Book Review

Deathright: Culture, medicine, politics, and the right to die

N Engl J Med 1995; 332:341-342February 2, 1995

Article

Deathright: Culture, medicine, politics, and the right to die
By James M. Hoefler, with Brian E. Kamoie. 291 pp. Boulder, Colo., Westview Press, 1994. $55 (cloth); $16.95 (paper). ISBN: 0-8133-1701-0 (cloth); 0-8133-1702-9 (paper).

In the wake of the recent electoral results in the state of Oregon — where voters approved a referendum that decriminalized physician-assisted suicide under specific circumstances — Deathright is a timely addition to the debate on the ethics and politics of the movement in support of physician-assisted suicide and euthanasia. James Hoefler, a professor of political science at Dickinson College, and his research assistant, Brian Kamoie, provide a sweeping overview of events in the past 15 to 20 years that relate to what has become an increasingly bitter and controversial issue in medicine, law, and ethics. Specifically, they ask under what circumstances (if ever) it is permissible for physicians either to aid their patients in committing suicide or to bring about the deaths of their patients outright. Because of Hoefler's perspective as a policy analyst, the book leans heavily on the notion of the right-to-die movement's policy process, with forces pushing toward the liberalization of laws described as “progressive” and those opposing change in this area as “conservative.”

That synopsis, in some sense, is responsible for both the book's greatest strength and its weakness. Hoefler does a creditable job of analyzing several important political and legislative developments in this country over the past 30 years, many of which made it possible, for example, to liberalize laws regarding physician-assisted suicide in Oregon. In addition, he takes note of several ancillary developments, many of which have contributed indirectly to this movement: for example, the recently recognized right of patients to forgo any life-sustaining medical treatment, the development of the women's rights movement, and perhaps most important, the devaluation of the role of physicians in adjudicating problems in medical care.

The book suffers, however, from its interpretation — at times simplistic, if not outright erroneous — of events that are, at best, complicated and irreconcilable. For example, sometimes Hoefler falls into jargon-laden analysis, as when he speaks of the Buddhist religion as being “progressive” and Judeo-Christian ethics as being “conservative” — a viewpoint, he says, “in which change and death are both things to resist.” There may be ways in which what he says is true, but his points require more development than a two-paragraph summary can provide.

In addition, there are times when Hoefler appears to be arguing at cross-purposes to himself. For example, the thrust of the book is the development of right-to-die laws and laws permitting physician-assisted suicide. The general trajectory of events has been to liberalize these laws, yet the author states: “It seems that Americans have drawn the line on liberty at death's door. In a culture obsessed with rights and choices, death — the point after which the ideas of rights and choices have no currency — seems pretty much beyond the pale.” That statement makes no sense in and of itself, but more important, it is at variance with the tone of the entire book.

Hoefler is stronger when he limits his analysis to the specifics of policy and legislation. He correctly identifies the trend away from specialization, and the view of patients as “collections of parts, some of which needed to be fixed,” has in some ways allowed physicians and their patients to recapture a sense that body, mind, and spirit are whole and that the physician and the patient need to be collaborators in achieving common goals, rather than opponents. Almost in the same breath, however, Hoefler makes statements that would be difficult to substantiate and that, again, detract from his overall argument. He writes, for example:

Medical training (which tends to discourage compassion and encourage autonomy), the ethos of not telling the truth about death (“surely, the patient can't take it”), and adherence to the technological imperative (“do everything possible for the patient”) all are responsible, to one degree or another, for driving the wedge between physicians and their patients even deeper.

Such statements, which are overgeneralizations and, in some sense, antiquated, detract from the strength of Hoefler's overall argument. Similarly, the language sometimes degenerates into cliches that do not particularly advance the debate — “The bottom line is that change is in the air” — or other statements that the author would be hard pressed to substantiate: for example, the Physician's Desk Reference “was a carefully guarded trade secret of physicians.”

In general, this book attempts too much — the subject matter is at least enough for several volumes — and its focus is at times too diffuse and fractured. The book is much stronger in terms of the categories that Hoefler uses to analyze the policy debate, though there are many (including myself) who would take issue with the way he has characterized the debate over physician-assisted suicide and euthanasia in general as primarily a policy matter. Whether we will ever find a resolution (as Hoefler seems to suggest in the conclusion of the book) or whether this debate will continue to be fractious and ill-considered may depend, to some extent, on books of this sort and on the continuing dialogue among the different speakers in this debate. To that end, this book, even with its limitations, serves a useful purpose.

Carlos F. Gomez, M.D., Ph.D.
University of Virginia School of Medicine, Charlottesville, VA 22908