This volume, by a group of
physicians, ethicists, lawyers, and activists, is a defence of the legalization
of physician-assisted dying for the few and mostly terminally ill patients who
voluntarily request it. It is written in response to the one previously edited
by Kathleen Foley and Herbert Hendin also for Johns Hopkins University Press,
one of the leading publishers in the field of medical humanities (see The
Case Against Assisted Suicide: For the Right to End-of-Life Care, 2002,
reviewed in Metapsychology by Tony O’Brien on Sep 12th 2006).

The book, which provides a
comprehensive account of the issue and will be of interest to professionals and
patients at large, is divided into four parts. The first examines the
perspectives of mercy, nonabandonment, autonomy and choice. The second explores
the clinical, philosophical, and religious issues that underlie end-of-life
practices (including a piece by John S. Spong, a Bishop arguing for the
compatibility of Christianity with suicide!). Part three examines practice in Oregon and the Netherlands, two places where physician-assisted dying is now legal (but
controversial). The last section deals with some of the turmoil that has
surrounded the debate on this issue in the United States.

Its contributors are well-known,
especially distinguished authors such as Quill, Battin, Cassell, Beauchamp, or
Brock. In general, they champion the causes of patient autonomy, mercy, and
ongoing commitment to the patient, and answer the charges of those who oppose
physician-assisted suicide because their worry about the wrongness of killing,
the diminished integrity of physicians, and the risk of abuse. The Oregon and Dutch cases are carefully described, often by leading agents in those experiences,
such as Els Borst-Eilers, Minister of Health in the Netherlands for many of the
years under study.

In the introduction, Battin and
Quill expose how the argument over physician-assisted dying has often been
based on a false dichotomy: "What would you have, access to hospice and
palliative care (that is, medical relief of pain and suffering in dying) or
access to physician-assisted death?" Put it this way, most people would
choose the former option, not the latter. But that is not a genuine choice,
this book argues, as the Oregonian and Dutch experiences show that good
palliative care, including that provided by hospice, is compatible with
physician-assisted death. As Lee argues, from the viewpoint of Compassion, a
nonprofit organization, it is possible to implement a model that integrates
assisted dying with excellent end-of-life care, and it is necessary because
"suffering may be more tolerable when it is endured voluntarily."

Many of the articles include moving
and detailed cases, such as the one by Angell, who describes the tragic
circumstances of her father’s suicide and concludes that mercy requires
physicians not only to provide pain relief, but also to consider the wishes of
dying patients with unrelievable suffering. Other articles provide more
theoretical perspectives, such as the one by Preston, Gundison and Mayo, who
explain the role of autonomy in choosing physician aid in dying, defending it
against concerns about decision-making capacity, or about extreme
individualism. Quill and Cassel provide an elaboration of the concept of
non-abandonment as a central obligation for physicians, stressing that they
should make every effort to find common ground with those patients. Some pieces
are based on empirical studies, such as the one by Pearlman and Starks
describing why people seek physician-assisted death. The patient’s wish to
retain some measure of control and the doctor’s communication skills (studied
in the article by Back) seem to be crucial in this process of decision making,
one in which the patient’s wishes and competent consent are more morally
relevant, Beauchamp and Brock suggest, that whether the act are categorized as
"active" versus "passive," or "killing" versus
"letting die."

 The book is dedicated to
Andrew Batavia, scholar and founder of AUTONOMY, Inc., who died before it was
published. In his article, Batavia describes the history and inner tensions of
the disability community in the USA, which is not as against this practice as
it is normally understood, and the central essays assess the effects of an open
practice of physician-assisted dying in two legally tolerant environments, one
in Europe and the other in America.

Three essays discuss the Dutch
practices since 1973. Van Delden, Visser, and Borst-Eilers summarize the debate
on legalized euthanasia, and conclude that there is no empirical evidence to
support the suggestion that the Netherlands is on a slippery slope. Even though
there are a number of cases of life-terminating acts without explicit request
of the patient, the Dutch law is supported by a large majority of the
population and is grounded in good medical practice; van Kloot Meijburg
provides a vivid narrative of one of those cases in which everything goes well.
Kimsma and van Leeuwen provide evidence that the emotional impact of assisted
dying on physicians shows that these practices are not easier options than
palliative care, as their critics have suggested.

 As for the US, the essay by
Sylvia Law compares the movement for legalization of physician-assisted death
with other liberation movements over the past forty years, and Baron traces the
legal risks of maintaining the current policy of passive legal prohibition
outside of Oregon, where from the 1997 enactment of the Oregon Death with
Dignity Act until 2003, 171 terminally ill patients have secured legal
assistance from their physicians in ending their lives. Stutsman discusses some
of the politics that made this possible; Ganzini provides a comprehensive
account of the experience, and Goodwin an assessment of those ill-directed
critiques that saw in the data evidence of abuse. Additionally, Tucker
describes the two legal cases contesting the issue before the US Supreme Court
(Glucksberg v. Washington and Vacco v. Quill), and Meisel
analyses the legal implications of the vague distinction between actively and
passively hastening death, suggesting that public policy needs to provide
adequate safeguards regardless of the means by which death is hastened.

The conclusion by Quill and Battin
is clear: excellent palliative care should be the standard, and
physician-assisted dying the last resort, but a legal one. In view of the
panoply of arguments and data offered by this excellent book, it is easy not to
disagree. However, this issue is emotionally very charged, and the controversy
will surely go on. There are even a number of films dealing with it now. In The
Barbarian Invasions (2003), it seems that no-one who took part in the
medically assisted suicide of the main character was convinced that it was
morally wrong. Million Dollar Baby (2004) depicts a more complex — and
realistic — situation, one in which family and friends are divided about it,
and one that suggests that hastening a patient’s death, when it satisfies a set
of strict safeguards, is not something that should be forbidden by the law.

© 2006 Antonio Casado da
Rocha

Antonio Casado da Rocha, Ph.D., teaches
Philosophy at the University of the Basque Country, Spain.

Categories: Ethics, Philosophical