Vital distinctions, mortal questions:

...Almost everyone can think of friends or family members who seem to have received unnecessary treatment in their dying...

...That helps nothing...

...It recognizes that the common good of families, or society, can and should on occasion take precedence over individual welfare...

...While this challenge comes most strongly from those favoring the legalization of active euthanasia, it seems to draw at least implicit or inadvertent support from some prolife groups as well...

...An increase in the time between the determination of a terminal illness, or fatal disease, and death is still another important change, now reaching three years in the case of cancer deaths...

...the crucial moral point is not how the person dies, but our intention...

...The Catholic tradition, ordinarily thought to be quite conservative on these matters, has long accepted in principle that the imposition of a grave burden on others is a justifiable reason for a person to choose to forgo life-saving care...

...God alone has the right to take innocent life...

...In any event, the fear of a shift to active euthanasia, a fear made more credible by the polls, has been the stimulus behind prolife resistance to almost all proposed legal changes...

...But there is little in the history of such legislation to date to indicate that it can overcome the reluctance of contemporary medicine to declare that anyone is, in fact, dying, and to give up the hope for therapeutic success that is its driving impetus and the greatest source of constantly escalating costs...

...That argument eventually lost...

...How can it be morally plausible to condemn the one but allow the other...

...such has been the history of organ transplantation, as it moved from the experimental to proven therapy...

...As William S. Kilbourne, Jr., put it in the Euthanasia Review, "not all the torture dealt out by all of the totalitarian governments in the world causes as much pain as overtreat-ment of the terminally ill...

...Cases with costs of $500,000 to $1 million become more common...

...There is another problem about the use of this principle...

...Or to refuse other forms of expensive, efficacious treatment as well...

...Even if we grant the ordinary validity of the distinction between killing and allowing to die, what about those cases that combine (a) an illness that renders a patient unable to carry out an ordinary biological function (to eat or breathe unassisted, for example), and (b) our decision to turn off a respirator or remove an artificial feeding tube...

...The persuasiveness of these arguments seems to be growing for many...

...Its meaning is not yet clear...

...It would seem to many an outrageous denial of freedom to refuse the choice of a treatment when, at least in the eyes of some, that treatment is perfectly valid...

...To attempt to deny the distinction between killing and allowing to die is, then, mistakenly to impute more power to human action than it actually has and to accept the conceit that nature has now fallen wholly within the realm of human control...

...The conflation of the allocation and euthanasia issues is becoming increasingly evident...

...Patients are as a rule more quickly put on respirators than was the case twenty years ago, and they are much more likely to be fed artificially should their critical illness render them incapable of or uninterested in eating...

...On one side are those who argue, with apocalyptic dread, that economic excuses and rigid cost-benefit analysis will now be deployed to carry out what is otherwise unthinkable: to rid our society of the retarded, the handicapped, and the burdensome elderly...

...By selling himself for a slave," he wrote, "[a person] abdicates his liberty...

...MAINTAINING THE DISTINCTION My contention is that, properly understood, the distinction between killing and allowing to die is still perfectly valid for use, both in the euthanasia debate and in the allocation discussion...

...Beyond the hospital setting there have been other important general trends...

...Without it, we face a number of stark alternatives...

...This is an obvious point, but, in practice, it is widely assumed that, once a treatment has proved efficacious, government is obliged to pay for it...

...The moral judgment, they claim, should recognize that no one has the right to judge that the life of another is meaningless...

...Behind this moral premise is the recognition that disease (of some kind) ultimately triumphs, and that death is both inevitable and not always the greatest human evil...

...Living will legislation, for instance, is looked upon as the leading wedge of a value system whose acceptance will lead first to legitimating active euthanasia, and then to killing the weak and powerless...

...The automatic presumption in favor of reimbursement for whatever treatment has been shown efficacious now must give way to one that is more neutral, that is, one subject to other considerations than progress and proven efficacy...

...The cleaner the separation between rationing and euthanasia, the better...

...The fact that we can intervene in nature, and cure or control many diseases, does not erase the difference between the self and the external world...

...The reason even voluntary slavery is wrong is not simply that we ought not, in the name of mercy or freedom, be able to alienate our freedom so fundamentally, but also that no other person should be given so total and decisive a power over our life...

...Proponents of continued care, moreover, argue that it is a moral, not a medical judgment, to say that a life of permanent unconsciousness is not a life suitable for suste- . nance...

...The decision of the Oregon legislature in 1987 to deny organ transplants under its Medicaid program, and to spend the money instead on prenatal care, will not remain an isolated event...

...We need a more philosophical argument, not dependent on religious premises, that might have a comparable force, and that would apply even if one granted that patients have a right to take their own lives (now legal in most states...

...To suggest that individuals may not have an unlimited claim on the assistance of their families or neighbors, or that the latter in turn may have only limited obligations to one another, is a disturbing thought...

...What is behind the change in public opinion on euthanasia...

...A third standard is that government has the obligation to encompass the full range of human needs, not simply health needs, and to address the entire range of conditions and programs that together make up a coherent society...

...But it is the task of those who provide care to make prudent judgments concerning treatment that provides no known medical benefits, and, based on present medical knowledge, to determine when someone has lost the capacity for meaningful personal life-at least to the extent that such life requires some minimal level of intact higher brain activity...

...Should that treatment be considered "useless...

...Medical The main social purpose of the distinction between killing and allowing to die has been that of protecting the historical role of the physician as one who tries to cure or comfort patients rather than kill them...

...There is an alternative interpretation...

...Medical care of the dying or the critically ill-long believed to be a frequent source of doubtful expenditures-has emerged as a place to curtail heavy medical costs...

...They must certainly meet some reasonable tests of justice and fairness, both substantively and procedurally...

...I am only trying to say that issues of this kind must be decided on their merits and not dealt with by ignoring or confusing the distinction between killing and allowing to die...

...Instead, I want to focus on the problem of finding the limits of our obligations to others...

...This principle, though well established, has been little analyzed, perhaps partly because until recently in most developed countries it has usually been possible for families or society to bear the financial burdens, however heavy...

...Does that same tradition also have the resources to cope with the allocation issue, and to do so in a way that respects human life and dignity...

...though theoretically justifiable, it could look selfish, and in application could evoke feelings of great doubt and guilt...

...But it will have limited force in the secular domain...

...The Nazis did not start with voluntary euthanasia and move on to involuntary euthanasia...

...How might one respond to that view...

...I believe it reasonable to say that, since this person's life was being sustained by artificial means (respirator or tube), and that was necessary because of the presence of an incapacitating disease, the disease is the ultimate reality behind the death...

...While the psychology behind that feeling is understandable, there is no significant moral difference between withholding and withdrawing treatment...

...Patients have lived on in this state for years-ten years in the instance of Karen Ann Quinlan and thirty-seven years in another famous case-and there may be ten thousand such patients in the United States today...

...The same cannot be said for taking the next step: that of possibly refusing to continue what some, but not all, would consider useless treatment, and the use of "excessive financial burden'' as a reason to deny treatment that might be efficacious...

...Here is where things come full circle: an awareness of that physician-nervousness serves all the more to increase patient anxiety...

...we are equally responsible morally...

...It is not easy to find a moral foothold for making such judgments...

...To say this is not to deny that allocation decisions have important life-and-death implications, or that some allocation decisions could be used to mask abominable moral attitudes or practices...

...PVS is an ambiguous category because there is a division of opinion, both medical and moral, about whether sustaining patients by artificial feeding is medical treatment, and about whether it is useful or useless...

...Nonetheless, more work is needed to develop the reasons for opposition to active euthanasia, reasons that do not depend too heavily on possible abuses...

...It is as "out there" as ever, even if more under our sway...

...Public opinion surveys have indicated a sharp shift in that direction...

...For affluent countries the decision is more complex...

...It is hard to see how a debate on that reimbursement issue can be forestalled much longer...

...To ask government, in the wake of these developments, to provide individual care regardless of the cost, is to ask too much...

...It is plausible to think that the public has become more fearful of an extended or painful death, and wants active euthanasia to regain mastery over medical attitudes and technologies it believes can no longer be controlled...

...The first such standard is that government cannot automatically be required to pay the costs of whatever new treatments result from scientific advance...

...More of those episodes are followed by a long decline toward death, often marked by sporadic acute recurrences where the patient is brought through once again...

...We have, then, a rightto end our own life...

...But these are just the kinds of decisions we may have to make...

...That is a way of saying that a government would be imprudent, if not irresponsible, to give over a disproportionate share of its resources to meet health-care needs, even if some of those needs are matters of life and death for individuals...

...Our action may hasten, but does not finally cause, this death...

...Let me venture an interpretation...

...But it is possible, I believe, to fashion some general standards for assessing those circumstances...

...It begins to seem that only acceptance of a policy of active euthanasia will prevent the possibility of overtreatment...

...Second opinions prior to surgery, strict criteria of efficacy for admission to intensive-care units, and development of standards for the use of various diagnostic procedures and treatment therapies, are among the techniques being used...

...CHANGING ATTITUDES Since the 1970s, death has been an institutional event, with over 80 percent of deaths occurring in hospitals...

...This already difficult set of issues is almost certain to be further complicated by the growing need to ration health-care resources...

...It has ordinarily been evaded by calls to remove excessive burdens from families and to lay them on the state...

...THE ALLOCATION DEBATE If the implications of doing away with the distinction between killing and allowing to die are momentous for the euthanasia debate and the treatment of individual patients, they are equally grave in their implications for the allocation debate...

...We need to develop a strong capacity to say no to some of these possibilities...

...That is another way of urging the government to sign blank checks, the amount of which is to be determined by unchecked medical progress as it constantly redefines and expands the concept of "need...

...The first is that people can die equally by our omissions as well as our commissions: we can refrain from saving them when it is possible to do so and they will be just as dead as if we shot them...

...The notion of physical causality in both cases rests on the metaphysical distinction between human agency and the action of external nature...

...To cease treatment may or may not be morally acceptable...

...Medical progress has not only raised the costs of care in general, it has also widened the range of costs...

...When a patient dies in a hospital it is almost always now the result of some conscious decision, the result of a medical power able to give almost every patient at least a few more hours or days...

...Precisely because of the growing need for health-care rationing, there is all the more reason to avoid the possible abuses of active euthanasia...

...It is not freedom to be allowed to alienate his freedom...

...While there is now said to be less total resistance to policy change among prolife groups, and some actual recent initiatives, their political power has intimidated politicians...

...We can cure disease, but not always the chronic illness that follows the cure...

...Its primary argument has always been a relatively simple one: a dying person (or one whose life has become intolerably burdensome) has the right to have his or her life ended by another if that is necessary to avoid suffering...

...But I do want to suggest that, just as we would consider it neurotic and hypochondriacal for an individual to give over an excessive portion of his or her psychic energy and economic resources to the preservation of health, the same is possible for a society...

...A reported increase in mortality rates in some places as a result of the diagnostic related groups (DRG) cost-containment strategy under Medicare is, however, the kind of evidence that should be followed...

...We could in this country always spend more on health care...

...The standard objection encompasses two points...

...It would seem an offense against justice to deny someone a treatment judged medically and scientifically valid on the grounds of its costs, either to a family or to a society...

...If such a right is conceded, does it follow that another may be given the right to kill such patients...

...Government cannot be held hostage to medical progress, which in the nature of the case is constantly devising new, and often more expensive, treatments and cures...

...Patients need more power, they say, including the right to active euthanasia and assisted suicide and the means to curb the physicians' appetite for aggressive medicine regardless of a patient's prospects...

...There is an even greater difficulty.in relying upon voluntary methods to do a decisive job in lowering costs...

...The euthanasia and allocation debates are easily likely to mutually confuse, even pollute each other...

...The traditional answer has been: not necessarily...

...I have no doubt that the seeds of such a possibility are present-one can find some indication of just about any trend one likes in this area-but there is as yet no good evidence that it is strong or widespread...

...On the level of physical causality, have we killed the patient or allowed the person to die...

...Living will" and durable power-of-attorney statutes are certainly desirable for individual welfare, and may be of some economic help...

...This is now the case with kidney, heart, and liver transplants...

...A conflation of killing and allowing to die mistakenly assumes that the self has become master of everything within and outside of the self...

...The distinction rests on the commonplace observation that lives can come to an end as the result of (a) the direct action of another who becomes the cause of death (as in shooting a person), or as the result of (b) impersonal forces where no human agent has acted (death by lightning or by disease...

...PVS is commonly defined as that condition in which higher brain [neocortical] functions have been lost, but the brain stem remains alive...

...I do not think so...

...It is as if the conceit that modern humans might ultimately control nature has been internalized: that, if the self might be able to influence nature by its actions, then the self and nature must be one...

...The most difficult case would be one in which the ex'pensive available treatment is effective and where the prognosis for a full and extended life span is high...

...No clear answer can be given to a question of this kind, in part because much depends upon particular circumstances...

...We can forestall death with modern medicine, but death always wins because of the body's inherent limitations, stubbornly beyond final human control...

...Within medicine, a fear of indictment in some places for termination of treatment and a more generalized anxiety about malpractice suits (however overblown in actuality) has created a climate of uneasiness...

...It would create a profound relationship between that other person and myself, transcending our individual acts...

...It has not only a logical validity but, no less important, a social validity whose place must be as central in moral judgments about allocation as in individual patient decisions...

...Otherwise, it would open the way for powerful misuse and, no less important, represent an intrinsic violation of what it has traditionally meant to be a physician...

...Societies need education for their children, police and fire protection, national defense, roads and transportation systems, jobs and economic infrastructures, social welfare programs, and so on...

...These arguments gain weight from the reality that contemporary medicine can and does draw out our dying, or our suffering lives, beyond all decent limits...

...The principle of freedom cannot require that he should be free not to be free...

...As the history of the debate over "death with dignity" and allowing to die has shown, it has been exceedingly hard in practice to make termination decisions...

...To allocate money, say, to education rather than to health care could be seen as a decision to kill people for the sake of education (more specifically, to kill the sick to help children...

...Instead, they have resorted either to government support or to public appeals...

...They are no more and no less than what they claim to be...

...There is an analogous issue of importance...

...Physicians frequently feel morally more responsible for stopping the use of a life-saving device than for not using it in the first place...

...To ask another to be the agent of my death, moreover, would cease to be simply an expression of my isolated autonomy...

...If I am by right master of my fate, I cannot transfer my right of mastery to another, nor can any other person receive it from me...

...It is not the task of medicine to decide whose life is worth living...

...Only now, when the resources of the state are being stretched and demands upon it seem to be reaching an intolerable limit, can the principle be considered more openly and directly, Yet how are we to do so in a responsible, fair, and humane way...

...Can they effectively be resisted-as I think they must be...

...The increased use of preliminary screening will also have to be matched by methods designed to stop those treatments already underway which are ineffective for a significant prolongation of life...

...As Arthur Barsky, M.D., has noted in his new book, Worried Sick: Our Troubled Quest for Wellness (Little, Brown, 1988), "while more effective medical care enables us to live longer, the proportion of life spent in ill health has actually increased...

...or that, in practice, some allocation decisions can be wrong or unfair...

...The tradition must strengthen the arguments against active euthanasia and, at the same time, develop morally justifiable criteria for limiting life-sustaining health care at the societal level by defining the circumstances when such limitation is necessary or sensible...

...Given that understanding, health needs would ordinarily trump all other social claims (unless they could be justified also on health grounds...

...Moral At the center of the distinction between killing and allowing to die is the difference between physical causality and moral culpability...

...But there are many who think that this is nothing more than a form of direct killing, equivalent to active euthanasia...

...From my side, I would be recruiting an accomplice, asking him to take into his hands a decisive power over me, one that could not be recalled once he had acted...

...At the heart of the issue is a distinction between physical causality-the realm of impersonal events-and moral culpability-the realm of human responsibility...

...We can distinguish between an aging body and a diseased body, but in the end they always become one and the same body...

...But of late, the strongest challenge to the tradition has been a denial that there is a meaningful distinction to be made between killing and allowing to die, between an act of commission and one of omission...

...Put another way, the obligation to resist the lethal power of disease is limited-it ceases when the patient is unwilling to have it resisted, or when the resistance no longer serves the patient's welfare...

...Even those dying in nursing homes are likely, in an acute crisis, to be taken to a hospital...

...We can, then, be responsible for the death of another by intending that they die and we accomplish that end by standing aside and allowing them to die...

...Despite these criticisms-resting upon ambiguities that can readily be acknowledged-the distinction between killing and allowing to die remains valid...

...Little imagination is required to see how the distinction between killing and allowing to die can be challenged...

...They are also given great privileges in making use of that knowledge...

...Government would be well justified, I believe, to say that it cannot allow health claims always to override other social claims, to allow expensive individual health needs to overcome public interest needs (organ transplants over schools), or to allow issues of life and death always to trump issues of social amenities (hospitals over parks...

...In those cases, the lines of physical causality and moral culpability happen to cross...

...In one sense, it is our action that shortens the person's life, and yet in another sense it is the underlying disease that brings that life to an end...

...he foregoes any future use of it beyond the single act...

...The de facto legalization of euthanasia in Holland does not necessarily signal the beginning of a larger trend, but its occurrence is a significant break with a long-standing prohibition in Western societies...

...THE EUTHANASIA DEBATE While the euthanasia movement has deep historical roots, going back to Greek and Roman times, it has had a special force in the West for a number of decades (and in England since the nineteenth century...

...Yet the fact that they can cross in some cases in no way shows that they are always, or even usually, one and the same...

...An important implication of this principle-though rarely drawn-is that neither society nor families have an obligation to take on excessively heavy financial burdens to save the life of another...

...The likelihood that society will ride this slippery slope, from voluntary to involuntary, may increase once the principle of direct killing has been introduced...

...To deny the distinction between killing and allowing to die, and then to use that denial as a way of circumventing a necessary debate or decision about allocations, only adds a social error to a metaphysical one...

...It is inherently communitarian...

...There have been no concerted efforts to have Medicaid or Medicare deny payment for care of PVS, or to have private insurance carriers do so...

...I will not take up those important questions here...

...It is thus all the more important that their social role and power be, and be seen to be, a limited power...

...That is the most basic threat to, or violation of, the right of self-determination that can be imagined...

...and whole categories, such as neonatal care, increase the discrepancies within individual medical subspe-cialties...

...The greatest danger is not that patients will be overtreated or their lives too long extended, but that socially burdensome patients will be targeted for elimination, sacrificial victims on the altar of cost-benefit analysis...

...The appeal to a combination of freedom and science is a powerful one...

...1 think that it is rich enough to encompass both problems simultaneously, but that at some crucial points it needs further work and elaboration...

...There has obviously been a great societal reluctance to follow through on such logic...

...How, then, can we make difficult allocation decisions in ways that avoid any suggestion that they are being used as a way of wrongly killing people...

...Hospitals themselves have become different institutions, more than ever oriented to intensive care...

...Metaphysical The first and most fundamental premise of the distinction between killing and allowing to die is that there is a sharp difference between the self and the external world...

...Those who make such judgments can reasonably conclude that continued treatment of a PVS patient is "useless"and economically indefensible...

...Recently, various court decisions have upheld the validity of terminating treatment, including artificially provided food and water...

...Screening for access to treatment A number of experiments and policies have been established in recent years both to evaluate better the efficacy of various treatments and to limit, by preliminary screening, access to therapies that are expensive and unlikely to be helpful to some patients...

...I will call them boundary standards...

...The moral foundation of this claimed right is that our body is our own, and that our life should be subject to our self-determination...

...and the society could well claim that it had no obligation to provide expensively useless treatment (Medicaid has most commonly paid the costs of PVS victims...

...As more can be done to save the lives of individuals, and to save the lives of those afflicted with relatively uncommon conditions or syndromes, the range of spending possibilities broadens...

...we cannot be required to act heroically, or severely to jeopardize the welfare of others for whom we may also be responsible...

...The purpose of the distinction is to separate those deaths directly caused by human action, and those caused by nonhu-man events...

...Unlike the childish fantasy that the world is nothing more than a projection of the self, or the neurotic person's fear that he or she is responsible for everything that goes wrong, the distinction is meant to uphold a simple notion: there is a world external to the self that has its own, and independent, causal dynamism...

...Prolife groups may acknowledge a strictly logical distinction between the two, but argue that "allowing to die" is a slogan that has come to be used as a legitimizing rationale to end the lives of those who are burdensome or judged to have lives not worth living...

...There are many reasons why the death of one person can be of advantage to another...

...The popular phrase "mercy killing" refers to the killing of one person by another as an act of kindness, not as an act of malice or self-interest on the part of the one who does the killing (or assists in a suicide...

...As a way of elucidating the distinction, 1 propose that it is best understood as expressing three different, though overlapping, perspectives on nature and human action: metaphysical, moral, and medical...

...Does the long-standing Western tradition that rejects active euthanasia and assisted suicide have the intellectual resources to withstand the growing pressures to legitimate them...

...and if we cannot accomplish that on our own, another person has the right to end it for us, as an act of compassion...

...Even when there is general agreement that excessive and unwanted care should not be given, disagreements among physicians and family members, uncertainty of prognosis, and fear of legal or moral liability, have made individual decisions troublesome...

...But there is no reason to exempt the health-care sector from that debate...

...This simultaneous challenge from the liberals and the conservatives promises maximum confusion, making it that much harder to discuss carefully the euthanasia issue and all but impossible to consider coherently the allocation problem...

...I quickly add, and underscore, a moral point: the person who, without good moral reason, turns off a respirator or pulls a feeding tube, can be morally culpable if there is no good reason to do so...

...Efforts to evaluate the efficacy of various therapies, while widely commended as a goal, have been pursued only fitfully, especially with respect to the development of standards for the termination of a particular treatment...

...However strong the motive to do so, that fundamental right cannot be set aside without contradicting its very nature...

...The broadest and most encompassing is the increase in chronic illness, particularly that ensuing upon acute episodes of life-saving interventions...

...These new developments raise two questions...

...How could even a carefully drawn law avoid possible outright coercion of dying patients, or more likely their subtle manipulation...

...I believe that way of thinking, whether from right or left, is misleading and harmful...

...From the side of the person who killed me his would be an irrevocable act, one that becomes his act as much as mine...

...Can a government claim that the provision of some forms of treatment constitutes a grave and excessive burden-which is, in effect, what the state of Oregon has done...

...Beyond that plausible possibility is the further danger of a move to involuntary euthanasia...

...For another, those who believe continued treatment (including food and water) of PVS is unjustified have been willing to support only court decisions pertinent to individual cases in that respect...

...There is just enough scientific uncertainty about diagnosing PVS (or making definite judgments about the state of consciousness of those in that condition) to give these opponents a small degree of medical credibility...

...Were it not for the disease, there would be no need for artificial sustenance in the first place and no moral issue at all...

...I offer here no formula for making those hard allocation decisions...

...These slippery slope arguments are, then, not fully adequate...

...Physicians have been given special knowledge about the body, knowledge that can be used to kill or to cure...

...It is a long list...

...In a society less than pleased to care for those who are costly or burdensome, the social pressures in that direction would be all the stronger...

...It is more than the principle of self-determination historically has, or morally should, encompass...

...To demand of physicians that they always struggle against disease, as if it were always in their power to conquer it, would be to fall into the same metaphysical trap mentioned above: that of assuming that no distinction can be drawn between natural and human agency...

...We should not, then, use the ambiguity of such cases to do away altogether with the distinction between killing and allowing to die...

...Even if one grants a right to have one's life ended, how could it safely be enacted into law...

...Their use to promote efficiency and economic savings only enhances their attractiveness...

...An extended life with a chronic illness, and an extended dying, are growing consequences of improved medical care...

...Others have been no less quick to complain: for a society to deny health resources to the needy, or to want to limit an entitlement program, is a murderous course, a selfish way to keep for oneself resources that would save the lives of others...

...Comparative Louis Harris surveys show that 53 percent of respondents in 1973 opposed active euthanasia (with 37 percent favorable), while by 1985, 61 percent were favorable, with only 36 percent opposed...

...We can usually dissect the difference in all but the most obscure cases...

...David Andrusko, an editor of the National Right to Life News, has called this trend a' 'juggernaut of death.'' On the other side are those who argue that it is precisely the denial of a right to die that grievously exacerbates our financial plight...

...We need to scale down the priority routinely given to health-care needs, and to stand firm in the face of the inevitable medical progress that promises to deliver some benefit, even life itself, to some individuals if only we will collectively pay for it...

...This problem is all the more complicated for affluent nations...

...The attraction of using it as a way of assisting cost-containment efforts would increase the risks of abuse all the more...

...In practice, moreover, it has been a principle that few would be likely to invoke, particularly within the family...

...In the Medicare case, the available evidence suggests that behind the high costs lies the difficulty of making a prognosis that death is imminent.Moreover, no one has shown that the costs, though high, are unreasonable or unjust...

...any other choice would be seen as direct killing...

...We can be asked to do our duty toward one another...

...I do not invoke here a hypothetical worry...

...We need to combine an ability to determine limits with sensitive and open public debate about just what it is that makes for a good society, and what is the proper and sensible place to be given to the pursuit of health and the avoidance of death...

...To avoid that, it is necessary to be clear about the difference between directly killing a known patient and making an allocation decision whose effect will be to allow many to die who might otherwise be saved...

...Let me stalk them by moving through a sequence...

...Even now, those who have tried to limit health allocations have been accused by some of using financial arguments as a covert way of ridding society of people unwanted on other grounds, or simply thought too burdensomely expensive to be worth support...

...None of these evaluation, prognosis, and screening methods will be of much economic benefit unless their use becomes mandatory...

...Let us take a step to the next category, even more troubling, that of possibly denying the provision of expensive medical treatment that is undeniably efficacious...

...That is the kind of principle that Americans at least have been reluctant to embrace...

...That fact establishes the basis of the second point: if we intend a person's death, it can be brought about as well by acts we omit as by those we commit...

...So is ready access to hospice services and facilities...

...Theirs may be a minority voice, but it is a strong one...

...they started with the latter, and their rationale for involuntary euthanasia had nothing to do with either self-determination or the avoidance of medical over-treatment...

...For many, that belief remains the ground for resistance...

...A long-standing assumption of many is that greater patient choice, particularly in terminal illness, would significantly reduce costs...

...Since the cost of such transplants is totally beyond the economic capacity of the average family, there has rarely been discussion about families' obligations to take on those costs...

...Thus there are cases where, morally speaking, it makes no difference whether we killed or allowed to die...

...But, of course, that is a fantasy...

...For most physicians, the course of least resistance is simply to treat, and the more aggressive their treatment, the safer they feel...

...To all of these long-standing objections, I would add another...

...prudent judgments based on available knowledge...

...Though California voters recently defeated an initiative to put a euthanasia referendum on the ballot, public opinion surveys, here and abroad, indicate growing support for active euthanasia and assisted suicide...

...Supporters of euthanasia argue that if there is no serious distinction to be drawn between killing and allowing to die, then our present acceptance of allowing to die ought to be extended to active killing, when such killing would be more merciful...

...Those of us who use such arguments against euthanasia should realize that, for all of their intuitive plausibility, they rest upon a calculus of probabilities that has little grounding in history or experience...

...to continue would be to treat a dead body, by definition "useless" treatment...

...The often-invoked Nazi analogy has limited value for our situation...

...It is, as a distinction, meant to say something about human beings and their relationship to the world...

...That we could, by providing more choice to patients, also reduce unnecessary and unwanted costs is still another important consideration...

...A family would certainly be justified in claiming that any financial burden imposed upon it was excessive (for the cost of any useless treatment would be excessive...

...But when would it become unreasonable to do so...

...Voluntary methods of choosing treatment Some 25-30 percent of Medicare costs, for instance, are incurred by 5 percent or so of its beneficiaries in their last year of life...

...The right to die could become a duty to die...

...Today brain death is the accepted medical and legal standard...

...The most common objection to active euthanasia is based on the abuses it could engender...

...The point of this now almost universal denial is precisely that an intervention into the disease process does not erase the underlying disease...

...They will be treated by doctors nervous about malpractice suits, but in any case trained to save life unless there is a powerful presumption against it and, most important, increasingly ingenious in the extension of life against great odds...

...individual and social good could be jointly served...

...Or of making them in ways that properly allow us to let disease shorten, or end, life...

...A traditional religious position has supplied the missing argument: self-determination does not extend to a right to take our own life...

...If we cannot morally distinguish between killing and allowing to die, then every allocation decision can be construed as directly killing those who lose out in the process...

...What about the continued treatment of patients in a permanent vegetative state (PVS...

...We can ask what is a proportionate share for each of those categories, and as a society we will argue about that...

...To lose sight of the paramount reality of the disease is to lose sight of the difference between ourselves and the outer world...

...In an earlier time when medicine was comparatively less effective, there was a relatively uniform range of medical costs...

...There is a parallel here: to cede to another the right to kill us is to give that person the power to remove our freedom once and for all...

...A second standard is that government cannot be obliged to meet every individual medical need, however valid that need...

...Once in hospitals, patients are faced with a strong bias toward aggressive technological care...

...Yet if it is possible for physicians to misuse their knowledge and power in order to kill people directly, are they therefore required to use that same knowledge always to keep people alive, always to resist a disease that can kill the patient...

...Reasons of both expediency and mercy will have been used to make that introduction acceptable...

...In the first section, I have tried to sketch, all too briefly, why I think that the traditional prohibition of direct killing has been correct: active euthanasia runs the risk of corruption and wrongly extends to another the right to control our bodies...

...A refusal to provide life-saving coverage under an entitlement program will be seen as a means of active involuntary euthanasia...

...But that sway, however great, is always limited...

...The moral question is whether we are obliged to continue treating a life that is being artificially sustained...

...It is hard, in fact, to see how we can have a reasonable allocation debate without making the distinction central to that debate...

...Let us take another step...

...On the one hand, to bring the life of another to an end by an injection is to directly kill the other-our action is the physical cause of death...

...Individual costs of care varied, but only within a relatively narrow range...

...The ambiguity arises precisely because we can be morally culpable of killing someone (unless we have a moral right to do so, as in self-defense) and no less culpable for allowing someone to die.(if we have both the possibility and the obligation of keeping that person alive...

...Useless and financially burdensome treatment A striking feature of efforts to increase patient choice and to use scientific methods of evaluation and screening, is that they build upon widely accepted values...

...These changes closely parallel changes in medical practice, especially the shift to deaths in institutional settings...

...These judgments may be wrong, but they are not patently irresponsible or indifferent to human life...

...Less dramatically but more pervasively, the failure to control medical costs has stimulated a national effort to reduce unnecessary and wasteful treatments...

...SOME BOUNDARY STANDARDS Must we, however, judge that, in an otherwise affluent society, a government decision to refuse to support organ transplantations would be morally unjustifiable...

...It attempts to articulate the difference between those actions for which human beings can rightly be held responsible and those of which they are innocent...

...For nations that have nothing, there are only "lifeboat" choices, that is, giving only to one because there is not enough for both...

...There is one group of ambiguous cases that is especially troublesome...

...A great deal of the emerging debate is coming to turn on not simply what is, or may be, happening, but also on what it means and how it should be interpreted...

...I see no moral basis for so ultimate a transfer of the power of life and death...

...If there are some lives "not worth living"-and not just the lives of the terminally ill but of others whose quality of life is low-why not, then, for their sake as well as that of society, simply end those lives...

...that is indeed a moral issue...

...In this view, our culture is now disposed to take the value of life less seriously than it once did...

...Physicians argued that it should be left to them to make a choice between the traditional definition- spontaneous cessation of heart and lung activity-and the newer definition of brain death...

...It is these "failures of success" that account for the rising incidence of some late-onset diseases, such as Alzheimer's...

...Our decision itself, and not necessarily how we effectuate that decision, is the reason for their death...

...General public awareness of these shifts is an important reason, I am convinced, for the rise of interest in active euthanasia...

...Yet there is no actual evidence that greater choice would reduce costs...

...Once a patient has been declared dead by that standard, medical treatment must be stopped...

...Ambiguity may obscure, but it does not erase the line between the two...

...This standard applies even if, in the eyes of his or her family, a patient is by their lights not dead...

...For the physician's ultimate obligation is to the welfare of the patient, and excessive treatment can be as detrimental to that welfare as inadequate treatment...

...They ought also to reflect some coherent vision of a good society...

...We might best approach the problem in stages, working first to minimize financial burdens by voluntary methods and then gradually using more stringent methods...

...The needed resources were available...

...On the other hand, to allow someone to die from a disease we cannot cure (and that we did not cause) is to permit the disease to act as the cause of death...

...When the death of the whole brain was proposed in the late 1960s as the standard for declaring a person dead, there was great resistance...

...These work directly against the grain...

...To accept the fact that a disease cannot be controlled, though an effort was made to do so, is as morally acceptable as deciding in advance that it cannot be successfully controlled...

...That power may be used only to cure or comfort, never to kill...

...John Stuart Mill, in his classic work, On Liberty, argued that the one exception to our right to do with our person as we will is the right to sell ourselves into slavery...

...There are those who believe there are neither medical nor solid moral reasons to stop treatment of those in PVS, particularly the provision of food and water (which some do not want to call " treatment'' in any case...