COLUMN ONE : Support Grows for Euthanasia : Medical killing runs against thousands of years of professional tradition, but interest is increasing as advances allow doctors to prolong life and, sometimes, patients’ suffering.

On the surface, the idea seems repugnant: A doctor killing or helping to kill a patient.

But the once taboo practice of euthanasia is attracting increasing support as the ability of intensive care and other medical technologies to forestall death has grown ever more powerful.

Although in many cases medical advances help extend productive life for years, in other instances they only prolong a painful death. The suffering of the dying is often compounded by the anguish of the family as it witnesses the deterioration of a loved one.

The prospect of a suffering patient motivated a New York physician to help a leukemia patient named Diane kill herself, as he candidly explained in a New England Journal of Medicine article in March.

The physician, Dr. Timothy E. Quill, was convinced that Diane’s fears of suffering “unspeakably” while dying justified his decision. Prolonged dying, Quill wrote, “can occasionally be peaceful, but more often the role of the physician and family is limited to lessening but not eliminating severe suffering.”

Two years ago, 10 of the 12 members of a group of distinguished medical ethicists came to the conclusion in another New England Journal of Medicine article that “it is not immoral for a physician to assist in the rational suicide of a terminally ill person.”

The ethicists said “only the rare patient should be so distressed that he or she desires to commit suicide.” But they added that some physicians believe it to be the last act in caring for the hopelessly ill patient to “assist patients who request (suicide), either by prescribing sleeping pills with knowledge of their intended use or by discussing the required doses and methods of administration.”

Last year, there was wide publicity about the case of Dr. Jack Kevorkian, the Michigan pathologist who assisted in the suicide of a 54-year-old woman in the early stages of Alzheimer’s disease. Murder charges against Kevorkian were dropped and he was banned from assisting people who want to die.

“The new interest in euthanasia is very much a response to the failure of medicine to adequately reassure people about their dying,” said Daniel Callahan, the director of the Hastings Center, a medical ethics research institute in Briarcliff Manor, N.Y.

“As fast as we have been trying to figure out how to allow people to die more peacefully, we keep improving the technology that makes it all the harder to do so,” Callahan said. Despite all its efforts, “medicine has really not managed to control people’s dying very well.”

In the state of Washington, a “death with dignity” initiative is scheduled for the ballot in November. Among other things, the initiative would legalize “aid in dying,” a euphemism for physician-assisted killing, for mentally competent adults with less than six months to live who voluntarily choose the procedure.

The initiative appears to have a good chance of passing, which would make Washington the only place in the world with legal euthanasia.

Even in the Netherlands, where it is estimated that euthanasia occurs several thousand times each year, the practice technically remains a criminal offense. The Dutch law, however, is almost never enforced. Euthanasia is generally accepted by the courts if strict conditions are met.

Success in Washington would spur efforts to pass euthanasia initiatives elsewhere, such as in California, where a similar initiative failed to qualify for the ballot in 1988, as well as in Colorado, Florida and Oregon.

“We are hopeful that there will be a domino effect,” said Derek Humphry, the founder of the Hemlock Society, the nation’s best known euthanasia advocacy group.

Some advocates of legalizing euthanasia, such as Margaret Battin, a philosophy professor at the University of Utah, even predict that the topic will become the “most important social issue of the next decade.”

Many medical ethicists and physicians welcome the discussion but feel what they view as the enthusiasm of euthanasia advocates needs to be tempered.

Medical killing “runs counter to an entire tradition of medicine for thousands of years. It really needs to be looked at in a very cautious light,” said Dr. George D. Lundberg, the editor of the Journal of the American Medical Assn. “The potentials for abuse are enormous.”

Some of these traditional medical values are embodied in the writings of Hippocrates. The venerated Greek physician urged his colleagues to “first, do no harm” and to “neither give a deadly drug to anybody if asked for it,” nor to make a suggestion to this effect.

The term euthanasia derives from Greek words that mean a “good death.” Only in recent times has the term been associated with the act of hastening death, specifically when a physician helps end the life of a patient who is hopelessly ill and suffering.

Some draw a distinction between “assisted suicide,” in which a patient intentionally overdoses on drugs that may have been provided by a physician, and “active euthanasia,” in which a physician directly administers the fatal overdose. But opponents of euthanasia are usually opposed to both; practically speaking, they consider them the same thing.

No one knows for certain how often euthanasia takes place in the United States, but many physicians acknowledge in private that they know of instances in which it has occurred.

Even many who believe that euthanasia can be justified in selected circumstances feel that it should remain illegal as a safeguard against abuses. As a result, they say, doctors who feel strongly enough to participate in euthanasia should be willing to risk prosecution.

Sanford Kadish, a criminal law expert at UC Berkeley’s Boalt Hall Law School, predicted that laws to legalize medical killing would “constitute a radical affront to accepted life and death mores” of much of the population.

Kadish added: “It is a threatening business to give the power to kill someone to a private person without much guidance except that in their judgment someone is terminally ill.”

In general, physicians as well as medical ethicists support the right of patients to forgo respirators and other life-sustaining treatments at the end of life and to receive ample pain relief and humane care.

Many can accept the “double-effect” situation in which the large dose of narcotic necessary to relieve the pain of cancer or other diseases hastens death by interfering with breathing or by contributing to the development of a fatal pneumonia.

Many experts believe that popular sentiment for euthanasia would diminish greatly if the health care system did a better job of meeting the physical and psychological needs of dying patients.

A substantial number of physicians also urge their patients to complete living wills or durable powers of attorney for health care. Living wills are written statements from patients calling for the withholding of heroic measures at the end of life. The powers of attorney allow individuals to appoint surrogates to make medical decisions for them, including the withholding of treatment, if they become incompetent.

But many physicians draw the line at “actually bumping people off,” as Lundberg put it.

Nevertheless, in the public mind such disparate practices as the forgoing of medical care and mercy killing are often lumped under the category of euthanasia, according to Arthur Caplan, the director of the Center for Biomedical Ethics at the University of Minnesota in Minneapolis.

“There is a huge confusion,” Caplan said. “From appearing on radio call-in shows and reading the mail from columns I write, it is very clear to me that the distinctions are not there” in the public mind.

Recent public opinion polls show that 50% to 60% of Americans favor the legalization of euthanasia and physician-assisted suicide under certain circumstances. Limited opinion surveys of physicians suggest that significant but smaller percentages favor legalizing euthanasia, although many of the same doctors say that they would not perform it themselves.

A survey of 1,105 members of the Washington State Medical Assn., conducted earlier this year, found that 60% opposed the use of a lethal dose of medication to end a patient’s life and that 70% are not willing to participate in the mercy killing of a patient.

Some objections to euthanasia are rooted in a belief that doctors must not kill under any circumstances, according to Alexander M. Capron of the USC Law Center in Los Angeles. For instance, the American College of Physicians, the leading professional organization of internists, maintains that even if it is legalized, assisted suicide or direct killing “would violate the ethical standards of medical practice.”

Other objections are more pragmatic, such as the difficulties in determining who should be eligible and of designing adequate safeguards.

If the procedure were legalized, even on a very limited basis, Callahan of the Hastings Center doubts that it would stay limited for long. Callahan, who opposes legalizing euthanasia, fears that some people would push to expand the eligibility, for example, to people who are seriously ill, but not terminal, and to people who have impaired thinking. “It seems to me perfectly arbitrary to say that somebody has to be dying or to be mentally competent,” Callahan said. He asks rhetorically: “If it is my body and my right to dispose of it as I want, why shouldn’t I be able to command any doctor to kill me just because I want to be killed?”

A particular concern is the possibility that euthanasia will be used to victimize members of groups that fall through the cracks in America’s under-funded and fragmented health care system, such as minorities, the elderly, the poor and the disabled.

At a time when soaring costs have made limiting access to medical services, or health care rationing, “the top priority of health policy,” advancing the cause of active euthanasia is “sending a dangerous message that could undermine doctor-patient relationships,” said Caplan of the University of Minnesota.

Caplan wonders whether physicians will soon be telling their patients, “I am sorry that we have to ration health care but there is ‘good news’: We have made euthanasia legal.”

Paul K. Longmore of Stanford University, who has written about the history of people with disabilities and who had polio himself, thinks that euthanasia will “open the door so that a lot of people with serious disabilities will be terminated.”

Even some euthanasia advocates, such as Battin, acknowledge the possibility of abuses. In the Netherlands, Battin believes, this possibility is limited by a national health insurance system and the high standards of the medical profession. But she is concerned that in the United States the cost of health care as well as a tendency for some doctors to make decisions for their patients could lead to abuses.

Many people date the current era of medical ethics to 1976, the year the New Jersey Supreme Court, in a landmark decision, authorized the removal of Karen Ann Quinlan, who was in a permanent coma, from a respirator. The court ruled that Quinlan’s privacy rights and her terminal condition justified the withholding of life support. Since then, many state courts and legislatures have enlarged the scope of what ethicists call “patient autonomy.”

Autonomy allows patients to have the final word about which treatment to choose and to refuse treatments that they do not want. In addition to the euthanasia question, the growth of patient autonomy has manifested itself in the abortion debate as the right to control one’s body.

It is inevitable that the discussion of patient autonomy has reached “the question of why can’t I save my family greater suffering and my estate considerable assets? Why can’t I have a gentle and humane exit?” said Paul Menzel, a professor of philosophy at Pacific Lutheran University in Tacoma, Wash. “Once you see it that way . . . you see yourself doing very good deeds by taking a quicker exit.”

Some wonder how society can allow the killing of fetuses but prohibit the killing of the dying. The distinction, according to Callahan and others, involves the status of the fetus. Most supporters of legal abortion believe that the fetus in early stages of development does not have the status of a person. This view is strongly disputed by most opponents of abortion. They believe that the fetus becomes a person at the time of conception.

But as the principles of patient autonomy have become widely accepted, the potential for physicians to forestall death with new treatments and technologies, including respirators, antibiotics and organ transplants, has advanced as well. This has strengthened the fear that patients and their families will lose control of the dying process.

In the case of Diane, the leukemia patient, she “remained very clear about her wish not to undergo chemotherapy and to live whatever time she had left outside the hospital,” wrote Quill, her physician. “She articulated very clearly that . . . odds of 25% (of long-term survival) were not good enough for her to undergo so toxic a course of therapy.”

Before Diane developed leukemia, Quill had treated her for years for a variety of ailments. He knew her well. He decided to write his commentary after reading an anonymous description of an apparent act of mercy killing published in 1988 under the headline “It’s Over, Debbie” in the Journal of the American Medical Assn.

The “Debbie” case shocked many. The lethal injection was given by a physician in training in the middle of the night. The recipient was a hospitalized cancer patient whom the doctor had never met before. The patient was in severe distress and said “let’s get this over with,” which the doctor interpreted as a justification for euthanasia. The physician acted alone without consulting the patient’s physician. His actions were generally regarded as an abuse of good medical practice, even by many euthanasia advocates.

Supporters of euthanasia feel that euthanasia can be made lawful, as long as there are strong protections against abuses.

In the Netherlands, for example, the strict conditions for euthanasia include a repeated, conscious and entirely uncoerced request by the patient, a hopeless medical situation, and an opinion from a second physician as to whether the procedure is appropriate.

The physician or the coroner is required to report deaths from euthanasia to the police. But this reporting is done in less than 10% of cases, according to Callahan, which makes him wonder if the other conditions are being followed a small percentage of the time as well.

Under Initiative 119, the Washington state proposal, a conscious and mentally competent terminally ill individual would be able to voluntarily request a “medical service, provided in person by a physician,” that will end his or her life.

The request would have to be made by the individual, through a written directive witnessed by two people at the time “aid in dying” was to be provided. Others such as minors and adults with impaired thinking, as well as all pregnant women, would not be eligible, nor could they designate someone else to request euthanasia for them.

The Washington initiative would grant immunity against criminal charges or allegations of unprofessional conduct to physicians who provide “aid in dying” consistent with the law. On the other hand, no physician would be required to perform “aid in dying” and hospitals could ban the procedure within their facilities.

Unlike the Netherlands, the Washington proposal includes no requirement for an opinion from a second physician. Some view this as a major problem.

“If medicine ever embarks on (euthanasia), it should probably surround the physician decision with some sort of review and consultation,” said Albert R. Jonsen, a professor of ethics in medicine at the University of Washington. “I just don’t like the idea of a kind of privatization of killing. That is the big danger.”

The November vote in Washington may set the agenda for the euthanasia debate for many years.

“It is a real tough area,” said Lundberg, the editor of the Journal of the American Medical Assn. “I think in the next century death without pain and with dignity and perhaps even at a prearranged time will be the norm. But I hope that we do not get there quickly because there is a tremendous gulf of philosophical and historical experience that runs counter to that.”

Dorothy Ingebretsen of the Times Library assisted with the research for this story.