Angels of Death: Exploring the Euthanasia Underground [Hardcover]

Roger S. Magnusson (Author)

Book Description

Publication Date: June 1, 2002 | ISBN-10: 0300094396 | ISBN-13: 978-0300094398 | Edition: 1

An exploration of the hidden world of illicit physician-assisted suicide and euthanasia. Through the frank and often troubling first-hand accounts of health professionals who have been involved in assisted death, it records this secret but real area of medical and nursing practice. Through face-to-face interviews with these "angels of death", Roger S. Magnusson explores the social practices, relationships and networks that constitute "underground" euthanasia. How is assisted death actually practised within health care settings? What are the issues that surround the making of such a momentous decision? How do health care workers justify their attitudes and actions in this area? This volume aims to offer detailed answers to these questions and many others. The doctors, nurses and therapists who were interviewed pseudonymously for this study work in the HIV/AIDS communities in the United States and Australia. Their perspectives and practices, attitudes and feelings, should illuminate the assisted death debate and expose a variety of disturbing issues, including the reality of "botched attempts", euthanasia without consent, and unduly hasty measures to bring about death.

Editorial Reviews

From The New England Journal of Medicine

Roger Magnusson's Angels of Death describes the practice of extralegal assisted suicide and euthanasia by physicians, nurses, technicians, and other health care professionals who provide care to seriously ill patients and patients with AIDS who are dying. It is based on a snowball sample of 49 detailed interviews carried out over a period of three years with health professionals specializing in the care of patients with the human immunodeficiency virus and AIDS, principally in Sydney and Melbourne, Australia, and in San Francisco. This book is about cooperative euthanasia -- that is, physician-assisted suicide and euthanasia occurring underground, mainly among patients with AIDS at home and those in large, tertiary-care hospitals in the United States and Australia. It describes networking among sympathetic physicians, nurses, and other health care workers and traces patterns of referral. It portrays ways in which health care professionals provide advice about drugs, assistance to those who wish to obtain drugs (often from an underground pharmacy), and informal psychiatric assessments. It also describes how they manipulate hospital procedures, fabricate information when signing death certificates, and collaborate with funeral directors in the orchestration and general facilitation of assisted dying at the bedside. It describes ways they may support both the patient and the family as well as debrief the family after a death. In Angels of Death (the name given to informal groups of physicians and nurses known to be willing to provide assistance in suicide or euthanasia), Magnusson finds, as have other researchers, that cooperative aid-in-dying is easier and more direct in the community than in the hospital but that it frequently still occurs in hospital settings. Some occasions of cooperative euthanasia involve direct, deliberate, life-ending measures: "A common example of shared involvement was for one health care worker to access the patient's vein, while another injected the drugs." Other occasions involve stretching applications of the principle of double effect, particularly in deaths that involved "understood," deliberate overdoses of morphine: The physician in charge of Erin's unit . . . approached Erin [a nurse] about another distressed patient they were caring for. ‘Use as much morphine as you need,’ said the physician. ‘I'll sign for it.’ Erin was taken by surprise. ‘Do you know what I mean?’ said the physician. ‘I'm not sure,’ said Erin. ‘Do you want me to make him comfortable, or do you want me to make him ultimately comfortable?’ ‘Yes,’ replied the physician, ambiguously. The patient died that night. Magnusson, professor of law at the University of Sydney, and his associate, Peter H. Ballis, of Monash University, also in Australia, applied considerable skill in eliciting first-hand accounts from physicians, nurses, and other health care professionals working in legally delicate settings, and as a result they obtained very revealing interviews. They stress that the physicians involved in these cooperative networks are "not isolated and wild-eyed miscreants acting from the fringes of their professions" but rather respected, mainstream physicians. Underground euthanasia is a "culture of deception," and it is practiced everywhere, although Magnusson observes that it is "more deeply entrenched, with a longer and richer history" in California than in Australia. Angels of Death has several limitations. The study was limited to patients with AIDS in cities where large, interactive, and mutually supportive populations of gay men have helped shape the nature of health care. Its methodology involved reportorial interviews that were not cross-checked by interviewers of different background commitments. Most irritating, the book does not clearly identify the three-year period during which the interviews were conducted, so the reader cannot know when, during the years of the AIDS epidemic, the practices described were implemented, whether before or after the development of protease inhibitors and other drugs. The study is also presented with a certain sensationalism, which its title betrays. And it does not explore the philosophical issue of whether occasions of the "understood" overuse of morphine -- as in the example of Erin, noted above -- are conceptually closer to a "double effect" and hence legally permissible or, as Magnusson clearly believes, closer to euthanasia. Despite these shortcomings, Angels of Death is a comprehensive, compelling, and deeply responsible description and analysis of practices in contemporary health care, and it includes an extensive bibliography. A superbly thought-provoking book, it should be read by both opponents and proponents of the legalization of assisted dying. It is here that Angels of Death has its greatest strength, as an importantly ambiguous, litmus-test book. Opponents of physician-assisted suicide, euthanasia, and aid-in-dying generally will see it as an account not merely of a potential abuse but of an already existing abuse of seriously ill and dying patients within the health care system: a wink here, a nod there, and the patient is dead. Proponents of legalized aid-in-dying, in contrast, will see the same account, with the same rich observations of winks and nods, as a comforting reassurance that seriously ill and dying patients can still manage to obtain what they want -- easeful death -- even in a climate of legal suppression. What Magnusson describes is a fact that both proponents and opponents of the legalization of euthanasia must face: practices such as those delineated in the book occur when a practice is kept illegal. Magnusson's view is not to be mistaken for the naive belief that such practices can be stamped out; he believes that this is simply not possible and that "it is not a choice between having no euthanasia and making euthanasia legal." Moreover, he does not think that the cooperative practices he describes are the only forms of euthanasia now being used. "Protestations aside," he writes, "there is little doubt that hospitals do provide euthanasia, under the guise of sedation." Although Magnusson believes that the prohibition of such practices is not tenable, that the existence of "euthanasia networks illustrates the failure of the policy of prohibition," and that the legal prohibition of assisted dying produces a culture of silence, resulting in flawed transmission of information, botched euthanasia processes, substantial stress for care providers, and "a complete absence of stable criteria for involvement in assisted death," he does not supply a remedy. That will be the work of the many physicians, nurses, policymakers, and patients who should be encouraged to read this book. Reading it will permit them to diagnose their own biases; it will also allow them to see that there are multiple ways to view the phenomenon of collaborative, underground aid-in-dying. Whatever one's view of the stories he tells, Magnusson is clearly right about one thing: "the closing times of life are too important, and patients deserve better." Margaret P. Battin, Ph.D.
Copyright © 2003 Massachusetts Medical Society. All rights reserved. The New England Journal of Medicine is a registered trademark of the MMS.

Review

Clearly written...[A] good basic reader...[for] both students...and seasoned professionals. -- Choice

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Product Details

• Hardcover: 336 pages
• Publisher: Yale University Press; 1 edition (June 1, 2002)
• Language: English
• ISBN-10: 0300094396
• ISBN-13: 978-0300094398
• Product Dimensions: 9.4 x 6.4 x 1 inches
• Shipping Weight: 1.6 pounds (View shipping rates and policies)
• Average Customer Review: 4.0 out of 5 stars  See all reviews (1 customer review)
• Amazon Best Sellers Rank: #2,545,463 in Books (See Top 100 in Books)
  • #60 in Books > Medical Books > Medicine > Euthanasia

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Most Helpful Customer Reviews

4.0 out of 5 stars Helping Other People to Die, August 30, 2010

By 

James L. Park "James Leonard Park" (Minneapolis, MN USA) - See all my reviews
(REAL NAME)   

This review is from: Angels of Death: Exploring the Euthanasia Underground (Hardcover)

Roger S. Magnusson
Angels of Death: Exploring the Euthanasia Underground

(New Haven, CT: Yale University Press, 2002) 325 pages
(ISBN: 0-300-09436-6; hardcover)
(Library of Congress call number: R726.M276 2002)

This book explores all the dynamics of helping victims of AIDS to die.
The research took place in Australia and San Francisco, USA.
But the experiences of these doctors, nurses, social workers, & other friends
can easily apply to the situations of any patients
who need aid and support in the process of dying.

Once we understand that aid-in-dying is already taking place,
we should be willing to bring the process out into the open.
What is now an underground practice--with no public safeguards--
can in future decades become an open and honest process,
which can be endorsed by almost everyone
who thinks carefully and deeply about the process of dying.

Extreme opponents of the right-to-die want to prohibit
any action that might hasten death.
Extreme advocates of the right-to-die want no regulations at all:
Let the patient decide.
Problems are created by both of these extremes.
Perhaps a rational middle ground can be created.
Exploring what is actually happening now
should empower us to create wise and compassionate ways
of helping people who have good reasons to die.

Doctors and nurses often conspire to help patients to die,
sometimes with the cooperation and help
of friends and relatives of the patients.
Because all of the cases discussed in this book
were people dying of AIDS, secrecy was not very difficult to achieve.
The gay-and-lesbian communities where these deaths occurred
were close-knit and therefore easily able to cover their tracks.
The deaths were all recorded as having occurred from natural causes
--almost always from complications of AIDS.

However, the necessity for secrecy meant that
no public safeguards could be applied to these deaths.
The doctors or nurses were acting alone,
without consulting anyone who might have provided different perspectives.

Giving excessive amounts of pain-killing drugs
is one of the most common methods of helping the patients to die.
Another common method is turning off the life-supports (without authorization).

Secrecy means that there is no paper-trail
that would show that anything out of the ordinary occurred.
Because merciful death is still not legal,
these 'angels of death' needed to operate in secret.
A system of public safeguards could have achieved the same end
with much less stress and danger for the helpers.
It would have taken a few days longer
to approve a voluntary death or a merciful death,
but under a system of careful public safeguards,
the process of planning for death
could have begun days or even weeks earlier.
And everyone concerned could have been consulted.

(This book proposes no safeguards for assisting others to die,
but here is a discussion of 15 proposed safeguards for life-ending decisions:
Search the Internet for this precise title:
"Fifteen Safeguards for Life-Ending Decisions".
In the opinion of this reviewer,
almost all of the cases discussed in this book
could have fulfilled these 15 safeguards.
And the very few doubtful cases
could have been clarified by using these safeguards.)

Doctors are divided concerning the right-to-die.
But the general public is more favorable.
And AIDS victims are overwhelmingly in favor
of the right-to-die for themselves
if their medical conditions become hopeless.

Usually the AIDS patients are the first to raise the issue of voluntary death,
but in some rare situations, the option of choosing
a less painful pathway towards death is first mentioned by the care-givers.

The fact that the patients are dying of AIDS
sometimes creates family chaos
because the other members of the family-of-origin
are learning for the first time that their son or brother is gay.
It is sometimes too difficult to ask the family to deal with
both homosexuality and death at the same time.

Terminal sedation is one medical alternative to the more controversial
voluntary death with assistance or merciful death.
In terminal sedation the physician prescribes enough pain-killers
to keep the patient unconscious until death occurs by natural causes.
(Sometimes the drugs shorten the process of dying by suppressing breathing.)
This method protects and doctor, hospital,
& anyone else involved in the life-ending decision
because no laws have been broken.
But terminal sedation takes away
the autonomy of the patient for the last few days,
since an unconscious patient can make no decisions.

(However--here back to this reviewer's opinion--
all the applicable safeguards for life-ending decisions
could be fulfilled before the terminal sedation begins.
Then it would be a fully voluntary death or an approved merciful death.)

Doctors and nurses sometimes refer to a "tacit understanding"
about the effects of increasing the sedation.
The care-givers believe that the patient and the family
understand that the medication being given will shorten the dying process.
But no one wants to say out loud:
"This is the final dose."
or "This medication will bring death."
When the right-to-die is openly affirmed by all,
then no such unspoken decisions need be taken.

Some palliative-care nurses interviewed for this book
admit to using 'left over' morphine to bring death.
Whenever morphine is used, the dose ordered by the doctor
might be less than the full amount in the ampule.
Whenever some morphine is not needed for this patient,
the nurse is supposed to destroy the excess--witnessed by another nurse.
But they can easily agree not to destroy the excess
(and to create a false record that they have discarded the unneeded morphine)
so that they can use the excess morphine later for a merciful death.

Some doctors interviewed always refuse requests for death.
They do not want to violate the laws as now written.
But they call for changes in the laws
that would permit more rational decisions about end-of-life care,
including the possibility of choosing an earlier death
when the only other alternatives is lingering suffering.
Doctors do need to protect themselves,
so they can continue to care for other patients
instead of languishing in jail because they helped a patient to die.

At the other end of the spectrum, there are doctors and nurses
who readily cooperate with requests for death.
They admitted to the author
that they had assisted in dozens of voluntary deaths.
But these care-givers would also like to see changes in the laws
so that the process of making such life-ending decisions
could be more transparent.
Fulfilling public safeguards would prevent
some abuses and mistakes that probably now occur.
But until the laws are changed,
these compassionate care-givers will continue
their secret and informal assistance in the process of dying.

There are a few doctors in the euthanasia underground
who resist the creation of public safeguards for life-ending decisions.
These doctors believe that they have enough experience of attending deaths
so that they can decide the most appropriate pathway towards death
without any input from others.
They make life-and-death decisions every day.
Why bring in other doctors to second-guess their choices?
The doctor already knows everything
about the physical condition of the patient
and has already chosen the wisest course.
Why call for a psychiatrist?
The doctor already knows that the patient is perfectly sane.
Why involve the family in a very-traumatic choice for death?
The doctor knows best and can take the burden of choice upon himself.

These free-lance 'angels of death' do not want more regulation.
They do not want to see the creation of a bureau of death-decisions.
Legalizing what they now do in secret
would only create more paperwork and use up valuable time
that could be devoted to caring for more patients.
These agents of death want to rely on
common sense and their professional judgments.

Legalizing voluntary death and merciful death
could either make life-ending decisions too easy or too difficult.

The process could become too easy if a panel of experts
routinely approved all requests for voluntary death or merciful death.
Then some doctors would be tempted to dispose of difficult cases
by applying for approval for death
rather than working to save a difficult patient.

The process could become too difficult
if a new system created a large bureaucracy of professionals
who had to become familiar with all the facts of each case
before approving a voluntary death or a merciful death.
If the process became too difficult and time-consuming,
some doctors and nurses would continue to help their patients to die
without consulting the bureaucrats.

Almost all of the... Read more ›