Toward the end of Death and Compassion: A Virtue-Based Approach
to Euthanasia, the author opines, "One of the most significant
developments in ethical theory over the past few decades has been
the revival of virtue ethics, which occurred mainly as a response
to the perceived shortcomings of principle-based ethical systems"
(177). This book is a solid contribution to the virtue ethics
"revival." Although the tradition of virtue ethics has
never really been dead such that it needed reviving (Alisdair
MacIntyre's After Virtue notwithstanding), van Zyl is correct
in claiming that the field of medical ethics or, more broadly,
bioethics has been dominated by principle-based ethical systems.
Since medical ethics itself is preoccupied with end-of-life issues,
van Zyl's virtue-based approach to euthanasia is a welcome alternative
in that it uses "the problems surrounding euthanasia as a
vehicle for radically rethinking the dominant mode of thinking
in bioethics" (ix).
The six chapters in this book each contribute to an overall argument
about the virtue of virtue-based approach to euthanasia. The first
chapter traces the historical development of medical practice
from Graeco-Roman antiquity, to the Middle Ages, to the modern
scientific era, from an ethic of virtue to an ethic of duty in
order "to develop a fuller understanding of the state of
contemporary medical science and ethics" (14). This historical
study yields a picture of the contemporary as "a detached
authority-figure, his competence rooted in experimental science
and the elaborate methods of clinical evaluation and patterns
of clinical care" (30). Not surprisingly, the ethical approach
bound up with this contemporary understanding of medical practice
is a principle-based one.
Chapter two takes up the issue of how principle-based ethic deals
with end-of-life care and how it understands and responds to the
issue of euthanasia. In sum, van Zyl argues, "The language
of rights and principles is ill-suited to dealing with the problems
and questions surrounding the treatment of terminally- or chronically-ill
patients" (39). Van Zyl wonders whether Seneca was right
when he said that "death is sometimes a punishment, often
a gift" (58), whether euthanasia can ever be seen as the
appropriate expression of compassion and, furthermore, whether
death can ever be seen as the appropriate goal of treatment. He
concludes that, sadly, compassion has largely lost its relevance
in science and ethics in the modern era, that "the application
of universal rules of conduct to specific cases often results
in a failure to achieve the best possible outcome" (68),
and that the modern principle of respect for patient autonomy
has distorted what it means to respect human dignity. Van Zyl
takes up these points at some length in the next three chapters.
Chapter three begins van Zyl's positive argument for the appropriate
response to euthanasia. His primary concern in this chapter is
to develop an account of compassion which demonstrates "that
scientific and humane values do not constitute two incommensurate
forces" (70). It is at this point that van Zyl introduces
two works that will figure in the rest of the book, Sophocles'
Philoctetes and Tolstoy's The Death of Ivan Ilyich.
He uses these works to show that his account of compassion is
immune to the Platonic and Stoic criticisms that compassion is
irrational and rests on false beliefs and that compassion is disrespectful
towards the sufferer. Developing Aristotle's concept of phronesis,
van Zyl's point is that properly understood, compassion does not
have to be reduced to the Nietzschean concept of pity, and though
compassion contains a necessarily rational element, it nevertheless
allows a more comprehensive understanding of the sufferer's condition
than does a purely scientific point of view.
In chapter four van Zyl faces Kant and Mill head on in order to
develop "a teleological notion of 'responsible benevolence'
as a means to overcome some of the shortcomings of principle-based
ethics" (103). Kant objects to virtue ethics claiming that
benevolence has to be motivated by a sense of duty, rather than
sentiments or virtues such as compassion. Mill objects that compassion
is not sufficient for producing acts that are truly beneficent.
Indeed, some utilitarian "would argue that it is exactly
the compassionate person's emotional involvement that prevents
him from acting beneficently" (106). From van Zyl's more
comprehensive understanding of benevolence, he can argue that
"apart from its role in understanding suffering and conveying
respect to the sufferer, compassion plays an important role not
only in motivating us but also in enabling us to
benefit others" (143).
Chapter five again confronts Kant and Mill, this time on the meaning
of autonomy. The problem with the Kantian emphasis on the principle
of autonomy, claims van Zyl, is that respect for persons is determined
"by an evaluation of that person's ability to understand
and rationally weigh up medical facts. The Kantian ethic has too-limited
a conception of respect for persons" (156). As or Mill, "the
obvious problem with the utilitarian justification for the principle
of respect for individual freedom is that mature people, particularly
the ill, are simply not as rational and as competent as Mill believes
they are" (161). Thus, the question whether euthanasia can
ever be seen as showing respect for a person, allowing that person
to 'die with dignity'" (ix). Van Zyl develops an account
of autonomy s that does not derive from the notion that "individuals
are, or should be, independent" (163), one not grounded
primarily in rationality.
Chapter six offers us van Zyl's positive, virtue-based, account
of the appropriate response to euthanasia. One of the most common
criticisms of virtue-based ethical systems is that they cannot
offer anything but vague guidelines for morel decision-making.
In this chapter van Zyl acknowledges "the need for a clear
set of moral guidelines that can be used as a basis for policy-making"
and offers "a virtue-based approach to policy-making"
(177) that "does allow us to formulate a set of rules that
can be used to decide about the moral acceptability of intentionally
terminating or shortening a person's life" (211). Van Zyl
understands that "we cannot expect to completely substitute
rule-following for careful and arduous moral decision-making"
(212) and that there will always be a certain amount of "creativity"
necessary. But his is in fact the strength of his approach. His
approach to the Cruzan case is typical. "Giving absolute
priority to the principle of patient autonomy requires one to
attempt to decide what the patient would have wished of she
were capable of wishing and if she were at the same time capable
of experiencing her current situation. This, to my mind, is
a thoroughly nonsensical question" (194). For van Zyl, in
a virtue-based approach the way a decision is made is just as
important as the context of the decision.
Death and Compassion represents the best in philosophy.
It grapples with a difficult, topical issue; it cogently argues
for a specific position; and it calls on a number of the best
minds in the western tradition in order to do so. It calls on
the likes of Homer, Hippocrates, Aristotle, Plato, Sophocles,
Seneca, the New Testament, Verdi, Thomas Sydenham, de la Mettrie,
Descartes, Hume, Kant, Mill, Nietzsche, and Cabot, to name a few.
I truly hope this book reaches a wide audience. It has the potential
of widening and deepening the debate about euthanasia, at a time
when those looking to bioethics for guidance seem to finding the
same narrow considerations again and again, just packaged in this
way rather than that. Death and Compassion is a truly insightful
work that could well contain the new ideas that the euthanasia
debate needs to move beyond the intractable.
© 2001 Ben Mulvey
Ben Mulvey, Ph.D., is an
Associate Professor of Philosophy and Director of Liberal Arts
at Nova Southeastern University. He received his doctorate in
philosophy from Michigan State University with a specialization
in political theory and applied ethics. He teaches ethics at NSU
and is a member of the board of advisors of the Florida Bioethics