Killing off the dying?

Public Interest, Spring, 1998 by Adam Wolfson

The risks and burdens of continuing with the current prohibitions [against physician-assisted dying] have been less clearly articulated in the literature. The most pressing problem is the potential abandonment of competent, incurably ill patients who yearn for death despite comprehensive comfort care. These patients may be disintegrating physically and emotionally, but death is not imminent.... In fact, there is no empirical evidence that all physical suffering associated with incurable illness can be effectively relieved. In addition, the most frightening aspect of death for many is not physical pain, but the prospect of losing control and independence and of dying in an undignified, unesthetic, absurd, and existentially unacceptable condition.

So the noble language of death with dignity, of the sovereign right to choose what is best for oneself, has its underside, an implicit valuation of the kinds of life that are supposedly not worth living - life, for example, that is characterized by dependency, or life that is "undignified, unesthetic, absurd ... existentially unacceptable," as the doctors put it.

This hidden judgment is made somewhat more explicit by Dworkin, who argues that one reason many people want to die is that their lives have ceased to have meaning for them. This is surely true, but then Dworkin offers a startling quote from Nietzsche to back up the point: "'In a certain state it is indecent to live longer. To go on vegetating in a cowardly dependence on physicians and machinations, after the meaning of life, the right to life, has been lost, that ought to prompt a profound contempt in society.'" Dworkin did not italicize the last clause, but I have done so to emphasize what he ignores: In a society that allows doctor-assisted death, valuations of what is a dignified and meaningful life, and what is an undignified and meaningless life, will be made, inevitably, not just by the individual whose life is at stake but, as Nietzsche urged, by the larger society.

The importance of this last point justifies including the entire passage from which Dworkin selectively quotes - it comes from Nietzsche's Twilight of the Idols. The passage begins, ominously enough, "The sick man is a parasite of society," and leads into Dworkin's abbreviated quotation, ending with this:

The physicians, in turn, would have to be the mediators of this contempt - not prescriptions, but every day a new dose of nausea with their patients. To create a new responsibility, that of the physician, for all cases in which the highest interest of life, of ascending life, demands the most inconsiderate pushing down and aside of degenerating life - for example, for the right to procreation, for the right to be born, for the right to live.

Who is to die?

I do not for a moment believe that those who support assisted death intend to become what Nietzsche calls the "mediators" of contempt towards those who are less fortunate, and I do not think that they intend to create for themselves what he calls "a new responsibility," that of the physician who kills in the interest of "ascending life." However, signs of intellectual ferment, pointing in unsavory directions, are not absent.