The Case Against Assisted Suicide: For the Right to End-of-Life Care edited by Kathleen Foley and Herbert Hendin (Johns Hopkins University Press)

I. As every doctor knows, the number of operations that have beendevised for a given pathology is inversely proportional to the probability that any of them is entirely satisfactory. Thus there have been dozens of surgical methods designed to treat the notoriously resistant problem of acid reflux disease, but there has been only a single technique for appendicitis, because it succeeds every time. The opposite can be said about the number of definitions for a given noun. The more there are, the more valuable is each one. Multiple definitions, each subtly different from all the others, convey multiple shades of meaning. They expand the uses of the word and the contexts in which it can appear; language is enriched, thought is widened, and interpretations increase or dilate to fill the potentialities of association. The very impossibility of absoluteness in the definition of certain nouns adds to the levels of connotation they may reach. The inner life of a writer says more than most readers can know; the mind of a reader discovers truths that go beyond the intent or perhaps even the comprehension of the writer. And all of it finds expression because a word can mean many things. "Hope" is such a noun. In thinking about its multiplicity of uses, we might consider for a moment what "every doctor knows," beyond the data and the complexities of human biology and its discontents. For if there is a single theme interwoven into the education of all medical students and verified in the crucible of daily experience, it is the unstated precept that hope is the subtext of every encounter that a doctor will ever have with a fellow human being who is sick. People come to us seeking hope, and we are meant to convey hope in every facial expression and clinical intervention that we undertake. Hope is a powerful element in the therapeutic arsenal. Almost always, it is synonymous with a reassuring optimism that we can do something to fend off the depredations of a disease. But what happens when there is no treatment adequate to fight the malady? As a student I was taught–and for four decades I have taught others–that under no circumstances must a physician allow a patient to lose hope. Of what, then, does hope consist, when there can be no optimism that cure will be attained or life lengthened? How can the word be defined for a man or woman whose life is near its inevitable end?cTo hope is to be imbued with expectation of a good that is yet to be; but at the time of terminal illness it must be sought in precincts where the remission of disease is not to be found. It lives in those other places, awaiting discovery. For the "good that is yet to be" does in fact exist elsewhere and in other forms, even when there is no remedy for the sickness. As a physician or as a person about to lose one who is loved, we can provide hope by a spoken or unspoken promise that this man or woman who puts such trust in us will not be abandoned to die alone; that the meaning of the life soon to end will be perpetuated within our memories and our actions; and that insofar as this can be managed, no suffering will disturb the tranquillity of the final days. Of these three forms of hope, only the last is not always possible to fulfill. But that is not the end of the story. Dwelling only on the obstacles to providing physical and emotional comfort may lead to medical complacence or philosophical fatalism. For the relief of suffering is possible far more often than many of those who attempt to influence public opinion have realized or been willing to admit. The methods of palliative care, or comfort care, have in the past few decades reached a level of effectiveness such that suffering thought at first to be intractable can almost always be relieved. And this is the ultimate message of this vastly important book that now makes its timely appearance, in which are included essays by some of the most prominent names in the movement to oppose physician-assisted suicide and euthanasia. Like the underlying theme of all medical care, the book's message is hope. It is a form of hope that will leave some readers–myself included–incompletely convinced; but it is a hope so well articulated in the writings of these authors that this book will long stand as the definitive counter-argument to the wild-eyed Kevorkians and the impatient Hemlockers. More important, it addresses and in specific ways corrects some of the most basic assumptions of the majority of voters in Oregon and the deeply committed right-to-die physicians, lawyers, and ethicists whose lead they followed in passing ORS 127.800-897, the presumptuously named Death With Dignity Act. The Case Against Assisted Suicide is certain to change plenty of minds, and some of them will be in Oregon. About half a dozen years ago, I heard a vague reference to a description of hope by Vclav Havel that seemed so appropriate for the situation in which the dying and their families--and their attending physicians as well--so often find themselves that I determined to discover the precise words that the writer had used. None of the well-read colleagues whom I consulted was able to provide the statement's source, until one day I chanced to use it in the presence of Kathleen Foley, a professor of neurology, neuroscience, and clinical pharmacology at the Weill Medical College of Cornell University. Dr. Foley directed me to an essay in Havel's book Disturbing the Peace: Hope is definitely not the same thing as optimism. It is not the conviction that something will turn out well, but the certainty that something makes sense, no matter how it turns out. It is no accident that Kathleen Foley alone, of all those whom I consulted, was so familiar with this passage that she could unerringly lead me to its source. The search for "something that makes sense" when therapeutic triumph becomes an impossible goal is the stuff of her career and the mission to which she has dedicated her life. As an attending physician on the Pain and Palliative Care Service at New York's Memorial SloanKettering Cancer Center, she has achieved renown as one of medicine's foremost experts on end-of-life issues. Hers is also one of medicine's most prominent voices in the contentious debate about just what it is that makes sense when a suffering patient asks for help in dying: she is a vehement opponent of physician-assisted suicide. Whether in her clinical work or as program director of George Soros's Project on Death in America, Foley has long been an outspoken and very articulate leader in the fight against legislation that would enable such programs. And now she and an equally authoritative colleague, Dr. Herbert Hendin, medical director of the American Foundation for Suicide Prevention, have brought together a group of like-minded and highly respected colleagues to join them in the crusade. On the list of contributors are names familiar to veteran observers of the fray: Leon Kass, Edmund Pellegrino, Daniel Callahan, Yale Kamisar, Joanne Lynn, and Cicely Saunders. Together with somewhat less prominent authors, they make up a formidable team, and a very persuasive one. As a longtime participant in the battle (one of the contributors to this book refers to me as "an American euthanasia proponent," and he has it somewhat right), I was reassured to note the title of the introduction that Foley and Hendin have written for their volume: "A Medical, Ethical, Legal, and Psychosocial Perspective." Though several of the contributors to this book are well-known to have strong religious backgrounds and commitments, there is precious little moralizing here, and there is no appeal to any emotion arising from doctrines or dogmas of faith. The emphasis throughout is on facts, data, logic, and a powerful conviction about public and private consequences. If there is zealotry in these pages, it is in the cause of benefiting the sick, their families, and the larger society. Responsible members of the opposition who read this book cannot help but admire what its contributors have accomplished. I suspect that the most skilled and thoughtful of them will respond with an equally impressive volume of rejoinder. II. Throughout the long history of medicine, physicians have always sought to distinguish between those sicknesses that can be successfully addressed by their ministrations and those that cannot be so addressed. One of the proudest attributes of the healer during the era of Hippocrates was his ability to prognosticate, because it allowed him to withdraw when he saw that death would be the certain outcome of the natural process that he had been summoned to treat. For more than two millennia thereafter, the doctor was rarely present at the bedside of his dying patient, whose care was left to the devotion of family and clergy. It was not until the late nineteenth century, after morphine had been synthesized (1816) and hypodermic syringes had been invented (1860), that the physician began to appear in the sickroom of the terminally ill, when he could actually do something of value to relieve the suffering of his dying patient. The medical profession, as it always had, recognized the onset of certain kinds of symptoms as a signal that continuing efforts to cure would be fruitless or even cruel, and that the time had come to provide comfort. A medical dictionary from 1874 defines euthanasia as "an easy death." An easy death was the goal of every patient and every doctor. But the advent of modern biomedicine would change all of that. With the introduction of therapeutic agents and technologies that sometimes figuratively snatched patients from the edge of the grave, the doctor became a heroic figure of almost mythic proportions. The very same symptoms that a century earlier had been the signal to palliate now became the catalytic factors that stimulated even further the high-energy struggle of yet one more attempt at defeating the implacable enemy. Doctors, once so skilled in easing death, now focused their biotech abilities on the more dramatic effort of saving lives that were all but lost. The healer's pastoral role was forgotten, replaced by the image of a warrior riding into battle. Dr. Kildare metamorphosed into the embattled star of ER. And many lives have indeed been saved. The constantly falling mortality statistics are a source of great and justified pride for doctors and of healthy longevity for patients. And yet something has been lost. What has been lost is the ability, or perhaps the will, to recognize when to stop, and to provide an easy death when stopping is the only thing that makes the sense that Havel defines as hope. Too often, the struggle to prolong life has only resulted in the prolongation of dying. Even the word "euthanasia" has come to mean something different from before, and it is not something pretty to contemplate. Foley and Hendin quite rightly point out that were the medical profession better at implementing the word's old meaning, we would hear fewer calls for it to be applied in its new meaning. The know-how is available, but too many physicians do not know how. As Dame Cicely Saunders, the founder of the hospice movement, puts it in her contribution to this book, "The old methods of care and caring must be rediscovered." The old methods include compassion, which has never entirely left the arena, though it often becomes submerged beneath the onrushing flood of dramatic rescue. In fact, it is compassion that is one of the two foundation stones on which proponents of assisted suicide and euthanasia build the imposing edifice of their case. The other is something new: self-determination, the cri de guerre that drowns out the protestations of friends and relatives whose lives are affected by decisions made in the name of an autonomous will, without regard for the needs of those left behind. Like hope, these nouns--compassion, self-determination--are interpretable in various ways, and it is a strength of this sobering book that it addresses the glibness with which they have been used. Under close scrutiny, neither the something old nor the something new supports the conclusions that it is claimed to validate.; "Help is in almost all cases possible, if only patients and their doctors were aware of it." Leon Kass ably states the argument of the self-determinationists and his response to it, which is reiterated and verified by clinical observations, surveys, case reports, studies of the pertinent literature, statements by participants, and data that are to be found in various chapters of The Case Against Assisted Suicide: [Its advocates state that] the request for assistance in death is to be honored because it is freely made by the one whose life it is, and who, for one reason or another, cannot commit suicide alone. But this too is fraught with difficulty: How free or informed is a choice made under debilitated conditions? Can consent long in advance be sufficiently informed about all the particular circumstances that it is meant prospectively to cover? And in any case, are not such choices easily and subtly manipulated, especially in those who are vulnerable? Truth to tell, the ideal of rational autonomy, so beloved of bioethicists and legal theorists, rarely obtains in actual medical practice. Illness invariably means dependence, and dependence means relying for advice on physician and family. This is especially true of those who are seriously or terminally ill, where there is frequently also depression or diminished mental capacity that clouds one's judgment or weakens one's resolve. With patients thus reduced--helpless in action and ambivalent about life--someone who might benefit from their death need not proceed by overt coercion. Rather, requests for assisted suicide can and will be subtly engineered. Every physician and every nurse who has spent long hours at the bedsides of dying patients knows that Kass's description of their common inability to make rational or consistent decisions is accurate. These experienced witnesses know also that choices made inprevious circumstances, when they seemed proper and wise, are often changed in the face of the reality of grimmer circumstances. A very sick person is not the same man or woman who months or years earlier calmly signed an advance directive or described for closest relatives and a trusted doctor the point at which they should desist from further efforts to maintain life. Family members and caregivers--including the putatively distanced doctors--have goals and agendas that not infrequently confuse what is best for the wavering patient with what is in fact best for themselves. That much of this understanding is below the level of actual awareness, that much of it proceeds from the best of intentions, does not make it less influential on the minds of the sick. Unknowing coercion is as effective, if not more so, than that which is deliberate. Add to this the well-known fact that the most common reason given by people asking for assisted suicide is not pain or some other specific form of suffering, but their wish not to be a burden to those whom they love. In this way, sometimes unwittingly and sometimes deliberately, loved ones too often influence the decisions of the debilitated and needful. And the dying are not the only ones vulnerable to the verbalized and silent guidance, expectations, and benefit of others. So, too, are the elderly, the frail, the disabled, the economically disadvantaged. The term "duty to die" has been bandied about, and not in idle conversation but as a consideration in social policy. Following a presentation of my own views on euthanasia at a symposium organized in 1997 by a society of Harvard medical students, I was confronted by a woman in a wheelchair who had positioned herself near the rostrum. She expressed her certainty that people such as herself have a great deal to fear should enabling legislation become acceptable. I thought that she was overstating her case, but I should have known better. Sitting in the audience was a previous speaker, Derek Humphry, the founder of the Hemlock Society and author of Final Exit, the best-selling how-to book for would-be suicides. In the following year, Humphry and a co-author would publish yet another of the polemics that have marked his tireless campaign in the name of self-determination and compassion. This one was called Freedom to Die. Here is what the book says about these matters. Read it and think about coercion. As technology advances, as medical costs skyrocket out of control, as chronic diseases predominate, as the projected rate of the 85-and-older population accelerates, as managed care seeks to cut costs, and as Medicare is predicted to go bankrupt by 2007, the pressures of cost containment provide impetus, whether openly acknowledged or not, for the practicalities of assisted death....[T]he right-to-die movement is gaining momentum in response to alegitimate societal problem--the emotional, physical, and economic toll of the dying experience on not only government, employers, hospitals, and insurance companies, but on families as well. This is terrifying stuff. Where is the vaunted freedom of which Humphry and his sympathizers boast? And where, pray, is the self-determination? Probably in the same hellhole that they occupied in Germany in the 1930s, where such philosophies led to their natural culmination in murder. If the principle of autonomy can be shown to be a weak argument for assisted suicide and euthanasia, what about compassion? It is surely a merciful act to grant a suffering man or woman the quietus that he or she seeks, when anguish is intolerable and no means can be found to relieve it. The response to such a seemingly straightforward statement lies in the matter of where the seeking is being done. An overly large number of American physicians are untrained in the provision of comfort care, and are not even aware of its easy availability. Their standard for powerlessness in the face of suffering is set very low. They are susceptible to requests for help in dying in situations where their colleagues skilled in palliation would have plenty of hope still to offer. They are, in fact, more likely to be proponents of assisted suicide than such colleagues. As Foley and Hendin point out, "It is not surprising that studies show that the more physicians know about palliative care, the less they favor assisted suicide or euthanasia, while the less they know, the more they favor it....In Oregon, when given any palliative care options, patients were far less likely to choose physician-assisted suicide." And this is true even though few of the involved Oregon physicians knew enough about palliation to describe with any experience the high likelihood of its success or the full range of options available to their patients. It will come as a surprise to many readers of this book that the vast majority of those who seek help in dying do so not because of present suffering, but to avoid what they project will have to be endured as their disease progresses. In almost all cases, a palliative-care expert has the skills necessary to assure them that the tribulations that they expect, or perhaps those that they have seen others experience, can be prevented. Such patients have multiple physical and psychosocial symptoms compounded by a substantial degree of existential distress....[P]hysicians inadequately equipped to care for those who are dying would substitute physician-assisted suicide for rational, therapeutic, psychological, and social interventions that could enhance the quality of life for dying patients....When a knowledgeable physician addresses the desperation and suffering that underlie the request for assisted suicide and assures patients that he or she will continue to do so until the end of their lives, most patients change their minds, no longer want to hasten death, and are grateful for the time remaining to them. But at this time only a minority receive such care. That is the real issue, the problem that must be solved before legislatures and society rush toward measures that only perpetuate the conditions under which the anguish of too many terminally ill people remains unresolved, leading them to believe they have no recourse but to end their unhappy lives. Help is in almost all cases possible, if only patients and their doctors were aware of it. III. Rather than agitate for more Oregons, proponents of assisted dying would serve the sick far better by pursuing a course of action that would change the culture in which we now treat terminal illness to include better public and professional education in what can nowadays actually be done, and improvements in research to make it even better, and changes to health-care policy introducing reforms to acknowledge and finance the needs of the dying and other at-risk or vulnerable populations. But, it might be argued, why discourage proponents of assisted dying when we have two great laboratories in which it is being studied, and where the results thus far indicate that the programs being implemented can serve as models of success for the rest of the world? After all, the Dutch have been so pleased with their many years of permitting euthanasia that last month they legalized it. And in our own country, the great fears of a mass migration of would-be suicides along a new Oregon Trail have not materialized, with a total of only ninety patients having availed themselves of the benefits of that state's Death With Dignity Act in the four years of its existence. Surely there is by now plenty of evidence that the concerns of the Foleys and Hendins--that there would be failures of safeguards, deliberate abuses, and slippery slopes--have proven to be unjustified. Or have they? Hendin, in an exhaustive data-filled chapter whoseinformation comes largely from studies authorized by the government of the Netherlands, presents figures that substantiate the charge made by two Dutch physicians in the Journal of Medical Ethics in 1999, that "the so-called strict safeguards laid down by the courts and the Dutch Medical Association ... had largely failed." His conclusion: When, as the 1990 and 1995 studies [supported by the Royal Dutch Medical Association and sponsored by the government] document, 59 percent of Dutch physicians do not report their cases of assisted suicide and euthanasia, when more than 50 percent feel free to suggest euthanasia to their patients, and when 25 percent admit to ending patients' lives without the patient's consent, it is clear that terminally ill patients are not adequately protected. Among the factors from which they are not adequately protected is the heedlessness of their physicians to other possible ways of relieving distress. Official sanction for assisted suicide and euthanasia interferes with efforts to improve care at the end of life. If the Netherlands is a laboratory for anything, it is surely for this depressing discovery (which is supported, not surprisingly, by the findings from Oregon). Palliative medicine has not progressed nearly as far in that country as it has in most Western nations, and facilities are few, as described in a chapter by Dr. Zbigniew Zylicz, the director of a small Dutch hospice. There, using thorough consultation with family doctors, it has been his experience that "nearly all the patients who initially propose assisted suicide change their minds at a later date when reassured by the demonstration of effective care and the promise of nonabandonment." It will escape no reader's notice that these sick men and women come from the same population pool who are said to demand help in dying as an expression of their self determination in the permissive atmosphere that has in recent decades been a hallmark of their nation's culture. But, it might also be argued, we Americans must certainly be doing better at our own laboratory in Oregon. And that is precisely what I thought--until I read the provocative chapters in The Case Against Assisted Suicide that have given me pause in making such an assessment. Impressed with the small number of people who have availed themselves of the law, I had put away my earlier concerns about safeguards that I considered inadequate. Several omissions in the legislation had bothered me: a mandatory requirement for consultation by an expert in palliative care; a mandatory psychiatric consultation (the law requires it only when the attending physician thinks judgment is impaired); a mandatory notification of next of kin. None of these were provisions of the act. But in laying these worries if not entirely to rest, then at least to some ease after several years of watching ORS 127.800-897 in action, I seem to have missed a few things about which Foley and Hendin's book has enlightened me. It has also enlightened me about my notion--shared with so many other close observers--that, unlike in the Netherlands, the opportunity for detailed study of every case of assisted suicide in Oregon would in fact serve as the laboratory experiment that so many were proclaiming it would be. It seemed a golden opportunity for objective researchers to answer the many questions and to lift the shades of doubt and accusations of clandestine activity that have for so long hung over this issue. It was widely thought that the United States Supreme Court ruling in 1997--that there is no constitutional right to help in dying--would open the way for individual legislation in each state, creating in effect fifty laboratories in which fifty states would approach the problem each in its own way. Oregon would be the first. The pluralistic approach was expected to lead toward an ideal,and idealized, American solution, and a scientifically based one at that. Well, it turns out that we have no laboratory, not even one. Invoking patient confidentiality, the Oregon Health Department (OHD) does not ask doctors or families for much information about the cases of assisted suicide that are carried out under its jurisdiction. The information that it does possess, which is in the main epidemiological, is not available for inspection by the public, nor is there any provision for independent researchers to study it. Under present circumstances, the Oregon experience cannot be evaluated as would any other innovation in medical practice, with full disclosure and all participants and data made available for review by experts. In fact, a physician with cause to refuse a request for assisted suicide by a patient who later found a willing doctor is legally forbidden to talk about his or her reasons, in the misappropriated name of confidentiality. That such situations are common is indicated by the figuresavailable: "[I]n six of the fifteen [assisted-suicide] cases in 1998, and in eighteen of the twenty-seven patients for whom the information is available in 1999, the first physician seen by the patient did not agree to assist in the suicide; none of these physicians was contacted by OHD." Worse yet, none of them is free to reveal the reasons for refusal. And to whom did these distraught patients turn when they were refused? Though OHD does not ask this question, it was later determined that eleven of those first fifteen patients obtained their legal assent from doctors associated with Compassion in Dying, an advocacy group that moved into the state two weeks after the law was put into effect. Its executive director, Barbara Coombs Lee, has said: "If I get rebuffed by one doctor, I can go to another.";"...large numbers of people are being assisted to their deaths without anyone even attempting to find out whether the underlying reason for their suffering is a treatable depression." OHD has published periodic reports, but they would hardly satisfy a critical examiner seeking the sorts of clinical details that are of such importance in the evaluation of any new departure from standard medical practices. In an editorial in The New England Journal of Medicine in February 2000 commenting on complications described from the Netherlands (a not-insignificant number, including the fact that18 percent of reported assisted suicides required the intervention of the involved physicians because the attempt was not going as it should), I noted with barely disguised skepticism that neither of two papers from Oregon in the same issue described any complications at all. This seemed strange, since it might be expected that at least some of these terminally ill and perhaps debilitated men and women would be as unsuccessful as many of the Dutch in their attempts to swallow enough pills to bring death, leading in some cases to untoward events such as vomiting or convulsions, which preclude the tranquil death being sought. After reading this book by Foley and Hendin, I find myself wondering what else is going unasked and unsaid--or at least unreported--that is of considerable clinical consequence. Dr. N. Gregory Hamilton, providing anecdotal and other evidence that certain problems are unavailable for public scrutiny has titled his chapter on these matters "Oregon's Culture ofSilence." And then there is the issue that lurks like an ever-present shadow over every study of assisted death, namely depression. Notoriously difficult for internists and family physicians to diagnose even when there is no organic disease, its complexities magnify as death approaches. Even psychiatrists find it a challenge. Only 6 percent of those surveyed in Oregon felt very confident, absent a long-term relationship, that they could in a single visit determine whether a patient was competent to make a decision about suicide. And yet the law permits just that. The decision whether to request such psychological consultation is in the hands of the physician to whom the request for death is made (with no requirement that this doctor have any previous knowledge of the patient). This means that a doctor who may never before have met the patient in his or her consulting room or at the bedside (not infrequently, as noted above, recruited by Compassion in Dying, a group dedicated to easing the process) is empowered to decide if psychiatric evaluation is required. And even when done, it is likely to consist of no more than the one visit that 94 percent of Oregon psychiatrists believe to be inadequate for making a judgment. OHD's reports indicate that only 19 percent of cases were referred for psychiatric consultation in 2000, down from 31 percent in 1998. In the Netherlands, the figure is 3 percent. This means that large numbers of people are being assisted to theirdeaths without anyone even attempting to find out whether the underlying reason for their suffering is a treatable depression. In their chapter of this book, the psychiatrists Harvey Chochinov and Leonard Schwartz, well-known for their extensive studies of this issue, point out that clinical depression "is a highly treatable source of suffering among those who are dying." When the pathological sadness lifts, renewed meaning is found in life, the subjective aspects of suffering diminish, and the last days of the dying individual can be spent in the comforting presence of loved ones. IV. So why is a man who is described as "an American euthanasia proponent" (to which I plead guilty, with an explanation) so taken with the arguments of a group of authors whose writings are dedicated to prohibiting physicians from helping their suffering patients die? A part of the answer to this question is inherent in every paragraph of what I have written here. Foley, Hendin, and their colleagues have presented a powerful indictment of physician-assisted suicide and an equally powerful argument that, in all but very few cases, appropriate palliative care will eliminate the reasons for which such requests are made. But it is those "very few cases" about whom, as a bedside clinician for four decades, I worry. I worry about them a great deal. Again and again in this book, there is the barely noticeable admission that a very small number of people will remain unresponsiveto every measure--pharmacological, psychological, sociological, spiritual--directed by the most expert of palliative physicians toward the relief of their anguish. What are we to do for such men and women? Some of them will ask for help in dying. How are we to respond? What is the duty of those of us who are committed to the proposition that the relief of human suffering is an even greater good than is the cure of disease or the prolongation of life? There is no perfect solution; there may not even be a good solution. Any suggestion or plan will be fraught with uncertainty, with objections from various constituencies, and with difficulties in implementation, not to mention the possibility of error in any individual case. But such is the very nature of caring for the sick that physicians live with far greater uncertainties than this one every day of their professional lives. They often make decisions in the face of an ambiguity that is at times not only clinical but also moral. The field of medical ethics has taken on two sorts of responsibility: to point out directions when they are clear, and to help find the way when they are not clear. It is this latter place, the thicket of doubt and inexactness, in which men and women of good will find themselves in the bioethical conundrums of our time. Help in dying is among the most baffling of them; but this does not mean that we should shrink from trying to find a solution, flawed as it may be, though it is needed only for the minuscule number who cry out for it. I believe that we should heed their pleas. For those few men and women, it must be required that their repeated requests are made to a physician who has had a long-standing relationship with them; that the consultant chosen by that physician be one whose specialty is in the area of the patient's disease, to be sure that therapeutic options have been exhausted; that, in that grim event, consultation with a palliative-care expert be mandatory, as well as evaluation by a psychiatrist experienced with patients at the end of life. Since I have witnessed situations in which members of the clergy bring spiritual respite to a person tortured by self-doubt, I enter here the suggestion that even unbelievers be offered the consolation such a visit may sometimes bring. And then there is the matter of those to be left behind by the chosen death of someone they love. I believe such a choice must be defensible to the few people to whom the dying are closest. It is not so much their assent that I would seek, but their understanding that, in the beloved face at which they will soon be looking for the lasttime, they see the relief that such a decision can bring. To support that decision, it is necessary to agree with it. Principles of individual freedom, respect for the humanity of the dying, and, yes, the reality of the individual's moral autonomy demand that it be honored when other options have been explored, in the ways that I have outlined, and have been found wanting. By granting the right to be given help in dying, a society is commenting on its values. In fact, it comments on its values each and every time that such a right is exercised. If that is so, then society should affirm each and every such decision. And here I offer a suggestion that may seem odd, superfluous, and even antiquated. It is that final consent should be in the hands of a kind of council of elders, people in a community or institution known for their probity, wisdom, and sense of civic responsibility. In some instances, a hospital's bioethics committee could fulfill the purpose, but there might be objection that it serves the interests of the institution. Instead, I would seek out representative members of the community who would convene on the rare occasions when such a thing is necessary. The limits of individual fallibility and the complexities of shared decision-making notwithstanding, such a council might constitute an influential forum deliberating on the moral principles of a period, a place, and a polity of reflective citizens. For a plan such as this one to have usefulness as a guide for further decision-making, every step of every patient's case must be documented in detail and available for study, as would be the medical record in any other form of clinical research. From time to time, a comprehensive report of the national experience should be made available for public scrutiny, prepared by a panel appointed by a central non-political body such as the Institute of Medicine or the American College of Physicians. Much is yet to be learned. Should all of this be legislated? Until now, I was convinced that putting matters of such a nature into the hands of politicized officials would be a serious error. I had the perhaps fanciful notion that American medicine and the public might together arrive at a sort of consensus, in which adherents of opposing viewpoints could, realizing that the safeguards in a plan like this would correct the deficiencies of Oregon or the Netherlands, compromise on viewpoints and achieve what might be called common law, the consent of the people. But after reading of all the possibilities for abuse that Foley and Hendin's book describes, I am of two minds. It may be that carefully policed legislation will be the only way to ensure compliance with every element of the plan. I have twice in this essay noted that the mode of death that I am said by this book to support is euthanasia. The term "assisted suicide" does not appear in the description of my position. And this is as it should be. Not only does common sense indicate that attempts at suicide made by dispirited, very sick people acting without help are prone to ineffectiveness and complications, but such intuition is borne out by the Dutch reports and by published information from elsewhere as well, when physicians were anonymously polled about their personal experience. The fact that the Oregon Health Department does not mention these mishaps should not be taken as evidence that they do not occur. Physicians who believe that they have a moral and ethical obligation to provide assistance in dying should do so with the same attention to avoiding untoward events as they pay to all other aspects of medical care. It does not suffice to hand a stricken patient a prescription for barbiturates and instructions for how they should be used, and then presume that all will turn out as planned. If the termination of suffering is the physician's aim, there should be certainty that his or her intervention will not add to the affliction that it is meant to relieve. Physicians so inclined should become skilled in the techniques of euthanasia, or, all of the appropriate confirming steps having been taken, make a referral to someone who has mastered the necessary methods. These are my proposals, and the contributors to this important volume have made me feel more convinced than ever of their validity. I say of their validity, but not necessarily of their correctness in every case. In extreme situations, extreme measures must sometimes be taken, and those who take extreme measures must be prepared not only for the controversy and the criticism that will ensue, but also for the possibility that they may, in individual cases, be in error. My proposals are susceptible to being shot full of holes, but the holes will surely be smaller in size and number than those so appropriately exposed by Kathleen Foley and Herbert Hendin. If, as Vclav Havel says, hope is the conviction that something makes sense, perhaps it makes sense to relieve, in the way I have described, the terminal suffering of that tiny percentage of desperate men and women who are resistant to even the best efforts at palliation. I suppose that statement does indeed make me "an American euthanasia proponent," but I prefer to think that I am a proponent of hope. "Such is hope," Charles Dickens observed in Nicholas Nickleby,"Heaven's own gift to struggling mortals; pervading, like some subtle essence from the skies, all things, both good and bad." Pervading even death.