Barry Rosenfeld nicely captures
the central virtue of his book Assisted Suicide and the Right to Die in
the final paragraph: "Although this book began as a summary of what we
know and do not know, it has resulted in a litany of opportunities for
contributing to this important and still-evolving social and legal policy
issue" (175). Rosenfeld’s work canvasses the territory of assisted
suicide, euthanasia, and other means of "hastened death" by providing
both an historical account of these practices as well as a critical overview of
some of the most recent studies on end-of-life issues. Through careful
examination of the data from these studies, Rosenfeld challenges many of the
most common assumptions about the reasons why people request aid in dying and
the effects of legalizing hastened death practices. Rosenfeld’s remark that his
book reveals a "litany of opportunities for contributing" to research
in this issue does not mean that he spends one-hundred and seventy-five pages
merely asking questions; rather, his investigation provides a foundation for
those researching this issue, shows us what questions have already been asked
and what answers have resulted, and thus naturally inspires us to consider what
new questions need to be asked, or how better to ask the old ones.

Rosenfeld begins by addressing
the assumption that debate about assisted suicide and euthanasia is a relatively
recent development (Chapter 1). In ancient Greek and Roman culture suicide
itself was considered to be permissible, if not laudable, in particular
situations. Assistance in dying was similarly regarded. This attitude came to a
halt first with the rise of the Hippocratic school of medicine, with its
imperative that doctors must not provide harmful substances to their patients,
and later during the Christian era, as views about the "sanctity of
life" led theologians such as St. Augustine to condemn human interference
in the dying process, which was presumed to be an occurrence rightly determined
by God alone. During the Renaissance and Enlightenment periods, scholars such
as Thomas More, Francis Bacon, and David Hume challenged the view that hastened
death is always wrong, essentially arguing that a good is secured through death
in the relief of unrelenting pain. Such challenges went largely unheeded, as
the medical views on hastened death continued to follow the Hippocratic
tradition in condemning such practices. Although the issues were debated in
nineteenth century England and the United States, supporters of hastened death
remained a stark minority, and bills proposed in the early twentieth century to
legalize assisted suicide in order to increase patient autonomy failed. These
topics went largely unaddressed during the World War II era because of the
association of euthanasia with Nazi practices. Assisted suicide was first
decriminalized (albeit not legalized) in the Netherlands in 1984, and most
prominently entered the American spotlight in the 1990’s during the publicity
and controversy surrounding the practices of Jack Kevorkian.

Rosenfeld goes on to discuss
landmark legal cases in the United States, which showed the Supreme Court
gradually making room for hastened death, although not directly condoning such
practices (Chapter 2). Rosenfeld also considers the effects these legal
decisions had upon other end-of-life issues, such as how do not resuscitate
orders, living wills, advance directives, and surrogate decision-making should
figure into decisions about how to treat those with terminal illnesses and when
to withhold treatment (Chapter 3).

The heart of Rosenfeld’s work
focuses on methodological issues and recent studies about the causes for
aid-in-dying requests (Chapters 3-7; these issues reoccur in Chapters 8 and 9
where he specifically looks at hastened death practices in the Netherlands and
Oregon, respectively). Here, it is the data rather than Rosenfeld himself which
force us to take a much more tentative view of some common assumptions. Two of
the most central assumptions are (1) that physical pain or the threat of
physical pain is a main cause of desires or requests for hastened death, and
(2) that the presence of depression or depressive symptoms entails that a
person is incapable of making a "rational decision" about end-of-life
matters.

The most striking challenge to
the belief that pain provides a central motivation in requests for hastened
death is found in a study in which patients "who reported experiencing
pain at the time of study participation were actually less likely to approve of
euthanasia in the vignette describing unremitting pain than were patients who
were not in pain" (96). Other studies suggest differences in judgments depending
on the level of pain experienced. The upshot is that low levels of pain may not
increase the desire for hastened death, and appropriate palliative care (or
having this option proposed) seems to some extent to lessen the desire for
hastened death. In fact, other physical factors such as loss of physical
autonomy, loss of ability to control excretory functions seem to figure much
more prominently into the desire for hastened death. In addition, concerns
about dying with dignity (e.g. not in a state of physical or mental
helplessness) seem to influence the desire for hastened death much more than
physical pain, in studies of people suffering from terminal illnesses. Such
considerations suggest, for example, that arguments in favor of hastened death
as a means to relieve unremitting pain may be misguided, and that the ability
of physicians to provide adequate palliative care may make such arguments
irrelevant in many cases.

Another issue in aid-in-dying
issues is the effects of depression on decision-making. Rosenfeld notes a
survey of forensic psychiatrists in which "most (73%) of the respondents
indicated that a finding of a major depressive disorder ‘should result in an
automatic finding of incompetence’ regardless of the extent to which depression
appears to have influenced decision making" and adds that 38% of these
psychiatrists believed that even less severe mental diagnoses warranted a
similar judgment of incompetence (118). Rosenfeld suggests that such results
may indicate a bias against those who request aid in dying, since "the
physicians who favored an automatic finding of incompetence in the context of
depression were also significantly more likely to consider physician-assisted
suicide unethical." These are troubling facts, given several studies of the
effects of depression on decision making in which there were "very few
participants who demonstrated significant impairments in decisional
capacity," and suggesting "a relatively weak relationship between
severity of depression and decision-making impairment" (123). There are
even a few studies suggesting that people with depression are more
rational in decision-making. (Such results are found, for example, in studies
in which depressed people were less optimistic about the probabilities of the
occurrence of future events than non-depressed people who were more likely to
make overly optimistic predictions.) But it remains unclear whether these
results, which come from general studies of decision-making, apply to the
specific decisions involved in end-of-life matters.

A key problem in assessing the
role of depression in the desire for hastened death is that a desire to die is
generally included among the indicators of depression, for example, in the
widely used Beck Depression Inventory. But the very question is whether the
desire for hastened death, in circumstances such as the person’s having a
terminal illness, can be a rational response to the person’s unfortunate
circumstances. Rosenfeld calls attention to the possible utility of studying
the association between hopelessness (as a construct separate from depression
which can be rated by tools such as the Beck Hopelessness scale) and the desire
for hastened death, rather than focusing upon depression, since its role and
influence in end-of-life decision making is at best unclear.

The final section (Chapters 8
and 9) of Rosenfeld’s study focus on how the legalized practices of assisted
suicide and euthanasia have developed in the Netherlands and Oregon (only
assisted suicide has been legalized in the latter). Opponents of legalized
aid-in-dying often cite the possibility of a "slippery slope": that
the legalization of hastened death practices, once legalized, will be applied
to broader and broader groups of people and may cause the quality or availability
of palliative care to decline. In the Netherlands, euthanasia has been utilized
much more frequently than assisted suicide. (One estimate puts euthanasia at
1.8% and assisted suicide at 0.3% of all deaths resulting in 1990 (128,786).)
Furthermore, recent legal decisions seem to have extended the availability of
aid-in-dying to people who do not have a terminal somatic illness. Rosenfeld
cites the case of Ms. B. who ended her life with a lethal prescription after
battling severe mental illness for several years. The prescribing doctor was
reprimanded for not having "an independent medical expert" actually
examine Ms. B., but the practice itself was essentially vindicated. Although
such practices might seem to support "slippery slope" worries,
Rosenfeld notes that the number of requests for assisted suicide are quite low
in comparison to the number of requests made (2-5 fulfilled requests from over
300 requests made each year).

In Oregon, the Oregon Death With
Dignity Act (ODDA) seems, according to Rosenfeld’s review, to be running
smoothly. Here the "slippery slope" worry is not well supported.
Assisted suicide is restricted to people who have a terminal illness with less
than six months to live, have made more than one request for assistance, and have
been judged psychologically healthy enough to make such a decision. Studies of
the reasons people requested assisted suicide largely confirm the studies
mentioned above, which put a much higher premium on concerns about the loss of
autonomy and dignity than on concerns about physical pain. One feature of the
ODDA which Rosenfeld questions is the process by which psychological health
must be determined for a person to qualify for assisted suicide: the physician
decides whether to refer the person to a mental health professional for further
analysis. Rosenfeld points out that physicians are generally not well-trained
in recognizing mental disorders, and studies show that physicians grossly
underestimate the existence of depression in their patients (see, for example,
90-92).

Rosenfeld’s book is clear,
concise, and even-handed (even when he addresses his own past studies). He
provides a very useful history and survey of the research on this topic, and as
he himself recognizes, raises many questions and criticisms of this research
that will likely lead to improved and advanced studies in the future. This book
will be of most interest to social scientists and research psychologists
studying end-of-life matters, and will be informative to medical ethicists
wanting to know more about the sociological and psychological terrain of
end-of-life and aid-in-dying decision-making.

© 2005 Matthew Pianalto

Matthew Pianalto is a Ph.D. student in philosophy at the
University of Arkansas, where he has also taught logic and introduction to
philosophy. He holds a B.A. in English, and an M.A. in Philosophy. His master’s
thesis, "Suicide & The Self," attempts to reinvest in the
philosophical nature of the problem of suicide. More info at his website: http://comp.uark.edu/~mpianal. (See
"Suicide & Philosophy" link for resources on suicide.)

Categories: Ethics, Psychology