(RNS)--Diagnosed with cancer of the mouth, the cigar-smoking genius with the larger-than-life ego persuaded his doctor to euthanize him when the time was right.

When Sigmund Freud decided the time was right--16 years after the diagnosis--Dr. Max Schur gave him 21 milligrams of morphine. The father of psychoanalysis, the man who popularized such terms as "id" and "oedipal complex," died within hours.

But the impact of Freud's final exit endures. As Congress grapples with a national anti-suicide bill, Maine prepares for a November referendum on legalizing physician-assisted suicide, and Oregon continues its landmark experiment with doctor-aided death, Freud has emerged as a powerful emblem for the right-to-die movement.

The pro-euthanasia authors of an article published in a medical journal have labeled Freud's 1939 passing "physician-assisted death" and "voluntary active euthanasia." Other, anti-euthanasia physicians argue that Freud's palliative care (treatment designed to minimize pain and suffering but not to cure) would be commended today as appropriate, compassionate, and legal. Either way, the details illustrate an important but often overlooked point in the contemporary political, medical, and moral debate over euthanasia and physician-assisted suicide.

Most people, like Freud, choose doctor-aided death not to avoid pain but to exert autonomy. This truth is confirmed in studies from the Netherlands, the only country where euthanasia is allowed nationwide, and from Oregon, the only U.S. state to legalize physician-assisted suicide.

Yet as the U.S. Senate responds to Oregon's assisted-suicide law with the so-called Pain Relief Promotion Act, pain--not autonomy--remains center stage. The bill would ban use of federally controlled substances, such as barbiturates and morphine, in assisted suicides. It overwhelmingly passed the House last October and awaits action in the Senate Judiciary Committee.







Freud knew pain. It came with the malignant oral epithelioma that was first diagnosed in 1923, a consequence of the cigars he could never give up, the cigars he believed made him more creative and productive. Freud had to use crude prostheses to talk and eat, and he dealt with the pain of more than 30 surgical procedures. He also endured repeated primitive X-rays and radium therapy.

Yet in the years from diagnosis to death, he wrote 20 books and scientific articles as he directed the international development of psychoanalysis. "Based on Schur's writings, reading between the lines, I think the reason Freud chose this type of death was control," says Dr. Jack McCue, the co-author, with Dr. Lewis Cohen, of "Freud's Physician-Assisted Death," which was published last year in the Archives of Internal Medicine. "He really was a control freak, so it's not surprising he would want to control his own death. He desired and achieved a reconciled death, what he would consider a good death."

McCue, a former member of the pro-euthanasia Hemlock Society, continues: "I don't fear pain. I fear dependency. I fear the humiliation of losing my wholeness as an adult. I can relieve pain, but what I don't want to do is waste away, losing control of my bladder and my bowels, having to rely on people to take care of me when I have no future.

"I want the most graceful exit possible, and I think that's what most people want."

They want it in increasing numbers. In 1947, when a Gallup survey asked Americans if the law should allow doctors to end the lives of terminally ill patients who request such assistance, 37 percent said yes and 54 percent said no. In 1999, 61 percent said yes and 35 percent said no, revealing a significant historical shift.

In March of last year, Gallup asked, "If you personally had a disease that could not be cured and were living in severe pain, would you consider committing suicide or not?" Forty percent said yes, they would consider it. But the key words, and the source of misunderstanding, are "severe pain."

In February, an article in The New England Journal of Medicine examined an Oregon Health Division study of the 33 people who requested and received lethal medications in 1999. The article came to an emphatic conclusion: "The patients requested assistance with suicide because of concern about loss of autonomy and control of bodily functions, not because of concern about inadequate control of pain."

Widespread support for euthanasia depends on belief in autonomy, a value summarized in the United States as "my body, my choice." The word comes from the Greek "auto" (self) and "nomos" (law). "Personal autonomy" suggests a person who is a law unto himself. That describes Freud, who "gives us a model of modern autonomy," says Harold Vanderpool, a professor of the history and philosophy of medicine at the University of Texas medical branch in Galveston.

In naming him one of its top 100 persons of the century, Time magazine said that Freud, "more than any other explorer of the psyche, has shaped the mind of the 20th century." Freud was born a Jew in what is now the Czech Republic, suffered persecution under the Nazis in Austria, and died an atheist in England. The fact that he had no belief in God helps explain his openness to euthanasia, Vanderpool says.

On a societal scale, he adds, the increasing desire for physician-assisted suicide corresponds with the increasing secularism of culture. Doctors also see the link between declining religious influence, autonomy, and the increasing desire for assisted suicide. "Don't get me wrong," says Dr. Peter Goodwin, who co-sponsored the voter-approved Oregon law and has assisted in several suicides. "There are religious people who want aid in dying. I have many Catholic friends who want it. But in general, it is somebody who has a polytheistic belief or an agnostic belief or perhaps an atheistic belief."

It's no coincidence that the only state where assisted suicide is legal has the highest percentage of atheists and one of the lowest churchgoing populations. When compared with other European countries, the Netherlands is similarly nonreligious. "If you think God is lord of your life, you already believe in a check on autonomy," says Richard Doerflinger, the secretariat for pro-life activities for the National Conference of Catholic Bishops, which has aggressively lobbied Congress to pass the Pain Relief Promotion Act.

Hardly any of the discussion in Congress has been about choice and autonomy. With the exception of Congressman Barney Frank, the Massachusetts Democrat, no one has been politically willing to defend assisted suicide, especially on those terms. Instead, the focus has been on whether the bill will encourage or discourage physicians to provide pain relief.

In Freud's case, there's little doubt about the intent of his physician, who was never charged with a crime. Schur made the details known in his memoirs, which weren't published until 1972. According to Schur, Freud clasped the physician's hand during his final hours and said, "My dear Schur, you certainly remember our first talk. You promised me then not to forsake me when my time comes. Now it's nothing but torture and makes no sense anymore."

Schur indicated that he hadn't forgotten. Freud, he wrote, "sighed with relief, held my hand for a moment longer and said, 'I thank you.'" The giant of psychoanalysis exited with an autonomous death.

