Consent To Die: When Should It Count?

Confronting death

Thursday at Pacific Lutheran University, Dax Cowart and Robert Burt will discuss Cowart's battle to refuse burn treatment in a classic medical ethics case. "Confronting Death: Who Chooses? Who Controls?" will be presented at 7:30 pm in Chris Knutzen Hall (University Center).

WHEN is the consent of a person confronting death not really consent?

Some cases are clear: You refuse life support under the mistaken impression that you have no significant chance of recovery, and your physician makes no reasonable attempt to correct your false belief. This hardly counts as consenting to your death.

Other cases are not clear: You observe the emotional and financial burden your illness places on your closest relatives, and you share society's doubt about the value of your increasingly dependent, unpredictable, "embarrassing" state of physical and mental health. Have you come to your own desire not to live if you're a burden, to your own sense of embarrassment, or have you picked these up from others under subtle but powerful pressure?

Jack Kevorkian's latest patient's alleged consent is ambiguous. One day, Nancy DeSoto, 55, apparently came to talk with Kevorkian and tell him she had multiple sclerosis; the next day she was dead. Yes, by her own push of a button controlling the lethal drug, but under what influences or possible misimpressions?

Columnist Mona Charen recently interpreted such cases to indicate there would be a horrendous danger in legalizing physician-assisted suicide. Tired of the elderly and the "burden" they constitute, the rest of us may talk them into suicide. That may characterize the danger too strongly, but in the cases Charen has in mind, it is at least correct to say that we have not given the dying our clear support for living. When we do not offer that support, how compelling is a demand to die?

Through a part of the current physician-assisted suicide debate, this worry is hardly new. Decades ago, in what became a classic case in medical ethics, burn victim Dax Cowart sparked precisely the same questions about consent when he demanded to be allowed to die by refusing treatment. Age 25 at the time, blinded for life and with severely deformed hands, Cowart pleaded not to continue the months of excruciatingly painful whole-body tankings necessary to prevent lethal infection. Deemed eminently competent by all examining psychiatrists, he persisted articulately for years in his demands to stop treatment. All were rejected - he was forced to live.

Cowart's physicians were right about his eventual partial recovery. Blind and physically impaired, he later studied law and is now a practicing attorney. He had, though, recognized that potential. He just insisted that no recovery could compensate for the pain he had to suffer through - hardly an irrational or implausible judgment, and one he sticks by today.

Any defense of the physicians' behavior would have to question the authenticity of Cowart's demands. In fact, one of the few critics who later defended the doctors, Robert Burt of Yale Law School, claimed that Cowart's relatively low estimate of the value of his future life was subtly reinforced by professional caregivers and family around him. He felt they had subtly conveyed how hard it was for them to care for him - an impression certain to make him feel burdensome.

The excruciating pain of Cowart's treatments, of course, still may have weighed heavily in favor of respecting his choice. But will we ever really know what his desire - even with that pain - would have been if his doubts about the value of future life to himself and others had not been reinforced by those around him?

How much should our view on legal rights to physician-assisted suicide be influenced by similar dilemmas about the authenticity of consent? Does being near death anyhow - "terminal illness" - dilute the danger of mistaking superficial consent for the real thing? Is so much less lost - months, not lifetimes - that we need not let that danger dominate our thinking? Could we guard against pollution of consent, for example, by barring anyone from raising the option of physician-assisted suicide to a patient, though not from actually assisting if the patient asks?

Shouldn't we be asking such questions independently of the debate about physician-assisted suicide? For chosen deaths of all sorts, we must be diligent in creating the conditions for genuine consent.

Paul Menzel is a professor of philosophy at Pacific Lutheran University in Tacoma. His specialty is health-care ethics, and he is also currently the university's provost.