Book Review

Letting Go: Death, Dying, and the Law

Advance Directives and the Pursuit of Death with Dignity

N Engl J Med 1994; 330:294January 27, 1994

Article

Letting Go: Death, Dying, and the Law
By Melvin I. Urofsky. 204 pp., New York, Charles Scribner's Sons, 1993. $22.50. ISBN: 0-684-19344-2

Advance Directives and the Pursuit of Death with Dignity
By Norman L. Cantor. 209 pp. Bloomington, Indiana University Press, 1993. $24.95. ISBN: 0-253-31304-X

The growing complexity of the process of dying in an age of sophisticated medical technology has been very good for business recently -- the publishing business, that is. A tremendous spate of books, not to mention journal articles, has been issued in the past several years, discussing from a variety of perspectives the legal and ethical implications of medical decision making for seriously ill persons. Even in this increasingly crowded market, two new entries merit close attention.

Letting Go and Advance Directives and the Pursuit of Death with Dignity possess a number of similarities. Both are intended for an audience of sophisticated laypeople, with medical and legal professionals as an important secondary readership. Both works are strongly colored by the vigorous bias in favor of broad interpretations of personal autonomy in medical decision making, including choices about life-sustaining medical treatment, held by the respective authors and by their prejudice against physicians who refuse to honor the wishes of patients and families to lessen aggressive intervention. Most important, both authors humanize, and indeed personalize, the legal and ethical issues at stake, Urofsky through the use of anecdotes or stories -- thick factual recitations -- and Cantor by relating intellectual questions to his own fears, values, and advance-planning efforts.

Urofsky's is the more readable of the two books, condensing into a highly accessible form a large amount of material about the way that society, through the legal system, has treated life-and-death dilemmas centered on rational and incapacitated patients, condemned criminals, handicapped newborns, suicide, and formal advance directives. Although largely successful in conveying important information quite understandably, the author in some places pays a price in terms of oversimplification and outright error, as, for example, when he states erroneously that federal Baby Doe regulations “require” hospitals to establish infant care review committees and that the important Conroy case involved a conscious, competent patient. Furthermore, such assertions as “hospitals and doctors have every reason to fear civil and criminal liability, and know full well that the American people will go to court over every real or imagined harm,” especially when uttered as part of a discussion of advance directives, serve rather poorly the causes of high-quality patient care, individual autonomy, and risk management by physicians.

For readers willing to do some heavy intellectual lifting, Cantor's is by far the richer treatise. The author joyfully wallows in the complexity of the legal and ethical implications of end-of-life decision making, providing both a cogent and provocative text and prodigious references. He recognizes the often wide expanse between legal theory and actual behavior and, to his great credit, does not shy away from or gloss over the most difficult practical issues facing participants in this drama. Physicians should carefully study chapter 3, dealing with conflicts between patients' wishes and restrictive advance-directive legislation by states, and chapter 7, addressing the enforcement of advance directives in the face of recalcitrant physicians.

Despite complaints about legal intrusions into intimate personal affairs, we will no doubt continue, for better or worse, to look to the legal system for guidance about conundrums involving life-sustaining medical treatment. These two books help interpret and explain the evolving pertinent legal limits to physicians and their patients.

Marshall B. Kapp, J.D., M.P.H.
Wright State University School of Medicine, Dayton, OH 45401-0927