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Related Topics
Physician-Assisted DyingReview - Physician-Assisted Dying
The Case for Palliative Care and Patient Choice
by Timothy E. Quill and Margaret P. Battin (Editors)
Johns Hopkins University Press, 2004
Review by Antonio Casado da Rocha, Ph.D.
Sep 19th 2006 (Volume 10, Issue 38)

This volume, by a group of physicians, ethicists, lawyers, and activists, is a defence of the legalization of physician-assisted dying for the few and mostly terminally ill patients who voluntarily request it. It is written in response to the one previously edited by Kathleen Foley and Herbert Hendin also for Johns Hopkins University Press, one of the leading publishers in the field of medical humanities (see The Case Against Assisted Suicide: For the Right to End-of-Life Care, 2002, reviewed in Metapsychology by Tony O'Brien on Sep 12th 2006).

The book, which provides a comprehensive account of the issue and will be of interest to professionals and patients at large, is divided into four parts. The first examines the perspectives of mercy, nonabandonment, autonomy and choice. The second explores the clinical, philosophical, and religious issues that underlie end-of-life practices (including a piece by John S. Spong, a Bishop arguing for the compatibility of Christianity with suicide!). Part three examines practice in Oregon and the Netherlands, two places where physician-assisted dying is now legal (but controversial). The last section deals with some of the turmoil that has surrounded the debate on this issue in the United States.

Its contributors are well-known, especially distinguished authors such as Quill, Battin, Cassell, Beauchamp, or Brock. In general, they champion the causes of patient autonomy, mercy, and ongoing commitment to the patient, and answer the charges of those who oppose physician-assisted suicide because their worry about the wrongness of killing, the diminished integrity of physicians, and the risk of abuse. The Oregon and Dutch cases are carefully described, often by leading agents in those experiences, such as Els Borst-Eilers, Minister of Health in the Netherlands for many of the years under study.

In the introduction, Battin and Quill expose how the argument over physician-assisted dying has often been based on a false dichotomy: "What would you have, access to hospice and palliative care (that is, medical relief of pain and suffering in dying) or access to physician-assisted death?" Put it this way, most people would choose the former option, not the latter. But that is not a genuine choice, this book argues, as the Oregonian and Dutch experiences show that good palliative care, including that provided by hospice, is compatible with physician-assisted death. As Lee argues, from the viewpoint of Compassion, a nonprofit organization, it is possible to implement a model that integrates assisted dying with excellent end-of-life care, and it is necessary because "suffering may be more tolerable when it is endured voluntarily."

Many of the articles include moving and detailed cases, such as the one by Angell, who describes the tragic circumstances of her father's suicide and concludes that mercy requires physicians not only to provide pain relief, but also to consider the wishes of dying patients with unrelievable suffering. Other articles provide more theoretical perspectives, such as the one by Preston, Gundison and Mayo, who explain the role of autonomy in choosing physician aid in dying, defending it against concerns about decision-making capacity, or about extreme individualism. Quill and Cassel provide an elaboration of the concept of non-abandonment as a central obligation for physicians, stressing that they should make every effort to find common ground with those patients. Some pieces are based on empirical studies, such as the one by Pearlman and Starks describing why people seek physician-assisted death. The patient's wish to retain some measure of control and the doctor's communication skills (studied in the article by Back) seem to be crucial in this process of decision making, one in which the patient's wishes and competent consent are more morally relevant, Beauchamp and Brock suggest, that whether the act are categorized as "active" versus "passive," or "killing" versus "letting die."

 The book is dedicated to Andrew Batavia, scholar and founder of AUTONOMY, Inc., who died before it was published. In his article, Batavia describes the history and inner tensions of the disability community in the USA, which is not as against this practice as it is normally understood, and the central essays assess the effects of an open practice of physician-assisted dying in two legally tolerant environments, one in Europe and the other in America.

Three essays discuss the Dutch practices since 1973. Van Delden, Visser, and Borst-Eilers summarize the debate on legalized euthanasia, and conclude that there is no empirical evidence to support the suggestion that the Netherlands is on a slippery slope. Even though there are a number of cases of life-terminating acts without explicit request of the patient, the Dutch law is supported by a large majority of the population and is grounded in good medical practice; van Kloot Meijburg provides a vivid narrative of one of those cases in which everything goes well. Kimsma and van Leeuwen provide evidence that the emotional impact of assisted dying on physicians shows that these practices are not easier options than palliative care, as their critics have suggested.

 As for the US, the essay by Sylvia Law compares the movement for legalization of physician-assisted death with other liberation movements over the past forty years, and Baron traces the legal risks of maintaining the current policy of passive legal prohibition outside of Oregon, where from the 1997 enactment of the Oregon Death with Dignity Act until 2003, 171 terminally ill patients have secured legal assistance from their physicians in ending their lives. Stutsman discusses some of the politics that made this possible; Ganzini provides a comprehensive account of the experience, and Goodwin an assessment of those ill-directed critiques that saw in the data evidence of abuse. Additionally, Tucker describes the two legal cases contesting the issue before the US Supreme Court (Glucksberg v. Washington and Vacco v. Quill), and Meisel analyses the legal implications of the vague distinction between actively and passively hastening death, suggesting that public policy needs to provide adequate safeguards regardless of the means by which death is hastened.

The conclusion by Quill and Battin is clear: excellent palliative care should be the standard, and physician-assisted dying the last resort, but a legal one. In view of the panoply of arguments and data offered by this excellent book, it is easy not to disagree. However, this issue is emotionally very charged, and the controversy will surely go on. There are even a number of films dealing with it now. In The Barbarian Invasions (2003), it seems that no-one who took part in the medically assisted suicide of the main character was convinced that it was morally wrong. Million Dollar Baby (2004) depicts a more complex -- and realistic -- situation, one in which family and friends are divided about it, and one that suggests that hastening a patient's death, when it satisfies a set of strict safeguards, is not something that should be forbidden by the law.

 

2006 Antonio Casado da Rocha

 

Antonio Casado da Rocha, Ph.D., teaches Philosophy at the University of the Basque Country, Spain.


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