Question: Who Will Play God?

Colorado's Governor causes a furor on the issue of dying

The words seemed calculated to provoke an uproar. Elderly people who are terminally ill "have a duty to die," declared Colorado Governor Richard Lamm, 48, at a meeting of the Colorado Health Lawyers Association last week in Denver. "Like leaves which fall off a tree forming the humus in which other plants can grow, we've got a duty to die and get out of the way with all of our machines and artificial hearts, so that our kids can build a reasonable life."

An uproar is just what the Governor got. In Washington the American Life Lobby, an antiabortion, anti-euthanasia group, quickly called for Lamm's resignation. Florida's Representative Claude Pepper, 83, Congress's leading advocate for the aged, accused the Governor of "downgrading the elderly." Lamm was confronted by angry older citizens in Denver. "I used to think the world of you, but I hate you for what you said," declared Lilian Bono, 76.

Lost in the ruckus was Lamm's original intent: to call attention to the alarming fact that "medical science is replacing God in deciding when we die," and to encourage discussion of the implications. "We can prolong our lives a few months or a year, but at what price?" Lamm asks. The Governor insists that he did not intend to endorse mercy killing: "In euthanasia, somebody else makes the decision. [ am merely saying people have the right :o die without medical science intervenng." In addition, he notes, the "falling leaves" metaphor was an attempt to paraphrase an article in the American Scholar by University of Chicago Philosopher Leon Kass: "It was unfortunate that it suddenly became my quote."

However infelicitous his phrasing, Lamm was praised in some quarters for broaching one of the most sensitive issues of the day. Medical technology has become increasingly successful at keeping frail and withered leaves on the tree long after nature would have let them fall. Today, 80% of Americans die in hospitals or nursing homes, generally in the course of receiving some sort of medical treatment. Doctors no longer speak of death by "natural causes." Because physicians have the capacity to extend life, they often feel obliged to use it, observes Dr. Bernard Towers, who helps direct a U.C.L.A. program for the study of medicine, law and human values. "Most people fear dying in the midst of electronic gadgetry," he says, "but it looks like there may come a time when we will not be allowed to die without an I.V. tube running."

The legal problems involved in allowing elderly patients to die have created a dilemma for physicians and hospitals, even when the wishes of patients or their families are clear. For instance, doctors at Good Samaritan Medical Center in Phoenix last week insisted that a court order be obtained before they would comply with an 83-year-old woman's wish to be disconnected from the respirator that was keeping her alive and in pain. Nearly three years earlier, the woman had drawn up a "living will," a document that requested hospitals not to prolong her life by extraordinary measures. Because Arizona does not recognize such a will (15 states and the District of Columbia do), doctors did not want to take legal responsibility for her death.

There is good reason for caution. In 1982 two physicians in California were charged with murder for complying with a family's request to remove feeding tubes from a hopelessly brain-damaged patient. The charge was dismissed upon appeal last fall. But, together with similar cases around the country, it has "sent a chill into the medical community," according to Washington Gerontologist Joanne Lynn, principal author of a 1983 Presidential Commission report on medical ethics.

Fear of legal reprisal has apparently led some hospitals to conceal decisions on life support so that no one can be held responsible for deciding to pull the plug. A New York grand-jury report last month charged administrators at a Queens hospital, widely recognized as La Guardia, with "shocking procedural abuses" in the care of elderly patients. According to New York State Prosecutor Edward Kuriansky, the hospital would put purple decals on the charts of patients who were not to be resuscitated should they start to fail. After death, the charts were destroyed so that there was no record of the fatal decision. La Guardia officials deny the charge, but there is no doubt that a number of American hospitals lack clear procedures for observing and recording the wishes of dying patients. Says Dr. S. David Pomrinse, recently retired president of the Greater New York Hospital Association: "In hospitals that have no rules, in the middle of the night you have a poor 21-year-old nurse trying to decide whether or not to call in the resuscitation team."

Because of the attention such cases have received in the past few years, many hospitals and states have begun to set guidelines so that life-and-death decisions are not made rashly in the heat of the night. By playing the gadfly, Governor Lamm may have promoted further discussion, and clarification, of a troubling ethical issue.