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Faced with a painful and tenuous future and an all-too-tangible present crisis, how does the doctor decide what to do? Does he make the decision alone? Dr. Malcolm Todd, president elect of the American Medical Association, wants doctors to have help at least in formulating a general policy. He proposes a commission of laymen, clergy, lawyers and physicians. "Society has changed," says Todd. "It's up to society to decide." The desire to share the responsibility is reasonable, but it is unlikely that any commission could write guidelines to cover adequately all situations. In individual cases, of course, many doctors consult the patient's relatives. But the family is likely to be heavily influenced by the physician's prognosis. More often than not, it must be a lonely decision made by one or two doctors.
Some conscientious physicians may not even be certain when they have resorted to euthanasia. Says Dr. Richard Kessler, associate dean of Northwestern University Medical School: "There's no single rule you can apply. For me it is always an intensely personal, highly emotional, largely unconscious, quasi-religious battle. I have never said to myself in cold analytic fashion, 'Here are the factors, this is the way they add up, so now I'm going to pull the plug.' Yet I and most doctors I know have acted in ways which would possibly shorten certain illnesses−without ever verbalizing it to ourselves or anyone else."
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Kessler's ambivalence is shared by Father Richard McCormick of Loyola University's School of Theology. There are cases, McCormick observes, where the line is hard to draw. One example: a Baltimore couple who let their mongoloid baby die of starvation by refusing permission for an operation to open his digestive tract. The operation might have been considered an ordinary means of treatment, if the child had not been a mongoloid. "In cases like that," says McCormick, "you're passing judgment on what quality of life that person will have. And once you pass judgment that certain kinds of life are not worth living, the possible sequence is horrifying. In Nazi Germany they went from mental defectives to political enemies to whole races of people. This kind of judgment leads to the kind of mentality that makes such things possible."
For cases where the line is unclear between ordinary and extraordinary means, Roman Catholic theology offers an escape clause: the principle of double effect. If the physician's intention is to relieve pain, he may administer increasing doses of morphine, knowing full well that he will eventually reach a lethal dosage.
When Sigmund Freud was 83, he had suffered from cancer of the jaw for 16 years and undergone 33 operations. "Now it is nothing but torture," he concluded, "and makes no sense any more." He had a pact with Max Schur, his physician. "When he was again in agony," Schur reported, "I gave him two centigrams of morphine. I repeated this dose after about twelve hours. He lapsed into a coma and did not wake up again." Freud died with dignity at his chosen time.