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 20^th 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, a.obrien@auckland.ac.nz

Categories: Ethics, Philosophical