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Death and CompassionReview - Death and Compassion
A Virtue-Based Approach to Euthanasia
by Liezl van Zyl
Ashgate Publishing, 2000
Review by Ben Mulvey, Ph.D.
Oct 18th 2001 (Volume 5, Issue 42)

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 Network.


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