To the Editor:
As a physician who has spent the last quarter-century working with
frail homebound elderly people, I would like to respond to Dr. Tom
Preston's ['55] views on physician-assisted suicide ("The Future of
Dying," June 1997).
Now that the Supreme Court has determined that no constitutional right to physician-assisted suicide exists, the race to determine which state will first legalize this action is underway. As the national debate intensifies, we are faced with a drastic change in what we have all held as a basic truth: that life is valuable and is to be preserved.
A most important concern is the risk that vulnerable persons, especially the frail aged, will be subjected to undue influence by others in making death decisions. There may be a venal basis for family members to seek a way to have an older relative die; or a political agenda may exist. When Richard Lamm, then the governor of Colorado, said several years ago that old people have "a duty to die and get out of the way," he was surely not expressing merely his own view. Policymakers and insurance companies are highly likely to press for further legal steps that will lead to the early death of older persons rather than to pay for those famous last six months of life that purportedly cost the health system so dearly.
Assisted suicide changes the role of doctors. No longer will the elderly be able to trust implicitly that their physicians will stand up for them and not harm them. The fear that the doctor may connive with the family will lurk in the patient's mind in some situations. All physicians are placed in an equivocal position, even those who know that they will never participate in an assisted suicide.
Deaths in younger persons, some of which are indeed disastrous and tragic, have been the prime concern of protagonists for physician-assisted suicide. However, the likelihood of death in younger groups is modest compared to that in aged. There are ever-increasing numbers of older persons in this country who have deteriorating conditions that will eventually lead to death. All of us who have worked with the frail elderly know of situations where families were ambivalent or worse about the survival of an aged parent. Pressure will be placed on doctors to cause death under new legal grounds. We also will see subtle demands placed on older persons to agree to die. Thus the Right to Die will become the Duty to Die.
In its decision to allow physician-assisted suicide, the 2nd Circuit Court judges&emdash;taking a position now reversed by the Supreme Court&emdash;leaned strongly on the fact that withdrawal of life support by doctors is already legal. The Equal Protection Clause of the 14th Amendment was construed to mean that because doctors are now allowed to withdraw life support, leading to death of patients, they may also assist in suicide. The 2nd Circuit judges simply passed over the extremely obvious distinction that in withdrawal of life support it is the disease that kills; in physician-assisted suicide, it is the doctor who is the killer.
Physicians are trained to preserve the lives and the good health of their patients. Once physicians are legally enabled to participate in killing their patients, other abuses must inevitably flow from this fundamental concession.
Philip W. Brickner, M.D. '50
New York
To the Editor:
The article by Tom Preston advocating the legalization of
physician-assisted suicide ignored the rapid changes in the health
care marketplace that make this a very dangerous concept.
Many fear living on in intractable pain or attached to machines or tubes. Advocates of assisted suicide claim that it gives control to those wishing to avoid this fate. But Dr. Preston admits that current law already allows doctors to use all means to relieve pain, even if death is hastened, and allows patients to limit in advance the extent of their treatment. Do we really need physician-assisted suicide, then, or could its availability actually diminish the support offered to the dying and disabled? Even for those of us most ill, the precise time and manner of our death cannot be known with certainty in advance, and it can be affected by a wide range of options that require a patient's full knowledge and choice. Some will prefer a treatment with only a small chance of cure, choosing painful side-effects over certain death. Others will not. Some may choose operations or medicines to buy time in order to see a grandchild get married, or to restore the use of a limb for a while before death comes. Others would elect only rest and relief of pain.
The choice can and should be determined by a patient's values but can also be influenced by the hopelessness and helplessness that arise from depression, unrelieved pain, inadequate support, or overwhelming expense. The current market-driven orientation of health care has restricted patients' access to mental health care, long-term care, and home services, and it has increased out-of-pocket expenses. A choice of suicide in this setting is hard to accept as free and unencumbered.
A patient's choice can also be influenced by a physician's presentation of his or her options. If in the past physicians may have been too inclined to encourage interventions, the opposite is increasingly true. Faced by monthly printouts comparing his or her expenditures with others', and by arrangements that tie physician income to "performance" in restraining costs, doctors may subtly encourage less expensive options, least expensive of which is physician-assisted suicide, though the patient's choice can be steered in less dramatic, but still cost-saving, ways. For those concerned with the autonomy of the very ill, physician-assisted suicide is the wrong cause. Instead, we should be struggling to preserve and expand what is necessary to allow true choice for these vulnerable people, people whose circumstances we may one day experience. We should overturn the financial incentives to undertreatment as much as those to overtreatment, support the expansion and improvement of care for physical and mental suffering, and assist the dying and disabled to live as fully as they wish, rather than accepting that the best we can do is to hasten their death.
Elisha H. Atkins M.D.'72
Cambridge, Mass.
To the Editor:
In his article on Honors, Professor Craig Williamson wrote, "We let
Swarthmore instructors finally give grades to their students in
Honors preparations because we no longer thought that this would
undermine independent inquiry or free debate." Herewith a comment
from an Honors student in the days before "people grew tired or
irritated or skeptical about the Honors Program": When I arrived at
Swarthmore as a freshman, I had a thin skin of sophistication over a
subcutaneous layer of defensive arrogance, these two covering a
jellied core of immaturity. In short, I was unpromising. What success
I enjoyed came largely in the Honors years through the patience of
four teachers&emdash;two men and two women&emdash;who overlooked my
prickly affectations and gently pushed me toward rational behavior.
Of knowledge, Swarthmore was generously giving, and I am grateful. (I
can still diagram the Battle of Agincourt.) But I am grateful for
something rarer than knowledge&emdash;wisdom. It was wisdom that I
absorbed because of close association with Mary Albertson, Elizabeth
Wright, Phil Hicks, and Townsend Scudder. And that closeness flowered
when, blessedly, they taught me but did not grade me, when friendship
was not (to use an archaic phrase) apple polishing.
The architects of the "new" Honors don't think that grading will
"undermine independent inquiry or free debate." Perhaps, but
offending the teacher-grader in these days of struggle for
fellowships or grants is daunting indeed. Perhaps today's
undergraduates are not as half-baked as I was and need only a good
fill-up from the fountain of knowledge, but I'm glad that my
association with my four mentors lasted for many years after college
and that they kept on helping me in the accumulation of wisdom.
Heywood Hale Broun '40
Woodstock, N.Y.
To the Editor:
I was very glad to learn about the "new" Honors Program in the June
Bulletin. The student profiles were especially useful in
understanding it. It seems to me that the principal differences
between the original (pre-1968) Honors Program and the current one
are in (a) a very clear structure vs. a very complex
structure&emdash;if any at all; (b) a program covering the entire
junior and senior years vs. one that covers half that; (c) an
individualistic approach to education vs. a more collaborative one;
and (d) no grades vs. grades.
I felt enormous freedom to learn in Honors in the 1950s despite the apparently rigid structure, but I presume that it is just this complexity and flexibility that gives students the same feeling today. It must be maddening for some faculty and administrators, however.
I also had my freedom for two full years rather than for an apparent hopscotch year's worth of study within a two-year period. Finally&emdash;but perhaps most of all&emdash;I felt that freedom because there were no grades. The current collaborative opportunity I think is excellent, and as you say very plainly, something new was needed or there'd be no Honors Program at all.
Charles A. Miller '59
Lake Forest, Ill.
To the Editor:
When I saw that picture in the March issue [of the man on the
bicycle&emdash;see also "Letters," June 1997], I did not think about
Bob Bartle '48 [who thought it was himself] at all. Of course it is
Frank Johnson '44, who started out in my class.
Juergen Heberle '45
Eggertsville, N.Y.
Charlie Newitt '44 called to concur. Sorry, Bob.&emdash;Editor
Writing to the Bulletin
The Bulletinwelcomes letters concerning the contents of the magazine or issues relating to the College. All letters must be signed and may be edited for clarity and space. Address your letters to: Editor, Swarthmore College Bulletin, 500 College Avenue, Swarthmore PA 19081-1397, or send by e-mail to bulletin@swarthmore.edu.
Swarthmore College. All rights reserved. 1997