ities of the patient and particularly his remaining assets and capabilities. The end in view was to make the best use of these latter by bringing to bear all the resources of the department and the community required for his rehabilitation either toward self-sufficiency and discharge to his own or a foster home, or, if that were not possible, to maintain and improve the quality of his life in hospital. With the transfer of most of the DVA hospitals to provincial control A&R boards were phased out, but a modified version has been reactivated at Ste. Anne's Hospital iti recent months. Ste. Anne's is a veterans' hospital 32 km west of Montreal. Established toward the end of World War I as a military hospital, it now contains 1000 chronic medical and psychiatric beds, a domiciliary-care unit, daycare centres
for medical and psychiatric patients and a visiting home service. DVA policy, inaugurated when the A&R boards were formed, has been to invite from time to time geriatric specialists from Britain to give clinics and lectures in departmental hospitals. Continuing this policy, Sir Ferguson Anderson, a Scottish geriatrician and author of a popular textbook5 on the subject, recently spent several days at Ste. Anne's lecturing and consulting. In his concluding remarks, impressed by what he had observed, Sir Ferguson urged the hospital to play a larger role by expanding its activities, becoming a training facility and making available to others of the health-care community interested in geriatrics the expertise gained over the years at Ste. Anne's. This is a very practical proposal as the hospital is in the same corn-
munity as two medical schools and within 240 km of five other schools and has a largely bilingual staff and patients; indeed the hospital could well become a centre in eastern Canada for postgraduate education in geriatric medicine and psychiatry. References 1. Federated Council of Internal Medicine statement on manpower. Ann I,aern Med 90: 108, 1979 2. BEESON PB: Training doctors to care for old people. Ann Intern Med 90: 262, 1979 3. DANS PE, KERR MR: Gerontology and Geriatrics in Medical Education. N Engl J Med 300: 228, 1979 4. STIEGLITZ EJ: Geriatric Medicine, in
Medical Care of Later Maturity, 3rd ed, Lippincott, Philadelphia, 1954 5. ANDERSON Sir F: Practical management of the elderly, 3rd ed, Lippincott, Toronto, 1976
To live or not to live: the moral and practical case against active euthanasia J. ARTHUR BOORMAN, PH D
Daniel Maguire, a Catholic scholar, tells a story about a Donegal Irishman on his deathbed. The dying man was visited by friends who knew, as he did, that this would be their final visit. At his father's request, a son brought whisky for the guests and asked the old man if he, too, would have a drink. "Oh no," the father replied, "I don't want to be meeting the Lord with the smell of the drink on my breath." Commens Maguire: "If we were as at home with death as he, our deliberations on the subject might be more wise." Although I disagree with Maguire's basic contention that in certain cases involving conscious terminal patients "direct positive intervention to bring on death may be morally permissible", he is surely right in the above comment. Ours Dr. Boorman is associate professor of Christian ethics at McGill University and principal of United Theological College. His article is based on a presentation given during a clinical day May 23, 1978 at Maimonides Hospital, Montreal.
is a generation that would, if it and the useful. To elaborate: * "Doing your own thing", in could, deny the. reality of death; witness the cosmetics, the slumber current jargon, is used to justify rooms, the memorial parks, the smoking pot, abortion on demand, avoidance of the word itself in refusal to accept unsuitable emfavour of euphemisms such as "pass ployment etc. I do not want to away". Perhaps the first step in an comment on whether these are intelligent approach to the difficult right, but to point out that each questions related to dying in the is claimed as a "right". So Joseph modern world would be a recovery Fletcher, Daniel Maguire and other of the simple recognition of death such ethicists speak of a patient's as a fact. "To every man upon this "right" to die. I will return to this earth, death cometh soon or late." point, but we should note here that such a position would make suicide One of the difficult questions for whatever private reason entirely about death is this: does an aged acceptable, rather than the rare, person have the right to determine heroic exception it has traditionally whether to live or not to live? I been. cannot answer "yes.. or "no.. to * As for the "softness" I menthat. tioned, one needs only consider the However, before I discuss eutha- incredible sums of money spent on nasia, I want to say something more patent medicines, especially painabout the human situation today, killers. I do not pass judgement on because I believe it has an impor- this, and certainly do not urge the tant bearing on the question. I reintroduction of physical misery refer to three characteristics of the into life. But I wonder how far we modern person generally: a pre- ought to go. Again, it is evident occupation with individual rights that the right to die implies freeand personal freedom; a certain dom to choose death if we feel softness in the face of hardship or that the misery facing us is unpain; a preference for the tangible acceptable. CMA JOURNAL/AUGUST 18, 1979/VOL. 121 483
alive) - but she didn't. There is a finality about direct euthanasia, perhaps a certain arrogance, that is not present in the passive approach. Moreover, miracles (or at least surprising recoveries) do occur, albeit rarely - there are some remarkable old people in our homes for the aged who bear witness to that. There is another factor, too one that was regarded as of overwhelming significance by British doctors some years ago when a bill to legalize euthanasia was debated - and defeated. That factor is the doctor-patient relationship. Can you imagine the thoughts that would go through a patient's head as he faced a critical illness wondering whether his. or her physician might decide the effort was not worth it? Finally, there is one consideration above all others that should help to guide our judgement in this matter. It will be too simplistic, perhaps, just to throw in the Biblical quotation "The Lord gives, and the Lord takes away; blessed be the name of the Lord." Whether one is a theist, or a nontheistic agnostic, there is a profound truth in the idea that human life is a gift - that every human life is therefore precious. Surely whatever enhances life should be affirmed, and whatever degrades it should be rejected. Is this not implicit in one of the physician's basic rules, "Do no harm"? Does our society really have a reverence for human life? Perhaps not; certainly, terrorism, racism, napalm bombs and other
forms of violence do not lead to an obvious yes. Perhaps we ought to ask: what will happen - what does happen - when society loses its reverence or deep respect for human life? I do not know whether "mercy killing" is the thin edge of the wedge. The meaning of "respect for life" may vary with circumstances. But some authors (I think of fletcher in particular) would have us believe there is something particularly disrespectful or undignified about intravenous feeding or the use of respirators or other artificial support systems. But why? If they are an expression of care - of genuine caring, rather than of medical pride or anxiety or mindless routine - they could be regarded as showing respect or creating dignity and worth. That, to my mind, is the operative word, caring: when the end is near, a too-large injection of morphine to relieve pain could be fatal, but it would not be wrong if it was an expression of caring. But such care ought also to give pause to those who claim the right to choose their own deaths (even by written authorization in a lucid moment earlier) because they care for their relatives or friends. Is it a tribute to a dear one to hasten death to spare expense, as if that was the really important consideration? Finally, to think of life as a gift should engender, in the presence of life and of death, a certain humility that would hold as presumptuous too much impatience in the face of the unknown.E
A cela s'ajoute l'administration de programmes pour Ic compte du minist.re des Affaires sociales (MAS): $48.3 millions de d6bours6s pour des services rendus hors du Qu6bec .t des b.n.ficiaires du programme d'assurance-hospitalisation, $1.3 million pour les services dentaires aux b6n6ficiaires de l'aide sociale ag6s de 14 ans et moms, $616 116 216 $262 000 pour les proth.ses mainServices medicaux 17 834 315 maires, $17.2 millions pour Ia r6Services optom.triques 46 884 548 mun.ration des internes et r6siServices dentaires Medicaments et services 94 238 057 dents, $52.5 millions pour les serpharmaceutiques vices diagnostiques et th6rapeutiProth.ses et appareils 4789 496 ques rendus en milieu hospitalier, orthopt.diques $244 000 vers6s en primes d'.loiBourses d'.tudes et de 1 444 657 gnement aux psychiatres. recherche
La R.gie se f6licite de la c616rit. de ses services. Ainsi, en 1978-79, plus de 45 060 000 demandes de paiement ont 6t6 trait6es; 99% d'entre elles ont 6t6 r.gl6es en moms de 28 jours. La productivit6 des employ.s de la R6gie s'est am6lior6e: chaque employ6 a trait6 environ 27 615 demandes de paiement, alors que la moyenne s'6tablissait .t 22 711 l'ann6e pr.c6dente. En 10 ans, le nombre des programmes administr6s par la R&gie est pass6 de 3 .t 16 et l'6ventaile des services s'est diversifi6, pendant que s'instaurait l'universalit6 des grands soins de sante jusque dans les r6gions excentriques.E
* The third point was perhaps best expressed by that great scholar Martin Buber. How commonplace for human relations to be expressed in terms of I-it, rather than I-thou; in other words, people are treated as things to be seen or used. In our era, says Erich Fromm, depersonalization is almost total. As one potent symbol of this, consider the professional athlete, the ball or hockey player - bought or sold like a prize racehorse. Now, applying this to the termination of life, we should ask: when is life expendable? If a man or a woman is no longer useful, if he or she is incapable of language, self-care etc. (just as useless and helpless as a baby) why should he or she not be "extinguished"? Is that an unfair way of posing the question? We could probably all accept the view, expressed by Pope Pius XII in 1957, that extraordinary efforts to keep alive the unconscious terminally ill, are not mandatory. Further, I suggest such efforts are probably immoral, although scientific research can conceivably justify heroic efforts. But why not, as Maguire suggests, engage in "direct, positive intervention" to terminate such life? There are, in my judgement, several reasons. Contrary to Fletcher and Maguire, I believe there is a difference between doing something and not doing something - even though the result may be the same. A case in point is that of Karen Quinlan. When taken off the respirator she ought to have died (assuming for the moment that she was and is LA REGIE suite de la page 471 Ia carte d'assurance-maladie est maintenant obligatoire. Les stats financiers pour 1'exercice se terminant le 31 mars 1979 distribuent comme suit le co.it des divers programmes:
CMA JOURNAL/AUGUST 18, 1979/VOL. 121 485
for medical and psychiatric patients and a visiting home service. DVA policy, inaugurated when the A&R boards were formed, has been to invite from time to time geriatric specialists from Britain to give clinics and lectures in departmental hospitals. Continuing this policy, Sir Ferguson Anderson, a Scottish geriatrician and author of a popular textbook5 on the subject, recently spent several days at Ste. Anne's lecturing and consulting. In his concluding remarks, impressed by what he had observed, Sir Ferguson urged the hospital to play a larger role by expanding its activities, becoming a training facility and making available to others of the health-care community interested in geriatrics the expertise gained over the years at Ste. Anne's. This is a very practical proposal as the hospital is in the same corn-
munity as two medical schools and within 240 km of five other schools and has a largely bilingual staff and patients; indeed the hospital could well become a centre in eastern Canada for postgraduate education in geriatric medicine and psychiatry. References 1. Federated Council of Internal Medicine statement on manpower. Ann I,aern Med 90: 108, 1979 2. BEESON PB: Training doctors to care for old people. Ann Intern Med 90: 262, 1979 3. DANS PE, KERR MR: Gerontology and Geriatrics in Medical Education. N Engl J Med 300: 228, 1979 4. STIEGLITZ EJ: Geriatric Medicine, in
Medical Care of Later Maturity, 3rd ed, Lippincott, Philadelphia, 1954 5. ANDERSON Sir F: Practical management of the elderly, 3rd ed, Lippincott, Toronto, 1976
To live or not to live: the moral and practical case against active euthanasia J. ARTHUR BOORMAN, PH D
Daniel Maguire, a Catholic scholar, tells a story about a Donegal Irishman on his deathbed. The dying man was visited by friends who knew, as he did, that this would be their final visit. At his father's request, a son brought whisky for the guests and asked the old man if he, too, would have a drink. "Oh no," the father replied, "I don't want to be meeting the Lord with the smell of the drink on my breath." Commens Maguire: "If we were as at home with death as he, our deliberations on the subject might be more wise." Although I disagree with Maguire's basic contention that in certain cases involving conscious terminal patients "direct positive intervention to bring on death may be morally permissible", he is surely right in the above comment. Ours Dr. Boorman is associate professor of Christian ethics at McGill University and principal of United Theological College. His article is based on a presentation given during a clinical day May 23, 1978 at Maimonides Hospital, Montreal.
is a generation that would, if it and the useful. To elaborate: * "Doing your own thing", in could, deny the. reality of death; witness the cosmetics, the slumber current jargon, is used to justify rooms, the memorial parks, the smoking pot, abortion on demand, avoidance of the word itself in refusal to accept unsuitable emfavour of euphemisms such as "pass ployment etc. I do not want to away". Perhaps the first step in an comment on whether these are intelligent approach to the difficult right, but to point out that each questions related to dying in the is claimed as a "right". So Joseph modern world would be a recovery Fletcher, Daniel Maguire and other of the simple recognition of death such ethicists speak of a patient's as a fact. "To every man upon this "right" to die. I will return to this earth, death cometh soon or late." point, but we should note here that such a position would make suicide One of the difficult questions for whatever private reason entirely about death is this: does an aged acceptable, rather than the rare, person have the right to determine heroic exception it has traditionally whether to live or not to live? I been. cannot answer "yes.. or "no.. to * As for the "softness" I menthat. tioned, one needs only consider the However, before I discuss eutha- incredible sums of money spent on nasia, I want to say something more patent medicines, especially painabout the human situation today, killers. I do not pass judgement on because I believe it has an impor- this, and certainly do not urge the tant bearing on the question. I reintroduction of physical misery refer to three characteristics of the into life. But I wonder how far we modern person generally: a pre- ought to go. Again, it is evident occupation with individual rights that the right to die implies freeand personal freedom; a certain dom to choose death if we feel softness in the face of hardship or that the misery facing us is unpain; a preference for the tangible acceptable. CMA JOURNAL/AUGUST 18, 1979/VOL. 121 483
alive) - but she didn't. There is a finality about direct euthanasia, perhaps a certain arrogance, that is not present in the passive approach. Moreover, miracles (or at least surprising recoveries) do occur, albeit rarely - there are some remarkable old people in our homes for the aged who bear witness to that. There is another factor, too one that was regarded as of overwhelming significance by British doctors some years ago when a bill to legalize euthanasia was debated - and defeated. That factor is the doctor-patient relationship. Can you imagine the thoughts that would go through a patient's head as he faced a critical illness wondering whether his. or her physician might decide the effort was not worth it? Finally, there is one consideration above all others that should help to guide our judgement in this matter. It will be too simplistic, perhaps, just to throw in the Biblical quotation "The Lord gives, and the Lord takes away; blessed be the name of the Lord." Whether one is a theist, or a nontheistic agnostic, there is a profound truth in the idea that human life is a gift - that every human life is therefore precious. Surely whatever enhances life should be affirmed, and whatever degrades it should be rejected. Is this not implicit in one of the physician's basic rules, "Do no harm"? Does our society really have a reverence for human life? Perhaps not; certainly, terrorism, racism, napalm bombs and other
forms of violence do not lead to an obvious yes. Perhaps we ought to ask: what will happen - what does happen - when society loses its reverence or deep respect for human life? I do not know whether "mercy killing" is the thin edge of the wedge. The meaning of "respect for life" may vary with circumstances. But some authors (I think of fletcher in particular) would have us believe there is something particularly disrespectful or undignified about intravenous feeding or the use of respirators or other artificial support systems. But why? If they are an expression of care - of genuine caring, rather than of medical pride or anxiety or mindless routine - they could be regarded as showing respect or creating dignity and worth. That, to my mind, is the operative word, caring: when the end is near, a too-large injection of morphine to relieve pain could be fatal, but it would not be wrong if it was an expression of caring. But such care ought also to give pause to those who claim the right to choose their own deaths (even by written authorization in a lucid moment earlier) because they care for their relatives or friends. Is it a tribute to a dear one to hasten death to spare expense, as if that was the really important consideration? Finally, to think of life as a gift should engender, in the presence of life and of death, a certain humility that would hold as presumptuous too much impatience in the face of the unknown.E
A cela s'ajoute l'administration de programmes pour Ic compte du minist.re des Affaires sociales (MAS): $48.3 millions de d6bours6s pour des services rendus hors du Qu6bec .t des b.n.ficiaires du programme d'assurance-hospitalisation, $1.3 million pour les services dentaires aux b6n6ficiaires de l'aide sociale ag6s de 14 ans et moms, $616 116 216 $262 000 pour les proth.ses mainServices medicaux 17 834 315 maires, $17.2 millions pour Ia r6Services optom.triques 46 884 548 mun.ration des internes et r6siServices dentaires Medicaments et services 94 238 057 dents, $52.5 millions pour les serpharmaceutiques vices diagnostiques et th6rapeutiProth.ses et appareils 4789 496 ques rendus en milieu hospitalier, orthopt.diques $244 000 vers6s en primes d'.loiBourses d'.tudes et de 1 444 657 gnement aux psychiatres. recherche
La R.gie se f6licite de la c616rit. de ses services. Ainsi, en 1978-79, plus de 45 060 000 demandes de paiement ont 6t6 trait6es; 99% d'entre elles ont 6t6 r.gl6es en moms de 28 jours. La productivit6 des employ.s de la R6gie s'est am6lior6e: chaque employ6 a trait6 environ 27 615 demandes de paiement, alors que la moyenne s'6tablissait .t 22 711 l'ann6e pr.c6dente. En 10 ans, le nombre des programmes administr6s par la R&gie est pass6 de 3 .t 16 et l'6ventaile des services s'est diversifi6, pendant que s'instaurait l'universalit6 des grands soins de sante jusque dans les r6gions excentriques.E
* The third point was perhaps best expressed by that great scholar Martin Buber. How commonplace for human relations to be expressed in terms of I-it, rather than I-thou; in other words, people are treated as things to be seen or used. In our era, says Erich Fromm, depersonalization is almost total. As one potent symbol of this, consider the professional athlete, the ball or hockey player - bought or sold like a prize racehorse. Now, applying this to the termination of life, we should ask: when is life expendable? If a man or a woman is no longer useful, if he or she is incapable of language, self-care etc. (just as useless and helpless as a baby) why should he or she not be "extinguished"? Is that an unfair way of posing the question? We could probably all accept the view, expressed by Pope Pius XII in 1957, that extraordinary efforts to keep alive the unconscious terminally ill, are not mandatory. Further, I suggest such efforts are probably immoral, although scientific research can conceivably justify heroic efforts. But why not, as Maguire suggests, engage in "direct, positive intervention" to terminate such life? There are, in my judgement, several reasons. Contrary to Fletcher and Maguire, I believe there is a difference between doing something and not doing something - even though the result may be the same. A case in point is that of Karen Quinlan. When taken off the respirator she ought to have died (assuming for the moment that she was and is LA REGIE suite de la page 471 Ia carte d'assurance-maladie est maintenant obligatoire. Les stats financiers pour 1'exercice se terminant le 31 mars 1979 distribuent comme suit le co.it des divers programmes:
CMA JOURNAL/AUGUST 18, 1979/VOL. 121 485
