Running To Do Evil

The Conservative Jewish prayerbook for the Day of Atonement includes a communal confession listing various sins. Among the expected sins an unusual one stands out: "Running to do evil." This may be based on Proverbs 6:18, but what is this interesting sin? I believe it means embracing evil enthusiastically instead of being drawn into it reluctantly. For example, suppose there is an attractive woman at my workplace. After months of struggling against temptation, I finally give in. I am married , so this is adultery. But suppose I pursue her daily for months until she finally yields. This is adultery and running to do evil.

There are other examples. When I was a medical resident four decades ago, one of my colleagues had a pregnant patient with severe heart disease. Neither she nor the baby could survive if the pregnancy continued, and the pregnancy was not far enough along for the baby to be delivered. The perceived choice was: one survivor or none? As was required, two senior consultants agreed that abortion was necessary. The day it was scheduled, the atmosphere on the ward was somber. I paid close attention to so rare an event. Other patients died despite the doctors' best efforts; this baby was to die because of them. Even though the mother and baby were not my patients, I felt a sense of failure, because my colleagues were deliberately ending a human life, whereas our fundamental purpose was to save life. Perhaps my sense of failure was due to the prohibition of abortion in the Hippocratic Oath, which young doctors took in those days. Perhaps it was a more basic aversion to taking innocent life. The source of this aversion may have been the Jewish religion I had been taught as a child, or it may have been the respect for human life I had absorbed from parents and teachers, or a combination of these. In any case, I had been taught to be receptive to the inner voice telling me that all human life is precious.

Perceiving that they were forced by circumstances to choose the lesser of two evils, the doctors acted reluctantly and sadly (after all, whatever is deemed a lesser evil is by definition still evil). This perception, and the bad feelings that accompanied it, provided a brake on their behavior. They would be reluctant to do something similar in the future, and unlikely to extend the activity further. Whether or not one agrees with the "lesser of two evils" approach in cases such as this or thinks that the lesser evil was truly chosen in this case - in other words, whether or not one concurs with what the doctors did - everyone can agree, and this is my point, that the doctors had not run to do it.
Now things are different. Judges, feminists, and "ethicists" tell us that abortion is not the lesser of evils but a positive good; not an admission of failure but an expression of freedom. Such an attitude evokes no bad feelings. It acts not as a brake but as an accelerator. If we are doing something good, why not do more of it? Why not extend it further? Most young doctors no longer take the Hippocratic Oath. I believe the cause of the oath's demise is its prohibition of abortion. But the oath also prohibits assisted suicide and euthanasia: "I will give no deadly medicine to anyone if asked, nor suggest any such counsel."

The brake is off and we are pressing hard on the accelerator - and racing downhill fast. Assisted suicide and euthanasia are favored by almost half of Americans and have been enacted into law in at least one state. In the Netherlands at least 2.7 percent of all deaths are now "hastened" by doctors. Applied to America, this would
mean over 61,000 deaths annually - far more than the annual toll of deaths from auto accidents, for instance. Worse, over 1,000 Dutch patients are "euthanized" annually without their consent, because their families or doctors think they are better off dead. Indeed, psychiatric disorders are now an acceptable reason for euthanasia. Is the Netherlands really a model to be emulated?

Medical care is largely free in the Netherlands; financial motives are less likely to affect decisions. Medical care is hardly free in America. In addition, "managed care" pressures doctors to deny potentially helpful therapy. But beyond financial motivation is the problem of determining whether we wish to end people's lives in order to spare them suffering or spare ourselves discomfort. Such considerations affect the patient's family, but they affect doctors as well. In psychological terms, repressed fears of death and disability are projected onto the patient. Doctors or relatives then believe that they are liberating the patient from these fears, when they may actually be soothing themselves.

Doctors have at least as much fear of death and disability as other people. Indeed, they rate the "quality of life" of elderly or disabled patients lower than the patients themselves rate it. What doctors (especially young ones) see as "poor quality of life" may seem tolerable to their patients. The same is true for relatives, who sometimes cannot bear to watch the suffering that the patient finds bearable. Christopher Reeve - the actor who broke his neck falling off a horse - reveals in his autobiography that when he was first rendered quadriplegic his mother asked that his respirator be turned off. Reeve later resumed acting and took up directing. Healthy people may say they would rather be dead than old or blind or paralyzed. The old or disabled often feel differently. The young or healthy are poor judges of what is unbearable.

Moreover, physicians need to feel in control, which is why they often make difficult patients when they become ill. This need is a normal companion to life-and-death responsibility. How could a doctor accept such a heavy responsibility if he did not feel in control of the situation? But the need to feel in control may also be related to the doctor's fear of death and disability. This fear is kept at bay, despite daily reminders of death and disability, by the idea that the doctor is in control. Incurable disease or disability is threatening evidence that the doctor is not in control. Anticipated death is even stronger evidence. in the face of such evidence, the doctor may subconsciously try to repress these fears. This may be accomplished by deciding to end the patient's life. In this way, at least the illusion of control is preserved. The need to be in control, which can help doctors function in trying circumstances, may also produce harm by impelling them to hasten the patient's death.

The only way I can see to inhibit this harmful effect is the realization, painful though it may be, that the doctor is at most only partially in control. I trained in internal medicine four decades ago. Many of my patients were elderly or had chronic diseases for which treatments were often inadequate. I then took further training in medical oncology, which at that time often involved experimental treatments on patients with far-advanced cancer for whom there was no other hope. The lesson that I was not in control was inescapable. Now there are more effective treatments for many diseases, and many more invasive ways to insert tubes into every orifice and even where there is no orifice. Young doctors today thus have more reassurance that they are in control, so the realization that they are not may come as a shock. We older doctors learned earlier that we were not in full control, so we needed the illusion less. I believe this is one reason why doctors today are more receptive to assisted suicide and euthanasia than were doctors in prior decades.

But there is a deeper reason as well. Many of my generation were brought up in religious homes. We might have fallen away from formal religion in our college and medical-school days, but the foundation had been laid. Therefore it came as less of a shock when we teamed that we were really not in control, because we had already been taught that Someone else was. Whether or not we were aware of this consciously, I believe it affected our subconscious thinking. My not being in control was less anxiety-provoking, because I subconsciously realized that even when I was not in control, God was. The move toward assisted suicide and euthanasia is thus related to the decline in religious belief, both for the obvious reason (loss of belief in the God-given sanctity of human life) and for a less obvious reason (greater need to retain the illusion of human control). Declining religious belief also leads to the current worship of youth, beauty, and health - which in turn intensifies the fear of old age, disability, and death. If life has no transcendent meaning, then health is all that matters. If all human life is not sacred, then beautiful and healthy life appears even more desirable, while unbeautiful or disabled life appears worthless, abhorrent, and frightening.
Articles and editorials favoring assisted suicide and euthanasia, some authored by members of ethics committees at hospitals or medical schools, are published in leading medical journals. One such article advises physicians how to proceed with these acts that are now illegal, apparently trusting that the advice will be followed only if the law is changed. In Nazi Germany they exterminated "useless eaters" who were a drain on the Fatherland; here we hasten their deaths out of "compassion." The end results may be difficult to distinguish. (As John O'Sullivan has remarked, "In Europe, the fascists goose-stepped; in America, they jog.")

Decades ago, when I was in training, rare exceptions were allowed in extreme cases, but the rules remained. Today, when a rule is inconvenient it is often just thrown out. Or it is simply ignored as we speed ahead with the pedal to the metal. If you doubt that we are going too far too fast, consider late-term abortion, which is nothing but infanticide. Note the growing list of reasons for doing away with malformed or retarded babies and disabled or elderly adults. Observe that we no longer raise children to be receptive to the voice telling them that all human life is precious. Today the taking of innocent life, often for trivial and selfish reasons, is greeted with indifference, or sometimes even joy - look into the eyes of "Doctor" Kevorkian. Indeed, we are running to do evil.

David C. Stolinsky
David C. Stolinsky, M.D., who is of the Jewish faith, lives in Los Angeles. He is retired after 25 years of medical school teaching at the University of California at San Francisco and the University of Southern California.

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