In 1991, Diane Wood Middlebrook, a professor of English at Stanford University, published a biography of the poet Anne Sexton in which, among other things, she used as source material some 300 tapes of Sexton's psychotherapeutic sessions with her psychiatrist, Dr. Martin Orne. After some years of reluctance and with the concurrence of Sexton's daughter and literary executor, Linda Gray Sexton, Orne released the tapes to Professor Middlebrook. Middlebrook's picture of Sexton drew heavily on the tapes, supplemented by scrapbooks, letters, photos, clippings, unpublished poems, and hospital records.

I never saw a dead body until my first anatomy class. Today those who have willed their bodies to science receive letters of gratitude, visit with our students, and have their names put up on memorial plaques; but 37 years ago our subjects were derelicts and anonymous old men found dead in flop house hotels. George C, his name written on a tag tied to one toe, lay stretched out on one of the six dissecting tables in the anatomy laboratory that autumn morning when 1 was 22 and beginning medical school. I remember hesitating at the door and then joining my four partners at Mr. C.'s side, trepidation giving way to curiosity, the moment imprinted forever in my memory by the smell of formalin.

The phenomenon of misconduct in scientific research illustrates how great can be the social damage of not knowing the incidence of a malady. Many urgings about such phenomenon have predicated views about the extent of institutional and governmental vigilance on observers' differing surmises about how frequently misconduct occurs. Such is the measurement error of extant data about incidence1 that one can venture little more than the deliberately imprecise conclusion that “misconduct is neither common nor rare.”

Physician aid in dying is a broader topic than euthanasia in that the latter usually refers to active euthanasia, while physician assistance also encompasses the issue of assisted suicide. Volumes could be and have been written on physician-assisted death. But my purpose here is to address a specific aspect of the topic: the policy implications with regard to proposed legislation on physician-aided death.

Although the title's reference to physician assistance suggests a focus on the role of the professional, what people often take to be most important and at the heart of the topic is the issue of the patient's rights, usually seen as being manifested in four different ways. First is the right to a dignified death, as free from pain and suffering as possible. In crossing national boundaries and preceding the organization of the professions and the creation of societies, this right is viewed as one that ought to be recognized.

Wittgenstein, in his famous critique of philosophy, noted that the influence of an idea can be such that it alters the way that we see the world. “It is like a pair of glasses on our nose through which we see whatever we look at,” he said. “It never occurs to us to take them off.” This view of the power of an idea suggests that the interpretation of an event, and what response this event calls for, can depend upon the view one has of the world. A person who is naive about medical facts may, for example, interpret chest pain upon exertion as a sign that he is “overdoing it”; were he more medically knowledgeable, the same symptom might be interpreted as a possible indicator of coronary artery disease. The naive interpretation calls for rest; the informed interpretation calls for medical attention as well.

I am currently caring for a child named Priscilla who is ventilator-dependent and whose care confronted me with questions of justice. Priscilla was born at the County Hospital after a normal pregnancy to a 17-year-old single mother. At birth, she was noted to have some dysmorphic features: widely spaced eyes, low-set ears, and a cleft palate. Her chest X-ray showed hypoplastic ribs and scapulae. Her chromosome studies were normal. Eventually, a diagnosis of a rare dwarfing syndrome campomelic dysplasia – was made.

The physician–patient relationship is anchored in trust. Historically the relationship has been a paternalistic one, with the patient expected to trust the physician's training and skills in doing what is “best” for the patient. But medical knowledge has expanded, as have treatment options and knowledge of the risks of treatment. The physician must now possess volumes of specialized knowledge about procedures and treatments, side effects and alternatives, drugs and their contraindications. Information has become a companion to trust. The patient, while still dependent on the physician's expertise, now wants information about choices and hazards in treatment. Expanded choice has made the patient a consumer of healthcare and its risks rather than a passive recipient of treatment from the professional.

More than three decades after its introduction as a legal requirement for medical treatment in the clinical setting, informed consent continues to be viewed with skepticism as to its need or effectiveness. Some maintain that it is not required because the ordinary individual believes that doctors can be trusted to behave In the best interests of their patients. This issue will be discussed in a later portion of this article. Others are persuaded that informed consent is an unattainable ideal given the limited capacity of the ordinary individual to understand the relevant information. This view is supported by studies intended to show that satisfactory understanding on the part of patients cannot be achieved. In rebuttal, Apple-baum, Lidz, and Meisel observed that:

Such statements are easily refuted by reference to studies of situations in which reasonable comprehension actually has been achieved. A sounder interpretation of all these studies might be that patients and subjects can attain a good level of understanding in many cases, but that several factors — including the manner in which disclosure is made as well as patients' limitations — may get in the way.

Assisted suicide is a tragic issue, one of those for which the tools of mere logic are inadequate and in which the power of the individual case is compelling and seductive but not necessarily clarifying. Meaningful dialogue is difficult. Persuasion is limited because the resolution of the issue, on a moral level, must be founded upon fundamental notions of what it means to be human, especially in the midst of suffering or disability or at the point of death.

In gender mythology woman is nature, the embodiment of life, destruction, and death. Semantically encoded in good and evil, the one conceptual stability woman represents is ambivalence. As a walled garden in which nature works its demonic sorcery, she turns a gob of refuse into a spreading web of sentient being, floating on the snaky umbilical by which she leashes every man. But as an ontological entity, woman is the real First Mover. The pregnant woman is devilishly complete. She needs nothing and no one.2 Confronted with the terrible sense of woman's power, man is forced to wrestle with her nature to gain his identity, never to fall back into her. Man is the essential, the norm, the absolute One without reciprocity. Woman is “the Other, posed by the One to define itself, the inessential who never goes back to being the essential and the absolute Other without reciprocity.

If economics has been the “dismal science” of the past century, health policy promises to be that of the next. Health policy issues evoke far less passion than the emotion-laden immediacies of bedside decision making. Nevertheless, it is patent that “macro” issues in all their obscurity and complexity are unavoidable if the health care delivery system of the future is to be fiscally sound and publicly acceptable. In addition, as Americans are now learning, options for care at the bedside are ineluctably constrained by seemingly distant societal choices.