Book Review

Death and Dignity: Making Choices and Taking Charge

N Engl J Med 1993; 329:817September 9, 1993

Article

Death and Dignity: Making Choices and Taking Charge
By Timothy E. Quill. 255 pp. New York, W.W. Norton, 1993. $21.95. ISBN: 0-393-03448-8

This book, written from the heart, is compassionate and empathic. It makes a compelling argument for legalizing physician-assisted suicide, by discussing cases in which comfort or palliative care proved inadequate. Dr. Quill first described a case in the Journal (1991;324:691-694) where he admitted prescribing barbiturates for a young woman, Diane, who was dying of cancer. She used them to free herself from the discomfort, pain, and uncertainty of dying. Alone, she took the medications and died. He believes that this was the only option available to him at that time and feels that his actions were justified. He regrets that she died alone.

Quill recounts his experiences with death in childhood and in his work over many years of caring for the dying. He believes that physician-assisted suicide should be an option available to patients and physicians when comfort care fails to meet the patients' physical, emotional, psychological, or spiritual needs. Diane's case is a powerful argument for legalizing assisted suicide. He discusses the limitations of palliative or comfort care and presents a useful update on initiatives in the United States and guidelines used in the Netherlands. He presents potential clinical criteria that could be used to develop policies for effectively legalizing and implementing physician-assisted suicide.

Finally, three chapters at the end of the book deal with advance directives. These chapters are vague and somewhat disappointing. Quill should have suggested a process to implement his guidelines and presented their limitations instead of discussing advance directives, which one cannot help feeling were an afterthought. He does, however, give some useful examples of living wills and proxy directives in the appendix.

There clearly are cases in which comfort care has limitations. People may have intolerable physical, emotional, or spiritual suffering in a state that they do not want continued. They may request assisted suicide as a release. Quill had such a patient. He went to the limit of his ability to heal and comfort and then provided what he believed was the only option left to him -- he assisted his patient in committing suicide.

One must admire his honesty and integrity. He is driven by compassion and the desire to relieve suffering. This book is his attempt to deal with a difficult issue, and he has ventured into territory where few have gone and where fewer still have the desire to go or even to speak about. We will never know how different physicians would have handled Diane's case, and it may not matter.

The sparsity of the discussion about the limitations of guidelines for physician-assisted suicide was disappointing. The guidelines presented are, at best, vague, and it is hard to determine whether their reliability or validity could be measured. How does one measure suffering or interpret many of the terms used in the guidelines? I was left with an uncomfortable feeling that we are allowing some people to suffer needlessly at the end of their lives because we are limited in our ability to understand, comfort, and help the dying. I have no idea how common cases like Diane's are and how many more Quill has seen. Despite his compelling reasons for action in this particular case, I am not convinced that his solution is the best we can come up with. Notwithstanding these limitations, however, I would definitely recommend this book to anyone who cares for the dying. It challenges us all and sheds light on an area that we have all neglected for far too long. For this, I commend Dr. Quill.

D.W. Molloy, M.D.
McMaster University, Hamilton, ON L8N 3Z5, Canada