There has been a tremendous increase in interest in bioethics, which has come in direct response to the substantial advances in biomedical research and medical technology over the past 30 years. The more sophisticated medical science and technology becomes, the more sophisticated are questions that are raised: Who has the right to decide whether a medical treatment should be initiated, continued, or stopped? How much information are healthcare professionals required to give to patients? When should a patient's right to confidentiality be violated? When, if ever, is active or passive euthanasia or abortion justified, and who has the right to decide on these issues?

Some years ago I received the following letter from a friend who became my patient.

In pursuit of my ultimate objective of being in control of my self-deliverance at the time when my physical condition no longer warrants continuance, I have joined the Hemlock Society of Los Angeles. The Society urges its members to explore with their personal physicians this subject well in advance of the actual moment of necessity, and in particular the problem of acquiring a lethal dose of a drug that will provide a release consistent in quality with the degree of peace and serenity sought in life. It is my hope that we can find a process commensurate with your moral and professional concerns which will allow us to collaborate.

Dutch developments on euthanasia have drawn much attention over the years. Defenders and opponents have been telling very different stories about the practice of euthanasia and the frequency of cases, and the Dutch government has been struggling with the legal and moral problems involved. Concern about the procedures followed by physicians as well as questions on the “real” figures led the government to decide to organize an epidemiological study on the extent and the decision making. The results of the study were published in November 1991 (The End of Life in Medical Practice, 1991). Interpretation of the data may lead to a final settlement of the debate on euthanasia and has inevitably led to a revival of the moral debate of the 1970s. For the moment it has been decided that euthanasia will remain officially illegal under the Penal Code. However, in cases where euthanasia does occur, Attorneys General will continue to check the procedures followed by physicians to ensure no abuses have occurred and to safeguard physicians against prosecution. In this contribution, we discuss the development and intertwinement of legal, medical, and moral aspects of euthanasia in The Netherlands and the effects of the empirical studies of 1991, both on definitions and procedures for medical decisions at the end of life(MDEL)

This document was developed by prosecutor A. Josephus Jitta, Chief, Office of Justice, Alkmaar, The Netherlands, with assistance from physicians and is typical of the euthanasia report forms completed by medical examiners and coroners In The Netherlands.

Many recent events have contributed to the resurgence of the historically cyclical debate over euthanasia. Now, the focus rests on physician-assisted suicide. Many landmark events regarding physician-assisted suicide have occurred within the last year alone. For example, Derek Humphry's Final Exit recently became a best seller, giving people the detailed knowledge of how to “self-deliver” In The New England Journalbf Medicine, Dr. Timothy Quill shared his touching experience of assisting his patient “Diane” after she chose to decline treatment options for leu- kemia. Dr. Jack Kevorkian made use of his highly publicized “death machine” to help Janet Adkins and subsequently, several other women, end their lives

Approximately 30 years ago, a son prepared a cup of milk mixed with insecticide and arranged for his mother to unknowingly administer the poison to his father, who had been suffering severe pain after a cerebral apoplectic attack and demanding that his son assist him. in dying. After drinking the mixture, the father died, and the son was charged with homicide.

Methuselah, it is said, lived 969 years. His state of health at death is not revealed. It can only be surmised that he was surely not robust and, no doubt, was subject to all of the infirmities of old age and the tragic indignities associated with senility.

Jonathan Swift captured well the “curse” of immortality when, in Gulliver's Travels, he created a group of individuals, the Struldbrugs, who, when encountered, dulled what had heretofore been an appetite for perpetual life. The Struldbrugs were allowed to be born totally exempt from the “calamity of human Nature,” in that their minds were free “and disingaged (sic), without the Weight and De pression of Spirits caused by the continued Apprehension of Death.” They were thus condemned “to a perpetual continuance in the World.” In his travels, Gulliver found some Struldbrugs well over 1,000 years old.

CQ: Do you see the Patient Self-Determination Act as a positive step toward the goals you and the Hemlock Society have been pursuing for many years?

DH: The main value is education; it has impressed on health professionals that the federal government backs right-to-die issues. The federal government did not legislate when you would die or how you would die, but it did say providers must obey state regulations, and if you do not they are going to withdraw our funds. I am a great believer that legislation in needed to back up education. We were enormously pleased to see the Patient Self-Determination Act come into law without much fuss. It is a very useful step.

In the fall of 1991, voters in Washington state were asked to consider a public initiative that sought to legalize physician-assisted death: Initiative 119. Drafted by Washington Citizens for Death with Dignity, the initiative was intended to amend the existing state natural death act in several ways:

1) expand the definition of “terminal condition” to include patients in irrevers ible coma or persistent vegetative state;

2) specifically name “artificial nutrition and hydration” as life-sustaining medical procedures that could be refused or withdrawn;

3) legally allow mentally competent patients with certifiably terminal conditions to request and receive “aid-in-dying” from their physician as a medical service.

The first two proposed amendments were widely acknowledged as timely and appropriate; a coalition of medical, religious, and community organizations had been actively working on such additions for several years. It was the proposal to legalize “aid-in-dying,” however, that represented a radical shift in the conduct of physicians towards their patients and a dramatic shift in social policy.

Chinese medicine has a history of at least 2,000 years. The first explicit literature on medical ethics did not appear until the seventh century when a physician named Sun Simiao wrote a famous treatise titled “On the Absolute Sincerity of Great Physicians” in his work The Important Prescriptions Worth a Thousand Pieces of Gold. In this treatise, later called The Chinese Hippocratic Oath, Sun Simiao required the physician to develop first a sense of compassion and piety, and then to make a commitment to try to save every living creature, to treat every patient on equal grounds, and to avoid seeking wealth because of his expertise.

Mr. K. was a 28-year-old professional ice skater who presented to the emergency room with shortness of breath that had gotten worse over several weeks, accompanied by left pleuritic chest pain, cyanosis, and a cough productive of green-brown sputum. He had been unable to take food well for about 10 days because of shortness of breath and general malaise.His past medical history included an episode of esophageal candidiasis diagnosed by endoscopy 4 months prior to admission. He had been otherwise healthy. He was homosexual with multiple partners. An HIV test was done 1 year previously, but he never found out the result. He had avoided regular medical care. He was from Australia and had no kin in the United States.

The last three articles within this section of Cambridge Quarterly have focused on organizations or disciplines outside the mainstream of bioethics that are making inroads within the field. This issue's article may be viewed as a departure, but it is not-my thesis is that despite the active presence of the clergy in the ethics field, individuals involved in pastoral care are often thought by health professionals, as well as by a sizeable number of pastors themselves, to not be within the mainstream of ethical decision-making for patients.