Commentary on Tanida, Asai, Altun & Ersoy

- Frank J. Leavitt
Director, Center for Asian and International Bioethics,
Faculty of Health Sciences,
Ben Gurion University of the Negev, Beer Sheva, Israel
Fax: Int+972-7-6239396

Eubios Journal of Asian and International Bioethics 8 (1998), 145-6.

I used to complain every time Darryl sent me papers on euthanasia and the end of life to comment on. Shouldn't we bioethicists be thinking more about happy matters like how to live healthily rather than all this morbid discussion of thanatoethics, the ethics of death? But readers keep sending us papers on the end of life, and I have to be fair and admit that there is plenty of justification to this. Not only are physicians and nurses understandably troubled by something which many of them have to face every day, it has already become so obvious that it is trite to say that medical technology has learned to sustain life beyond what was heretofore imaginable. So our very ethics of life and death, which was developed in all religions and cultures in contexts where people died in quite different circumstances from today, has to be rethought. And there is perhaps another reason. Perhaps the world-wide resurgence of mysticism is a symptom of the fact that the global, technological society has failed so obviously to give people any deep meaning in life that we naturally seek something deeper, something beyond this life. Maybe that is why people are so fascinated with the point of passage from life to death, which nowadays takes place perhaps too often in the hospital wards.

But on the other hand I was fascinated by Altun & Ersoy's remark that in an Istanbul research: "The life satisfaction levels were found higher with those living with their spouses, those satisfied with their homes, those having regular health control, and Jews". I'd like to understand more about how Judaism helps people find satisfaction in life. Judaism is known, and has been criticized for being a "this-worldly" religion. It doesn't talk too much about other worlds or other lives (except for in esoteric Jewish mysticism, kaballa, which is not universally accepted among religious Jews and is often frowned upon). Perhaps Judaism has found some secret for being satisfied with this life without worrying too much about what is going to be when we get to the next one (if we ever do). Or maybe it is not Judaism as a doctrine at all but rather genetics. We hear plenty about Jewish genetic mutations, the various BRC's as well as Tay-Sachs and Gaucher and others. But maybe there is a Jewish gene for finding meaning in life? (I am only partially joking.) And this would explain the generally firm stand of Israelis against active euthanasia.

But now I have to correct myself. For I have conducted a number of surveys among my students over the past couple of years. The populations of my classrooms range from first-year medical and nursing students to experienced physicians and nurses. I explain the differences between active and passive euthanasia, assisted suicide. And I ask: Should Israel legalize active euthanasia? YES or NO? My data are not yet ready for a scientific article, but I can already say that my classrooms are usually close to 50-50, with sometimes high percentages in favour of legalization. This is surprising in a country which used to be thought of as sanctifying life and taking a firm stand against active euthanasia

Dr. Tanida's paper suggests a similar trend in Japan. Indeed the world-wide trend in favour of legalizing euthanasia may be so strong that I am tempted to say about active euthanasia what I have been saying about cloning and germline gene therapy, viz. that the important question for bioethicists is not whether we are for it or against it. The important question is what is life going to be like in a world where it becomes commonplace?

But we need more studies before we decide whether this is a global trend or not. I'll probably use Asai's paper as required reading for a unit on futility in medical ethics courses. It is both a comprehensive study of the subject and it prescribes for physicians that medicine which they often need the most: humility. As he says: "I strongly object to physicians' imposing their value judgments on patients and their family in any situation."

I showed Asai's paper to Prof. Shimon Glick whom many people regard as the dean of medical ethics in Israel. Glick showed similar humility and wrote to me: "I have no objection to the doctor giving his opinion -- it is probably no less valuable than other opinions: as long as it is an opinion and not a diktat."

But I am afraid I have to disagree to some extent with Asai and Glick. They are both internists. But I am sometimes fond of saying that internist ethics is not a fair representative of the wide range of bioethical approaches needed in a modern multi-specialty hospital. Internists' patients are usually mature people and their families can be expected to be able to represent them well, having come to know them over many years. But this is not the case in pediatrics, especially in neonatology. In neonatology the parents are not the patient, nor do they own the patient like a piece of property. The patient is a full human being in his or her own right. He or she simply lacks the ability to carry on a conversation. But the little baby can express himself or herself in other ways, sometimes by exhibiting a "will to live" which perhaps an experienced neonatal nurse or physician can recognize better than can the parents. So I try to persuade my students that in a case of a newborn baby with serious anomalies, where there is a question of whether or not to continue care, if the staff think that continued care is futile but the parents plead that care should be continued, the parents should be heeded and care should be continued. But, as indeed can happen, if the staff believe that a baby can be saved with a reasonable prospect of quality of life, and the parents want to stop treatment, then the staff have to override the parents' authority -- by legal coercion if necessary-- and save the baby's life. For the baby, not the parents, is your patient. Of course this advice applies only in countries with advanced neonate ICU facilities, and with a normal health system where care does not depend on ability to pay.

Having commented on a paper from Turkey, my thoughts return to a beautiful week which I just spent in Ankara, with some other members of your Eubios team -- Darryl, Jay, Song Sang-Yong, and Shinryo Shinagawa -- hosted by Prof Yaman Ors and his gracious colleagues. Like Ibn-Sina, for whom Ankara University Medical School's teaching hospital is named, Ors is both a physician and a philosopher, and I deeply enjoyed the sharp philosophical debate in the seminar which Ors organized. Turkey is like Israel with olive-oil, wine and guns plentiful everywhere. But like Israelis the Turks seem very interested in deepening bioethical cooperation with other Asian countries. I believe the Ankara seminar was just a beginning, and that we shall see a good Turkish representation in Tokyo and Tsukuba.

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