The development of new and improved diagnostic procedures and treatments that allow physicians to treat diseases more effectively has complicated the practice of medicine. In elderly, frail, and disabled patients who are dying of chronic, irreversible conditions, the use of advanced "life-saving" technology is problematic and may only serve to prolong the dying process. Now, in addition to making a diagnosis and deciding on the most appropriate treatment, physicians must also decide when and for whom these expensive diagnostic procedures and treatments are appropriate. These new forms of technology are a double-edged sword. They have raised many difficult ethical, clinical, legal, and social issues concerning the limits of medicine, particularly in the care of chronic, incurable illnesses.
The issues of withholding and withdrawing life-supporting treatment, palliative care, voluntary euthanasia, and physician-assisted suicide lie at the heart of these complex and controversial problems. Euthanasia and Physician-Assisted Suicide, written by two professors of philosophy and a fellow at the Harvard Center for Population and Development Studies, tackles these issues head-on. It has two parts; in the first, the moral and ethical case for legalizing physician-assisted suicide and voluntary euthanasia is presented; in the second, arguments against these practices are provided.
In the first half of the book, Dworkin and Frey argue that physician-assisted suicide is morally permissible and that it ought to be legal for physicians to provide the knowledge or the means, or both, by which a patient can take his or her own life. They propose that autonomy and relief of suffering are important values and that dying patients have the right to make the process of dying as painless and dignified as possible and to control the time and manner of their death. They argue that objections to allowing physicians to serve these values are mistaken and that, once they are seen to be mistaken, physicians will favor physician-assisted suicide and voluntary euthanasia. Furthermore, Dworkin and Frey believe, withdrawal of life support that will result in death is morally equivalent to physician-assisted suicide and voluntary euthanasia in certain circumstances, because there is no moral asymmetry between refusal or withdrawal of treatment and assisted dying.
Dworkin and Frey reject the view that considerations stemming from the nature of medicine, or professional norms, preclude the participation of physicians in assisted dying. They discuss the "quintessential" case of physician-assisted suicide, in which the patient is competent, informed, and terminally ill and has voluntarily requested the doctor's assistance in dying; moreover, the patient still requests such assistance after being treated for depression. The moral distinctions between switching off a ventilator, prescribing morphine to relieve suffering even though it will hasten death, and providing a pill that will kill a patient are rejected. In the case of the morphine, the doctor acts and has control, whereas in the case of the pill, the patient acts and is in control. In the latter case, the doctor and patient act together to produce the patient's death. Dworkin and Frey believe that the actions are morally equivalent, since both are intended to bring about the patient's death, and they argue that there is no conclusive moral difference between allowing a patient to die by refusing treatment and by giving a pill, since these are merely similar ways of achieving the same end.
In the third chapter, "The Fear of a Slippery Slope," the authors reject the concern that distinctions between physician-assisted suicide and active voluntary euthanasia and between terminal illness and chronic nonterminal illness will be blurred and that it will be impossible to contain physician-assisted suicide, thereby leading to mass killing. If a physician rigs up a machine that enables the patient to inhale carbon monoxide, then what moral difference does it make whether the physician who arranged the device or the patient actually pushes the button in the end? Dworkin and Frey reject any real moral difference between physician-assisted suicide and active voluntary euthanasia, since in both cases the doctor and patient act together and the only difference between the two is in who acts last. They also suggest that terminally ill, competent patients should not be denied what they choose because of the fear that perhaps more vulnerable and more numerous patients are likely to be "terminated" as well. They believe that it is possible to use safeguards to prevent such a rationalization of killing. Finally, they argue that the burden of proof falls on those who would override a patient's request or deny physician-assisted suicide to provide evidence that horrible consequences are likely.
The fourth chapter deals with public policy and physician-assisted suicide. It is not apparent to Dworkin and Frey why the legal system would have a harder time dealing with physician-assisted suicide and active voluntary euthanasia than with withdrawal of life support, termination of artificial hydration and nutrition, proxy consent, or substituted judgment.
In the second half of the book, Sissela Bok argues against legalizing physician-assisted suicide and active voluntary euthanasia in four chapters: "Choosing Death and Taking Life," "Suicide," "Euthanasia," and "Physician-Assisted Suicide." She disagrees fundamentally with the approach of Dworkin and Frey, who provide a more focused series of arguments dealing mainly with the ethical and moral aspects of these issues. Bok has found it more useful to find shared views and premises and to study the ways in which they diverge. Unlike her coauthors, who limit themselves mostly to moral arguments, she offers a broader perspective. She draws on personal experiences, presents more clinical material, provides a historical and literary context, quotes poetry and literature, and discusses previous experiences with physician-assisted suicide and active voluntary euthanasia in the Netherlands and current practices in the United States.
Bok's writing has a practical and clinical ring to it, and that will certainly appeal to practicing physicians who recognize the multiple aspects of these problems. In clinical practice, these issues are reviewed from a variety of perspectives, and more compelling arguments than the moral ones alone can be used to influence and persuade. This part of the book is much clearer and easier to follow. Bok writes with passion and provides a comprehensive, multidimensional assault on her thesis. Patients seek control at the end of their lives. Few want to die in the hospital (yet over 80 percent of Americans die in hospitals). She argues that there is inappropriate use of physician-assisted suicide and voluntary euthanasia in the Netherlands and that it is almost impossible to prevent such inappropriate use. For example, although the majority of the 9700 requests for physician-assisted suicide or voluntary euthanasia in the Netherlands were turned down, 3700 were granted. About 1000 people who were not competent to make such a decision were put to death, in violation of the guidelines. Many cases of voluntary euthanasia and physician-assisted suicide are not reported. Many patients who were comatose or demented -- who had never expressed a wish for voluntary euthanasia or physician-assisted suicide -- were terminated. In some cases, severely disabled babies were killed.
I found Bok's writing more accessible and her accounts richer than those of Dworkin and Frey. The philosophers provide moral arguments that are eloquent, intricate, and at times difficult to follow. In contrast, Bok provides a more resonant, readable, and clinical approach. In the end, I agree with Bok that it is impossible to view these issues from a single perspective. Two pairs of hands, pulling against each other on a rope in a tug-of-war, are displayed on the front cover. In my opinion, Bok wins on the first pull.
Reviewed by D.W. Molloy, M.D.
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