Book Review

Physician-Assisted Suicide

N Engl J Med 1997; 337:943September 25, 1997

Article

Physician-Assisted Suicide
(Medical Ethics Series.) Edited by Robert F. Weir. 266 pp. Bloomington, Ind., Indiana University Press, 1997. $29.95. ISBN: 0-253-33282-6

Intense public and professional attention has been focused on physician-assisted suicide since 1990, when Jack Kevorkian performed the first in a highly publicized series of assisted deaths. The debate is likely to continue in the wake of the recent Supreme Court decision that there is no constitutional right to physician-assisted suicide, which decisively shifts the policy focus to state legislatures and referendums. Those seeking a guide to the moral landscape of physician-assisted suicide — one of the deepest and most controversial issues of medical ethics — will be rewarded by reading this multiauthored book. It is organized in sets of paired chapters that discuss the historical, ethical, clinical, and policy dimensions of the topic.

Harold Vanderpool places the current debate in cultural and historical perspective. Although physician-assisted death is an ancient issue, our current concern reflects the recent development of life-prolonging technology and the preeminence of patient autonomy in medical ethics. Daniel Callahan forcefully argues that the emphasis on autonomy gives a skewed perspective to the ethics of physician-assisted suicide. A legal right to physician-assisted suicide would undermine the values of community by sanctioning a dangerous and uncontrollable power in the hands of doctors. Dan Brock contends, however, that the ethical considerations that ground the established right to refuse life-sustaining treatment — individual self-determination and well-being — also support the moral legitimacy of physician-assisted death. Contrary to the traditional view that physician-assisted death would constitute a radical ethical departure in the practice of medicine, Brock argues provocatively that physicians engage in morally justified killing of patients when they withdraw life-sustaining treatment.

Ira Byock, a hospice physician, challenges various assumptions that lie behind the momentum in favor of legitimizing assisted suicide. Despite his opposition to this option, Byock takes the position that in the event that assisted suicide were to be legalized, hospices must continue to provide care to enrolled patients who seek assisted death but must not directly participate in assisted suicide. Howard Brody offers a cautious and nuanced case for a trial policy of legalizing physician-assisted suicide subject to clinically based regulations. A major premise of his argument is that assisted suicide is not contrary to the professional integrity of physicians if performed as a last resort when competent palliative care fails to provide adequate relief of suffering.

The policy debate over legalizing and regulating physician-assisted suicide needs to address the potential impact of this option on “vulnerable” patients. Kristi Kirschner, Carol Gill, and Christine Cassel raise troubling issues concerning physician-assisted death for people with disabilities. They focus on cases of profoundly disabled patients who were not terminally ill but who sought death by withdrawing life support or forgoing food and water. Are these patients making autonomous, rational decisions, or are they motivated by frustration and despair, owing to the lack of adequate care and supportive help? The authors argue that the ethical quandaries posed by such cases within the scope of the legal right to refuse treatment should give pause to those advocating a legal option of physician-assisted suicide. Using the perspective of gender as a lens, Susan Wolf argues that legalized assisted suicide would have a negative impact on women and other vulnerable groups. The final two chapters take opposing positions on the potential adequacy of safeguards in the regulation of physician-assisted suicide.

This collection of well-written and carefully argued essays should be interesting, illuminating, and thought provoking for students, clinicians, and scholars. The authors generally avoid the heated rhetoric and tendentious posturing characteristic of much of the recent debate over this emotionally charged topic. The reader is left with a heightened sense of the depth and complexity of the issues at stake. This book would have been enhanced by the inclusion of a critical review of the empirical literature on physician-assisted death, both in the United States and the Netherlands, where systematic data have been generated. The ethical and policy debate on physician-assisted death should be informed by an understanding of what is known and what remains unknown about this controversial practice.

Franklin G. Miller, Ph.D.
University of Virginia, Charlottesville, VA 22903

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