The Oxford Handbook of Ethics at the End of Life explores contemporary moral issues regarding death and dying.  Contemporary medical understanding and technology allow human beings more control over when, and how, people die and this book seeks to address the ethical issues surrounding this control.

The book contains 27 new essays, and is divided into four sections.  Section 1 — Clinical and Legal Issues contains 10 essays discussing the law and patients’ rights.  Section 2 — Theoretical, Cultural, and Psychosocial Issues contains 10 essays exploring a variety of issues related to death and dying, including how people feel about death and dying across various groups (age, race, culture), including an engaging essay by Susannah L. Rose and Janelle Highland that explores the immense personal and financial costs associated with dying and how these affect the health care choices of those facing death.

Section 3 — Physician-Assisted Death includes only 4 essays on physician-assisted suicide and euthanasia.  This includes one essay titled “The Case Against Physician-assisted Suicide and Euthanasia” by Ira Byock and one essay titled “Goodbye, Thomas:  The Case for Physician-Assisted Dying” by Margaret P. Battin.  Section 4 includes 3 essays on palliative care and hospice.

What is most striking about this collection of essays is its incompleteness.  This is most apparent in section 3, which is disproportionately brief considering the expansive literature regarding euthanasia — both regarding questions of its moral acceptability and legal challenges.  This review will primarily focus on the incompleteness of this section.

Is it fair to expect completeness from this text?  Perhaps not.  Sections 1 and 2 contain a variety of essays with little connection between the topics.  However, many of these essays address important topics that you would expect to find in such a collection — Mark R. Wicclair’s “Conscientious Objection” is a largely accessible analysis of important issues regarding conscientious objection that provides important context for many discussions to follow.  “Continuous Sedation at the End of Life,” by Sigrid Sterckx and Kasper Raus explores an important alternative to euthanasia and physician assisted suicide (oddly, this is contained in section 1, rather than section 3).

In contrast to the other sections, Section 3 presents a clear, unified narrative, beginning with Gerrit Kismsma’s “Physician-Assisted Death in the Netherlands” — an essay exploring the moral and legal challenges associated with physician assisted suicide, followed by Byock’s set of arguments against suicide and active euthanasia and Battin’s defense of physician-assisted suicide, and ending with Nathan Fairman and Scott A. Irwin’s “Depression and the Desire to Die Neat the End of Life” — an exploration of the impetus for physician-assisted death.

Given the relative unity of the essays in section 3, one could make a case that section 3 succeeds in what it intends to — giving new readers a foundational understanding of physician assisted suicide — how it is implemented today, reasons for and against, and motivation to pursue it.  Setting aside the content of these essays, this might be sufficient for a The Oxford Handbook of the Ethics of Physician-Assisted Suicide as a part of a series on end of life ethics.  However, there are robust contemporary debates regarding a variety of issues for end of life care, and the topic of physician assisted suicide is mostly understood as an alternative to other options.  In particular this section largely neglects the following topics (each still very heavily debated in contemporary literature):

·         (The morality of) Suicide

·         Is there a right to die?

·         (Voluntary, involuntary, non-voluntary) Active Euthanasia

·         (Voluntary, involuntary, non-voluntary) Passive Euthanasia

·         Is there are morally relevant difference between acting and refraining, killing and letting die (active and passive euthanasia)

Byock’s analysis of physician-assisted suicide is largely handicapped by a failure to offer a cogent analysis of the morality of suicide in other contexts.  In his often- reprinted article “Why Abortion is Immoral,” Don Marquis presents a theory of the value of human life according to which suicide is usually a great harm to the person — it harms the person by robbing them of all possible futures of value; however for Marquis, when suicide does not cut off a possible future of value (in those hopefully rare cases where there are no valuable futures possible for the agent), death is not a harm to the person.

Furthermore, suicide and physician-assisted suicide are often done in radically different contexts — and the illegally of the later contributes to unnecessary suffering and likely avoidable deaths (after all, there are surely situations in which a suicidal person, seeking physician-assisted suicide, would be dissuaded from their choice given other options; indeed, this is the operating thesis of suicide hotlines).

Byock discusses the possibility of a right to die under a section titled “Public Confusion,” saying:

“Right to die” may be an effective social marketing slogan; however, the concept does not withstand ethical or legal scrutiny.  No civil right to suicide is found in social compacts… The United States was founded on certain unalienable rights, “that among these are Life, Liberty, and the pursuit of Happiness.” (373)

This is quite a dismissive and — ironically — contradictory.  Judith Jarvis Thomson’s well known article “A Defense of Abortion” illustrates this; there she argues that persons have a right to decide what happens to and in their bodies.  This right is sometimes construed as a property right (Fischer 2013), but is better understood as a right to liberty (Simkulet 2016).  Even if human beings have a separate moral obligation never to kill themselves, to have a right to liberty is for others not to have the right to make those sorts of decisions for you; as such the very rights Byock discusses provides the foundation for a right to die.

          The move from a right to die to physicians being allowed and/or obligated to help a patient end their life is fraught with perils — many of which Wicclair’s earlier article on conscientious objection touches upon — but that Byock refrains from exploring.

          Another challenge facing Byrock and Battin’s contrasting articles is a failure to distinguish the moral question of whether physician-assisted suicide is acceptable from the policy issues associated with implementing them.  The same can be said for euthanasia, which — surprisingly — gets very little attention in this collection of articles.

Any talk about euthanasia would be incomplete without a thorough analysis of the difference between voluntary, involuntary, and non-voluntary euthanasia, and the purported difference between active and passive euthanasia — both morally and legally.  James Rachels is well known for “Active and Passive Euthanasia”, a short, concise, and rigorous article raising concerns with the longstanding practice of treating active euthanasia (illegal in most places) differently from passive euthanasia (legal in most places).  At the core of this article was the question of whether there is a morally relevant difference between acting and refraining, in these cases killing and letting die.  How one answers this question has wide-ranging implications for a variety of issues in health care ethics, yet the issue gets almost no sensible attention here.  At best, the topic skirts discussion of the doctrine of double effect in several articles. 

The lack of any serious or rigorous discussion about euthanasia in this text is inexplicable.  The Oxford Handbook of Practical Ethics explores some of these issues in detail, but this book fails to even offer a summary of these issues, instead featuring two alternatives — physician assisted suicide, notable only insofar as it provides a way for physicians to distance themselves from the death in question, and continuous sedation until death, notable for robbing agents of the same kind of futures — either having or lacking value — that Marquis grounds the wrongness or acceptability of killing in.

Lastly, it is worth noting that the book contains almost no discussion of scarcity, rationing, or life-boat ethics.  These topics are largely left to the reader’s imagination during discussions of financial costs, but these discussions of financial costs are presented mostly in isolation of other concerns and largely as hurdles to individuals pursuing an idealized notion of end-of-life care.

Many of the essays in this collection provide adequate (and sometimes even compelling) introductions to some of the most important topics in contemporary health care ethics.  However, in this review I discussed highly influential, often reprinted articles in health care ethics by Don Marquis, James Rachels, and Judith Jarvis Thomson — that deal with foundational concepts regarding the value of life, the distinction (or lack thereof) between active and passive euthanasia, and the right to control one’s body respectively.  Before reading this book I never would have imagined that these topics — the crux of many of the issues in the contemporary debate concerning the health care at the end of life — would be absent.  There is good work here, but the missing pieces are more noticeable than the present pieces.

 

References:

Fischer, John Martin, 2013, “Abortion and Ownership”, Journal of Ethics: An International Philosophical Review, 17(4): 275-304.

LaFollette, Hugh (editor), 2003, The Oxford Handbook of Practical Ethics, Oxford University Press

Marquis, Don, 1989, “Why Abortion is Immoral”, The Journal of Philosophy, 86(4): 183-202.

Rachels, James, 1975, “Active and Passive Euthanasia”, The New England Journal of Medicine 292(9): 78-80.

Simkulet, William, 2016, “Abortion, Property, and Liberty”, Journal of Ethics: An International Philosophical Review, 20(4), 373-383.

Thomson, Judith Jarvis, 1971, “A Defense of Abortion”, Philosophy and Public Affairs, 1(1): 47-66.

 

© 2017 William Simkulet

 

William Simkulet, Ph.D., University of Wisonsin, Marshfield/Wood County