Justice For the Severely Ill Leads to the Freedom of Living

George Isajiw
Reproduced with Permission

For the past thirty years, medical ethics has undergone tremendous changes and upheavals, which have been much more than merely cultural adjustments or changes in terminology, but rather an intrinsic change in the entire value system and point of reference. This change is best characterized as a complete reversal of the traditional "sanctity of life" principle of ethics, which is based on objective definitions of human life and human nature, to a change to a "quality of life" ethic based on subjective, if not often arbitrary personal wishes and desires of the patient, and even worse, the subjective and arbitrary personal wishes and desires of the physician who no longer subscribes to any objective norms concerning the reality and the mystery of human life itself.

This quantum reversal of all the previously held sacrosanct tenets of medical ethics which are summarized in the words of the Hippocratic Oath, has become manifest in the alarming speed with which abortion has been transformed from being an "unspeakable crime" to a "woman's right" and a "therapeutic option." The same has happened at the other end of life, where euthanasia has become commonplace in today's practice of medicine, although this has happened in a more subtle and hidden manner, more difficult to perceive and understand and which often masquerades under the guise of compassionate care and is even justified by invoking the Magisterium of the Catholic Church.

The entire process of the past thirty years has been perceptively and accurately described by our Holy Father, Pope John Paul II, as "The Culture of Death." The traditional Hippocratic medical ethic, known as the "sanctity of life" ethic has been rejected and the new ethic, based on the "Culture of Death," the "quality of life" ethic has become firmly entrenched. Although there are legitimate instances when the effect of a given treatment on the quality of life of a patient can be considered in medical decision making, in general these two concepts of medical ethics are diametrically opposed and incompatible with each other, leading to completely different processes of medical decision making, and resulting in completely different clinical outcomes.

If these two philosophies of medical practice are so diametrically opposed, then they cannot both be correct, since their application results in completely opposite outcomes in clinically similar instances, either continued life or imposed death. Thus it is worth analyzing these phenomena from a more basic point of view of human justice and human freedom, in the hope of better understanding why such drastic changes in the practice of medicine have occurred so quickly, and with so little resistance to their implementation. In other words, is it possible to answer the question WHY this has occurred as well as analyzing HOW this has occurred.

The American Heritage Dictionary defines justice as "Conformity to truth, fact or sound reason." Freedom is defined as "Possession of civil rights; immunity from the arbitrary exercise of authority" (1). Applying these definitions to the practice of medicine, treatment decisions can only he ethically correct if they, in fact, conform to the truth, the clinical facts, and sound reason, and necessarily must be immune from the arbitrary exercise of authority, either by the physician or the patient himself.

Injustice results if truth is denied, if the facts are misrepresented, or if reason is perverted because it is based on false premises, thus leading to improper conclusions. Similarly, freedom is perverted, or a form of oppression is created if improper authority is exercised by either the physician or the patient.

In 1970 a prophetic editorial was published in the Journal of the California Medical Association, which predicted the intrinsic changes which have occurred in the practice of medicine:

"The traditional Western ethic has always placed great emphasis on the intrinsic worth and equal value of every human life regardless of its stage or condition. This ethic has had the blessing of the Judeo-Christian heritage and has been the basis for most of our laws and much of our social policy. The reverence for each and every human life has also been a keystone of Western medicine and is the ethic which has caused physicians to try to preserve, protect, repair, prolong, and enhance every human life which comes under their surveillance. This traditional ethic is still clearly dominant, but there is much to suggest that it is being eroded at its core and may eventually even be abandoned. This of course will produce profound changes in Western medicine and in Western society.

"The process of eroding the old ethic and substituting the new has already begun. It may be seen most clearly in changing attitudes toward human abortion. In defiance of the long held Western ethic of intrinsic and equal value for every human life regardless of its stage, condition, or status, abortion is becoming accepted by society as moral, right, and even necessary. It is worth noting that this shift in public attitude has affected the churches, the laws, and public policy rather than the reverse. Since the old ethic has not yet been fully displaced it has been necessary to separate the idea of abortion from the idea of killing, which continues to be socially abhorrent. The result has been a curious avoidance of the scientific fact, which everyone really knows, that human life begins at conception and is continuous whether intra- or extra-uterine until death. The very considerable semantic gymnastics which are required to rationalize abortion as anything but taking a human life would be ludicrous if they were not often put forth under socially impeccable auspices. It is suggested that this schizophrenic sort of subterfuge is necessary because while a new ethic is being accepted the old one has not yet been rejected." (2)

The prophetic nature of this editorial concerning abortion is obvious. However, less obvious is that the word "euthanasia" can he substituted in each instance of the word "abortion," and the statements are equally true. For example; "In defiance of the long held Western ethic of intrinsic and equal value of every human life regardless of its stage, condition, or status, euthanasia is becoming accepted by society as moral, right, and even necessary. Even without any substitutions, the following sentence applies to euthanasia as well as abortion: "It is worth noting that this shift in public attitude has affected the churches, the laws, and public policy rather than the reverse. And finally, this substitution: "The very considerable semantic gymnastics which are required to rationalize euthanasia as anything but taking a human life would be ludicrous if they were not often put forth under socially impeccable auspices."

Before identifying how euthanasia is a form of injustice and oppression of freedom, euthanasia must be defined, and those practices which are, in effect, euthanasia, but are not identified as such by those who promulgate them must be described. This job has already been done for us by the Sacred Congregation for the Propagation of the Faith in 1980, in the landmark Declaration on Euthanasia: (3)

"By euthanasia is understood an action or an omission which of itself or by intention causes death, in order that all suffering may in this way be eliminated. Euthanasia's terms of reference, therefore, are to be found in the intention of the will and in the methods used. It is necessary to state firmly once more that nothing and no one can in any way permit the killing of an innocent human being, whether a fetus or an embryo, an infant or an adult, an old person, or one suffering from an incurable disease, or a person who is dying. Furthermore, no one is permitted to ask for this act of killing, either for himself or herself or for another person entrusted to his or her care, nor can he or she consent to it, either explicitly or implicitly, nor can any authority legitimately recommend or permit such an action. For it is a question of the violation of the divine law, an offense against the dignity of the human person, a crime against life, and an attack on humanity. It may happen that, by reason of prolonged and barely tolerable pain, for deeply personal or other reasons, people may be led to believe that they can legitimately ask for death or obtain it for others. Although in these cases the guilt of the individual may be reduced or completely absent, nevertheless the error of judgment into which the conscience falls, perhaps in good faith, does not change the nature of this act of killing, which will always be in itself something to be rejected. The pleas of gravely ill people who sometimes ask for death are not to be understood as implying a true desire for euthanasia; in fact, it is almost always a case of an anguished plea for help and love. What a sick person needs, besides medical care, is love, the human and supernatural warmth with which the sick person can and ought to be surrounded by all those close to him or her, parents and children, doctors and nurses.

The most important part of this definition of euthanasia is that it points out that those who ask for or commit euthanasia usually do so with good intentions, hoping to relieve pain and suffering, and are convinced that they are doing good, and that they are providing a benefit for the severely ill person. This explains why any opposition to such acts brings about a counter-accusation of lack of compassion, as the perpetrators are convinced that they are NOT harming the patient, and thus they feel insulted by such an implication.

Except for the legalization of physician assisted suicide in the state of Oregon, direct euthanasia, such as that now found in the Netherlands, where lethal injection resulting in immediate death is commonly committed, is not yet common in the United States. Here, euthanasia is more commonly committed by the process of omission or withdrawal of treatment, under the pretext of withholding or withdrawing so-called "extraordinary," or "heroic" treatment, or under the pretext of "patient autonomy," i.e, complying with the patient's own wishes. The cover for these acts of euthanasia is provided by an incorrect interpretation of "advance directives," or more commonly known as "living wills", and the incorrect interpretation of what constitutes ordinary and extraordinary treatment. The latter is especially common in Catholic hospitals and nursing homes, and is often condoned by Catholic theologians who sit on the ethics committees of these institutions. This is most often done by the withholding or withdrawal of assisted administration of food and water, with death resulting as a result of dehydration and/or starvation. The justification for this is often based on a false interpretation of the previously quoted Declaration on Euthanasia, as well as a false interpretation of the Ethical and Religious Directives for Catholic Health Care Services, published by the United States Conference of Catholic Bishops. (4)

The Declaration on Euthanasia states that ordinary treatment is morally obligatory whereas extra-ordinary treatment is morally optional. I quote:

"If there are no other sufficient remedies, it is permitted, with the patient's consent, to have recourse to the means provided by the most advanced medical techniques, even if these means are still at the experimental stage and are not without a certain risk. By accepting them, the patient can even show generosity in the service of humanity." The Vatican document further states that "... it is also permitted, with the patient's consent, to INTERRUPT these means [treatments], where the results fall short of expectations."

Most importantly, however, the Vatican document provides a safeguard against an arbitrary withdrawal of ordinary treatment by the patient or the patient's family with the following statement: "...But for such a decision to be made, account will have to be taken of the REASONABLE wishes of the patient and the patient's family, as also of the ADVICE OF THE DOCTORS WHO ARE SPECIALLY COMPETENT IN THE MATTER."

If "extraordinary" treatment (which may legitimately be withheld or withdrawn) is defined as a treatment which has ceased to be of benefit (that is, can no longer achieve its intended therapeutic effect under the particular clinical circumstances), or has become too burdensome (that is, even if a therapeutic benefit still exists, the burden. imposed upon the patient by the treatment itself is out of proportion to the benefit), then it is necessary for a JUDGMENT to be made that a given treatment does, in fact, meet the criteria of being "extraordinary' in the moral sense. While it is always the PATIENT (or in the case of incompetence, the patient's surrogate) who makes the DECISION whether or not to withdraw treatment (and this is of utmost importance because the patient has the right to continue treatment EVEN if it is judged to be "extraordinary treatment) the Vatican document clearly states that it is the PHYSICIAN who must make the JUDGMENT that a given treatment is or has become "extraordinary". I further quote: "The latter [i.e., the physicians] may in particular judge that the investment in instruments and personnel is disproportionate to the results foreseen; they may also judge that the techniques applied impose on the patient strain or suffering out of proportion with the benefits which he or she may gain from such techniques."

The Declaration on Euthanasia also teaches that the same treatment which is ordinary in some circumstances can become "extraordinary" in others, depending on the clinical situation: "When INEVITABLE death is IMMINENT in spite of the means used, it is permitted in conscience to take the decision to refuse forms of treatment that would only secure a precarious and burdensome prolongation of life, so long as the normal care due to the sick person in similar cases is not interrupted." Thus, a particular treatment, such as a ventilator, which would be "ordinary" for a reversible pathology such as an infectious pneumonia, can become "extraordinary" in the case of irreversible end stage lung disease. These principles governing medical treatment decisions have been concisely summarized in a pamphlet published by the Scholl Institute of Bioethics (5). It is the doctor who makes the JUDGMENT, and it is the patient who makes the DECISION. One cannot act ethically without the consent of the other. The patient has the right to continue treatment, even if in the opinion of the physician a given treatment is judged to be "extraordinary." This protection for the patient reaffirms the "Sanctity of Life," and reassures us that no treatment on behalf of sustaining life, even if extraordinary, or even if "useless," can be considered objectively harmful, immoral or unethical.

Unfortunately, the Ethical and Religious Directives, even though the Declaration on Euthanasia is quoted, primarily emphasize the patient's judgment, rather than the physician's. Paragraph 57 states "A person may forgo extraordinary or disproportionate means of preserving life. Disproportionate means are those that in the patient's judgment do not offer a reasonable hope of benefit or entail an excessive burden, or impose excessive expense on the family or the community." Paragraph 59 further states "The free and informed judgment made by a competent adult patient concerning the use or withdrawal of life-sustaining procedures should always be respected and normally complied with, unless it is contrary to Catholic moral teaching."

This is often quoted in Catholic institutions to influence physicians to condone withdrawal of a given treatment even if the physician considers it to be beneficial or ordinary, based on this false interpretation of the patient's autonomy. Furthermore, these situations typically do not involve a competent patient, but rather a substituted judgment of a caregiver who has the so-called durable power of attorney.

Of course, even in a situation where the advice of the physician is taken into consideration, if the physician accepts euthanasia (as many do in our society today), the patient or the family consent to the withdrawal of treatment based on the physician's false contention that a given treatment is extraordinary, whereas in reality, it is ordinary. Once the treatment is withdrawn and the patient dies, it becomes a "self-fulfilling prophecy," with the false perception that the patient would have died even if the treatment was continued (in which case it would truly be extraordinary), whereas in reality the patient would have benefited from the treatment and would have continued to live.

Advance directives often have a checklist of treatments, such as ventilators, blood transfusions, antibiotics, assisted nutrition and hydration, etc., which the patient indicates are not wanted. However, the advance directive itself is not supposed to go into effect unless the patient is in a terminal condition, that is, a condition which will result in death in spite of treatment, thus rendering that treatment extraordinary. However, in reality, these "so-called" patient's own wishes (although few patients fully understand what they are signing in the first place) are carried out even if the patient is not in terminal state, and thus the treatment could have easily been successful, and resulted in continued life. This kind of application of the Advance Directive constitutes euthanasia, yet most patients and their families do not realize this and unwittingly consent to it. The dangers of the so-called "Living Will" have been well documented by author Mary Senander in a pamphlet entitled The Living Will, Expansion or Erosion of Patients' Rights (6).

The most egregious and the most common type of euthanasia committed today is in the form of withdrawal of assisted nutrition and hydration. The victim is typically a patient who has had a stroke and, as a result, cannot eat or drink efficiently but who is not terminal and is not dying. The assisted delivery of food and water, which is typically done through a tube inserted directly through the skin of the abdomen into the stomach and which causes no pain or discomfort for the patient, is withdrawn by stopping the feedings. As the patient experiences the suffering of dehydration and starvation, morphine is given to alleviate those symptoms, and usually in itself hastens death, which now becomes active euthanasia, an act of commission, along with the act of omission of the withholding of food and water. This is justified by many Catholic theologians and ethicists as a withdrawal of extraordinary treatment, or a legitimate exercise of the incompetent patient's autonomy based on a prior advance directive, and the food and water is declared as being of no benefit to the patient because they to not reverse the patient's underlying disease.

What they ignore is the fact that food and water are never intended to cure any disease, but are basic needs of every person, even the healthiest person. Thus, provision of nutrition and hydration for a patient who is not otherwise dying is always ordinary care (7). Without food and water, every person will die, regardless of the state of his or her health. At a recent international symposium on the care of patients who are in a prolonged state of diminished consciousness, The Holy Father stated:

"I should like particularly to underline how the administration of water and food, even when provided by artificial means, always represents a natural means of preserving life, not a medical act. Its use, furthermore, should be considered, in principle, ordinary and proportionate, and as such morally obligatory, insofar as and until it is seen to have attained its proper finality, which in the present case consists in providing nourishment to the patient and alleviation of suffering... Death by starvation or dehydration is, in fact, the only possible outcome as a result of their withdrawal. In this sense it ends up becoming, if done knowingly and willingly, true and proper euthanasia by omission. (8)

Author Wesley J. Smith has documented numerous cases of current day euthanasia in his book The Culture of Death: The Assault on Medical Ethics in America (9). In a recent article in the Human Life Review entitled "Not-So Catholic Bio-Ethics," the same author points out similar abuses in Catholic institutions, especially through the implementation of so-called "futility" policies, where a unilateral decision to withdraw treatment is made by the hospital against the wishes of the patient or the patients family. Author Smith writes: "Church leaders have been sound in promulgating Catholic doctrine on medical ethics but slow to recognize the threat from within. They must now act swiftly and diligently, to the point, if necessary, of prohibiting renegade institutions from using the word "Catholic" in their names. There is still time to preserve the concept of sanctity of life, with all that that implies. But if the fifth column is not rooted out, its penetration of Catholic institutions will continue, and before we know what happened, the new medicine will rule triumphant. (10)

In a paper presented to the International Federation of Catholic Medical Associations in 2002 in Seoul, Korea, I have also presented documentation of how this subtle form of euthanasia is committed in Catholic hospitals with the approval of the hospital ethics committees and their Catholic ethicists or theologians (11). This international body representing Catholic Medical Associations throughout the world concluded that it is time to apply the lessons learned from Catholic universities in the battle to re-establish orthodoxy known as "Ex Corde Ecclesiae" A similar program must be initiated by the Church in Rome and by the national bishops' conferences relative to Catholic health care institutions. All theologians who serve on ethics committees in Catholic hospitals must be approved and certified by the bishops in order to be in conformity with the Magisterium of the Church.

Another form of euthanasia (and I'm not sure whether this constitutes omission or commission) is the withdrawal of life sustaining treatment, such as a ventilator, before sufficient time for healing has occurred. For example, a stroke patient or a head trauma patient, who, given enough time, will resume breathing in his or her own, is withdrawn from the ventilator prematurely, causing the patient's death, whereas if more time was given, the patient would have resumed breathing and could be legitimately weaned from the ventilator and would have continued to live without the ventilator support. This is justified by the "quality of life" rationale which claims that because the patient might have permanent brain damage after recovery, it is better to allow the patient to die now, because of the assumption that the patient would not want to continue living with permanent disabilities.

So far I have presented HOW euthanasia manifests itself in the practice of medicine today, often imperceptively and under the guise of legitimate medical treatment decisions involving the removal of extraordinary treatment, whereas in reality, it is ordinary medical treatment that is withheld.

The most important question remains, however, once it is recognized how widespread the practice of euthanasia has already become in our advanced Western society, is WHY?. It becomes an even more perplexing question if we recognize that modern palliative treatments of pain and suffering are better than ever before, and physical pain can almost always be relieved without causing the patient's demise.

There is a basic erroneous assumption, a fundamental denial of a simple truth, which, by the definition stated in the beginning of this paper, renders a great injustice, even though it is not intentional. The fundamental injustice comes from the erroneous assumption that death represents relief of all suffering, and consequently, that no suffering can be experienced after death! And, since relief of suffering is the goal of euthanasia, it is easy to be seduced into accepting death as a means of ending suffering. Of course, it is easier to understand why atheists, or at least those who do not accept the reality of life after death, can fall into this error (although it might also be reasonable for an atheist to presume that continued life is more valuable, even in the presence of suffering, if one honestly believes that there is no existence after death).

How then can the trend towards euthanasia in religious institutions, especially those who claim to follow the Catholic tradition, be explained? I believe that this trend towards euthanasia in Catholic institutions has a heretical theological basis rooted in false understanding of Church teaching about the nature of death and the nature of life after death. It is rooted in the rejection of the possibility of suffering AFTER death, thus resulting in the false belief that death represents relief of all suffering. This, I have concluded, is the basic premise of the so-called 'Culture of Death" which presumes that death is a better alternative to continued suffering.

Historically, this is similar to the Albigensian Heresy, which was eventually defeated by St. Dominic and the devotion to the Blessed Mother through the rosary, but not until the population of Southern Europe was significantly depleted through this historically well documented version of the "Culture of Death." In essence, the tenets of this heresy, which was extensively studied and analyzed by the great Catholic writer Hillaire Belloc, consisted of the basic assumption that bodily life was evil because it was corrupted by the devil, and that redemption was achieved by releasing the soul from the corrupt body in order to achieve happiness in heaven. Only one sacrament was retained from the original seven, which could only be administered when a person was dying, and which forgave all sins and guaranteed heaven, but it could only be administered once in a lifetime.

However, a dilemma arose if the patient who was thought to be dying defied the diagnosis and prognosis and began to recover. In order to avoid the possibility of sinning again and being condemned to eternal hell without a second chance for forgiveness of sins, the patients were euthanized, usually by suffocation, in order to assure that they ended up in heaven!

I believe that the basis of the Church's strong condemnation of ALL EUTHANASIA is precisely based on the certain knowledge, through faith, that death is NOT necessarily the end of all suffering, and that eternal life is NOT inevitably achieved by death, but requires forgiveness of sins and the atonement for sin through the acceptance of our own suffering (either before or after death) in union with the redemptive suffering, death and resurrection of Our Lord Jesus Christ. Thus it is not death which ends suffering, but rather the mystery of redemption.

Perhaps, like the Albigensians, we have forgotten that man's eternal destiny is not the release of the soul from the body into heaven, but the re-unification of body with the soul and the eternal glorification of our body through our own resurrection, an eternal destination not achieved by our own merits, but through the resurrection of Our Lord Jesus Christ.

Thus I conclude that only through the acceptance of this eternal truth can we correct the great injustice of euthanasia and achieve true freedom for our patients to pursue the goal of life, which is "to know, love, and serve God," if we recall the Baltimore Catechism. This can only be achieved by a conscious rejection of any temptation to choose death as a solution to any problem. Only this can achieve true freedom for our patients to pursue their goal in life without interference, regardless of whether they continue to live or if they die from their illness, but without interfering with God's Will by means of human choices, regardless of whether the choice is made by the physician or by the patient.

Let us recall the word of God, as found in Deuteronomy, Chapter 30, verse 19: "I call heaven and earth today to witness against you: I have set before you life and death, the blessing and the curse. Choose life, then, that you and your descendants may live."

Finally, it is clear that history repeats itself. The temptation to accept euthanasia and to empower the medical profession to kill has raised its ugly head throughout history again and again, whether it was ancient Greece, which Hippocrates recognized and fought against with his famous Oath, or whether we look at the German euthanasia murders, which were initially committed not by Hitler and the Nazis, but independently and voluntarily by modern day physicians who had been trained in the Christian tradition as we are, not to mention the current day acquiescence of many in the medical profession to physician assisted suicide in the US, and the involuntary direct euthanasia currently practiced in the Netherlands. This propensity of the medical profession to go astray in this manner has been well documented and analyzed by psychiatrist Frederick Wertham in his landmark book (unfortunately now out of print) entitled A Sign for Cain: an Exploration of Human Violence. (12)

Dr. Wertham, as a US Army psychiatrist after World War II, was assigned to evaluate Nazi war criminals, including physicians, to determine their competence to stand trial in Nuremberg. Not only did he conclude that they were sane, intelligent and competent individuals who performed their hideous work voluntarily, without coercion, but he discovered that they, just as today's proponents of euthanasia, felt that they were doing good for humanity, and acted with a sense, at least in their own perception, of social justice.

In the chapter analyzing the German euthanasia murtiers, Wertham quotes the famous 19th century professor of medicine Dr. Christoph Hufeland (1762-1836): "If the physician presumes to take into consideration in his work whether a life has value or not, the consequences are boundless and the physician becomes the most dangerous man in the state."


REFERENCES:

  1. American Heritage Dictionary, 3d Edition, 1994.
  2. Separating the Idea of Abortion from Killing' California Medicine. vol.113, #3 6970). Available online at the Priests For Life website: http://www.priestsforlife.org/articles/caljournmed.html
  3. Declaration On Euthanasia, Sacred Congregation for the Propagation of the Faith, May 5, 1980, available on line at: http://www.vatican.va/roman_curia/congregations/cfaith/documents/rc_con_cfaith_doc_19800505_euthanasia_en.html
  4. Ethical and Religious Directives for Catholic Health Care Sereices, United States Conference of Catholic Bishops, No. 5-452. Fourth Edition, June 15, 2001 http://www.usccb.org/bishops/directives.htm
  5. Principles Governing Medical Treatment Decisions, (Scholl Institute of Bioethics, 2606 1/2 West 8th St.. Lot Angeles. CA 90057-3810).
  6. Mary Senander: The Living Will, Expansion or Erosion of Patients' Rights? (initially published by The Leaflet Missal Company, St. Paul, Minnesota. Available through Life Cycle Books, Lewiston. N.Y., 1996).
  7. Eugene F. Diamond M.D., "Definitions of Therapy, Treatment and Care." Linacre Institute of the Catholic Medical Association, presented at the International Symposium "Life Sustaining Treatments and the Vegetative State" Rome, March I7, 2004. Available online at http://vegetativestate.org/testi.htm
  8. Pope John Paul II, Papal Address on Food and Water, excerpts from the March 20, 2004 Statement of Pope John Paul II, Ethics & Medics volume 29. Number 6. (June 2004, National Catholic Bioethics Center, Boston, Massachusetts).
  9. Wesley J. Smith, Culture of Death, The Assault on Medical Ethics in America. Encounter books (San Francisco, 2000) www.encounterbooks.com
  10. Wesley J. Smith, "Not-So-Catholic Bioethics" Human Life Review, vol. XXVII, No. I (Human Life Foundation, New York, New York).
  11. George Isajiw M.D., "Advance 'Mis-Directives': Euthanasia in Catholic Hospitals in the United States," presented at the XXI World Congress of FIAMC (World Federation of Catholic Medical Associations) September 4, 2002, Seoul, Korea, available on line at http://perso.club-internet.fr/frblin/fiamc/03events/0209seoul/texts4/07isajiw/isajiw.htm
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  13. Frederic Wertham M.D., "The Euthanasia Murders", A Sign For Cain, An Exploration of Human Violence, Chapter 9 (Warner Paperback Library Edition 1969); out of print, available in libraries.

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