Dancing with Mr. D: Notes on Life and Death.

IS anyone so shut off from the world that he still does not know about the war? To make clear what I mean, here is an illustration. Not long ago on a medical-ethics panel, I spoke against playing God. My counterpart, a hospital chaplain, declared: "Of course it's okay to play God; at the hospital we do it all the time." He was too genteel to use the word, but everyone knew that when he spoke of playing God he meant killing.

The current stage of the conflict features two main views. In the traditional view, intentionally killing an innocent human being is always wrong. Such killing includes both active euthanasia and acting as an accessory to suicide. However, allowing to die is sometimes permitted. This means that a particular treatment may be withheld or withdrawn if the patient is dying, his death is imminent, the treatment is extraordinary, and his death is not the goal.

A canard of the radicals is that traditionalists are "simplistic." On the con- trary: although the traditional criteria are clear, they are far from simple. For example, extraordinary treatments are defined as those which impose excessive burdens on the patient or fail to offer reasonable hope of benefit, and all traditionalists recognize that judgment is needed to know when that line has been crossed. The real simplifiers are the radicals, who deny the moral distinction between allowing death and causing it, arguing that if one can ever withhold even the most heroic treatment, then one can also kill.

Then who dies? Here the radicals split, but none of their criteria bears scrutiny. Is the patient suffering? Even though not all doctors have adequate training in palliative care, today almost all physical pain can be rendered bearable. For the rare pain that resists amelioration the patient can ask to be sedated. Is he dying? The irrational thought behind this criterion seems to be that if we cannot guarantee the patient a length of life we think suffi- cient, he shall not have any at all. Has his life lost its worth? That which is in the image of God does not lose worth because it can no longer play the piano or use the toilet without assistance. Does he want to die? It is not quite merciful to offer the patient death as a reward for internalizing the embarrassment, contempt, and disgust of those around him; some of us would consider it a nasty trick. Would his death be in the best interests of all concerned? This is a dishonest way of asking whether he has become a nuisance. If ever we arrive at killing people just because they are in the way, we will have lost everything.

A glimpse of what losing everything might mean may be found in the Dutch best-seller Dancing with Mr. D, a rambling, disjointed journal of a physician's nursing-home practice. In the Netherlands, euthanasia is not precisely legal, but it is officially tolerated in an ever-expanding set of circumstances. Early in the narrative, author Bert Keizer is called to the bedside of a Mrs. Malfijt, who is choking on her food. There is no use trying to clear the blockage, he says, and so, rather than help in any way, he fills her veins with morphine. This he calls letting her decide her own course without being harassed from either shore. After 15 minutes he calls her son to tell him she is dead.

At the end of that passage I came to a full stop, then backed up. Had I just read what I thought I had? Yes. How could it be explained? It can't; in Dr. Keizer's universe, where God is dead and life is meaningless, categories like "cruel," "mad," and "normal" can no longer be distinguished. The author gives overdoses of morphine to every patient in sight, yet grows furious with their relatives for thinking that euthanasia is easy to arrange. Love for his patients? He declares to a colleague that he has none, but calls it good for the profession to heave a sigh from time to time and say that he does. On this page he mocks his country's official guidelines, which the ignorant in our country cite as proof that euthanasia can be kept within bounds. On another page he violates his private guidelines, never to kill just for the comfort of the spectators and never to do it in a hurry. Over here he explains the importance of rituals and says there should be one for euthanasia. Over there he mocks the mourners at funerals by answering their questions with gibberish. He admonishes one patient for loudly asking about euthanasia in the hearing of others. Yet having been offered some of another patient's shirts, he rummages among them in the very faces of the dead man's wardmates. He harangues a dying former hippie for not having aborted her only child, and he badgers a nurse for refusing on grounds of religious faith to administer a deliberate overdose of morphine to a woman with a broken hip. Because he considers human beings feces, one can hardly be surprised that he colors all their works with excre- ment, as when he compares an expiring woman's effort not to retch with the strain of holding in stool. But her death was a good one, he says, because she struggled at the exit.

Now that the book has been translated, it will win a following here too among the sort of people who think Kurt Cobain was a great poet. But perhaps I over- react. Dr. Keizer is but a drop in the sea of Dutch medicine. How typical could he be? The defenders of Dutch euthanasia hold that the stories of a social experiment gone berserk have been exaggerated, and that in any case the Dutch medical and legal systems are so different from our own that we have no reason to expect the legalization of euthanasia to have the same results here as it has had there.

THESE claims are put to the test in the compelling study Seduced by Death, by psychiatrist Herbert Hendin. Though the executive director of an organization devoted to the prevention of suicide, Dr. Hendin is not a traditionalist. When he arrived in the Netherlands he had not made up his mind whether euthanasia and assisted suicide should be permitted by law, and he is still uncertain about the ethics of treatment for people in coma and dementia. Perhaps for this reason, Dutch doctors and euthanasia advocates were willing to speak more frankly with him than they might have been with someone seeking weapons to use against them. In the process they seem to have revealed more than they may have intended, and the longer the author studied the "Dutch Cure" the more horrifying he found it.

The ambivalent will appreciate the book's sober demonstration that euthanasia and assisted suicide in the Netherlands have resulted in thousands of unjustifiable deaths even by the standards and statistics accepted by advo- cates of those practices. For instance, most proponents expected the change to increase the ability of patients to make their own decisions. "In practice," finds Hendin, "it is still the doctor who decides whether to perform euthanasia. He can suggest it, not give patients obvious alternatives, ignore patients' ambivalence, and even put to death patients who have not requested it. Euthanasia enhances the power and control of doctors, not patients." Though still outside the official guidelines, involuntary euthanasia has become so common in the Netherlands that many Dutch now carry cards to signify that they do not want to be put to death without their knowledge and consent.

Hendin is especially penetrating in his analysis of the interplay of motives among those who seek suicide, assist in it, and press for its acceptance. One obvious motive is the desire to reduce anxiety about death. Unfortunately, the new mores themselves become the main source of anxiety, and so assisted suicide is "the cure that causes another form of the disease." A more surpris- ing motive is the need for connection. Many of those who have assisted in suicide call it the most meaningful thing they have ever done; it gives them a sense of intimacy with another person that they could not otherwise have achieved. Most engrossing is the sheer need for absolution. Accessories to suicide often assuage their uneasiness or sense of guilt by writing about the act, justifying it, and recruiting others to its practice. Of course all these motives grease the slippery slope. Euthanasia breeds euthanasia; as Hendin shows, even some of those who have participated in it describe it as a con- tagious disease.

Other strengths of the book are its fine discussions of whom the Dutch euthanasia guidelines really protect, why they cannot contain the practice, how euthanasia promotes the atrophy of palliative care, why the United States and the Netherlands are the only two Western industrial nations to have strong euthanasia movements, and why the relaxation of anti-euthanasia laws might cause even greater horrors in our country, with its large underclass, than it has done in the Netherlands.

I have only two criticisms. Despite Hendin's clear and explicit recognition that "autonomy" can be another name for "narcissism," he seems, in otherwise helpful remarks on advance medical directives, to forget his own critique. Despite his equally clear recognition that right and wrong are not determined by social consensus, in the discussion of coma and dementia he seems adrift, in the end having no more to say than that somehow society must reach con- sensus.

Honorable mention is due Forced Exit, by Wesley J. Smith, a wide-ranging book on the state of the euthanasia debate in the United States. In comparison with the Hendin book, its advantages are a more thorough account of domestic euthanasia politics, a more acute perception of how people who change their mind about dying can be trapped by their own advance directives, and a more firm defense of the worth of people with diminished mental capacities. Its most persistent weakness is a tendency to propose ever more judicially enfor- ceable rights and entitlements, and to disregard the law of unanticipated con- sequences, especially as applied to medical economics.

A graver flaw is that at times the author seems disingenuous -- for example, when he tries to distinguish the arguments for euthanasia and abortion. He contends that sick people are indisputably human while unborn people are not. But abortion proponents lost the "human life" battle years ago; does anyone imagine that a dog is growing in there? As Mr. Smith must know, in its current phase the war over life and death concerns not humanity but "personhood," and the biographical criteria used by euthanasia supporters to deny personhood to the sick are precisely those used by abortion supporters to deny it to the unborn. I sympathize with his desire to pick up allies wherever he can find them, but he will not succeed through special pleading.

PART of the problem with Forced Exit is its insistence that euthanasia is "not a religious issue, it is a vital public-policy issue." Of course, like every "vital issue," it is both. This is not to say that atheists cannot possibly find a reason to oppose euthanasia -- plainly, some do. However, it is naive to expect politics and world-view to be unrelated. Given the evasiveness of most public-policy writing on the matter of faith and ultimate ends, one wishes for a book that would treat them more adequately. Unfortunately, Denial of the Soul, by psychologist and New Age theologian M. Scott Peck, is not it. Written with his trademark modesty -- "By 1985 I had become quite sophisti- cated on the subject of spirituality" -- the book is a muddle from start to finish. Even its terminology is a mess, for the author inexplicably reserves the label "euthanasia" for suicide. Then again, Peck has made rather a specialty of sonorous obfuscation. He is one of those people who think a per- son's "stage of religious development" can be discussed apart from his actual religion. Unfortunately, such an approach makes sense only on the assumption that at bottom all religions are getting at the same thing -- that they differ in rites and forms, but are the same in what they teach. Chesterton's comment about this perennial fallacy is best and plainest: "It is false; it is the opposite of the fact. The religions of the earth do not differ greatly in rites and forms; they do greatly differ in what they teach."

At last we come to But What if She Wants to Die? by George Delury. Myrna Lebov, the author's wife, suffered for years from multiple sclerosis. After pressuring her for many months to take her life, one day Delury gave her a lethal dose of drugs, waited a few hours, and went to sleep. When he awoke she was still alive, and so he suffocated her with a plastic bag. Though there seems to be no good evidence that she had consented, the authorities decided to regard the affair as an assisted suicide, and upon conviction the author spent six months in prison. This book is his effort at self-extenuation.

A law is written on the heart. We can't not know that killing is wrong; we can only hold the knowledge down. The chief value of this dreary book is the light it sheds on how the holding down is done --how the struggling conscience is suppressed. We know all about excuses, of course. For Delury, however, mere excuses are not enough; he freely admits to being haunted for months by a guilt so strong that it was "almost physical." His solution? To acknowledge the agony but deny its nature. As he finally explains to himself, his anguish is not the "moral" guilt of a human being who knows he has done wrong, but the "dissonance" of a primate over the violation of an instinctual block. And the proof? Precisely that the feeling is so powerful, so immediate, so close to home. That shows, you see, that it isn't rational.

Of course. We should have seen it ourselves.