Death with dignity.

Albert Camus wrote in The Myth of Sisyphus: "There is only one truly important philosophic problem, and that is suicide." The significance of that sentiment - forcing each of us to a heightened awareness of the elements of human dignity, the sanctity of life, and the very meaning of existence - has perhaps never been more explicit than it is today. For the first time in history, Americans have been asked to decide the crucial question: is it morally permissible (or even admirable) for a human being to end his or her own life or to assist another in shedding this "mortal coil"?

The development of medical technology, pregnant with blessings as well as threats to keep us alive as comatose lumps of flesh, has launched this controversy, commonly labeled as issues of the "right to life" Although a quietly perennial issue, the debate became a public matter in 1974 with the landmark case of Karen Ann Quinlan, a patient whose parents requested the removal of life-sustaining machines. By 1991, 28 states had ruled that patients have the right to refuse life,sustaining treatment. In some locales, the courts indicated merely that competent, mentally alert people could make this judgment; in other states, doctors and relatives are allowed to initiate death when patients cannot request it themselves.

Nine states specifically allow the withdrawal of artificial feeding from patients in a vegetative state, allowing them to starve to death. By 1991, a federal law required that every patient admitted to any hospital for any reason must be asked if they want to plan for their death by filling out a "living will."

Medical "ethicists" have tried to draw a very fine line between withdrawing or withholding treatment and actively assisting others to commit suicide. In practice, this distinction has increasingly lost its meaning. What in fact is the difference between a doctor who starves his patient to death and one who prescribes a dose of seconal with the warning that imbibing a gram will result in death? Most reasonable people today recognize that pulling the plug on a machine or injecting a lethal dose of morphine are both "active" measures that have the same result. What remains in doubt today is who - if anyone - has the right to decide on ending life and what - if any - conditions should limit that decision.

These ambiguities have resulted in a quagmire of contradictory legal opinions. Some states still carry laws on their books punishing the act of suicide as a "crime"; others are silent on the issue; and some punish those who assist in a suicide as "murderers" In Michigan, for example, the State Supreme Court in 1920 upheld the murder conviction of a man who placed poison within reach of his wife, who was dying from multiple sclerosis (People v. Campbell). Yet, 63 years later, in a case that never went to trial, a Michigan appellate court ignored this precedent and dismissed a murder charge against a man who gave a gun to a person who was talking of committing suicide and subsequently killed himself.

Dr. Jack Kevorkian exacerbated Michigan's confusion in 1990 when he connected Janet Adkins, a woman suffering from Alzheimer's disease, to a suicide device and watched as she pushed the button. He took the action out of concern for the patient and a desire to force the legal and medical establishments to consider euthanasia as an ethical action. Adkins and her family, anticipating years of degeneration from the disease, requested the procedure. Dr. Kevorkian reported himself to the police immediately after she died. On July 21, 1992, murder charges against Kevorkian were finally dismissed in a Pontiac, Michigan, court; in the meantime, Kevorkian had assisted in several additional suicides.

Voters in the state of Washington decided to put the matter on a democratic ballot. In 1991, citizens of Washington considered a legislative proposition unlike any other ever debated by Americans. Initiative 119 asked: "Shall adult patients who are in a medically terminal condition be permitted to request and receive from a physician aid-in-dying?" The proposition provided that adults could execute a medical directive requesting aid-in-dying only after two physicians certified that they were mentally competent, terminally ill, and had less than six months to live. Two independent witnesses had to certify the patient's decision.

Although public opinion polls indicated that 61 percent of Washingtonians favored the initiative, a majority of voters - 54 percent - opposed the measure when it actually came before them. Some, motivated by religious arguments, feared it would undermine the sanctity of life. Others favored euthanasia but questioned whether this proposal had too many loopholes.

Among the issues that disturbed the opponents of the proposition were these: can physicians really know patients' wishes? Can they accurately diagnose and predict how much time is left? Might not patients mistakenly labeled as terminal choose to die needlessly? Would the elderly choose suicide - or even be pushed into death - simply to spare their families' energies, emotions, and pocketbooks?

The Washington vote hardly ended Americans' anguish over the process of dying. A Boston Globe poll showed that 64 percent of the public favors letting doctors give lethal injections to the terminally ill; Derek Humphry's Final Exit, a handbook on how to commit suicide, achieved bestseller status. And other states have prepared new and improved versions of initiative 119; the first such measure was voted down by Californians in the 1992 elections.

The fact is that the euthanasia issue, especially when linked to the controversy over abortion, has emerged as one of the great debates in turn-of-the-century America; the public must choose between the various "right to life" and "pro-choice" arguments as they apply to death as well as to birth.

Because some Western nations (notably the Netherlands) have long tolerated euthanasia, people on both sides of the issue look to them for enlightenment. The Dutch experience is particularly relevant since the practice of euthanasia is more open and extensive there than any place else in the world. Although Dutch law formally forbids assisted suicide, authorities and doctors have long chosen to ignore the prohibition. According to a government report, 25,300 cases of euthanasia (active or passive) occur each year in the Netherlands; this represents 19.4 percent of all deaths. Of that total, there were 13,691 cases in which an overdose of morphine or the withdrawal of life-sustaining treatment brought about death; and in approximately 39 percent of those deaths, the physicians and families reached the decision to practice euthanasia after the patient's deteriorating state had rendered him or her unconscious and there was no prospect of improvement. In the other cases, the patients themselves reached their decision after rational and prolonged consideration. One study, Regulating Death by Carlos S. Gomez, indicates that there are no rigid rules governing the Dutch system. Contrary to American opponents of euthanasia, the Dutch approach has met with wide public approval and has not led to a devaluation of human life per se.

Should America follow the Dutch example? In the great debate over this issue - a controversy which is bound to inflame the 1990s - two issues require careful separation. First, does the individual human being have the right to end his or her existence? Second, should society remain aloof from this decision, or should policy establish the ground rules governing the individual, his or her family, and the medical profession?

On the level of the individual, a classic lineage of thinkers from Socrates to Shakespeare to Arthur Koestler have affirmed that humans should have the privilege of selecting their own death - a voluntary, rational, conscious ending chosen not by accident but by lucid free choice. The great Stoic tradition particularly emphasizes that persons have the prerogative of rational suicide-a humane and dignified termination of life chosen courageously and with deliberate selfcontrol.

Following Epictetus, the Stoics sought to rid themselves of "the fetters of the wretched body" and to assert their will "against kings or thieves who, by controlling men7s bodies, try to dictate their fate" The Stoics and the Epicureans treasured life; they were not in any sense nay,sayers who wished to escape into a realm of nothingness. As Epicurus wrote: "He is a little man in afl respects who has many good reasons for quitting life' " And as Epictetus advised his disciples, "Wait upon God. When He gives the signal and releases you from this service, then you shall depart to Him." Nonetheless, the Stoics and the Epicureans believed that the final choice was properly their own-not that of fate or attributable to a super, natural being. Rational persons should make the choice with dignity and fortitude. Remember," Epictetus wrote, "the door is open. . . . Depart instead of staying to moan."

Similarly, in recent times, Friederich Nietzsche deplored the "unfree, coward's death" that most people, trapped in contemptible conditions at the wrong time and deceived by a slave's morality, must endure. Instead, he celebrated "free death." "From love of life," Nietzsche argued, "one should deserve a different death: free, conscious, without accident, without ambush."

Today, those who contemplate asserting control over suffering and dying contend that the possibility of rational suicide preserves humankind's fragile dignity in the face of brutal circumstances, ironically prolonged by the most modern of medical technology designed to sustain or preserve life. Indeed, they point out that one of humankind's unique and defining attributes is the ability to foresee, to contemplate, and potentially to control our own death; it is this noble quality which sets us apart from all other animals. Rather than degenerating helplessly, the ill person can choose the timing, the setting, and the circumstances of death. He or she may prepare friends and family for the end, make reasonable provisions for the welfare of others, complete worldly duties, and take leave of loved ones in a dignified manner.

By affirming this uniquely human capacity to mediate and mold death, we enhance our threatened autonomy in the face of a remorseless fate. To take the opposite path - as most people do in a mindless submission to the dictates of fate - betrays our highest quality: our capacity for freedom. A death with dignity is a final proof that we are not merely pawns to be swept from the board by an unknown hand. As a courageous assertion of independence and self-control, suicide can serve as an affirmation of our ultimate liberty, our last infusion of meaning into a formless reality.

If rational suicide can serve the cause of human dignity and autonomy, it should also be recognized that such a death may often represent a compassionate act of shielding the person's family, children, and comrades from suffering, needless toll, psychological torture, comrades from suffering, needless toll, psychological torture, and even economic catastrophe.

By these considerations - dignity, autonomy, and compassion - a rational suicide may be a noble alternative to enduring the excruciating torment of a final illness. After contemplation, mature persons may choose a death with dignity that affirms their ultimate autonomy and consequently softens the blows that fall upon those they leave behind. Thus, for defenders of rational suicide, as for the ancient Stoics, the image of perfect nobility is the rational person lovingly doing his or her duty to others and meeting death with pride and freedom and courage.

Opponents of the whole concept of a "right" to death appeal to a wide range of orthodox Jewish and Christian dogmas. They draw, too, on the organizational strength of the right-to-life movement, which portrays euthanasia as one more step toward justifying the elimination of the helpless and the unfit. For them, the biblical command "Thou shalt not kill" applies to oneself as well as others, thus precluding suicide as well as any assistance in suicide. The absolute sanctity of life takes precedence over all other considerations; life must be prolonged regardless of the cost in suffering or debasement.

The sanctity of human life does not depend upon its costs, Cardinal O'Connor of New York argues, and since humans are made in the image of God, the act of suicide necessarily involves deicide. To usurp God's gift of life would be an act of the gravest hubris. The duty of a community of faith is to extend its care to the weakest, sickliest members - not to destroy them. Christians invoke the example of Jesus: "Our Lord healed the sick, raised Lazarus from the dead, gave back sanity to the deranged," Malcolm Muggeridge has pointed out, "but never did he practice or envisage killing as part of the mercy that held possession of his heart."

However, the fact is that the orthodox religious traditions have often sanctioned killing - or even suicide - in the service of some higher goal. For Jews, the mass suicide of the Maccabees in defiance of Roman oppression is now celebrated as a glorious event. For Christians, the other-worldliness of the Pauline tradition sometimes led early converts into an epidemic of suicide. Tertullian describes how entire populations of Christian villages would flock to the Roman pro-consul imploring him to grant them the privilege of martyrdom. Lucian regarded these Christians with scorn; they desired death and gave themselves up to be slain in eager anticipation of eternal salvation. Like Shi'ite martyrs today, some early Christians sought to be slaughtered by their enemies as a sure means of gaining immortality.

Contemporary Christians can dismiss these early tendencies as aberrations and argue that dogmatic justification of some forms of killing - capital punishment and "just wars," for example - are misinterpretations of Jesus' commands. Jesus certainly did not describe martyrdom or suicide as a path to salvation, but, just as surely, he never told humankind to cling to life at all possible costs. His two fundamental commandments - to love God and to love one's neighbor as one's self - do not, in themselves, logically condemn suicide. In fact, a death with dignity, if undertaken in a spirit of compassion for others, could be considered as an ultimate fulfillment of these injunctions. Jesus' poignant acceptance of a crucifixion he could have easily escaped testifies to his conscious willingness to sacrifice his own life for a higher goal.

Regardless of religion, some philosophers - such as Immanual Kant and Albert Schweitzer - have been firm opponents of suicide. Kant knew of the Stoic concern that a noble death for a wise man was "to walk out of this life with an undisturbed mind whenever he liked (as out of a smoke-filled room)." Nonetheless, Kant argued, "man cannot deprive himself of his personhood so long as one speaks of duties, thus so long as he lives." On grounds that are far from clear, Kant thought suicide obliterates morality and degrades humanity since "it eliminates the subject and morality."

Albert Schweitzer, the great proponent of "reverence for life" as a supreme ethical principle, believed that suicide "ignores the melody of the will-to-live, which compels us to face the mystery, the value, the high trust committed to us in life." Schweitzer did not condemn those who relinquish their lives but felt that "we do pity them for having ceased to be in possession of themselves." in truth, Schweitzer did not apply his principle of "reverence for life" very strictly or under all circumstances, since he did not hesitate to eat animal flesh and believed that some wars were justified.

Current opponents of death with dignity believe that society must maintain the taboo against suicide because the right to choose one's own death can quickly become mixed up with the right to "choose" someone else's. Were suicide to be legalized, these people foresee a quick descent into other forms of euthanasia, an unreasonable expansion of the powers of physicians, and an increase in state control over life. Indeed, during the debate over initiative 119, Washingtonians made clear their concern over these possibilities. Many Americans approve of death with dignity for themselves but fear taking the grave step of giving physicians or the state lethal power over others.

When we consider euthanasia as a public policy, we must directly confront these issues. In California and the other states to follow, the clash over current medical and legal arrangements for death will undoubtedly raise such stark problems as these:

* Should the "right" to die extend to those who have already lost the mental capacity to choose for themselves? Opponents of rational suicide believe that allowing such an option would open the door to eliminating everyone deemed "unfit." To avoid reviving the nightmare of Nazism, proponents of euthanasia must clearly affirm the principle of autonomy: the conscious, free, and consenting person must make the original choice of terminating life. "Living wills" and the protections afforded by initiative 119 must guarantee that the patient voluntarily and intentionally requested assistance in death before an incapacitating illness or coma occurred. Such a provision would bar the door to experiments in eugenics and would, in fact, impose stricter restrictions on the "right to die" than now exist in many states.

* Should persons afflicted with serious conditions but who are not near death be allowed to end their lives? Proponents contend that people who are still able to choose but who are physically helpless (such as paraplegics) and those who are diagnosed as being on the brink of an inexorable decline (such as Alzheimer patients) should be allowed to consider suicide as a viable option. Opponents contend that such a concession would open the door for the mentally unstable, the temporarily depressed, or the immature to end their lives prematurely.

Clearly, people who pass through a period of clinical depression often entertain the idea of suicide but reject it when they are properly treated. Similarly, a large number of American teenagers - roughly one in 12 high-school students (grades nine to 12) - say that they have tried to commit suicide at least once. (In fact, the rate of actual suicide is much lower than for the elderly and those with degenerative diseases.) Nonetheless, the fact remains that temporarily dejected people - for example, teenagers who have separated from someone they love - or even revengeful persons do commit suicide. While it will be impossible to prevent all of these deaths, an argument for the right to die with dignity does not mean that society would make it easy for the deranged, irrational person to end life capriciously.

To guard against this, public policy should provide that only mature, mentally competent adults with acceptable reasons are allowed to make the decision - and then only after a certain waiting period. Before a person's request for assistance in dying is approved by a public body, it would be wise to have psychologists or psychiatrists consult with the patient and explore all of the options open to that person. While such an approach would screen out some disturbed, impetuous, harassed, or temporarily dejected patients, it would allow people who rationally anticipate a life of misery to choose death with dignity.

Some other issues to consider:

* Should physicians be in charge of the actual death? Their oath requires them to prolong life; if they shorten it, this sends an ambiguous message to the society. Thus, in general, physicians should not be directly involved in ending life - certainly less so than they are now. In the termination of feeding or, indeed, in capital punishment, Kevorkian has suggested that doctors should not use his suicide machine; instead, consistent with the principles of autonomy and dignity, the patients themselves (or trusted relatives) must take the final action. Kevorkian envisions suicide clinics administered by paramedical workers who would be salaried so that there would be no profit motive involved.

* What if doctors make a mistake? Inevitably, doctors may miscalculate their diagnoses or a "miracle" may extend the life of a hopeless patient. Conceivably, a new treatment could result in unexpected cures (although the lag between the discovery of a beneficial therapy and its application is seldom less than a year). This is unquestionably one of the great risks of medical practice, and it suggests again that the role of the physician should be

minimized; the doctor should be an expert counselor but not the person who controls or executes the decision. The burden of the choice must be born by the patient; the exercise of an individual's autonomy should be that person's sole responsibility.

* If rational suicide were freely and broadly allowed, would the elderly, terminally ill, or even seriously ill choose it simply to spare their families' lives and pocketbooks? Possibly. Like the terminally ill in pre-modern Eskimo society, patients might well act out of consideration and compassion for their families. Such self-sacrifice should not be condemned as necessarily evil, but it must not be undertaken lightly. As in other cases, a frank, open, and loving consultation between patient and family should precede any action.

* Is there a grisly possibility that someone - even a person's own family - could push that person into suicide against his or her will? Is it possible that a murder could be hidden as suicide? This could occur - as indeed it already does. The Dutch experience, however, indicates that the legitimation of rational suicide does not increase this possibility. With the safeguards proposed even in initiative 119, it seems reasonable to suppose that the chances of murder masked as suicide would actually be decreased.

* Doesn't the hospice movement offer a better alternative than rational suicide? It certainly provides an important alternative and a humane mode of coping with death under circumstances of relatively little pain. However, whether it is better to perish slowly, benumbed by morphine cocktails, or to be allowed to choose the mode, manner, and timing of one's death is, in the opinion of this author, a matter best left to individual discretion.

The obstacles to a public policy of euthanasia are admittedly formidable, but they are not insurmountable. A failure to decide these issues because of personal or social anguish over "contemplating the unthinkable" will continue to condemn many people to humiliating debility, pointless suffering, and perhaps meaningless "final exits." In contrast, sensible provisions for rational suicide - governed by the principles of autonomy, dignity, and compassion - offer humankind the possibility of ending a life that was so acceptable that it required no further deeds or days.

William McCord, a sociologist at the City University of New York, was the author of numerous books, including Voyages to Utopia and The Dawn of the Pacific Century. Sadly, he was severely injured in an auto accident and died on August 3, 1992.