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World Watching, But No Consensus on Ethics of Death

While U.S. politicians and courts debated the implications of removing Terri Schiavo's feeding tube, the rest of the world looked on this week with a mixture of revulsion and approval.

Many commentators disagreed with the intervention of President Bush and Congress in the case of the brain-damaged 41-year-old, saying such vital, complex decisions are best left to courts, physicians and the family. They accused Bush and his religious-right allies of hypocrisy and political posturing.

Other commentators gave plaudits to Bush — or at least welcomed the attention on Schiavo, saying it had revived much-needed public debate on when and how to prolong life in apparently hopeless cases.

"American moral melodramas quite often prove to be soap operas, but at least serve some useful purpose in focusing public attention on important issues that might otherwise be ignored," Australia's Canberra Times said about the Schiavo case.

Across the globe, there is no consensus on a patient's right to die. Many developing nations simply don't have the medical resources to keep coma patients alive indefinitely, nor the expectation that anyone would do so.

In Western Europe and in Australia and other developed countries, however, the question of when to allow patients to die has been argued for decades. Several countries have adjudicated cases broadly similar to Schiavo's, and European courts in recent years have tended to allow life support to end if physicians and a competent patient or guardian agree the case is hopeless.

Belgium and the Netherlands are the most radical. Both countries allow doctors to commit euthanasia, or mercy killing, of patients who state that wish and who are deemed to be suffering unbearably with little or no hope of recovery. Other European countries have backed away from that, fearing the authorization could be abused.

"I do make a distinction between giving a lethal injection and withdrawing treatment," said Dr. Piers Benn, a lecturer in medical ethics at London's Imperial College.

The Schiavo case is additionally troubling because the patient, although in what doctors say is a persistent vegetative state, is not otherwise in a crisis, he said.

"If there is a proper diagnosis of persistent vegetative state, and if there is no prospect of any conscious life, and there is another [medical] crisis, then I think it would be legitimate not to resuscitate," Benn said. Absent a crisis, he said, he is not sure.

Polly Toynbee, a writer for Britain's left-leaning Guardian newspaper, cited the drawn-out, "unkindly" death of her own ill mother in a column Friday arguing that doctors should be allowed to induce death.

Toynbee complained that the "religious lobby forces people to die in pain and indignity due to beliefs on the nature of life and death shared by very few."

In Switzerland, doctors may supply lethal drugs to a patient who wishes to commit suicide, but they may not administer them.

In Britain, the courts have allowed a sort of loophole, saying doctors may give potentially lethal doses of drugs to terminal patients if the aim is to relieve pain, not to deliberately bring about death. No one knows how many British patients have died in this way.

Israel had been weighing the right-to-die issue in recent months, even before the Schiavo case came to prominence.

In February, the Knesset gave initial approval to a bill permitting, for the first time in the country's history, passive euthanasia for terminally ill patients who had requested it.

The parliamentary measure moved forward on the recommendation of a two-year study by experts led by Avraham Steinberg, a neurologist and a leading international authority on Jewish medical ethics. Steinberg, a practicing Orthodox Jew, found what he described as ample basis in Jewish law, or Halakha, for ending the suffering of patients whose cases were considered hopeless.

China, too, has weighed the issue in recent years. But Zhou Xiaozheng, a sociologist at People's University in Beijing, said he didn't expect China to legalize euthanasia anytime soon, owing to widespread corruption.

"If it were allowed here, it could be subject to abuse by people who want to get rid of someone they don't like," he said.

Any kind of active euthanasia is banned in Germany and is punished as murder, manslaughter or denial of assistance, depending on circumstances. A physician isn't allowed to assist a suicide even if it is the declared will of a patient.

The strict laws are a reaction to the Nazi era, when thousands of disabled people were labeled "unworthy to live" and killed. But activist groups have been lobbying for a clear law to permit patients to state their preferences for treatment in living wills.

This pressure has increased because of Schiavo's case, which has dominated German newspapers' front pages. The main political parties are drafting joint legislation expected to go before parliament this fall, which would let people with terminal diseases decide in advance how they want to be treated.

Bush's intervention, meanwhile, has won some respect in Germany. The centrist Berlin newspaper Tagesspiegel said the president's actions made moral sense.

"A person is going to starve to death who is neither suffering from a deadly disease nor has left a living will," the newspaper said in an editorial Tuesday. "That may be in accord with the laws in Florida, but then these laws are simply wrong.

In November, French lawmakers passed a right-to-die law in the wake of a highly publicized case of a 22-year-old man, partially blinded and paralyzed in an automobile accident, whom his physician and his mother helped to die.

Marie Humbert had appealed for help to President Jacques Chirac before she administered the massive dose of barbiturates to her son Vincent in September 2003. She and the physician, Frederic Chaussoy, remain under criminal investigation.

"Vincent is dead," Chaussoy, 52, wrote in a recent book about the case. "That's what he wanted. I just helped him leave his prison. I just hope this won't send me into one for the rest of my life."

In Roman Catholic Italy, the Schiavo case is under scrutiny. The Vatican and several Italian politicians have condemned the decision to remove Schiavo's feeding tube and have praised Bush and his brother, Jeb Bush, the Florida governor.

The Vatican does not usually comment on specific legal cases but made an exception for Schiavo. L'Osservatore Romano said in a front-page editorial that she had been condemned to "an atrocious death."

"Who can decide to pull the plug, as if we were talking about a broken or out-of-order household appliance?" the paper said.

"Who can, before God and humanity, pretend with impunity to claim such a right?"

Catholic teaching does not require extraordinary measures to artificially extend the life of a critically ill patient, especially if there doesn't seem to be a reasonable chance of recovery. But Pope John Paul II has said there is a moral obligation to provide water and nourishment to a vegetative patient.

Italian Health Minister Girolamo Sirchia branded the decision made by Schiavo's husband, Michael, to remove the feeding tube "a horrible shortcut camouflaged as an act of love." And he said laws to loosen restrictions on euthanasia, such as in the Netherlands, were "very dangerous" because the practice of assisted death could get out of hand.

Italy's minister for European affairs, Rocco Buttiglione, echoed the Vatican in branding as murder the removal of Schiavo's feeding tube.

When an Italian magazine asked Buttiglione what he would wish if he were in an irreversible coma, he replied: "I could only pray to God to take my life. I would never ask my children to kill me.

Wolfowitz Nomination

WASHINGTON — President Bush had an impressive list of candidates to choose from when he sat down with aides this month to pick a new nominee as president of the World Bank, the global antipoverty organization.

Among them were Carly Fiorina, the highly visible former chief executive of Hewlett-Packard, and Randall L. Tobias, former head of the pharmaceutical firm Eli Lilly and now the administration's global AIDS coordinator.

Bush also could have warmed relations with allies by choosing one of any number of foreign finance ministers.

Instead, the president picked one of his most controversial aides — Deputy Defense Secretary Paul D. Wolfowitz.

Coming a week after he chose conservative John R. Bolton as his ambassador to the United Nations, the move was widely seen as a major provocation of the same allies the president had been working to cultivate.

But the move offered important insights into Bush and his approach to his second term, showing a willingness to upset allies that made him unusual among recent U.S. presidents.

Bush's choice of Wolfowitz and Bolton also highlighted his willingness to act on deeply held ideological beliefs.

In the case of the World Bank and U.N., Bush shares the view that the United States must assert U.S. leadership of major multinational institutions, U.S. officials and Republicans close to the administration said.

Bush contends these institutions need urgent reform to bring them more in line with the administration's focus on fostering democracy and free-market economics in poor countries.

Bush's choices also show that he believes the best way to ensure reform is by putting loyal aides in top jobs.

He is impervious to criticism from abroad, believing progress toward democracy in Iraq, the West Bank and elsewhere proves him right.

One U.S. official said last week that the Wolfowitz and Bolton nominations reflect the fact that "the president always picks people with long-term goals in mind."

The administration's interest in reforming the United Nations and the World Bank, he added, "have not been a secret."

International reaction to the choice of Wolfowitz has been strong.

A committee of the European Parliament expressed "great concern" March 18 over Wolfowitz, a candidate described by Parliament member Luisa Morgantini of Italy, head of its development committee, as a leading advocate of "democracy by arms."

Some European officials considered trying to block the choice, while a number of diplomats predicted the Wolfowitz selection would damage the fence-mending effort begun by Bush during his February trip to the continent.

But in Washington, some prominent Republicans said Bush's efforts at reconciliation were misinterpreted by anyone who thought that the president would start deferring more to other countries.

"He wants the relationship on his terms," said Newt Gingrich, the former House speaker who now advises the administration as a member of the Defense Advisory Board. "He wants the relationship while defending American interests."

William Kristol, former chief of staff to Vice President Dan Quayle and editor of the conservative Weekly Standard, said the two appointments were part of a second-term pattern of moving loyal aides from the White House inner circle to high posts outside it to advance Bush's key foreign policy goals.

The appointment of Bush public relations advisor and confidant Karen P. Hughes as chief of public diplomacy at the State Department was a striking example of the same strategy, he said.

"It's a sort of tough-love diplomacy," Kristol said. "He really has focused on how to make [organizations] work more effectively, work in harmony, obviously to advance our interests and our principles."

Kristol acknowledged that Bush had been more willing than former Presidents Clinton and George H. W. Bush to make appointments that risked a strong negative reaction. In choosing Wolfowitz and Bolton, Bush is saying, " 'I got reelected — I think my policies are beginning to work out — and I want to advance them further,' " Kristol said.

Stewart Patrick, a former State Department official for the current administration, said the president's moves reflected a traditional American ambivalence about international institutions. The ambivalence dates back to President Wilson and the League of Nations, an idea that he failed to sell to the country.

Americans have shown support for multinational institutions by initiating organizations like World Bank and the United Nations, yet officials of both parties became dissatisfied with the groups as soon as they seemed to veer from U.S. ideals, he said.

In their attitudes, these Bush administration figures reflect a "distinctive American internationalism" that involves a "forthright use of American power, and an unapologetic view that international institutions should reflect their values and principles," said Patrick, now a research fellow with the Center for Global Development in Washington.

Both Clinton and George H.W. Bush "clearly had a more developed sense of the value of coalition consensus-building, and an awareness of the long-term costs of being seen as too coercive, or too unilateral, in your approach," Patrick said.

Bush administration officials have grown eager to reform the World Bank and United Nations because they contend the institutions are not only inefficient, but also fall short of spreading the democratic and free-market values that they see as key to helping the world's poor.

The bank, begun in 1945, has an impact on the economies of poor countries that makes it one of the world's most influential institutions.

Dominated by the major industrial countries, the bank lends $18 billion to $20 billion a year. Its presence in a country encourages private lenders to offer additional project financing, and advice from its thousands of technical advisors is a major source of know-how in the developing world.

Although the bank originally focused on huge infrastructure projects — roads, highways, ports and sewer systems — it has diversified into so-called soft sectors such as education, healthcare and other social and environmental programs.

Although many governments clamor for the bank's help, it also has come in for criticism. There has been debate about how much its efforts lift the poor from poverty, and how much its efforts simply enrich local elites. And many observers have charged that, largely in response to pressure from outside groups, it has spread itself too thin.

"It's really a case of mission sprawl," said Gary C. Hufbauer, a onetime deputy Treasury secretary and a senior fellow at the Institute for International Economics in Washington.

The administration has not been especially warm toward the World Bank for most of the first term, but neither has it been hostile, he said. One notable clash came when the administration pushed the bank to begin a program to help postwar Iraq, which it did after prodding.

Such signals are part of the reason that some allies in Europe and elsewhere fear the Wolfowitz appointment means the United States will try to redirect aid from sub-Saharan Africa to the Middle East, which is at the center of terrorism concerns.

But it has become increasingly clear that the administration has wanted reform. In one step toward greater accountability, it has pushed to replace World Bank loans with grants, on the theory that grant programs can be cut off more quickly if recipient governments don't do their part to make projects work.

In comments since the announcement, Wolfowitz has sought to defuse criticism by insisting that he intends to build consensus, not impose U.S. goals. He has said that he knows his job is fighting poverty, not changing the politics of poor countries.

Yet he also acknowledged that the job would be about changing the ways countries are governed and trying to induce political improvements. Bush gave the same signal when he said Wolfowitz was well qualified for the job because of his "deep understanding of development, economics and political reform."

The administration's critique of the U.N. has been similar. Officials have complained often about inefficiency and waste, but they are also trying to steer the institution toward Bush's short list of priorities.

The administration's top official for U.N. reform, State Department official Patrick F. Kennedy, told the U.N. in January that U.S. goals included better financial management, emphasis on fighting terrorism and weapons proliferation, and "a universal commitment in the U.N. to promoting democracy and market-based economic systems."

In the administration's view, this job, too, will require shaking people up, said a senior House Republican aide.

"There's a bit of the tough schoolmarm required in this kind of reform," said the aide, who spoke on condition of anonymity. "It's like the T-shirt — 'I hit my children because I care.' "