For Bioethicist With Ailing Spouse, End-Of-Life Issues Hit Home.

July 25, 2013

Guest: Bruce Katz - Margaret Battin

TERRY GROSS, HOST: This is FRESH AIR. I'm Terry Gross. When the city of Detroit filed for federal bankruptcy protection last week, news accounts were filled with troubling stories of urban decay in the city, vast areas of vacant lots and abandoned houses, shuttered parks, non-working street lights and police response times close to an hour. But our guest Bruce Katz writes that in many American cities, there are promising signs of renewal.

Katz is a vice president of the Brookings Institution in Washington, and he's written a book with Brookings fellow Jennifer Bradley called "The Metropolitan Revolution: How Cities and Metros are Fixing Our Broken Politics and Fragile Economy." The book argues that metro areas, cities and suburbs together, and powerful economic engines with considerable political power, and that local leaders are more likely to take on the nation's big challenges than politicians in Washington.

Bruce Katz is a former Senate staffer, and was chief of staff for Secretary of Housing and Urban Development Henry Cisneros in the Clinton administration. He spoke with FRESH AIR contributor Dave Davies.

DAVE DAVIES, HOST: Well, Bruce Katz, welcome to FRESH AIR. We've had cities and suburbs for decades. What exactly is the metropolitan revolution?

BRUCE KATZ: Well, there's no secret that the United States faces some major competitive and social challenges in the aftermath of the recession, and there's no secret that the federal government, for all intents and purposes, has left the building. It's mired in partisan rancor.

So what the metropolitan revolution is, cities and metropolitan areas and the networks of leaders who co-govern them, they're stepping up, and they're doing the hard work to grow jobs and make their economies more prosperous. They're investing in infrastructure. They're making manufacturing a priority again. They're equipping workers with the skills they need to compete in the global economy.

Our sense, Jennifer Bradley and myself, is that for the next decade, change is going to happen where people live. This is a wave of innovation, and we think it can really sweep across the country.

DAVIES: Now, you're not talking just about government leaders, like mayors and county commissioners, right?

KATZ: No. When I think about cities and metropolitan areas, I think about networks of leaders, mayors for sure, county elected officials for sure, but also the heads of universities, major employers, business associations, labor unions, civic and community and environmental organizations. The federal government is a government. States are governments. But cities and metropolitan areas are really networks of leaders and institutions. They're very powerful on their own, but when they come together and they collaborate to compete, they can do grand things together.

DAVIES: And philanthropic foundations are a piece of the puzzle.

KATZ: Philanthropic foundations are a major piece of the puzzle. In many places, they really provide the glue that pulls these different groups together. We have a great story in the book about northeast Ohio, a group of philanthropic organizations coming together, helping to finance and support and steward a set of intermediaries and institutions that are really focusing on helping small and medium-sized manufacturers get back into the production game.

For a whole bunch of reasons, the U.S. has the potential to compete in manufacturing again, and it's philanthropy in northeast Ohio that's been leading this.

DAVIES: If you look at what cities have been doing over the past 20 years, a lot of it, it seems to me a lot of the economic development initiatives have focused on, you know, tourism and hospitality, new convention centers, loans to start new hotels, stadiums, performing arts venues. Good ideas?

KATZ: Well, I think over the last 25 years, cities and metropolitan areas got caught up in the national growth model, which frankly, mostly focused on making the United States a consumer economy, a consumption economy. So in many cities and metropolitan areas, economic development essentially was what I would call Starbucks and stadia and stealing businesses, right.

And that, in many places, has made cities and metropolitan areas more quality places to live. But in the post-recession environment, given that the recession was a wake-up call, what I see cities and metropolitan areas doing now is beginning to focus on the fundamentals. What do you make? What services do you provide? What do you trade to either other parts of the United States, to other parts of the world? And who do you trade with? And do you have the skilled workers and the collaboration between universities and companies and entrepreneurs and labor unions so that you can really compete and prosper, but also build on your distinctive assets and advantages?

So there is a post-recession growth model that cities and metropolitan areas are embracing in the United States that I think will set a platform for much more productive, innovative, sustainable and inclusive growth over the next 25 to 30 years.

DAVIES: Give us an example of some transformative change in, you know, one of these really challenged areas, say in the East or the Industrial Midwest, where, you know, manufacturing jobs once, you know, drove the economy and have largely disappeared.

KATZ: So let's travel to northeast Ohio - not just Cleveland, but also the Cleveland metropolis, plus Youngstown, plus Canton plus Akron - very challenged because of the de-industrialization over several decades. The major innovation that happened was that philanthropy and business came together and said: We have unbelievable assets here, small manufacturing firms that are really good at what they do in the manufacture of quality products.

We need to help them in this global environment sharpen their business plans, attract private capital, retool their facilities, retrain their workers so they can produce new products for new markets. And that's exactly what's happened in the past 10 years: a fund for economic future, a set of intermediaries that work really, really closely with these small and medium-sized firms. In less than 10 years, we've seen the growth of about 10,500 jobs, over $300 million in payroll, $2 billion in private capital.

This is the kind of smart, post-recession economic development we need to participate in. And most importantly, because of the shale gas revolution, because of other global dynamics, rising wages in China, we can make things again in the United States. We can participate in an advanced industry economy, rather than just an economy of consumption.

DAVIES: You know, the typical kind of expansion of industry that we're used to seeing is a state or a region sees a chance to lure a manufacturer - you know, Toyota or Nissan. And so it becomes a competition of offering tax breaks and other economic incentives: We'll give you the best deal, and you come. It ends up being expensive for taxpayers. How is what happened in northeast Ohio different?

KATZ: Because I think what happened in northeast Ohio was they took a look at themselves, and they said: What do we have here? What are we really good at? Well, they have advanced research institutions, like the Cleveland Clinic, like universities in Akron and elsewhere that basically are very smart about either health care or about sectors of manufacturing, like polymers that they were involved in in prior generations.

They then have networks of small and medium-sized manufacturing firms that, again, have skilled workers manufacturing quality products. They're good at what they do. And then we have investors, other institutions that are supportive of these firms, because they can provide the skilled workers these firms need as they expand. Think community college. Think even high schools - with what we used to call vocational education - geared to the needs of firms.

So northeast Ohio did an assessment of themselves, and said: What are - what are our distinctive assets and advantages? Before we go outside of our metropolis of our region, why don't we try to buttress and leverage the assets and advantages we already have, and then perhaps maybe a German firm or a Japanese firm or a Korean firm will look to locate here, because they want to be part of this ecosystem, this interconnected web, intricate web of firms and entrepreneurs and research universities and skilled workers.

That's how the economy works. You know, if you're really focusing on just stealing businesses and throwing a lot of subsidy at them, well, then five years later, they may get a better deal. Why not build from your base, build from your foundation, build from the infrastructure you already have?

DAVIES: We're speaking with Bruce Katz. He is a vice president at the Brookings Institution. He is the author, with Jennifer Bradley, of the new book "The Metropolitan Revolution." We'll talk more after a quick break. This is FRESH AIR.

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DAVIES: This is FRESH AIR, and if you're just joining us, our guest is Bruce Katz. He is a vice president at the Brookings Institution. He has a new book with Jennifer Bradley called "The Metropolitan Revolution."

You've offered us some, you know, encouraging developments in an industrial area, but Detroit made national news last week when it filed for bankruptcy. Of course, that's being challenged in court, but the situation painted in the news reports is pretty dire, I mean, both in terms of the city's financial difficulties and in the quality of life: closed parks, street lights that don't work, neighborhoods that are blighted.

Your book actually cites Detroit as one place where some encouraging things are happening. What's your take on what's in store for Detroit?

KATZ: There's no doubt that the city of Detroit faces super-sized challenges, because the city has shrunk from two million people in the 1950s to less than 700,000 today. There are tens of thousands of vacant properties. There are serious crime issues, school and educational performance. But we should not let those challenges overwhelm or crowd out what is some real economic potential in the core of the city.

So what our book talks about is a relatively small portion of the city, about 3 percent of the land mass, which has close to 40 percent of the jobs. I'm talking about the downtown of the city, good bones, solid bones, old historic buildings near the riverfront, and then up the Woodward Corridor to Midtown,Mhe Woodward Corrdirword

What we're seeing in Detroit is a network of business and philanthropic and civic leaders really building off these - this good platform, this solid foundation, grow businesses, attract residents. There's going to be a new transit line up the old Woodward Corridor, mostly financed with local resources.

We think that Detroit, through this reset, can revive from the core. And over the next several years and on into the next decade, we can see the growth of tens of thousands of jobs and, more importantly, a revival of the tax base for the broader city. So we don't want to be Pollyannaish about Detroit - hard, tough challenges, the toughest in the country, but we shouldn't overlook the assets and advantages that city has.

DAVIES: You know, when you look at Detroit, I mean, you see this terrible imbalance that's, you know, decades old now of a declining population and an increasingly impoverished city, which has a weaker tax base and more demands on - you know, for services for those folks. And that's just put it in a terrible position.

And when I look at some of the developments that you describe in Detroit, as encouraging as they may be, my sense is that they are on a relatively limited scale in comparison to the size of the city, and also don't really involve manufacturing jobs. There seem to be essentially service jobs. I mean, is that enough of a catalyst?

KATZ: Well, there's some small-batch manufacturing happening. It's actually happening near the College for Creative Studies, because that's an advanced industrial design college, and that's really a part of the future of manufacturing. But you're right. I mean, what we're talking about at this point is still small scale, relative to the challenge.

But we've seen an enormous amount of market momentum in a relatively short period of time, large private investment coming from Quicken Loans, Dan Gilbert, other companies that are relocating into the downtown, and then sort of a pooled resources of philanthropies investing really in this core of the city.

So the question is: What's the possibility of this core of Detroit? How many jobs can be created? And then how do we match up residents in the city with very practical, customized, focused skills programs so they can work in the next generation of health care jobs, life sciences jobs, biotech, small-batch manufacturing, even some of the technical jobs that are developing in the core?

DAVIES: You know, one of the premises of the book is that metropolitan areas are powerful in the city and its suburban areas. Its surrounding areas, you know, find common cause and innovate together. What's Detroit's relationship like with its surrounding communities?

KATZ: Oh, I think this is part of the challenge in Southeast Michigan. I don't think you've seen the kind of city-suburban collaboratives - though recently we see it around transport, transportation and light rail. You haven't really seen this in Southeast Michigan to the extent you've seen it in Chicago, to the extent you've seen it in Minneapolis-St. Paul, or in Denver.

I think, going forward, given global dynamics, the rise of China, the rise of India, the rise of Brazil, American cities and their suburbs are going to need to collaborate to compete. And that really means reaching across these jurisdictional and sectoral and - to some extent - partisan divides in the country. But there are examples out there that Detroit can emulate.

And for those people living in suburban Detroit, or for those businesses located in suburban Detroit, they need to recognize that the world, when they think about Southeast Michigan, thinks about the fiscal distress in the core city and the other challenges facing the core city. And so nothing would benefit the broader metropolis more than the revival of the core of the city, and then ultimately the broader municipality.

So, cities and suburbs are completely intertwined, interdependent. They are one organic marketplace. And what we now need to do is get beyond administrative fragmentation and move towards this broader collaboration, which is happening in the country, and which the book shows.

DAVIES: You've said there are some good bones in the city, that's to say you know, interesting buildings and an infrastructure, and some initial efforts at creating and expanding jobs, which show some promise. But the bankruptcy highlights this tremendous burden of legacy costs. I mean, the city, it's hard to see how it could dig out of its financial hole, and there will be terrible questions to confront.

Do city pensioners take a loss? Do bond investors take a loss? And as this is worked out in political fights and legal fights, it'll be difficult, and it'll be wrenching, and it's hard to see how you get a solution which puts the city on a stable footing and doesn't tear it apart. What do you see happening in Detroit in the next year or two?

KATZ: Well, the next year or two is going to be, obviously, a lot of the legal wrangling that you talk about. I think the big question is whether we can see the market momentum in some portions of the city continue. And let's just go back several decades, right. Let's go back to the New York City situation in the '70s, or go back to the Washington, D.C. situation in the 1990s.

The promise of these kind of interventions is that it sets a new platform for sustainable growth that really benefits a broader segment of your residents. This is a reset moment now for Detroit. And what's positive in this, it's happening in a moment when the assets and the advantages of cities - the cores of cities - are being completely revalued by the marketplace, by companies that want to be in these open innovation areas and districts, as opposed to science parks 30, 40 miles away from the core, and for the new demographics, people who want to go to work, have transportation options, walk, bike, take transit and then leave their office and find themselves in a functioning community, right.

Something profound is happening in the broader dynamics that are revaluing cities and the urban cores of suburban communities. So if this was happening 30 years ago, we might be having a different conversation, frankly, right? But I think it's happening at a time where, as we go through the painful restructuring - and the complicated restructuring, given the legal battles ahead - we shouldn't lose sight of the role and function of cities in today's innovative economy, and particularly the role and function of the cores of cities, which really, I think, is the foundation on which a good portion of our economy will be built in this country.

DAVIES: Do you have an opinion about how the bills get paid? I mean, is it that bondholders don't get everything they're owed, and city pensions get cut, or federal or state tax dollars come in? Somehow, the books have to balance. I mean, do you have a sense of how that should go?

KATZ: Well, if you look at the prior interventions that happened in New York City and in Washington, D.C., there had to be more money put on the table, right. In both of those cases, actually, it was the federal government who came to the rescue, so to speak. I don't think that's happening anytime soon.

But I think we are at the beginning of a fairly long and elaborate story, here. I don't think we're at the end. And so, you know, history would teach us that there needs to be access to other resources, and now we have to really sort out which level, whether it's the state or the national government.

Obviously, private and civic investment will continue in those portions of the city that really have market potential and function, but these broader, hard, hard issues, you know, you've got to make the math work.

GROSS: Bruce Katz will continue his interview with FRESH AIR contributor Dave Davies in the second half of the show. Katz is the coauthor of "The Metropolitan Revolution: How Cities and Metros are Fixing Our Broken Politics and Fragile Economy." I'm Terry Gross, and this is FRESH AIR.

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GROSS: Let's get back to our interview with Bruce Katz, coauthor of "The Metropolitan Revolution: How Cities and Metros are Fixing Our Broken Politics and Fragile Economy." The book argues that metro areas - cities and suburbs together - are powerful economic engines with considerable political power, and that local leaders are more likely to take on the nation's big challenges than politicians in Washington. Katz is a vice president of the Brookings Institution. He spoke to FRESH AIR contributor Dave Davies.

DAVIES: You know, you talk about metro areas being kind of the economic units that we function on and an increasing power. But in our constitutional system, so many legal and institutional tools rest with state governments. I mean, they - often a city or region can't change its tax policy without permission from the state capital. And in state capitals, you see a lot of the same, you know, bitter partisanship that afflicts Washington. What do we do about that?

KATZ: Well, we have inherited a federal republic where we really have two constitutional sovereigns: the federal government and our states. The reality of our country, however, is that cities in metropolitan areas are the engines of the economy and the centers of trade and investment. So there are 388 metropolitan areas in the United States. The top hundred only sit on about an eighth of our land mass. They're two-thirds of our population. They're three quarters of our GDP.

But on everything that matters to modern economies - the education and skills of your workforce, how innovative you are in patents and advanced industry, the strength of your infrastructure to move goods and people and energy and ideas. The top hundred metros are 75, 80, 85, 90 percent of the national share and 47 of the 50 states have the majority of their GDP generated by their metropolitan areas. So I think we need to graduate to a point where we understand that the role of the federal and state governments are to be in service of metropolitan progress and prosperity. What that means on one hand is to do what these cities and metros can't do. On the other hand, it means more flexibility, less prescriptive rules, less technocratic rules. Unleash the power of your cities and metropolitan areas. And if you're a governor or a state legislature or a congressman or a senator, you will be seen frankly, as truly representing your community.

DAVIES: So you think we can, people can change their mentality in these offices, even though, you know, they run in partisan elections and, you know, partisan priorities often rule in caucuses and party organizations.

KATZ: Well, when I go to cities in metropolitan areas - as opposed to states, state legislatures or Congress, obviously. I have to tell you, it's pretty hard for me to figure out who is a Democrat and who is a Republican and who's a liberal and a conservative. What I find...

DAVIES: I agree.

KATZ: Yeah...

DAVIES: I hate to interrupt, Bruce, but, you know, that's been exactly my experience covering local government. But what I find then is that local governments need changes at the state level. They need authorization for tax changes, etcetera. And at the state level, they are hard-edged and ideological and partisan. The local officials who think more broadly, who don't think in a partisan way just in a wall.

KATZ: But here's I think the political math, right, because these metros are so powerful economically. If they come together, cities, suburban, exurban and rural, really come together around particular investments and priorities, then you can overcome the partisan divide. We have a story in our book about Los Angeles making a very substantial investment off their sales tax to build state-of-the-art transit over a 40-year period. What happened in the depths of the recession is they basically put forward an idea, we should accelerate construction into 10 years so we can create 160,000 jobs and help people get back to work. They went into dozens of metropolitan areas around the country - Republicans and Democrats, liberals and conservatives that said, you know, if we can get the federal government to give us some innovative finance, we all would be better off. That coalition came together, came to Washington and they passed infrastructure finance reform last year as part of a transportation bill.

The partisan divide can be overcome by pragmatism, by bipartisan effort at the local and metropolitan level by sending a signal, we want our representative members to be parochial, to actually represent us and get beyond this ideological nonsense, essentially, that permeates these higher level governments. I think at the end of the day, city and metropolitan innovation will be the cure to the partisan poison we have at the federal and state level.

DAVIES: Well, Bruce Katz, thanks so much for speaking with us.

KATZ: Well, thanks for having me.

GROSS: Bruce Katz is the coauthor of "The Metropolitan Revolution." You can read an excerpt on our website, fresh.npr.org.

Coming up, a bioethicist who is an advocate of the right to die, who has had to wrestle with the issue in her family. This is FRESH AIR.

TERRY GROSS, HOST: This is FRESH AIR. After writing books and essays about end-of-life issues and advocating for the right to die, my guest, bioethicist Margaret Battin, has had to wrestle with the issue in her own family. Her husband, Brooke Hopkins, an English professor at the University of Utah, where she's also a professor, broke his neck in a bicycle accident in 2008. It left him with quadriplegia, dependent on life support technology. In order to breathe, he requires a ventilator some of the time and a diaphragmatic pacer all the time. He receives his nutrition through a feeding tube.

This is technology his living will gives him the right to decline. Although he's chosen to keep living, there have been times he's told his wife he wants to die, and she's had to decide how literally to interpret that.

Battin and Hopkins are in their early 70s. She's a distinguished professor of philosophy and still teaches full time. When he's doing well and not suffering from one of the many infections that have plagued him since the accident, he's able to do some teaching from his home, talk with friends who come to visit, go in his wheelchair on walks with his wife, and even occasionally get taken to a concert or museum.

Battin and Hopkins were profiled in the cover story of last Sunday's New York Times Magazine.

Peggy Battin, welcome to FRESH AIR. At what point were you able to talk with your husband and ask him what his wishes were if he preferred to live or to die? And I'm making the assumption here that that was a conversation you felt you needed to have, that his quality of life was so drastically different from what he thought he'd want to live with that you felt the need to have that conversation?

MARGARET BATTIN: It's odd that we didn't have that conversation. At least, I don't recall that conversation. And I think it's because in those early days, you are so intent on survival - can he pull through these respiratory problems? And once those were a little more stabilized and he was able to communicate, there's a whole new phenomenon, and that's the enormous expression of love and affection and concern from family members, friends, people you haven't seen for five years, this overwhelming involvement and concern by other people.

So your circumstances are so altered, and altered by this phenomenon that doesn't occur for most people in their ordinary lives; you don't have all of your entire family and your entire range of friends all showering you with love all at once. That's quite heady in a way. You might even say it's even sublime and its extraordinariness. That made a huge amount of difference.

So, at the beginning, we'd been told that the initial paralysis would last five to six weeks, anyway, and only after that would you have some sense of realistic prognosis. So while you worry about it you, knew that there was no point in thinking about it until after this period. Would he be able to get up and walk away eventually? Well, maybe. That's the kind of thing you can't tell. So such a choice would have been premature. Also, walking isn't the only thing in the world.

GROSS: So when was the first time that you were actually able to talk with your husband about whether he wanted to live or die, where he had enough information so he knew something of what his future would be?

BATTIN: I can't recall, Terry, exactly when that might have happened. It's one of those things that comes as an understanding. But the first couple of years, I don't think we talked about it very much at all.

GROSS: For the first couple of years you didn't.

BATTIN: That's right. I don't recall talking about it very much. We kept a detailed account of our thinking about things, and there are reflections in that account about how one's existence has been transformed, how one's way of seeing things - everything from eating, to sex, to friendship, to how those are transformed. But I don't recall discussions of dying.

GROSS: The impression I've gotten reading about you both is that there are times when your husband has told you that he wanted to die, and there's other times when he's told you that his life feels full and has some rewarding aspects that it didn't even have before his accident and injuries.

BATTIN: Mm-hmm.

GROSS: But how do you, as a bioethicist, who's advocated for the right to die, feel about - like how do you interpret it when your husband says he wants to die? How do you know whether that's something that he's going to change his mind about in five minutes, or whether that's something that you need to take seriously and honor?

BATTIN: Well, I think you have to take it seriously. That doesn't mean that because he says I want to die right now, that you have to marshal action about it. He has said that he wishes to die. I've heard this, however, a number of times in situations in which he's - in which typically an infection is brewing. And he also recognizes that. So he will say, but I don't really mean it, or I really, really desperately want to stay alive. So it's, in a way, it's up to me to try to sort out whether the request to die is an expression of distress or whether it's genuine.

GROSS: That is some huge responsibility.

BATTIN: Well, it's not easy, I can tell you that. It doesn't diminish in any way my belief and firmly considered position that people ought to be able, ought to be legally protected, legally empowered to control the character of their own deaths. I do favor legalization of Death with Dignity laws, but that doesn't mean that these decisions are always easy. I'm not a physician, I don't pretend to be, so under the Death with Dignity laws it would be the physician who made the determination of whether ceding to this request was appropriate or not.

GROSS: If your husband reaches the point where he feels life has lost any pleasure or meaning for him and that the pain or the helplessness or the despair is more than he wants to handle any longer and he decides that he would prefer to end his life, if that ever happens somewhere down the line, what would his options be? And I ask this knowing that you're not only his wife, but you're also a bioethicist who is an expert on the right to die.

BATTIN: Mm-hmm. I can tell you, it's a very, very strange experience to have spent 20 or 30 years - 30 years, actually, thinking and writing about these issues and having been involved in various sorts of public defense of the right to die favoring...

GROSS: Court cases, probably, right?

BATTIN: Court cases, right, teaching courses, writing papers, writing books, doing research, all those things. You try to always take account of what folks on the other side of this issue say. So I've been interested in conjectures about the possibility of abuse, for instance, or inadequately reasoned choices. But to have it become so real...

GROSS: Mm-hmm.

BATTIN: ...that someone you love - and love a lot, deeply - would be enmeshed in the same - it's not quite the same, but in the very kind of choice that you had been thinking about academically for so long, is an extraordinary experience. In one way, it's a healthy experience. That is, it forces me to rethink everything. And even doing that, and even given the acute, you might almost say agony of being so close to something that is so difficult, it doesn't change my basic position, that people should be recognized to have the right to not only live their lives in ways of their own choosing, but be the architects of their own lives, but that includes the very to the ends of their lives, especially since the very end makes the greatest amount of difference to some people.

GROSS: Your husband once asked to be taken off the ventilator and to be allowed to die. And he was removed from the life support technology that sustains him. So before we get to what happened, how did he reach the point of asking to do that and how did you reach the point of going along with him on that?

BATTIN: Well, this was together with one of our staff who's a respiratory therapist, and she and I were there and he had said he wanted to die a number of times. And this moment was just a moment where this seemed to be the right thing to do. So he said I want you to disconnect it all. He was in a state of considerable anguish. I want you to disconnect the ventilator. We did that. We turned off the oxygen and showed him that it was off.

So there he is without any of these things. And he sat in his wheelchair. This was in the middle of the afternoon. It was a very gray - happened to be the first of April, April Fool's Day, although there was nothing fooling about this. And he sat there as upright as he's able to make himself sit with his eyes closed. And he sat there. And he sat there. It was completely silent in this room.

After some very, very long minutes he opened his eyes and he looked around and he said, am I dreaming? Am I alive? And it took the respiratory therapist and me quite a while to have him understand that, yes, he was still alive. He wasn't dead. And when finally he understood that, he said, oh, I'm so happy. I'm overjoyed, he said. And this is a phrase he wouldn't characteristically use, but he said I'm a particularly happy camper.

He was elated. So what lesson do we draw from that? Now...

GROSS: Did he not realize and did you not realize that he was capable of breathing on his own for several minutes without the life support machinery?

BATTIN: Yeah. No, both the respiratory therapist and I knew that he would not die, or not die immediately. That's because he is often not on the ventilator. It's also the case that he often does not require supplemental oxygen. So we didn't think that that would be fatal. In fact, we both knew that, even though we didn't have to say so at the moment. And furthermore, we have all this rescue equipment around.

We have the ventilator right there in the room...

GROSS: Would you have used that, though? Because that would've been violating his wishes. If he was serious about dying and then he started choking as if he were in the process of dying, would you have revived him?

BATTIN: So that's a very hard question, Terry. I think we would have tried to revive him, right? Because you still don't know how serious his wish is. Now, supposing, though, he had opened his eyes after a few minutes just the way he did and said, what, I'm still alive? Are you serious? I am so disappointed. Oh, no. This is wrong. Right? Would you have done it over again? Would you regret that you had done it?

I don't know how to answer that.

GROSS: Were you very relieved that he'd reached this realization he actually wanted to live?

BATTIN: It was very - it was a huge relief for me and it was also a huge relief for him. And the respiratory therapist went home and cried, she was so relieved. And we were all relieved.

GROSS: Yeah. No, let me just pose a question here. Because, like, say there was physician-assisted suicide and he was so convinced he wanted to die and he'd been administered a lethal dose of something, when it turns out there was still a part of him that really wanted to live. He didn't know that? And he wouldn't have been allowed to discover that.

What kind of second thoughts does that give you as a bioethicist?

BATTIN: It doesn't give me second thoughts in the following respect, because if you take these steps under the instruction of the law, so to speak, under the protection of the law, there - it requires a much more formal process in the sense of making formal requests, signing papers. There's a waiting period.

GROSS: So it takes a lot of time.

BATTIN: It takes time. Under three of the statutes there's a waiting period of, I think it's 15 days. There have to be two oral requests at least and a written request. And as I said, there has to be a psychiatric or psychological consult if there's any question about mental capacity. And the kind of situation that he was in, this sense of agitation at that time, I think wouldn't have passed those psych - that is, they would've said that there's some extreme temporary anxiety here.

I think. But a more considered, more discussed, more openly disseminated decision, one that doesn't show any hints of ambivalence, that I believe should be respected.

GROSS: My guest is bioethicist Margaret Battin. We'll talk more after a break. This is FRESH AIR.

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GROSS: My guest is bioethicist Margaret Battin. After writing many books and articles about end of life issues and the right to die, she's had to deal with related issues in her own family. Four years ago her husband, Brooke Hopkins, broke his neck. He has quadriplegia and is dependent on life support technology but he can still talk and manages to teach some classes from his home.

Besides teaching, what gives your husband pleasure now? It's not food, because he can't eat. He gets his...

BATTIN: Well, actually, we've talked about food. He does have a feeding tube now and he has the, if you can call it, pleasure of being less likely to contract aspiration pneumonias. But we also thought about eating. Well, if you think about eating, what does eating involve? It involves the appreciation of the presentation of food. It involves the aroma of food. It involves the taste of food. Right? And you can still do all those things.

You can see it. You can smell it. You can put it in your mouth and taste it. And then do what a wine taster does - spit it our discreetly. And so what you don't do is swallow it, right? Well, swallowing is the least interesting part of eating. Right? The pleasure is not in the swallowing. It's in all the stuff that comes before that.

GROSS: Your husband was raised Catholic but identifies now as Buddhist and there's a Buddhist teacher who has visited him and talked about how the body is ephemeral. You know, one...

BATTIN: The body is nothing, he said. The body is nothing. The mind is everything. The thing about Buddhism - I don't have a sense that he's particularly interested in the theology of Buddhism, such as it is, but the sense of not looking backward at what you've lost - and he has not ever really done that very much, nor has he been angry, nor has he wanted to blame other people...

GROSS: Including himself?

BATTIN: Including himself. Also this tradition discourages worrying about the future. But the thrust of Buddhism that was the most helpful for him was the focus on the current moment. Now, that can be exaggerated and can be a source of philosophic complexity. What is the moment? How big is it? You know, problems like that. But just to focus on what's here and now. So a way of thinking about it for me, Terry, is that, well, in my life what's here and now?

Well, I'm talking with you. That's rather wonderful. Right? So I don't need to be worrying about what was in the past or what might happen in future if I enjoy the pleasure of this conversation. Even if it's about painful things, it's still something good about this moment.

GROSS: So, Peggy, I have one other question for you. Of all of the bioethics writing you've done over the years, of all the writing you've done about the right to die, is there anything you wish you could change now because of what you've experienced with your husband?

BATTIN: Well, at one point I said I'm tempted to go back and look at everything I've ever written on this topic and maybe throw it all away, but as I do go back and look at it, I don't see much that I would change. Except that the issue has become much, much more subtle, complicated. But it's not that the issue is more subtle, it's that people are more complicated.

A decision in any situation where right to die issues are coming up, and as I said, it's mostly terminal illness, that every single one of the people facing death will think about it differently. These are all still people facing an end and considering how they hope to do this. I sometimes use the expression the least worst death. It's the notion of individual reflection on how, given that death is coming anyway, you could make it the least worst for you.

That's the thinking that I do that hasn't changed at all. And it hasn't changed in Brooke's situation either. What would he regard as the least worst? Well, that we'll see.

GROSS: Well, I want to thank you so much for talking with us, and I wish you well.

And your husband too.

BATTIN: Thank you.

GROSS: Margaret Battin is a professor at the University of Utah. She and her husband, Brooke Hopkins, were the subject of the New York Times cover story last Sunday. You'll find a link to that article on our website, freshair.npr.org.

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