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Of all the contemporary public debates involving ethics, law, politics, and religious belief, the issue of physician-assisted dying is the one most in need of clarification on all fronts.  By comparison with, say, the disputes over abortion, medical marijuana, gay marriage, and capital punishment, the discussions of physician-assisted dying are marked by a lot of arguing at cross purposes, confusion about the available empirical data, endemic imprecision in many of the terms central to the debate, scare tactics, logical hocus-pocus, and ignorance or (what amounts to much the same thing) misinformation.

Timothy Quill (a professor or medicine) and Margaret Battin (a professor of philosophy) have set out to address this problem with an extremely wide-ranging collection of twenty-one readable and impeccably documented essays dealing with everything from philosophical issues, legal matters, and religious views, to medical practices, case studies, empirical findings, the role of the handicapped, and more, written by an equally wide range of thinkers, activists, and specialists.  This collection is, simply put, the indispensable starting place for anyone wishing to become better informed about the present arguments over physician-assisted dying (especially in the United States), and it belongs in every high school, university, and medical library in the country.

In their Introduction, the editors make clear the major purpose of this collection: to clarify and redefine the language of the debate, particularly in response to a rival collection of essays (The Case Against Assisted Suicide, also published by Johns Hopkins).  They recognize clearly that activists in favour of physician-assisted death are facing a series of political battles, the course of which will be determined by the public’s response to the ways in which the issues are presented.  This point is explicit enough, as the editors concede, in the phraseology of the different titles: Assisted Suicide and Physician-Assisted Dying.

The shape of the political battle has emerged in the past decade as a result of the failure of judicial attempts to have legislation prohibiting assisted dying declared unconstitutional.  By a vote of 9 to 0, the Supreme Court in the US  ruled in 1997 that the right to life trumps the right to die and thus upheld existing laws against assisted dying.  The same decision was made in the Canadian Supreme Court somewhat earlier (1993) in the well-known Sue Rodriguez case (not mentioned in the book, which confines its attention almost exclusively to the United States), in a much narrower decision, 5 to 4.  Hence, in both countries we are left with the paradox that so intrigued John Stuart Mill in his discussion of prostitution: suicide is legal, but assisting someone in that legal activity is illegal.

Advocates for physician-assisted dying in the United States have an obvious recourse, however—a state-wide referendum.  Oregon has already taken that route successfully (in 1994) and repeated legal appeals against its “Death With Dignity Act” have been thrown out.  Similar attempts in other states, however, have been unsuccessful (in Washington State, California, Michigan, Maine, and Hawaii).  Hence, south of the border the political emphasis in this debate is emphatically on the need to make a better case to the general public, and that means, more than anything, offering a more persuasive and reassuring proposal in the face of opponents with a potent weapon—the emotionally charged vocabulary characteristic of many of the discussions up to now (“slippery slope” arguments, with frequent nods in the directions of Dr. Kevorkian or Nazi Germany are not uncommon, for example).

The editors open the discussion by offering a reassuring and necessary definition: physician-assisted dying applies only to terminally ill patients capable of clearly expressing their own wishes under a set of strict conditions.  We are not dealing here with what some scaremongers might characterize as death-on-demand clinics for anyone who shows up at the door.  Once that point is established, they move on to explain the meaning of the subtitle, that is, calmly to shred the argument that physician-assisted dying is, as many have claimed, a threat to improvements in or a commitment to palliative care (the rhetorically catchy but misleading dilemma “hemlock or hospice”).

An illuminating essay by Preson, Gundereson, and Mayo then addresses the central principle of those in favour of physician-assisted suicide, namely, respect for the patient’s autonomy, a particularly useful exploration because it confronts fairly and answers politely a number of very interesting objections based on this very principle (e.g., Given the complex pressures of the situation, can anyterminally ill patient be considered fully autonomous? Are we in fact increasing a patient’s autonomy by handing her over to the potentially intimidating authority of a physician in an unwelcome environment?).  No facile answers are offered to these objections, but the important point is repeatedly made (here and elsewhere) that where doubts occur about a patient’s autonomy, the burden of proof should lie on those questioning the validity of the patient’s consent.  One does not guarantee a person’s autonomy by forbidding her to exercise it just because there may be unspecified pressures at work.

Another useful (and provocative essay) by Beauchamp goes straight to the heart of the rhetorical struggle by taking on the most emotionally loaded word in the debates, killing.  We know that letting terminally ill people die by removing medical support which might keep them alive is not uncommon, and we make a distinction between that and killing.  But is that distinction relevant?  In a nuanced argument, which will, no doubt, prompt many responses, Beauchamp removes the term killing from the debates over the justification for physician-assisted death and argues that “unless a valid liberty-limiting principle warrants intervention to prevent an act of hastened death, there is no moral basis for condemning or punishing the envisioned autonomous acts of patients and their willing physicians.”

The ethical arguments have been complicated in recent years by improvements in the ways we treat pain, for now in many cases physicians may tacitly consent to what amounts to assisted dying by providing pain-relieving measures which the patient may then use to end his life (e.g., morphine drips).  An informative essay by Brock reviews a number of the ethical issues raised by this option in comparison with others (voluntary starvation and physician-assisted suicide) in order to collapse the distinctions made between them in law and public policy.

While such ethical discussions will be extremely illuminating for many general readers, lawyers, and students, they probably won’t win too much support on the campaign trail from voters with short attention spans.  For that, empirical evidence tends to be far more persuasive (particularly to counter “slippery slope” scare tactics).  The inclusion of five essays dealing with practices in Oregon and The Netherlands reflects the editors’ sense that this material is particularly important in the continuing struggle to have the law changed.

The final section of the collection focuses on the political and legal turmoil over physician-assisted dying.  Here, for all the interesting details, the exclusive focus on the United States somewhat limits the usefulness of the discussion for Canadians.  The section does, however, stimulate one to reflect on how our situation is different and how that might affect our options for practical action.  We have the immense advantage of a much more liberal tradition in the federal government, which does not usually engage in over-zealous prosecution of activities which violate its narrow moral sensibilities in “hot button” public issues (the Ashcroft syndrome), but we lack the means to initiate provincial referendums to advance the cause.   I suspect that will force us, in our authentic Canadian manner, to seek to exert pressure through professional associations (particularly those representing the medical profession and social workers) and through special interest groups (e.g., the elderly and the disabled) on members of parliament.

Whatever our tactics, we will need to keep ourselves up-to-date on an issue marked in recent years by rapid changes on almost all fronts.  There’s no better place to start that process than this collection of essays, stimulating and useful in themselves and offering all sorts of suggestions for further reading.