From The New England Journal of Medicine
Despite its general merits, A Time to Die suffers from several weaknesses. A theoretical question underlying the debate is the ethical distinction between, or equivalence of, physician-assisted death and the legally established, standard practice of forgoing life-sustaining treatment. McKhann effectively rebuts the traditional argument for a moral distinction: that it is the disease that causes death when life-sustaining treatment is withdrawn, whereas in physician-assisted suicide it is the provision of lethal medication that causes death and that terminating life is the intent of physician-assisted death but not typically of the withdrawal of treatment. Yet McKhann does not discuss the position that refusal of treatment, but not assisted death, is grounded in the basic right of persons to be free of unwanted bodily intrusion. According to that perspective, when a competent patient refuses life-sustaining treatment, physicians are morally obligated to comply. In contrast, competent, terminally ill patients are not owed assistance toward death as a right, though it may be the best option for patients facing intolerable suffering.
Within the penumbra of the patient's right to refuse medical treatment is the right to hasten death by voluntarily stopping eating and drinking. McKhann mentions but does not give due attention to this important alternative to physician-assisted death. This legally permitted option may seem less humane than the swift means of ingesting or injecting lethal medication; however, anecdotal evidence suggests that a peaceful death can be achieved by refusing food and water, provided that the patient receives standard palliative and supportive care. The time required to bring about death by ceasing to eat and drink, typically from a few days to a few weeks, should be compared with a mandatory two-week waiting period following a request for lethal medication -- a feature of the law in Oregon legalizing physician-assisted suicide and similar legislative proposals elsewhere. This alternative arguably displays greater evidence of the self-determination of patients and poses less threat to the professional integrity of physicians.
The weakest chapter of the book addresses the concern that legalizing physician-assisted death would invite intolerable abuse. McKhann appears confident that physicians empowered to assist patients in dying will engage in this practice responsibly. For example, he argues that "if withdrawing treatment is not considered to be an easy way out, assisted dying is even less likely to be." This may be true for euthanasia by lethal injection. But prescribing lethal medication at the request of a terminally ill patient, and not knowing whether the patient will actually use the drugs to cause death, may be a tempting "quick fix," obviating the demanding work of caring for the dying. Moreover, McKhann's position that physician-assisted death, authorized by patients' advance directives, should be available to patients with severe dementia is fraught with peril. It remains an open question whether safeguards such as mandatory consultation by an independent physician would provide adequate protection of vulnerable patients. In view of realistic concern about the potential for abuse, there is reason to doubt McKhann's prediction that the legalization of physician-assisted death, beyond the Oregon referendum, is inevitable.
Reviewed by Franklin G. Miller, Ph.D.
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