OPINION NATURE|Vol 453|15 May 2008

Enshrining the right to live or die

Developments in the life sciences inevitably members and clinicians. Although there are raise complex legal questions, such as when many differences between Schaller’s book a human life begins and ends, and how much and Easeful Death — Mary Warnock and L. DOWNING/REUTERS weight should be given to individual prefer- Elisabeth Macdonald’s elegant and thought- ences about how and when we reproduce, or ful discussion of the case for assisted dying die. The law cannot avoid getting involved in — the authors agree that private, consensual these finely balanced bioethical issues, but resolution of complex individual cases is courts and legislators are sometimes spectacu- almost always preferable to exposing them larly ill-equipped to deal with them. to the harsh glare of litigation and legislation. Take the sad case of Terri Schiavo, described Warnock and Macdonald, for example, seem in Barry Schaller’s riveting book Understand- to regret the ending of the ‘humane practice’ ing Bioethics and the Law, which describes a through which people could ask their “retired series of confrontations between US law and medical friends” for help in storing up “a col- some difficult bioethical dilemmas. Eight years lection of drugs for future use if they found after Terri lost consciousness and fell into a life intolerable”. permanent vegetative state (PVS), her husband The Terri Schiavo case, together with that of Michael sought court authorization for the Dianne Pretty — a British woman with motor removal of Terri’s feeding tube. By this time, neurone disease who wanted to be helped to Michael’s relationship with Terri’s parents, die — suggest that litigation may not resolve Robert and Mary Schindler, had broken down, conflict. But at least court proceedings do and the Schindler family objected to the focus on the individual. Schaller contrasts removal of the tube. Michael and the Schin- the US courts, which stuck to the question of Terri Schiavo’s case challenged bioethics law. dlers then engaged in virtually continuous whether Terri would have wanted to be kept litigation for the next five years during which alive in a PVS, with the “executive and legisla- vulnerable if we change the law in favour of the tube was removed, only to be reinstated tive branches” who “disgraced themselves by legalizing assisted dying”. two days later. The family pushing the boundaries Once an issue is before the legislature, the were joined in this unedi- Understanding Bioethics and the of law and decency in suffering of the individual, and the possibil- fying legal spectacle by Law: The Promises and Perils of the their self-aggrandizing ity of a compassionate and individualized various religious interest Brave New World of Biotechnology efforts”. Although this response to that suffering, is lost. Someone groups, advocacy organi- by Barry R. Schaller harsh criticism seems such as Dianne has to die in a distressing man- zations representing peo- Praeger Publishers: 2008. 241 pp. fitting given the politi- ner, not because we think that she is vulner- ple with disabilities, and $49.95, £27.95 cal exploitation of this able and incapable of making a considered, by the Florida House of Easeful Death: Is There a Case for “private ethical dilemma informed and voluntary decision to end her Representatives. With Assisted Dying? about a young woman’s life, but because we think that other people the support of governor by Mary Warnock and Elisabeth sad decline”, it points might be vulnerable. Is this fair? Many would Jeb Bush, the Florida Macdonald to a wider problem in say no, and if we support Dianne’s right to legislature passed Terri’s Oxford University Press: 2008. trying to use legislation assisted dying, then we should not expect her Law, a statute prevent- 155 pp. $26 to resolve complex bio- to suffer for the greater good of society. War- ing the withdrawal of ethical issues. nock and Macdonald accept that it would be nutrition and hydration from a patient “who Although the adversarial process has its hard to draft a law that would always succeed met the unique description of Terri Schiavo”. disadvantages, the courts can at least attempt in protecting the vulnerable, but they conclude After further legal challenge, Terri’s Law was to deliver individualized justice, but legisla- that, for compassionate reasons, we should at eventually ruled unconstitutional by Florida’s tion must apply to all. Translating compas- least try. Supreme Court. sionate responses to the suffering of someone The legislative process offers an opportu- The action then shifted to the federal level, such as Dianne into law is difficult precisely nity for special-interest groups to intervene. and a bill to nullify the Florida court’s decision because legislation cannot just apply to one In the Terri Schiavo case, the concern of many was introduced in the House of Representa- individual’s situation: it must apply to every- advocacy groups was not the dignity and prior tives and in the Senate. President George W. one. Warnock and Macdonald quote Robin wishes of Terri herself, but the effect that her Bush returned early from his holiday to sign Gill, a member of the British Medical Asso- case might have on other people. If Terri the Senate bill at 1 a.m. on 21 March 2005. All ciation’s medical ethics committee, who made were allowed to die, they asked, how would this legislative activity did not derail the court a submission for Dianne on compassionate this affect other Americans with disabilities? process. The US Supreme Court refused to grounds. Her case, in Gill’s view, “represented These powerful advocacy groups formed an hear an appeal to overturn the lower court’s a very, very strong case indeed for voluntary alliance with the even more powerful conserv- decision that Terri’s tube could be removed. euthanasia”. If it was just about her, and no- ative religious lobby, leading to what Schaller Terri eventually died on 31 March 2005. one else, he would be in favour of giving her describes as a “media mega-event”. Fortunately, the Terri Schiavo case is excep- access to assisted dying. But legislation can- The cases of Terri Schiavo and Dianne tional: most end-of-life decisions are resolved not be personalized in this way, and Gill con- Pretty raise different issues. Terri never con- privately, through discussions between family cluded “that more people will be made more templated ending up in a PVS, and her views

284 NATURE|Vol 453|15 May 2008 OPINION

on the withdrawal of life-prolonging treat- she died, were largely irrelevant and trumped cheap and rarely happens overnight”, Monmonier ment were unknown, whereas Dianne was by the possibility of harm to others. tells the story of the ambitious International intelligent and competent, and had clearly The law moves in ways that are mysterious to Map of the World project. Following a German articulated views on how she wanted her life many. Both these fascinating books, although geographer’s proposal at an international con- to end. It is odd, perhaps, given that Terri dealing with different jurisdictions and issues, ference in 1891, cartographers from the indus- would know nothing of the court’s decision, contribute to our understanding of the most trialized nations agreed to produce a series of that the outcome hinged on what her hus- important ethical challenges that lawyers will maps with uniform projection, symbols, style, band and parents claimed her wishes would face in the coming decades. ■ scale and technique, which would adequately have been, as a result of the so-called substi- Emily Jackson is professor of law at the London describe all of the mountains, rivers and key tuted judgement test. By contrast, the views of School of Economics and Political Science, coastal features of the world. When complete, Dianne, who went on to suffer greatly before Houghton Street, London WC2A 2AE, UK. the mosaic of assembled ‘millionth maps’ — drawn to a scale of 1:1,000,000 — would have covered more than 185 square metres (half the size of a basketball court) at a cost of £100,000 (US$200,000), a significant sum at the time. Charting the water’s edge Some maps were eventually produced but, with most nations reluctant to pay their share and Coast Lines: How Mapmakers Frame the exclude foreign vessels not pursuing expeditious with two intervening world wars, this grand World and Chart Environmental Change ‘innocent passage’ along the coast or into a project ended in a whimper in the second half by Mark Monmonier port”. Under pressure from military and eco- of the twentieth century. University of Chicago Press: 2008. 224 pp. nomic quarters, territorial waters have, in recent The failure of the International Map of the $25 decades, been extended from the traditional World project can, to some extent, be explained 5.5 kilometres to 22 kilometres from shore. by emerging technologies that made the old Coastal margins are drawn as precise lines on Coast Lines introduces the exclusive eco- standards obsolete. Some advances have revo- maps, yet anyone who has walked on a beach nomic zone (EEZ) in which maritime nations lutionized data collection and display, and knows that coastlines are unstable. Cliffs, can “manage fisheries, mine the sea bed, and some (such as intercontinental ballistic mis- rocks and sands change under the influence extract oil and natural gas” but cannot exclude siles) expanded the military’s need for maps of tides, storms, tectonic movements, global foreign vessels. The EEZ extends 370 kilometres that were increasingly accurate and sophis- climate change and other natural and artificial from shore, except where it encounters the EEZ ticated. Monmonier has good knowledge of phenomena. of another nation, in which case the boundary cartographic technologies. In a section on Mark Monmonier, professor of geography at is drawn equidistant between the two coastlines. overhead imaging, he introduces the problem the Maxwell School of Syracuse University in Islands can affect where the line is drawn. For of consolidating images taken from different New York, seeks to inform the public about how instance, because of the position of Key West angles and discusses techniques for remote cartography and society intersect. He wishes and the Dry Tortuga islands off the southwest- sensing. In another chapter he surveys the types us to look closely at maps, to recognize which ern coast of Florida, the compromise boundary of electronic chart that are now available. features are shown or missing, and understand between the United States and Cuba is much Today, the mapping of coastlines has envi- why. In Coast Lines, he offers an assortment of farther south than would be expected. ronmental and political implications. Proposing eclectic and fascinating information about how To show that “good cartography is seldom that cartographers can document global climate coastlines have been defined, determined and depicted, focusing on the United States in the twentieth century. Different maps and charts of the same coastal area show different cartographic coastlines.

Monmonier calls our attention to four types, NASA/JPL–CALTECH explaining that each is a human construct designed to serve a specific purpose, and the result of many observations and assumptions (the latter sometimes gaining the upper hand). One cartographic coastline is the high-water line visible from offshore. Another, introduced in the nineteenth century to aid safe navigation, is the low-water line. Two are more recent: storm surge lines are designed mainly for evacuation planning and flood insurance, and inundation lines describe the plausible effects of changing Satellite images help geological and meteorological conditions. map-makers to chart Monmonier discusses the international changes in coastal boundaries of territorial waters. These comprise margins, such as the region beyond a nation’s coastline, however shifting sands from defined, in which that nation has sovereignty, Louisiana to Alabama. where it can “enforce laws, levy taxes, and

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