Book Reviews

When Death Is Sought: goal of empowering patients strikes a letting nature take its course. In fact, sur­ sympathetic chord in many Americans. veys show that more than 60 percent of Assisted Suicide and People are afraid of the prolonged and Americans favor legalization of some painful dying often associated with mod form of physician assisted suicide (PAS). Euthanasia in the em life-sustaining technology. Our soci­ Oregon's citizens recently approved the ety's decades long emphasis on individu­ first such initiative. I.ike abortion, this Medical Context al self-determination has led main to issue is likely to polarize the American claim a new "right," the right not to suf­ public for years to come-and in the pro­ The New York State Task Force on Life fer indignity and loss of control at the cess generate more heated rhetoric than and the Law end of life. It seems plausible to many thoughtful discourse. New Turk City, 1995, 217 pp., $9 (paperback) Americans that assisted dying is an In New York, as in 31 other states, appropriate extension of healthcare. We assisting suicide is currently a statutory have seen a growing acceptance—and fre­ offense; active euthanasia is illegal in even' 1'NVSK IAN-ASSISTF.D SUICIDE IS LIKELY TO 1 be a focus of debate for some time. Dr. quency—of physicians' helping patients state. In 1992 the New York State Task Jack Kevorkian's suicide machines and die by removing unwanted or excessively force on Life and the law | NYSTFLL) parked vans may be easily dismissed as burdensome life-prolonging therapy. set out to study the public policy implica­ The discussion has now moved beyond publicity-seeking antics, but his espoused tions of legalizing these practices.

RESOURCE BRIEFS

Procuring Organs for Transplant: The In a mulrjdisciplinary approach, contrib­ prohibition against killing, ami benefi­ Debate over Non-Heart-Beating utors to this text examine the health, cence. The final chapter sketches a pas­ Cadaver Protocols medical, and social policy implications toral response to the euthanasia move­ of a vjiict\ of issues: public policy issues ment. Portions of this text were previ­ Robert M. Arnold, et a/., ids., Johns such as patient dumping and HIV resl ously published in the Catholic Health Hopkins University Press, Baltimore, ing; [Manning issues such as designing Association's 1994 publication. Eutha­ 1905, 249 pp., $18.85 (paperback), $50 services for the homeless; population nasia and Assisted Suicide: Positioning (hardcover) issues such as changing family role the Debate. issues such as cosi-effectiveness analysis Most organs used tor transplantation in policy formulation; and prevention come from patients declared dead by md intervention issues such as policies BOOKS RECEIVED neurologic criteria whose hearts are Still for pregnant adolescents beating. However, recent advances Medical Practice in the Current make it more feasible to procure organs Health Care Environment. Janine from persons whose hearts have Euthanasia: Moral and Pastoral ( Edwards, ed., [ohns Hopkins stopped beating and who arc declared Perspectives University Press, Baltimore, 1995 dead using cardiopulmonary criteria. In 19 chapters from various contributors, Richard M. Gula, Panlist Press, O Happy Fault: Personal Re­ this book explores the ethical, psy Malnvah, NJ, 1994. 85 pp., $5.95 covery through Spiritual Growth. chosocial, and public policy implica­ (paperback-> Robert M Garritv, Paulist Press. tions of procuring organs from these Mahwah, XL 1994' non-heart-beating cadaver donors This book "focuses on the religious perspective from which the Catholic Stroke Survivors, William H. Berg- moral tradition derives ITS opposition to quist, Rod Mclean, and Barbara A. Health and Social Policy euthanasia and physician-assisted sui­ Kobvlinski, Jo.ss.cv Bass, San cide," l-r. Gula writes in the introduc­ Francisco, 1994 Marvin 1). Fcir and Stanley F. Battle, tion. The brief volume clarifies the eds., Hawortb Press, Mnghamton, \'T, object of the debate: examines the A Change in Perspective (video). 1995. 290 pp.. $19.95 (paperback), vivion and values at stake: .w\i\ frames Eastern Paralyzed Veterans Associ­ 'i (harden these within the scope of autonomy, ation, Jackson Heights, NY, 1994

62 • JULY - AUGUST 1995 HEALTH PROGRESS The task force originated in 1985 and chronically ill. In the third chapter, add an "easy" medical option (i.e., com­ when Governor Mario Cuomo charged it the task force examines current pain passionate death) without addressing the with making public policy recommenda­ management practices. Studies repealed more difficult problem (i.e., compassion tions about developments in medical sci­ ly show that only 20 percent to 60 per­ ate care of the dying). ence. This 25-member group, which cent of cancer pain is treated adequately, Would legalizing PAS encourage physi- includes physicians, nurses, lawyers, cler­ even though good control of pain and cians to provide better palliative carer gy, and bioethicists, has generated a other symptoms is possible in more than When Death Is Sought says no. In tact, number of carefully reasoned reports, 90 percent of cases. This failure arises the PAS option would have deeply trou­ including public proposals on do-not- from healthcare professionals' lack of bling consequences for the patient-physi­ resuscitate orders, the determination of knowledge about state-of-the-art pain cian relationship, further eroding the death, decisions about withholding and management, as well as from false beliefs commitment of physicians and other withdrawing life-sustaining treatment, about the risks of addiction and respira­ healthcare professionals to care for dying organ transplantation, and surrogate par­ tory depression. Chapter 4 reviews the and incurably ill patients. "Patients in enting. Several of these initiatives have legal status of euthanasia and PAS, and turn might be fearful that they would subsequently been incorporated into chapter 5 presents a tight, well-written become candidates for these 'treatments', New York law. Thus the publication of account of the ethical principles at stake or might worn about the consequences When Death Is Sought, the task force's and their implications for public policy. of refusing these options once they are report on PAS and euthanasia, was await­ Pan II of the book summarizes the task presented by their physician," say the ed with anticipation by both friends and force's deliberations and elaborates the authors (p. 139). Burdened as they are by foes of assisted dying. recommendations. pain, depression, and worries about the Although members of the task force Many argue that the right to choose cost of care, patients with chronic illness held different views about the morality of the time and manner of one's death is an would also be susceptible to other inter­ acts of PAS and euthanasia, they unani­ appropriate extension of the right to nal and external pressures to choose sui mously agreed that existing law should make informed decisions about health­ Cide. This might be particularly true of not be changed. They argued that the care and to refuse medical treatment. the more vulnerable segments of our passage of such legislation would com­ Certainly, the option of PAS appears to population, including the aged and those promise the care of severely ill patients, enhance personal autonomy. Self deter­ of low socioeconomic status. enhance the power of physicians, pose mination is, in fact, central to the argu­ The task force also considers two types profound risks to certain disadvantaged ment in When Death Is Sought. But the of "slippery slope" argument. First, given groups, and lead to unacceptable changes task force reaches the somewhat counter­ the self-determination argument, a new ly in the social fabric. They rejected pro­ intuitive conclusion that legalization of established right to compassionate death posed criteria and safeguards for physi­ physician-assisted death would decrease, could not be limited to those who are cian-assisted death as vague, ill-founded, rather than increase, self-determination physically and emotionally able to per­ or unenforceable. Finally, the NYSTFLL for the terminally ill. form the deed. Some provision would argued strongly for improving the care of This reasoning begins with the phe­ have to be made for patients who are par severely and terminally ill patients, nomenology of serious illness. Sick peo­ alyzed or too weak to take the fatal including providing pain control, better ple are weak, are vulnerable, and feel out drugs. Thus a policy permitting PAS diagnosis and treatment of depression, of control. Their autonomy is attenuated must in some cases permit voluntary and more comprehensive palliative care. by disease itself. Physicians have the euthanasia. Moreover, if competent When Death Is Sought is a nuanced power to alleviate many or most of the adults are to be given the right to deter­ account of the reasoning behind these rec­ severe symptoms that compromise their mine the time and manner of their death, ommendations. Though the book is writ­ patients' sense of control. Yet, for various the exercise of this right should also be ten primarily for health professionals and reasons, many still allow their patients to provided for (e.g., through advance policy makers, interested laypersons will suffer more than necessary. Our health­ directives or healthcare proxies) in cases also find it informative, albeit a bit dry. care system is deficient in precisely this where patients lose their capacity for decision making. The book begins with a scries of chap­ type of symptomatic therapy (e.g., pain ters describing the clinical, legal, and eth­ management, treatment of depression, The second "slippery slope" is based ical background of the debate over and comprehensive palliative care). The on compassion rather than autonomy. It euthanasia and PAS. The first two chap­ NYSTFLL argues that, in this milieu, would be inhumane to deny a patient the ters, for example, deal with the epidemi­ patients are especially vulnerable to pres­ "best" therapeutic option simply because ology and clinical features of suicide, sure from physicians and others. Making of his or her incapacity to consent. Some- especially as it occurs among the elderly PAS available would allow physicians to doctors might feel so strongly that

HEALTH PROGRESS JULY - AUGUST 1995 • 63 BOOK REVIEWS

euthanasia is in the patient's best interest ing individuals, a lethal prescrip­ patient stories that immediately engage that they would promote assisted dying tion or injection would offer a sim­ the reader's attention. Both books argue as an option for comatose, vegetative, ple solution for profoundly human that we have a moral imperative to and other clearly incompetent patients: and complex dilemmas. It would improve the care of the dying patient. "Once euthanasia becomes an accepted also extend medicine from the However, the reader who wants to 'therapy' the expansion to include those realm of care or cure to dispensing understand more about the motives who are incapable of consenting would death tor problems endemic to the behind and moral justification for indi­ be a logical, if not an inevitable progres­ human condition, (p. 136) vidual acts of PAS will find in Death and sion," write the authors (p. 133). Recent Dignity much that is missing in the experience in the Netherlands certainly Instead, the NYSTFLL strongly rec­ NYSTFLL report. Quill, using a "bot­ suggests that such nonvoluntary euthana­ ommends that physicians and other tom-up" approach that starts with indi­ sia would occur. health professionals enhance their pain vidual cases, concludes that legalization Some bioethicists, including physicians management skills, that hospitals -^nd of PAS (and in some cases voluntary like Dr. Timothy Quill, in his recent other healthcare institutions develop bet­ active euthanasia) would help individual book Death and Dignity: Making ter palliative care services, and that insur­ patients and be good public policy, pro Choices and Taking Charge (New York ance companies eliminate financial barri­ vided that safeguards arc built into the City, Norton, 1993), have argued for ers to effective symptom management. system. The task force, using a "top legalizing physician-assisted death under When Death Is Sought is a gcx>d intro­ down" expert panel approach, concludes certain strict guidelines or conditions. duction for anyone who wishes to learn that strengthening our commitment to One proposed guideline, for example, more about the subtle and complex issue palliative care without PAS is the better sa\s that PAS should only be permitted of legalizing PAS. There are, however, route because the potential threats of in cases of terminal illness. Rut the some missing pieces. Because the argu­ PAS and euthanasia to society would NYSTFLL notes that "the logic of sui­ ment here turns primarily on policy impli­ outweigh their potential benefits. I am cide as a compassionate choice tor cations of PAS, some readers may find too not claiming here that logical argument is patients who are in pain or suffering sug­ little analysis of its underlying morality. inferior to anecdote. I do believe, howev­ gests no such limit" (p. 132). Those who The report also tends to gloss over the fact er, that serious moral discussion ought believe their lives intolerable because of that, even with the best palliative care, not lose sight of concrete human experi­ chronic illness would have .\n equally there is much suffering that simply cannot ence. In that sense, the two books com­ plausible claim to assisted dying services. be alleviated. This includes perhaps 10 plement one another. Moreover, the proposed requirement percent of severe physical pain, but, more With the passage of Oregon's Death thai PAS be the last option, offered only- important, it also includes much of the with Dignity Act last November, legally after other alternatives have failed, seems emotional and existential suffering experi­ sanctioned PAS became a reality in the to the task force an unwarranted restric­ enced by the dying. Moreover, in its cri­ United States. In the next few years, tion, inconsistent with strong support for tique of proposed PAS guidelines, the task other states will likely join Oregon. The self-determination. Why should patients force docs not do justice to the fact that, experience in these states will, one hopes, have to endure several failures of treat­ even if PAS were legalized, the state's provide us with data to guide future pub­ ment before choosing suicide? Finally, need to balance individual self-determina­ lic policy discussions. Meanwhile there is Quill's suggested requirement that PAS tion and preservation of life would not be no question that, at least until palliative lie conducted within an established eliminated. Impression of self-determina­ care is substantially improved and the patient-physician relationship overlooks tion would simply be given more weight. public's fear of prolonged suffering those patients who have no tegular physi­ In that case, restrictive guidelines might relieved, PAS will enjoy widespread pop­ cian (e.g., because they lack health insur­ well be warranted if they helped curb ular support. ance); it also fails to define an "estab­ abuses, prevent mistakes, .md Otherwise lished" relationship. promote the state's interests. John L Coulehan, MD Institute of Medicine in The task force concludes that: The main ingredient missing in When Conteiuporary Society Death Is Sought, however, is the passion State University of New York and immediacy that patient stories pro­ Medically assisted dying and direct at Stony Brook medical killing are unacceptable vide. Quill's Death and Dignity is an societal responses to the problem interesting counterpoint in this regard. Copies of When Death Is Sought are available of human suffering. Compared to Though both books consider the same from Health Education Services, PO Box "/Jo, the resources, caring, and compas­ moral terrain, Quill, relying greatly on Albany, ST. 12224, for $9 plus $2 postage and sion needed to respond to suffer­ the narrative method, presents a series of handling.

64 • JULY - AUGUST 1995 HEALTH PROGRESS