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The Case against Assisted SuicideReview - The Case against Assisted Suicide
For the Right to End-of-Life Care
by Kathleen M. Foley and Herbert Hendin (Editors)
Johns Hopkins University Press, 2002
Review by Tony O'Brien RN, MPhil
Sep 12th 2006 (Volume 10, Issue 37)

During the latter decades of the last century the issue of medical participation in death took on a new dimension, with several jurisdictions passing laws supporting assisted suicide, and public campaigns for and against in many others. Population demographics are partly responsible for this renewed debate. Increased survival rates from cancer, AIDS, and other diseases, together with an aging population, have led to increasing numbers of people with terminal illness, persistent vegetative states and Alzheimer's disease and other dementias. There is both a social and economic cost to this change in demographics. Health care is expensive, and health costs in the last year of life are extremely high. Increasing social emphasis on individualism at the expense of communitarian values means that the debate about euthanasia and assisted suicide is shaped by social influences that question the right to health care until the point of natural death, and that appear to pitch the rights of the dying against those of the rest of the population.

The Case Against Assisted Suicide makes the case for the retention of the traditional medical value of respect for life against the challenge of advocates for assisted suicide and euthanasia. This is a complex and deeply contested issue in which protagonists on both sides find themselves in unlikely alliances: libertarians alongside university academics; religious fundamentalists alongside humanist health professionals. There are health professionals and legal activists in both camps, and patient advocacy groups with diametrically opposed views. In such a divisive debate a single publication is never going to satisfy all those with an interest in the area; nor is it likely to canvas all perspectives dispassionately. This book's avowedly partial perspective means that those wishing to be well versed in both sides of the debate would be advised to read more widely, but as a start, The Case Against Assisted Suicide provides a good broad introduction into the history, medical science, ethics and sociology of assisted suicide. It also provides a clear statement of the views from one side of the debate.

The book is divided into four sections, with fourteen chapters written by doctors, law professors, academics and activists. They include some of the world's most prominent medical ethicists, who between them boast a formidable range of accomplishments in ethical theory and practice. The first section contains four chapters on the general issues of the ethics of assisted suicide, and the notions of autonomy and rights. The following section examines the operation of euthanasia and assisted suicide laws in the few jurisdictions that had such laws at the time of publication: the Netherlands and Oregon and, briefly, Australia's Northern Territory. Section three explores issues of disability and depression, with a further chapter written in the form of responses to claims in favor of assisted suicide. The final section covers hospice care and a summary of the alternatives to assisted suicide. A concluding chapter by the editors reviews the issues covered by the book, and outlines initiatives and programs for the future.

As the title suggests, The Case Against Assisted Suicide presents a twofold case: against physician assisted suicide and for the right to end of life care. The authors are under no illusion that palliative care is a panacea either medically or philosophically. They acknowledge that even with the best palliative care terminal illness can be undignified, painful, and uncomfortable. They also acknowledge the reality of double effect: that the treatment provided to palliate pain (especially opiate analgesics) can materially contribute to death. But their case rests on intent to relieve suffering (the first effect), not on the unintended, although well recognized hastening of death (the second effect). The distinction is a crucial one, underpinned by an abiding commitment to the doctor's commitment to life.

The twin issues of assisted suicide and euthanasia are modern dilemmas in that they have been highlighted by the capacity for medical technology to maintain life in cases where, in even the recent past, disease or degeneration would have spoken decisively. However it would be a mistake to conceptualize these issues as merely problems of adapting to technology. The individualism of the late 20th century and the changing role of the state create a social context in which end of life decisions, especially those based on a sense of duty to avoid making unreasonable demands on scarce health resources, render euthanasia and assisted suicide deeply problematic. Another theme of this book is that decisions on life and death should not be dependent on resources, and that the absence of good palliative care can act as a coercive influence in decision making. The justification of 'autonomy' might be as much the disciplined subject's response to devaluation of dependent life in the face of competition for resources as it is a radical expression of individual freedom. Even worse, as some of the Dutch research suggests, autonomy might be abrogated to the fatal paternalism of the doctor. The Case Against Assisted Suicide argues strongly that contextual factors, especially the availability of palliative care, and even the existence of laws allowing physician assisted suicide, mitigate against the exercise of autonomy. Against that argument it might also be said that autonomy is always constrained, and that to limit the exercise of autonomy out of concern that external influences might constrain it, is itself paternalistic.

The argument that legalization of assisted suicide changes clinicians' perceptions of the problems of terminal illness is addressed through several examples in which patients' clinical presentation is evaluated differently if assisted suicide is available. The point of this argument is that legalization is likely to have an independent effect in shaping not only clinicians' and societal views, but also on the expectations of patients. One example of this effect on perceptions is on the assessment of depression and suicidality, covered in a chapter by Harvey Chochinov and Leonard Schwartz. This example is also discussed by other contributors, who note a different standard applied to depression and suicidality in terminally ill patients than to those in the general population. In the terminally ill, they argue, depression and suicidal thinking are seen as an inherent part of terminal illness, not as problems to be treated. For that reason the rate of referral for psychiatric treatment is much lower in the terminally ill than in the general population. Suicidality is effectively normalized, setting a different standard than that otherwise applying in clinical practice. In some of this discussion there is a suggestion that suicidality is not only an accurate predictor of mental illness, but that it is also evidence of incompetence. More than one contributor suggests that suicidality in the absence of terminal illness would be grounds for a determination of incompetence and therefore for civil commitment. However the relationship between suicidality, mental illness and incompetence is by no means clear cut. In studies of emergency psychiatry, suicidality is a less reliable predictor of civil commitment than danger to others. There is certainly no ready acceptance by psychiatrists that suicidal thinking equates to incompetence. Nevertheless, Chochinov and Schwartz ask important questions regarding depression in the terminally ill, and especially of the possible effect on the evaluation of depression under conditions of legalized physician assistance. Given the high rate of depression in severe and terminal illness, a low rate of referral for psychiatric evaluation is of concern. The evidence presented in the book is consistent with the psychiatric literature in arguing that negative thoughts, including the wish to die, diminish with treatment of an underlying mood disorder. Depression and its relationship to suicidal ideas is one of a number of examples of where the drive for assisted suicide is strengthened by less than optimum health care.

The other example of the effect of available services on perception of terminal illness is the case of palliative care. Indeed, as the subtitle of this book suggests, in the view of these authors, palliative care is the issue that should take precedence over any right to physician assistance in suicide. The chapter by Cicely Saunders is devoted specifically to palliative care provided by hospice services, and other contributors stress that the availability of good palliative care would do much to reduce public demand for assisted suicide. The case of the Netherlands is cited as an example par excellence of how assisted suicide came to be the default option for the terminally ill because of the absence of a good network of palliative care services. In reviewing the Northern Territory experience David Kissane also comes to the conclusion that the answer to calls for assisted suicide is improvement of palliative care services. Foley and Hendin in their review of Oregon's Death with Dignity legislation make similar comments about that jurisdiction. Two chapters are given to the Oregon case, which is examined in considerable detail. Foley and Hendin background the development and implementation of the law, and psychiatrist N Gregory Hamilton discusses the issues of public and professional accountability thrown up by the Oregon legislation.

Altogether the coverage is comprehensive, even a little repetitive. The themes of how death is seen in society, the inadequacies of traditional health care in the face of death, progress in palliative care, and the dangers inherent in legalized euthanasia recur throughout the book, although it would be fair to say that the multiple explorations of these themes results in a breadth of coverage that would be difficult in a more limited publication.

One thing The Case Against Assisted Suicide doesn't do is to fully explore the philosophical debate on assisted suicide. The book's most powerful claim is to argue against the claims of proponents of assisted suicide: the benefits asserted are either not fulfilled, or they are outweighed by significant harms. The thrust of the book is deontological, although The Case Against Assisted Suicide is not fully analyzed in deontological terms; nor is there a full exploration of the utilitarian argument for assisted suicide. However this is not primarily a philosophically argued text; the arguments rest on interpretations of medical ethics, and implicit theories of social justice.

Like most professionals who seek solutions to the questions raised by end of life care, my own views are formed by a range of personal and professional experiences. My mother developed dementia in her seventies, as did her mother, although she was a decade older. In my nursing career I have cared for many elderly people with dementia, and not a few younger people as well. I have no doubt that dementia robs the sufferer and their family of some essential aspect of the person. Nothing can prepare a spouse, a son or daughter, a sibling, a loved one, for the vacant look of non-recognition, the perplexed gaze when you explain yet again that you are not leaving for school, there is no need to milk the cows, that the young person your mother has just spoken to really is your son or daughter. Yet amongst the sadness and despair of dementia there can be meaning not found in ordinary circumstances. To anyone who doubts that proposition I recommend Sandra Sabatini's The one with the news. In my own case I hold memories of time spent alone with my mother, visiting her in her nursing home. There was something in those shared moments that was more than a son's obligation to his mother. It had something to do with recognizing the absolute irreplaceability of a person, and the need to show that people are more than the abilities and attributes that allow them to function in the world. To some extent this goes against Singer's distinction between human beings and persons, but the most rationally defensible definitions do not necessarily fit with lived experience.

I also have very strong memories from my early years as a nursing student, of caring for people with terminal cancer, watching their lives ebb away, with no words that could do justice to the tragedy of a life lost. But what does it mean for a nurse or a doctor, professed as they are to upholding the sanctity of life, to acquiesce to the wish to end a life, to act as the final instrument of death? The contributors to this volume share the view that it is one step too far. They accept that their commitment prevents a 'release', something assisted suicide advocates hold up as a merciful and compassionate action. But they also share the view of Edmund Pellegrino that to attempt such an act of compassion is to take an existential position that for some people there is no meaning in suffering, and that the problem of loss of meaning can be extinguished by extinguishing a life. There might be some questions about whether opting for death really does mean that there is no meaning in suffering. But the contributors to this volume nail their colors firmly to the mast: physician assisted suicide is a denial of life.

In my own country public tolerance of assisted suicide was tested in a recent case involving a registered nurse who contributed to the death of her mother by manipulating her prescribed dose of morphine. Lesley Martin was subsequently jailed for manslaughter, although in a somewhat incoherent judgment by a professional disciplinary body, she was not struck off the nursing register, but given conditions under which, in the future, she could apply to practice nursing again. Despite a the tediously predictable chorus of support for Ms Martin - most of it confined to talkback radio and populist opinion pieces there has been no attempt to relax legislation preventing assisted suicide, and there appears to be little appetite for any such move. In the Lesley Martin case there were many references to the suffering of Ms Martin's mother, and to the futility of human life under such conditions. Martin's case illustrates one of the central problems in the debate about assisted suicide and euthanasia. As Yale Kamisar argues in The Case Against Assisted Suicide, there is no shortage of cases which, stripped of their full context can make an argument for premeditated death at the hands of a health professional. It also needs to be noted that such cases are not the best exemplars of The Case Against Assisted Suicide. Sensational cases make ready headlines but they seldom inform debate in a meaningful way.

The Case Against Assisted Suicide was published in 2002, and much water has passed under the bridge since that date. Late in 2002 Belgium became the second country in the world after the Netherlands to legalize euthanasia. In 2004, by a two to one decision, a US appeals court blocked attempts by Attorney General John Ashcroft to order doctors in Oregon not to comply with the State's euthanasia law. Whether such developments represent the emergence of an international trend is too early to say. The repeal of the Northern Territory law (albeit that it was poorly conceived) suggests that pubic views of euthanasia are far from settled, and that laws once passed will not always have the effect of cementing these measures in place. As a rule, countries seem loath to legalize euthanasia, citing (as in the case of the United Kingdom) the problem of ensuring decisions really are voluntary. No doubt the shadow of the Nazi era, together with pre-Nazi experiments with euthanasia and eugenics looms large over decision makers. They also seem to be persuaded by the concern expressed by contributors to this volume, that legalization of assisted suicide would undermine both respect for life, as well as the development of palliative care services. Their case is made easier by the sort of work described in The Case Against Assisted Suicide as they are able to cite improvements in palliative care and greater understanding of symptom management. Showing commendable even handedness, Johns Hopkins have since published a rejoinder to The Case Against Assisted Suicide. Medical professor Timothy Quill and philosopher Margaret Battin have edited a collection titled: Physician-Assisted Dying: The Case for Palliative Care and Patient Choice. The debate is by no means settled.

It is something of an oversight that The Case Against Assisted Suicide contains no contribution from nurses. At the risk of seeming opportunistic it needs to be noted that much of the care of the terminally ill, and almost all of the residential care of people with dementia is carried out by nurses. There is no shortage of nursing academics who could have contributed to this work. Oversight or not, the book provides a comprehensive, persuasively argued case against assisted suicide. Those who disagree with the ideas of this book have a dual task: to provide an equally compelling argument for their cause, and to provide it in a form that meets such a high standard of analysis and argument.


2006 Tony O'Brien


Tony O'Brien RN, MPhil, Senior Lecturer, Mental Health Nursing, University of Auckland,


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