Sometimes evil is simply the good that oversteps boundaries and has gone too far. It is this sort of evil that is hardest to perceive and is the most pernicious in its power to harm. In Western mythology the image of Lucifer, the “Being of light” who becomes Satan, “the fallen angel,” applies here. In that story Lucifer, once the most favored, is so convinced of his goodness he thinks he is the Supreme Being himself. He oversteps his created limits.

The debate regarding physician-assisted suicide continues in our society. Despite the recent opinions of the United States Supreme Court, this issue is unlikely to go away anytime soon. For a variety of reasons, this debate is now conducted in the legalistic terms of individual rights and liberties. As a result, perhaps we philosophers have been left behind. This is now a matter for the legal arena and philosophy is likely to be irrelevant. I would like to suggest otherwise for two reasons.

This paper examines the following line of argument against allowing euthanasia in Canada: “[Sue] Rodriguez... argued that she be given the able bodied person's freedom of choice. But true choice requires equal support for a decision to live. ... Were freedom of choice in fact a primary concern, liberalized euthanasia legislation would require full levels of mandated social support. ...”

In “Euthanasia and Health Reform in Canada,” Michael Stingl argues that the legalization of euthanasia can be made reasonable social policy only in the context of healthcare reform to deliver primary- and community-based care. Stingl accepts that euthanasia “is in effect a treatment for unbearable suffering caused by a patient's health condition” and that includes not only pain, but “a personal response to a medical situation that the individual finds unbearable given his or her beliefs and values about the meaningfulness of human life.” He is not worried “about the reasonableness or validity of their request, but about the validity of the situation which leads to their request.” The failure of the healthcare system to adequately respond to the needs of people who are suffering with chronic or terminal conditions may lead competent people to elect euthanasia. Stingl argues that it is the institutionalization of care for dying people that reduces their ability to find meaning in prolonged life, and thereby makes it more attractive to consider ending one's life sooner. Options such as palliative care at home that significantly improve quality of life and make euthanasia less attractive are currently only available to those who can privately subsidize healthcare services. If an emphasis is placed on community-based initiatives and well-supported self-help, then there would be less inequality of healthcare and the voluntariness of choices, including euthanasia, would be more equal for all people under the healthcare system.

According to the present argument, worries that some individuals might make premature or unnecessary choices for themselves regarding euthanasia should further motivate and help shape our discussions about healthcare system reform. The reason for this is that in some cases individuals with chronic or terminal illnesses may have their lives made more unbearable than they otherwise might have been by the failure of the healthcare system to respond appropriately to their needs. Until these apparent inadequacies are remedied, there will remain doubt about whether such individuals have made a free and reasonable choice in favor of euthanasia, or whether such a choice was in effect forced upon them by the effects of unjust gaps in the provision of health services. Thus, it is inferred that there is a deep connection between discussions regarding liberalizing euthanasia in Canada and the ongoing move to reform our healthcare system. Further, it is claimed that explicit recognition of these links in the context of public debate will better inform our decisions in regard to both.

The philosophical debate over the moral difference between killing and letting die has obvious relevance for the contemporary public debate over voluntary euthanasia. Winston Nesbitt claims to have shown that killing someone is, other things being equal, always worse than allowing someone to die. But this conclusion is illegitimate. While Nesbitt is correct when he suggests that killing is sometimes worse than letting die, this is not always the case. In this article, I argue that there are occasions when it is better to kill than to let die.

A number of common and generally noncontroversial practices in the care of patients at the end of life lead to their deaths. For example, physicians honor a patient's refusal of medical intervention even when doing so leads to the patient's death. Similarly, with a patient's or surrogate's consent, physicians administer sedatives in order to relieve pain and distress at the end of life, even when it is known that doing so will cause the patient's death. In contemporary U.S. public policy, these practices are accepted as ethical and legal while physician-assisted suicide (PAS) is—for the most part—rejected in current U.S. law and public policy. Some think, however, that if one accepts practices that are known to lead to a patient's death, then one cannot reasonably reject a patient's request for a lethal dose of medication so that she may kill herself (PAS).

Not everyone finds a “salvific meaning” in suffering. Indeed, even those who do subscribe to this interpretation recognize the responsibility of each individual to show not only sensitivity and compassion but render assistance to those in distress. Pharmacologic hypnosis, morphine intoxication, and terminal sedation provide their own type of medical “salvation” to the terminally ill patient suffering unremitting pain. More and more states are enacting legislation that recognizes this need of the dying to receive relief through regulated administration of controlled substances. Wider legislative recognition of this need would go far toward allowing physicians, in the exercise of their reasonable medical judgment, to administer a range of narcotics and barbiturates to the terminally ill without fear of legal sanctions. Sadly, social attitudes and governmental concerns about the spread of drug addiction provide an undeniable policy nexus that impedes unduly a rational approach or exception for the treatment of pain experienced by the dying.

In Márquez's Of Love and Other Demons Abrenuncio the physician and the Marquis discuss the outbreak of rabies that is the centerpiece of the book, since the Marquis' daughter has been bitten by a rabid dog. Abrenuncio notes that the poor “had the courage to poison the food of their rabid kin in order to spare them of a ghastly death... People believe that we physicians do not know that such things occur... That is not true, but we lack the moral authority to endorse them. What we do instead is... commend them to St. Hubert and tie them to a pillar in order to prolong and intensify their suffering.”

In a recent article Thomas May has argued that the use of advance directives (ADs) to respect a no longer competent patient's autonomy is a failed strategy. Respect for patient autonomy is clearly one of the guiding moral principles of modern medicine, and its importance is reflected in medical emphasis on informed consent. Prima facie, at least, ADs seem likewise to respect patient autonomy by allowing patients to make decisions about treatment in advance of situations in which the patient may no longer be able to specify the form of treatment desired. So a claim that ADs do not extend patient autonomy to these situations of diminished competence represents a serious criticism of our understanding not only of advance directives, but of autonomy as well.

“Breaking Bioethics” is the newest section of Cambridge Quarterly. Twice each year these pages will feature a colloquium on a breaking issue in bioethics.

When one examines the emerging debate about genetic patenting, it becomes clear that those who oppose so-called “gene patents” misunderstand genetics or apply inappropriate moral and jurisprudential theory. In this brief essay I examine some arguments against gene patents of the “methods for detection” variety, and conclude that patents on methods for detecting the presence of a genetic correlation with disease-related (and other) phenotypes can be appropriate, and that with several precautions the U.S. Patent and Trademark Office should continue granting patent protection to investigators who generate genetic disease diagnostic innovations.

Glenn McGee argues that the time is now for debating the morality of patenting human genes. In one sense he is surely right. While thousands of patents have been issued or are pending on many gene sequences, public policy with respect to ownership of the human genome is still far from settled. So a debate about the ethics of patenting genes is, if nothing else, timely. In another sense however, Professor McGee is wrong.

Dr. McGee presents a cogent argument for the patentability of the diagnosis of gene forms that are found to be associated with disease or other phenotypic manifestations. We're convinced he's wrong. An analogy will help explain why.

The decade-long debate over ownership of living human materials has recently intensified with the ability of biomedical research to isolate, purify, and use human genes and gene products as therapeutics, factories for the production of therapeutics, and targets for the identification of therapeutic pharmaceuticals. Indeed, advances in genomic research have resulted in the identification of hundreds of thousands of DNA fragments and hundreds of genes. Many within the scientific and business communities believe genes and gene fragments have commercial value and have filed patent applications on the nucleic acid sequences. This commercialization has amplified the discussion surrounding the ethics of patenting genes and the ownership of the human genome.

One strategy for defenders of gene patenting is to adopt a constructivist interpretation of genetic testing to avoid the “product of nature doctrine.” I argue that accepting this view (which seems to be the approach of the U.S. Office of Patents and Trademarks) results in an intolerable dilemma for physicians. They must either infringe patents or fail to act on all the medically relevant information they possess (malpractice).

To those defining euthanasia as a battle for the principle of self-determination, persons seeking physician assisted death (PAD) are soldiers in the fight for patient autonomy. The reasons they seek it, or the potential of other, non-life-threatening interventions is less important than this principle: individuals have the right not only to choose death (suicide), but to be assisted in dying. They should not be second guessed or denied on the basis of another's distaste for that decision. This paper offers a general review of deaths attributed to Dr. Jack Kevorkian's PAD practice in an attempt to answer two questions: Why do persons seek physician assisted death, and, to what extent does induced death seem, in retrospect, a reasonable and perhaps necessary medical response to specific patient complaints?

Tom Koch's review of Jack Kevorkian's “subjects” is a valuable look at this one (in)famous crusader's practices. The immediate question raised, and to which Koch provides his own perspectives, is what practical conclusions might be drawn from the final experiences and actions of this cohort of suffering individuals. My briefest and perhaps flippant answer is “few, if any”—including, unfortunately, those derived or hinted at by Koch himself.