussion is intended to lead to their being provided or withheld.
Manipulative terminology, using the language of treatment rather than
care, has also been used to describe not only the tube but also the food
itself. For example, referring to food received by tube as "artificially
implanted nutrition and hydration"78 seemed a patent attempt
to create the illusion that food and fluids themselves are exotic
medical treatment. Yet it seems doubtful that those who contend that
food and fluids become "treatment" if taken by tube would tolerate
others calling penicillin or milk of magnesia "food" when taken by
Lunch Trays Bearing Treatment
Whether one agrees or disagrees with what has transpired, the reality
is that, by the time of the Cruzan79 case, the
provision of food and fluids by means of a tube was clearly considered
to be a form of medical treatment by society at large and by the courts.
However, by the time that Cruzan was decided, some ethicists
and right-to-die advocates had already begun to expand the boundaries of
"treatment" once again this time to include oral feeding as a medical
intervention that could be withheld or withdrawn ethically. The
spotlight had now shifted from the method by which food and
fluids were provided to the actual food and fluids, no matter how
It is no longer unusual to observe a dispassionate discussion among
ethicists and medical professionals about the withdrawal of oral feeding
from frail, elderly or brain damaged, but non-dying patients. Such
discussions take place at many conferences, and can also be observed on
the Internet. They certainly take place in the clinical setting.
The willingness to extend denial of even spoon feeding was also
apparent in the l988 testimony of Ronald Cranford, M.D., in the
Cruzan case. Cranford, an associate physician in neurology at
Hennepin County Medical Center in Minneapolis, testified there really is
no definition of "artificial" feeding.8 He said that, if Ms.
Cruzan were able to take food orally, he would still consider provision
of food in this manner to be "medical treatment."81
This l988 statement, that no definition of "artificial" feeding
exists, differed from a position Cranford had held only four years
earlier when he differentiated between "artificial means" (nasogastric
tubes, gastrostomy tubes, hyperalimentation and intravenous lines) and
the ability to take food by the "natural route." At that time he
specifically stated that "it may be justifiable to consider
withdrawal of fluids and nutrition given by an artificial route."82
However, by the time he testified in l988, he included spoon feeding in
the category of what might be considered "artificial feeding." "There is
a legitimate difference of opinion concerning spoon feeding," he said.
"It is not fair to say that artificial feeding would only characterize
what we call gastrostomy and so forth."83
He stated that spoon feeding is denied in cases of like Ms. Cruzan's
(where profound brain damage has occurred) because to spoon feed her
"would be totally inconsistent" with what was wanted (i.e. death for the
In another 1988 case, also involving the denial of food and fluids
for a patient who was no longer able to make medical decisions, a
physician reasoned that if a patient is in a convalescent care facility,
even the patient's normal diet must be prescribed; therefore it is
always medical treatment.85 hus, in the minds of some, the
food on a nursing home patient's tray had now become "treatment" and, as
such, could be considered optional.
By l994, virtually anything that a physician authorizes, prescribes
or performs was said by some to fall within the meaning of "treatment."
This was evident in testimony given before the Senate Finance Committee
by Eric J. Cassell, M.D., of Cornell University Medical College, who
stated, "Treatments are not merely technologies or drugs, virtually
everything done to or for a sick person is part of the treatment."86
The notion that any and all patient care even the provision of food
and fluids taken by mouth was "treatment" which could be withheld or
withdrawn had gained wide acceptance within professional circles.
However, the general public was still far from embracing death by
starvation and dehydration as a desirable, noble "option" to be sought.
The bridge from tolerance of the concept to widespread support for it
was still needed if assisted suicide was to gain a foothold.
As far back as l972, at a conference of the Euthanasia Educational
Council,87 Cassell acknowledged this when, during a
discussion of effective ways to commit suicide and assisted suicide, he
"Maybe we ought to accord the right of the suicide [sic] to make it
an elegant and noble move. What you're describing is a turn around
of society in which death becomes the elegant thing: in which you
achieve an age when it's proper for you to die and to get help in
your dying, and you arrange for a death that's appropriate to your
life, with all the fittings, without pain and the proper pill.88
...What seems to me I hear [when people request assisted suicide] is
a way to dignify it, making it an honorable thing to do, make it
respected by other people. That's a profound change in the structure
of society which may well come, but it's going to be a while coming.
It's not just the finding of the pill that can be found. It's the
finding of the world in which one would have one's death as one
would have one's wedding and a few other things...."89
By 1996, the Euthanasia Educational Council (which by now was called
Choice in Dying) had begun to list dehydration in a guide to
end-of-life options. The organization noted that among the legal
ways to end life was to do without food and water: "A tray of food
is considered treatment. You have the right to refuse it. A growing
body of research indicates voluntary dehydration is not a painful or
unpleasant way to die."90
"Graceful Death" by Dehydration
The process of dignifying death by starvation or dehydration began in
a l994 article by David Eddy, MD., Ph.D., published in the Journal
of the American Medical Association.91/sup>In it, dehydrating to
death was portrayed as a way for an elderly woman -- who had no life
threatening condition to end her life "gracefully." Dr. Eddy wrote
that his mother was a spunky, self-sufficient widow who had enjoyed an
abundant life and who, when ailments made her quality of life no longer
acceptable, decided it was time to die. "As a physician's wife, she was
used to thinking about life and death and prided herself on being able
to deal maturely with the idea of death."92
With her son she explored ways to end her life. "Can I stop eating?"
she asked. He told her that if she was really intent on dying she could
stop drinking too since, "without water, no one, not even the
healthiest, can live more than a few days."93
On her 85th birthday, Virginia Eddy celebrated with her family at a
party with all the trimmings. Then, her son wrote, "She relished her
last piece of chocolate, and then stopped eating and drinking."94Her
son arranged for her to be placed on a self-administered morphine drip
to relieve the pain of dehydration. She died six days later.
"This death was not a sad death; it was a happy death," Eddy wrote.
"She had done just what she wanted to do, just the way she wanted to do
it." According to Eddy, his mother had chosen the time and manner of her
death and this had been a positive experience for the entire family: "[A]lthough
we will miss her greatly, her ability to achieve her death at the 'right
time' and in her 'right way' transformed for us what could have been a
desolate and crushing loss into a time for joy."95
Clearly, this article was intended to significantly influence its
readers' attitudes. In fact, the piece was referred to in a report about
the impact of medical journal articles on public opinion, clinical-care
standards and health care policies. George Lundberg, M.D., who oversees
all of the American Medical Association's forty-seven professional
journals, including JAMA, called Eddy's article the "most
important article published in the last 50 years." He said, "The
openness of the presentation, the competence and compassion, and the
method of dying by withholding food or drink were all salutary. The
argument presented was legal, ethical, moral and loving." Lundberg
predicted it would become "a landmark model of dying."96
The Hemlock Society's medical director, Richard MacDonald, M.D., who
was, at that time, campaigning to legalize assisted suicide in Oregon,
jumped on the bandwagon. He wrote, "She [Mrs. Eddy] chose a very
rational course, which is the right of every patient to refuse
treatment [i.e. post-birthday meals and beverages] which can extend
life but is futile as far as improving the quality of life or curing the
diseases contributing to that poor quality." Then, making a pitch for
Oregon's Measure 16, MacDonald added that "such a peaceful end to
suffering is not often available to someone who doesn't have the good
fortune to have a physician for a son, as this patient did."97
It was not the method of induced death that was emphasized but rather
the "right" to choose how, when, where and why to die and the right of
someone else to "assist" in bringing about that death that was being
promoted. MacDonald and others campaigning for the Oregon initiative
were working to extend the "good fortune" of Mrs. Eddy to all
Oregonian's by legalizing what would later be termed "comfort care."
Poisonous Prescriptions As "Comfort Care"
The Eddy article was indicative of yet another attitudinal shift
one that now saw intentionally ending life with a doctor's assistance as
a graceful exit from life. The right to be free of unwanted treatment
had been totally transformed into the right to be free of unwanted life.
It had taken many years, many attempts, many returns to the drawing
board, so to speak, and more than anything else careful manipulation
of language. In November of l994, Oregon, with the passage of Measure
16, became the only state in the history of the nation to approve a
proposal permitting physicians to intentionally prescribe lethal
overdoses to certain patients. (Because of an on-going legal challenge,98Measure
16 has not gone into effect.) As in previous attempts in Washington and
California to legalize assisted suicide and euthanasia, proponents had
always stated that the purpose of the law was to give a new "right" to
In fact, the major impact of legalizing assisted suicide was not to
give rights to those who would be dead, but was to bestow immunity on
those who would be instrumental in making them dead. This was
acknowledged by Barbara Coombs Lee, Measure 16's chief petitioner, who
described the measure, saying, "The [Death with Dignity] act creates
a safe harbor in Oregon's assisted suicide laws for an attending
physician to provide a prescription for lethal medication...."99Lee
has been vague in describing how the waters in this "safe harbor" would
Asked how patient deaths would actually be brought about, she said
that the new law isn't specific since "it would be pretty outlandish to
tell physicians what particular mode of care to provide."100 When
questioned about the need to educate physicians regarding assisted
suicide, she opined that courses dealing with assisted suicide would
eventually be taught in medical schools, saying, "Writing a lethal
prescription is one very small aspect of the total care of terminally
Problematic, of course, is the way a prescription for "care" of this
type would be labeled. Lee explained that a physician might write
something like, "take as needed to control symptoms."102 Without
question, a prescription for this type of "care" would "control
symptoms" permanently. That, however, leads to the difficulty about
how the outcome of this "care" would be described.
Almost immediately, after Measure 16's passage, rhetorical gymnastics
reached Olympian proportions as attempts were made to come up with a
label for the new death-producing medical procedure. The problem was,
how should deaths in compliance with Measure 16 be categorized,
particularly on death certificates? If the law survives legal challenges
and goes into effect, such deaths can't be called "suicides" because
Measure 16 prohibits suicide and assisted suicide.103 Lee claimed that
the word "suicide" would not apply and asked that deaths resulting from
the lethal drug overdose be called "self-administration under Measure
16,"104 while the Oregon Health Division recommended that the cause of
death be designated "drug overdose, legally prescribed."105
As far as categorizing the deadly practice for purposes of payment,
Oregon's Medicaid director, Jean Thorne, said the procedure would be
covered under a part of the Oregon Health Plan called "comfort care."106
As Oregonian reporter Mark O'Keefe observed, "One thing is certain.
Terminology matters. If it did not, politicians would not call tax
increases 'revenue enhancements.' Corporations firing thousands of
employees would not describe the act as a 'work-force adjustment.'"107
And a group that provides suicide assistance would not call itself
"Compassion in Dying." (During the first 13 months of its operation,
before it brought a court challenge to Washington's law prohibiting
assisted suicide, Compassion in Dying counseled 24 patients who
committed suicide with prescription drugs. Since then it has refused to
divulge the number of deaths with which is has been involved.)108
Compassion in Dying grew out of the Hemlock Society's failed 1991
attempt to pass an "aid-in-dying" initiative in Washington State. Until
recently the group was headed by Ralph Mero, who had previously served
as executive director of Hemlock of Washington State. (In the summer of
l996, Barbara Coombs Lee, Measure 16's chief petitioner, left her
position as a vice president for a large Oregon managed care program and
took over the helm of Compassion in Dying.)
As the first U.S. group to admit publicly to offering assistance in
committing suicide, 109 this Hemlock spin-off received a gigantic boost
in achieving one of Hemlock's objectives the right to decide the
manner and means of death110 when Judge Stephen Reinhardt wrote that
there is a constitutionally-protected liberty interest in determining
the "time and manner" of death.111
The Compassion in Dying opinion presents a stark picture of
the progress that has been made toward accomplishing the euthanasia
agenda by distorting legal precedent, misrepresenting philosophical
principles, and twisting the meaning of words. For example, contrary to
Judge Reinhardt's opinion, Cruzan112 did not recognize a "liberty
interest in hastening one's own death."113 It had, as its underlying
rationale, the right to be free of bodily invasion, not the right to be
free of life. Similarly, Judge Reinhardt's contention that the principle
of double effect permits a doctor to intentionally "assist" a patient
"to die through medical treatment"114 completely disregards
that principle's elements.115 Judge Reinhardt not only gave judicial
approval to the intentional termination of a patient's life, he did so
in a style previously reserved by the most outspoken euthanasia
activists placing the labels "medical treatment"116 or "medical
function" on actions that have death as their "necessary and inevitable
For a number of years, Jack Kevorkian has been carrying out actions
that have death as their inevitable consequence. Like Judge Reinhardt,
he refers to such acts as medical treatment.118 By mid-August
1996, when the body count from Kevorkian's "treatment" had reached
thirty-eight "patients," Linda Emanuel, vice president of ethics for the
American Medical Association, remarked, "The bizarre has become normal
and the ghastly is no longer seen as ghastly."119
Judge Reinhardt has given the ghastly a judicial seal of approval.
The success or failure of political or social revolutions often
depends on the terms used in the debate. If the movement is in accord
with accepted values as expressed by language, success is often the
But what if the existing lexicon and traditional understanding of
words and phrases hurt the cause and bog down the movement? The answer
is simple: If the people don't want to follow where you want to take
them, make the destination appear more attractive. This is precisely
what proponents of the "right to die" have done. By using fuzzy
euphemisms, by blurring vital distinctions, by using imprecise
phraseology, and by redefining well-understood concepts and ethical
principles, they created an Alice Through the Looking Glass World, where
previously understood concepts no longer apply. It's as if "up" were now
"down" and "hot" were now "cold." Words only mean what the speaker
intends them to mean, regardless of the understanding of the listener.
Terms like "killing" and "suicide" which have precise definitions but
negative connotations have become outcasts, replaced by subjective,
feel-good, meaningless phrases such as "gentle landing," "deliverance,"
"chosen death," or the ubiquitous "death with dignity." Thus the ongoing
revolution in ethics and values was preceded by a radical shift in the
use of language, all intended to beckon us to embark on a journey to
radical social change.
That direction may or may not be where we, as a society, will want to
go. But one thing is certain. We need to use clear definitions and
accurate terminology if we are to truly understand what awaits us at the
end of that road.
- "Politics and the English Language," Collected Essays,
Journalism & Letters of George Orwell, vol. iv, Harcourt, Brace
and World, Inc. (1968) p. 137.
- "Kevorkian Takes Stand in Own Defense," New York Times,
Apr. 28, 1994, p. A8. Dr. Levy called Jack Kevorkian's activities
"new age hospice care" while testifying for the defense during
Kevorkian's trial in the death of Thomas Hyde who died of carbon
monoxide poisoning on August 4, 1993.
- "'Mercy' Death Law Proposed in State," New York Times,
Jan. 27, 1939, p. 21.
- "Explaining Euthanasia: Proponent of Bill to Permit it Refers to
Such Actions as 'Merciful Release,'" letter to the editor from
Charles E. Nixdorff, Treasurer of the Euthanasia Society of America,
New York Times, Jan. 30, 1939.
- "'Mercy' Death Law Ready For Albany," New York Times,
Feb. 14, 1939.
- Keynote address by Dr. M.A.M. Watcher at the eighth biennial
conference of the World Federation of Right to Die Societies,
Maastricht, The Netherlands, June 7-10, 1990.
- State Committee on Euthansia, "Report on Euthansia," Government
Printing Office, The Hague (1985). The definition was also used in
the 1991 Remmelink Report and in the summary brochure, "Medical
Practice with Regard to Euthanasia and Related Medical Decisions in
The Netherlands," Ministerie van Justitie (1991), p. 3. The summary
brochure was distributed by Dutch consulates and embassies in
response to inquiries about the Remmelink Report.
- The official government report Medische Beslissingen Rond
Het Levenseinde, Sdu Uitgeverij Plantijnstraat (1991), The Hague
was released in two volumes. The 294-page report was the work of
the Committeee to investigate the Medical Practice Concerning
Euthanasia, appointed on January 17, 1990, by the minister of
justice and the state secretary for welfare, public health, and
culture. The six-member committee was chaired by Professor J.
Remmelink, M.J., the attorney general of the High Council of the
Netherlands and professor emeritus of criminal law at the Free
University. To assure accurate and complete information, physicians
who provided data were granted total anonymity and immunity by the
- Medische Beslissingen Rond Het Levenseinde, Sdu
Uitgeverij Plantijnstraat (1991), The Hague, vol. I, p. 13.
(Hereafter referred to as the Remmelink Report)
- Ibid., p. 15.
- Ibid., vol. II, p. 49, Table 6.4.
- Ibid., p. 50, Table 6.6.
- According to the Remmelink Report, 22,500 deaths (about 17.3
percent of all deaths) in the Netherlands in one year occured after
dosages of pain medication that may have shortened life. (Remmelink
Report, vol. I, p. 16) Of these, 36 percent took place with the
physician's deliberate intent to cause death. (Remmelink Report,
vol. II, p. 58, Table, 7.2.) As a clarification to the intent it may
be useful to recognize that in 64 percent of such deaths the stated
intent was to kill the pain; in the remaining 36 percent, a stated
intent was to kill the patient.
- Remmelink Report, vol. II, p. 61, Table 7.7.
- "Medical Practice with Regard to Euthanasia and Related Medical
Decisions in the Netherlands, Ministerie van Justitie (1991), p. 5.
The summary brochure was distributed by Dutch consulates and
embassies in response to inquiries about the Remmelink Report.
- Paul J. van der Mass et al, "Euthanasia, Physician-Assisted
Suicide, and Other Medical Practices Involving the End of Life in
the Netherlands, 1990-1995, New England Journal of Medicine,
vol. 335, no. 22 (Nov. 28, 1996), pp. 1699-1706.
- The campaign to place the "Humane and Dignified Death Act" which
would have legalized euthanasia and assisted suicide under the name,
"aid-in-dying" failed to gain enough signatures to be placed on the
1988 California ballot. California's "Death with Dignity Act,"
(Proposition 161) which would have permitted "aid-in-dying," did
qualify for the ballot, but failed on November 3, 1992 by a vote of
54 to 46 percent.
- Washington State voters turned down the "Death with Dignity Act"
(Initiative 119) that would have legalized "aid-in-dying," on Nov.
5, 1991 by a vote of 54 to 46 percent.
- Initiative 119, Section 2 (9).
- Proposition 161, Section 2525.2 (k).
- "Suggestions for Speakers," and "Suggested Format for Speech on
Initiative 119," distributed at July 1, 1991 meeting of Spokane (WA)
Friends of Initiative 119. The meeting was chaired by Rob Neils,
Spokane County coordinator for Hemlock of Washington State.
- "Newsday," CNN, July 31, 1991.
- Proposition 161, Section 2525.16.
- Ibid., Section 2525.23.
- Initiative 119, Section 10.
- Derek Humphry, "What's in a word?." Results of Roper Poll
conducted for ERGO! In August 1993, p. 1.
- Ibid., pp. 2-3.
- Model Aid-in-Dying Act," Iowa Law Review, vol. 75, no. 1
- John Hofsess, announcement of the availability of the Art &
Science of Suicide project made to the right-to-die mailing
list, August 20, 1996. Hofsess described Smith's chapters: "Ms.
Smith's chapters provide specialized information on such subjects as
trycyclic antidepressants; barbiturates; and carbon monoxide. Each
chapter has been updated (August 1996) to include the latest
research available. For example, the barbiturates article
incorporates new information derived from the experience of
Compassion in Dying in Washington State. The carbon monoxide article
includes reports of successful suicides in Canada and the United
States using various sources of CO."
- Tom Bates, "Write to Die," Oregonian, Dec. 18, 1994.
- Oregon "Death with Dignity Act" (Measure 16), Section 1.01(11).
After the passages of Measure 16, Cheryl Smith wrote that the
prescription only aspect was adopted "for the practical purpose of
getting a law passed." Cheryl K. Smith, "Once more to the ballot
box," Last Rights (newsletter of the Right to Die Society of
Canada), Issue #13, p. 42.
- Oregon "Death with Dignity Act," (Measure 16), Section 4.01 (1).
- Ibid., Section 1.01 (7).
- Derek Humphry, "What's in a word?." Results of Roper Poll
conducted for ERGO! In August 1993, p. 2.
- Oregon "Death with Dignity Act" (Measure 16), Section 3.14.
- Tom Bates, "Write to Die," Oregonian, Dec. 18, 1994.
- Compassion in Dying v. Washington, 79 F. 3d 790 (9th Cir.
- Quill v. Vacco, 80 F.3d 716 (2nd Cir. 1996).
- Compassion in Dying v. Washington, 79 F. 3d 790, 832
- Ibid., at 816.
- Ibid., at 821.
- Ibid., at 814.
- Ibid., at 827.
- Quill v. Vacco, 80 F. 3d 716, 730 (2nd Cir. 1996).
- Jacobellis v. Ohio, 378 U.S. 184 (1964). (J. Stewart
concurring) Justice Steward conceded that he might never be able
intelligibly to define "hard core pornography," but he observed, "I
know it when I see it, and the motion picture involved in this case
is not that."
- Paul J. van der Maas et al, Euthanasia and Other Medical
Decisions Concerning the End of Life, (Amsterdam; New York:
Elsevier Science Publishers 1992) vol. 2, p. 23. (English
translation of the Remmelink Report.)
- Ibid., pp. 23-24
- California Natural Death Act, Cal. Health & Safety Code Section
7186 (f) (1976).
- Idaho Natural Death Act, Idaho Code Section 39-4503
- Jack Kevorkian in speech to National Press Club, reported in
"Dr. Death: No law is neede on euthanasia," USA Today, Oct.
28, 1992, p. 6A.
- Jack Kevorkian, "A Modern Inquisition," The Humanist,
Nov.-Dec. 1994, p. 8. (emphasis added)
- Virginia Natural Death Act, Va. Code Ann. Sec. 54-325.8:2
- Wisconsin Natural Death Act, Wisc. Stat. Sec. 154.01 (8) (1984).
- Ibid., as amended by 1985 Wisc. Act 199 (April 10, 1986).
- American Medical News, August 1, 1986, p.46 and
Concern for Dying Newsletter, Spring 1986, p.4.
- Hazelton v. Powhatan Nursing Home, Inc., No. CH 98287
(Virginia Cicuit Court, Fairfax County), August 29, 1986. Appeal
denied, record No. 860814 (Virginia Supreme Court) September 2,
1986. The Hazelton case was the first in which the meaning of
"imminent," as it pertained to an advance directive was at issue.
Harriet Hazelton had four attending physicians, all of whom agreed
that she had a probable life expectancy of several months. However,
two of the physicians felt that her death could not be considered
"imminent" since she had months of predicted life. The other two
physicians believed that death could not be considered "immenent" if
months of life were expected to remain.
- James J. McCartney and Jane Mary Trau, "Cessation of the
Artificial Delivery of Food and Fluids: Defining Terminal Illness
and Care," Death Studies, vol. 14 (1990), p. 437. In another
article, McCartney, the former director of the Bioethics Institute
of St. Francis Hospital in Miami Beach, wrote, "St. Francis Hospital
in Miami Beach, Florida (a Catholic Hospital sponsored by the
Allegany Franciscan Sisters) has interpreted "imminent" to mean that
death will occur within one year for the purposes of implementing
F.S. 765 [Florida's Living Will law] in accord with hospital policy.
Since the legislature has given no guidance as to what means by
'imminent,' I believe that this interpretation is as valid as any
other." (James J. McCartney, "Prolonging Life and the 'Right to
Die': Perspectives from the Catholic and Jewish Traditions," (1988)
- Tracy L. Merritt, "Equality for the Elderly Incompetent: A
Proposal for Dignified Death," Stanford Law Review, vol. 39
(Feb. 1987), p. 731.
- Statement by Jorge A. Pereira-Organ, M.D., representing the
Deleware Medical Society, in testimony before the Deleware Senate. (The
News Journal [Wilmington, Deleware], May 31, 1996.)
- Compassion in Dying, at 822.
- Arizona Medical Termination of Life-Sustaining Procedures Act,
Ariz. Rev. Stat. Ann. Sec. 36-3201 (6) as amended (1991). (emphasis
- Veterans Administration policy guidelines, Nov. 18, 1991, M-2,
Part I, Chapter 31, Paragraph 31.02, pp. 31-32.
- Daniel Callahan, "On Feeding the Dying," Hastings Center
Report, October 1983, p. 22.
- Ibid. (emphasis added)
- Kuhse made her observation at the World Federation of Right to
Die Societies' fifth biennial conference held September 20-23, 1984
in Nice, France.
- See generally: Brophy v. New England Sinai Hospital, 398
Mass. 417, 497 N.E. 626 (1986); In re Jobes, 108 N.J. 394,
529 A.2d 434 (1987); Gray v. Romeo, 627 F. Supp. 580 (D.R.I.
1988); Cruzan v. Director, Missouri Department of Health, 110
S. Ct. 2841 (1990).
- Two articles published in the 1896 Transactions of the
Kentucky Medical Society, describe the ease with which feeding
by gastronomy tube was accomplished at that time. McMurtry, "Modern
Gasrrostomy for Stricture of the Esophagus, with Report of a Case,"
and Coomes, "Gastronomy, with Report of a Case," Transactions of
the Kentucky Medical Society (1896).
- Office of Technology Assessment, U.S. Congress, Life
Sustaining Technologies and the Elderly, (1987), p. 294.
- Major, "The Medical Procedures for Providing Food and Water:
Indications and Effects," By No Extraordinary Means: The Choice
to Forego Life-Sustaining Food and Water, p. 26 (J. Lynn ed. L986).
- In re Hier, 18 Mass. App. 200, 464 N.E. 2d 959 (1984).
- Ibid., at 964.
- President's Commission for the Study of Ethical Problems in
Medicine and Biomedical and Behavioral Research, Deciding to
Forego Life-Sustaining Treatment, (1983), p. 90.
- In re Hier, 18 Mass. App. 200, 464 N.E. 2d 959, 964
- "Rose Kennedy 'doing well' after surgery," Boston Globe,
July 29, 1984, p. 35.
- Brief of Amici Curiae SSM Health System, St. Joseph
Health Care System, Mercy Health Services, Catholic Health
Corporation, Rev. J. McCartney, Rev. Kevin O'Rourke, and the Center
for Health Care Ethics, St. Louis University Medical Center,
Cruzan, p. 8.
- Cruzan v. Director, Missouri Department of Health, 497 U.S.
261, 110 S. Ct. 2841, 11 L. Ed. 2d 224 (1990).
- Cruzan v. Harmon, 760 S.W. 2d 408 (Mo. 1988) (no. CV
384-9P). Transcript, p. 228.
- Ibid., p. 163.
- Ronald Cranford, "Termination of Treatment in the Persistent
Vegetative State," Seminars in Neurology, vol. 4 (1984), p.
41. (emphasis added)
- Cruzan v. Harmon, 760 S.W. 2d 408 (Mo. 1988) (No. CV
384-9P). Transcript. p. 228.
- Ibid., p. 229. The year after this testimony, Cranford and
eleven other physician authors published an article in which they
concluded that is morally acceptable for doctors to give patients
suicide information and the prescription for a lethal dose. (Wanzer
et al, "The Physician's Responsibility Toward Hopelessly Ill
Patients: A Second Look," New England Journal of Medicine,
vol. 320, no . 13 (March 30, 1989), p. 848).
The article was a "report" of a twelve physician panel funded by the
Society for the Right to Die, previously known as the Euthanasia
Society of America. In 1992, Cranford joined the board of directors
of the organization which by then, had changed its name again this
time to Choice of Dying.
During a nationally televised interview regarding the article,
Cranford acknowledged that assisting suicide is "the same as killing
the patient." He explained, "We broke new ground, and we were very
aware we were doing it. We felt it was an opportunity to make the
statement that's very controversial and stand by it."
("MacNeil/Lehrer NewsHour," PBS, March 30, 1989)
- McConnell v. Beverly Enterprises, 209 Conn. 692, 553 A.
2d 596, (1988)(No. 0293888). Transcript, p. 56.
- Testimony of Eric Cassell, M.D., before the Committee on
Finance, United States Senate, May 5, 1994, p. 4.
- The Euthanasia Educational Council began in 1967 as a branch of
the Euthanasia Society of America. It was then called the Euthanasia
Educational Fund. Soon after, it changed its name to the Euthanasia
Educational Council and then, in 1978, it became known as Concern
for Dying. Currently it, along with the group originally called the
Euthanasia Society of America, is called Choice in Dying.
- Euthanasia: Rights & Realities, excerpts from papers and
discussions at the Fifth Euthanasia Conference held on Dec. 2, 1972,
sponsored by the Euthanasia Educational Council, New York Academy of
Medicine, p. 24.
- Ibid., p. 26.
- Lori Montgomery, "The options legal and not," Detroit Free
Press, Dec. 26, 1996.
- David Eddy, "A Conversation with My Mother," Journal of the
American Medical Association, vol. 272, no. 3, pp. 179-181. Eddy
is a professor of health policy and management at Duke University
and a policy advisor to Kaiser Permanente Southern California. He
has also advised President Clinton and Blue Cross/Blue Shield on
health policy, and he is a strong advocate for health care
rationing. (See, for example: David Eddy, "Health System Reform:
Will Controlling Costs Require Rationing Services?," JAMA,
vol. 272, no. 4, (July 27, 1994) pp. 324-328.)
- Ibid., p. 179.
- Ibid., p. 181.
- Jennifer LaBarbera, "Editors of Medical Journals Wield Pens with
the Deftness of Scalpels," Physicians Financial News, vol.
12, no. 16, Sept. 30, 1994, pp. 1, 26.
- Richard MacDonald, M.D., "JAMA Article: Model of American
Death?," Hemlock TimeLines, September-October 1994, p. 4.
- Lee v. Oregon, 891 F. Supp. 1429 (D.Or.1995).
- Transcript of oversight hearing, "Assisted Suicide in the United
States," before the House Subcommittee on the Constitution,
Committee on the Judiciary, April 29, 1996, p. 71. (emphasis added)
- Tom Bates, "Chief petitioner answers questions on Measure 16,
Oregonian, Nov. 27, 1994. (emphasis added)
- Ibid. (emphasis added)
- See note 36.
- Mark O'Keefe, "Doctor-assisted-suicide law comes down to a war
of words," Oregonian, Dec. 1, 1994, p. A1.
- Dan Postrel, "State could cover assisted suicide,"
Statesman-Journal (Salem, OR) Dec. 1, 1994, p. A!.
- Mark O'Keefe, "Doctor-assisted-suicide law comes down to a war
of words," Oregonian, Dec. 1, 1994, p. A1.
- William Cartsen, "When Patients Choose to Die: Seattle Group
Crusades for Right to Die," San Francisco Chronicle, June 3,
1996, p. A1, A8.
- Dick Lehr, "Supporting those who want to die: A Seattle group,
including doctors and clergy, offers help and advice for the
suicidal," Boston Globe, Jan. 18, 1994, p. 8.
- Hemlock Quarterly, Issue 1, Oct. 1980, p. 5. Faye Girsh,
Hemlock's executive director, has reaffirmed that the group's long
held position that there is a right to a "certain death" that can
"only be accomplished with the help of a doctor." (Position
statement of the Hemlock USA, issued by Faye Girsh, Aug. 23, 1996.)
- Compassion in Dying at 793. Throughout his opinion Judge
Reinhardt used euthanasia advocates' buzzwords for assisted suicide.
- Cruzan v. Director, Missouri Depatment of Health, 497
U.S. 261, 110 S.Ct. 2841, 111 L. Ed. 2d 224 (1990).
- Compassion in Dying at 816.
- Ibid., at 828 and fn. 102.
- The "Principle of Double Effect" provides that it is permissible
to perform an act that has both a good effect and a bad effect only
if all of the following conditions are met:
1.) The act to be done must be good in itself or at least
2.) The good effect must not be obtained by means of the bad effect.
3.) The bad effect must not be intended for itself but only
4.) There must be a proportionately grave reason for permitting the
(A. Fagothey, Right and Reason: Ethics in Theory and Practice,
Second Edition (1959), pp. 152-160.)
- Compassion in Dying, at 828, fn. 102.
- Ibid., at 829.
- During one week in August 1996, Jack Kevorkian "assisted" four
deaths. One was that of Judith Curren who was taken to Michigan by
her physician husband where she died of a lethal injection. Curren
had no life threatning condition but had a history of depression.
She was also the alleged victim of spousal abuse. Following her
death, Kevorkian and his attorney said it was Curren's unacceptable
quality of life that made it necessary to end her suffering by means
of a "medical procedure." (See: "Indira Lakshmanan and Doreen Vigue,
"Death ended a troubled relationship," Boston Globe, Aug. 24,
1996; "Kevorkian Defends Actions on NBC," AP, Aug. 26, 1996;
"No Legal Action Is Anticipated as Kevorkian Suicides Multiply,"
Washington Post, Aug. 24, 1996.)
- "No Legal Action Is Anticipated as Kevorkian Suicides Multiply,"
Washington Post, Aug. 24, 1996, p. A2.
Rita L. Marker and Wesley J. Smith. "Words, Words, Words."
The International Task Force on Euthanasia and Assisted Suicide.
This article reprinted with permission from the International
Task Force on Euthanasia and Assisted Suicide PO Box 760
Steubenville, OH 43952 740-282-3810.
Rita L. Marker is the author of the critically acclaimed book,
Deadly Compassion. (Wm. Morrow & Co., 1993; Harper/Collins,
1994; Avon Books, 1995). Reviewers in the United States, Great
Britain, Australia and New Zealand all agreed that
Deadly Compassion is a compelling, persuasive, well-written
and revealing discussion of both the personal and public sides of
the euthanasia debate. Marker has been the executive director of the
International Task Force on Euthanasia and Assisted Suicide
since it began in l987. She was among the first to be profiled in
the American Medical Association's American Medical News
during its series on "people making news in an era of dramatic
change in medicine."
Wesley J. Smith is a senior fellow at the
Institute and an attorney and consultant for the
International Task Force on Euthanasia and Assisted Suicide
and the Center for Bioethics and
He is an international lecturer and public speaker, appearing
frequently at political, university, medical, legal, bioethics, and
community gatherings across the United States, Canada, Great
Britain, and Australia. Wesley J. Smith is the author or
co/author of 10 books including his revised
Forced Exit: The Slippery Slope From Assisted Suicide to
Culture of Death: The Assault of Medical Ethics in America,
Power Over Pain and
Consumer's Guide to a Brave New World.
Copyright © 2004 The
International Task Force on Euthanasia and Assisted Suicide