Maintaining distinctions: assisted suicide erases them.

For those of you still wrestling with moral qualms over the notion of physician-assisted suicide, there are those who would calm your concern. Bishop John Shelby Spong of the Episcopal Diocese of Newark has strongly endorsed the report of a diocesan task force which concludes that assisted suicide is now a morally and theologically justifiable choice. A federal appeals court has proclaimed that the Constitution grants a right to assisted suicide. Jack Kevorkian was acquitted of criminal wrongdoing in the deaths of two people who died from breathing carbon monoxide that he supplied.

This kind of support for the practice--from a significant religious body, a high-level court, and a criminal court--means that the lines in this debate are being drawn all too clearly. Assisted suicide is becoming an either-or proposition. But if there is any issue that is best allowed a gray area, this is it.

It is accepted medical practice, considered morally acceptable in major religious traditions, including Catholicism, to provide a dying person in great pain with relief even if the means chosen may hasten death. No physician has been convicted of murder for prescribing or administering such treatment. Acceptance of such relief is labeled suicide only by those at one extreme of the debate, who also consider it suicidal to refuse certain potentially life-prolonging technologies.

But societal near-consensus around relief for dying people has rested on the principle of double effect, meaning that while treatment may shorten the dying process, that is acceptable because the intention is only to relieve pain. The movement to legalize assisted suicide shreds this quiet consensus, thereby jeopardizing the integrity of the medical profession, the dying process, and the social fabric.

Actually, there are two movements involved here. One of them, the "right-to-die" movement, has spurred legislation throughout the country affirming people's right to refuse medical treatment at the end of life. The "right-to-die" movement challenges the technological ethos of the medical profession--the dogma that when something can be done it should be done; instead it insists that medical care must give a central place to patients' wishes, must acknowledge that caring for a patient does not always call for keeping a patient alive as long as possible and by any means necessary. There is still a long way to go in promoting an ethic of medical care that accepts the inevitabilty of death and provides supportive environments in which to die with dignity, in the company and care of loved ones not afraid to talk and grieve about it. But the growing acknowledgment of the benefits of hospice care by medical professionals attests to progress.

The assisted-suicide movement is trying to ride the coattails of this crusade, thereby spreading confusion. It would give patients ultimate authority to usurp the dying process altogether by calling upon doctors deliberately to end patients' lives. Instead of moving the medical profession toward a caring ethic for dying patients, it would thrust physicians into the role of death-providers, in effect giving them one more option on the menu of technical fixes for the messy reality of death.

The recent statement by the Episcopal Diocese of Newark justified its acceptance of assisted suicide in part by affirming that "death is part of the fabric of life." But facing one's imminent death, rather than an occasion to exercise absolute autonomy, puts one squarely in touch with one's absolute finitude. One can legitimately refuse to be controlled by medical technology, but the very message of death is that we are limited beings. Exalting human autonomy as a rationale for triumphing over death by choosing suicide reflects the grossly exaggerated status of "autonomy," "choice," and "self" in our culture.

It is literally overkill for the U.S. Court of Appeals for the Ninth Circuit to proclaim the existence of a constitutional right to be aided by one's physician in committing suicide" [see "Court-assisted suicide," Commonweal, March 22]. The court says it is ruling on the narrow issue of whether a terminally ill patient can solicit a doctor's help in hastening a death that is already in process, and asserts: "We believe that most, if not all, doctors would not assist a terminally ill patient to hasten his death as long as there were any reasonable chance of alleviating the patient's suffering or enabling him to live under tolerable conditions." But the court is declaring assisted suicide a liberty interest--an interest that cannot long be limited to the competent, consenting terminally ill person in intractable pain.

Consider, as well, the kind of exploitative pressure that can result from removing any legal barrier to helping people kill themselves. If it is permitted, is it also expected? Isn't this permission aimed at those who are feeling burdensome and vulnerable, whose disease frightens and alienates others? What about outright coercion of the elderly, disabled, and others for whom some (including, sadly, relatives) might be all too ready to assist in suicide? Proponents dismiss these concerns, arguing that strict oversight can curb abuses. But given the fact of human frailty, legalizing and legitimating assisted suicide will sow suspicion and distrust between the dying and their caregivers, and will provide incentives for hardening our hearts.

The effort to deal with the dying process better than we have been is a good and noble cause. But the push toward sanctioning assisted suicide will only further polarize the public without moving us to consensus on how to care for the dying so that they can die well. The best hope, perhaps a slim one, is that, out of all this, more people may be able to make the crucial distinction not grasped by the authors of the circuit court decision or the Episcopal task force: To provide effective pain relief that may hasten death is not to assist a suicide. If it sounds like a gray area, well it is. But that's okay.