With all due respects, Dr. Summerville, and much respect is due, you are wrong about euthanasia. There is no practical difference between euthanasia, (intending to kill an old person) and letting them die. Your argument is flawed because it doesn't work.

Any thesis is only true if it's logical extension is also reasonable. Your distinction based on the intent of the physician cannot work under most circumstances, especially the ones I encounter clinically almost everyday at work. What are my intentions really? To go home to my family as quickly as I can and this patient is impeding that. To do a good job not made easy by the conditions under which I practice and so to keep my cool and not let my patients know how frustrated I am, etc., etc.. The problem is I am a human and my motives and intentions are seldom single.

The Death Dealing Boulder (DDB) is an apt analogy. Joe anybody is walking along a pleasant path and minding his own business. Above him, poised to roll down the slope and kill him is a large boulder we will call death. If someone intends to kill Joe, deliberately waits until he is exactly in the right spot and gives boulder Death a good shove, he commits murder. If someone carelessly bumps the boulder to cause death, it is known as criminal negligence. If someone pushes the boulder to just to frighten Joe but kills him it is manslaughter. All these are fairly clearly defined but what if: a) a person knew the boulder could roll and kill Joe if he stopped holding it back but he let go anyhow because he thought Joe had lived long enough. b) Was determined to protect Joe but got tired of holding the boulder or felt there was some other activity which was more important. c) Was drunk and mistakenly leaned too hard on boulder death d) dislodged another boulder further up the hill while he was digging someone's garden because they were ill. e) Claimed some careless worker left the boulder there. f) Claimed they didn't realize it had the potential to kill etc. It becomes difficult to judge because all these people had different amount of different intentions although the outcome was the same; an innocent person was killed.

The underlying problem is that the round pegs of human thoughts and feeling do not fit the square holes of law and philosophy. Trying to make them fit distorts the everyday reality of physicians. As one who is continually encountering patients who ostensibly want to kill or slowly destroy themselves, allow me to comment.

I request every patient I evaluate for consultation, "Please tell me, are you suicidal?" In response I hear, "I was". "Sometimes" "If my partner keeps up his/her drinking, I will be" "I am but I won't because of what it will do to my children". "I am not but the idea keeps creeping into my mind", "I couldn't kill myself but I wish someone would run me over" "I'm not suicidal but I often feel that life is not worth living." "I can't tolerate the pain any more but if I could get even 15% better I would be happy to be alive." "I wish I could but because I believe in reincarnation, I'm terrified that I would only come back to something worse." "I think I don't deserve to be alive and so I am drinking myself to death" Etc. So, Dr. Summerville how should any physician respond to this mess of ambivalence and indecision?

Because everyone is ambivalent about life and living almost all the time, any decision about suicide, assisted or not will probably change with time and circumstance. So any "living will" as an indication of someone's true intent, isn't worth the paper……..

If the patient's desire and intent so fluctuates, don't you think the same is true for the physician not matter how ethical and dedicated?

May I suggest we begin again from 1st principles.

A) Life collectively and individually is in a delicate balance that can be tilted one way or the other with remarkable ease. This is partly why humans are such social animals. We need each other to encourage us to keep hoping and struggling.

B) People are ambivalent about being alive. This is why family and physicians try to be optimistic. Eg. "We can't do anything more to prolong your life, but we can make you 20% more comfortable. Is that good enough?" And "Hang in there old dad, your favorite daughter should arrive tomorrow and you know you need to talk".

C) From conception, everyone is dying; some much faster than others; some from known causes and most from a host of factors over which they have little control. Entropy has got us all. We are all affected by the energy infusing or diffusing powers of the universe.

D) Suicide is murder. All the dynamics of murder apply. When my suicidal patient's are asked, "If you weren't going to murder yourself, who would it be?" They tell me in 5 seconds flat. It is a moot point, how much suicide is self inflicted and how much it is an attempt to resolve conflicts put into play by others.

E) We have an instinctual awareness that the probability of surviving individually is greater if we are in a group. A wolf is much more likely to kill game if he is aided by the pack and so there is an instinctual restraint to intra-species aggression. This is true of humans but that "species specific instinctual restraint to aggression", (SSIRA) is weakened whenever anyone contributes to another's death. This is the biological basis for the guilt felt when a family member consents to pulling the plug. Grief in necessary but when complicated by guilt, it becomes difficult to resolve. Often a problematic depression results. In a group we can encourage specialized functions which benefit the whole. This also why the government has a vested interest in protecting and prolonging life, especially the lives of the most vulnerable.

F) All those in the "tragic triangle" of Perpetrator, Victim and Observer contribute to any desire to end life. Each must understand how he/she contributes to the problem before they attempt any resolution, otherwise scape-goating will result.

G) There is a perpetually interlocking cycle between, Doer and Done To. What we do to others is happening to us simultaneously. When we contribute to killing, especially someone of our family or tribe, a part of our humanity dies.

H) A family member's dependency is a gift, if only we could recognize and appreciate it. The struggle to gently wash an aging mother's emaciated, feaces covered body teaches us to be loving when the going gets rough like no other experience. This is one of the most civilizing influences among humankind. Without it we would much sooner all become the narcissistic, hedonistic, materialistic monstrosity that the media pushes us to be.

I) There is a definable, discernible beginning and ending to life. A homo sapiens is defined as human as long as they have a God given human spirit. When the spirit enters the most basic human life form, they become a person. When the spirit departs or is surrendered, the body is no longer human and plugs can be pulled with a completely clear conscience.

J) Even when the mind is clouded and the body wracked with pain, the spirit of man can keep growing.

If you put this all together, it can result in a practical guide for those who society has granted the awesome responsibility to nurture, protect and treat human lives.