The Challenge of Definition by C. Everett Koop, MD, ScD
Surgeon General of the U.S. Public Health Service
U.S. Department of Health and Human Services
Presented at the International Conference on Euthanasia and the Future of Medicine
October 24, 1988
In 1988, euthanasia was still in discussion as a way out of intractable pain in one's terminal illness, but had not yet
gone through the transformation of being a decision based on other premises. At the time of this writing, 2003, euthanasia
is a different subject. First of all, assisted suicide is openly talked about and is legal in the state of Oregon. Secondly,
euthanasia is not talked about in reference to intractable pain - in part, due to the fact that medicine has learned to deal
better with terminal illness pain - rather, it is offered as a way of dying at a time chosen by the patient for reasons that
vary greatly, but include dying in a different way than one's illness would ordinarily dictate.
I made it clear that as an official of the federal government speaking on a subject such as the one before this conference,
I tried to separate fact, history, and previously enunciated public policy positions from my own personal experience and belief.
This occasion, however, was a little different - and a little more difficult - because the government had not stated its official
position on euthanasia. Society was trying to come to some resolution of the matter. And so, like ourselves, government and
society as a whole were locked in the debate as well.
Hence, on the occasion of this address, I said I would ask some questions, hesitantly venture some answers, but presented
essentially nothing that I had not said already in some other forum in the last decade.
I started with a caveat. We were trying very hard at this conference to make sense out of a profound human event - death itself
- an event that many people in this century had already tried to render senseless.
This audience had been exposed to a great deal of thinking by eminent scholars in the field, and I chose to speak on "definition".
In other words, do our words really mean what we think they mean?
I acknowledged that I had always had a problem with the term "euthanasia" itself, "good death", and "happy
death". Then implicit in the concept of euthanasia, death is the result of someone's conscious choice. Both "happy
death" and "death by someone's choice" are rather in conflict with religio-social tradition in which the human
race is presented with "a blessing and a curse, life and death", and we are instructed " . . . therefore, to choose
I then question other things: active euthanasia vs. passive euthanasia, delegation of authority, durable powers of attorney,
living wills, and boards of review.
Historical examples were recalled, such as Kitty Genovese, Binding & Hoche, and Baby Doe and noted that we seemed very
slow to learn that nothing in medicine, nothing anywhere else in our western Judaeo-Christian tradition, enables one person
to make a true judgment about another person's "quality of life". That was the root of the Binding & Hoche
theses, and it led to the Holocaust.
It is very difficult to summarize a philosophical lecture of such depth and which involved such crucial decision-making. I
continued to use real-life examples, examples from my own life experience, and stereotypical examples as well.
I raised the question of state-sponsored euthanasia and called it the terror of the euthanasia ethic. Germany identified millions
of people who were eligible for the honor of being labeled "devoid of value". We do the same thing. Germany killed
those people -the question is, will we ever try the same thing?
I finished with a plea to understand definitions better than we do. Our debate is deteriorating from rationalization to imprecision:
quality of life, withhold nutrition and fluids, death with dignity, assisted suicide, heroic measures, passive euthanasia,
surrogate, extraordinary care, and so on. These terms can mean different things to different people. Let's be sure the
words mean what they mean. There is safety in shared values. Safety for the best of us . . . safety for the worst and least