Book Review

Physician Assisted Suicide: Expanding the debate

N Engl J Med 1998; 339:1563-1564November 19, 1998

Article

Physician Assisted Suicide: Expanding the debate
(Reflective Bioethics.) Edited by Margaret P. Battin, Rosamond Rhodes, and Anita Silvers. 454 pp. New York, Routledge, 1998. $21.99. ISBN: 0-415-92003-5

In the current debate about physician-assisted suicide, proponents argue that legalization would respect contemporary values of patient autonomy and that the practice, if legalized, would be limited in application. Opponents maintain that physician-assisted suicide would violate contemporary values because it would be applied both coercively and extensively. Most of the essays in this collection acknowledge that physician-assisted suicide would indeed constitute a change in contemporary values and that the practice might become widespread; nonetheless, they convincingly show that these propositions are not in themselves sufficient ground either to support or to oppose its legalization. These essays, most by philosophers, thus move the current debate to a new level of interest and sophistication.

The opening chapter, by Patricia Mann, sets the tone for the entire volume. Mann states that the way the value of autonomy is currently invoked to justify assisted suicide “ignores the fabric of relationships, good and bad, within which our actions necessarily occur” and that if physician-assisted suicide is legalized, “our cultural expectations [about dying] will be transformed” and “may become a ubiquitous form of death within the next quarter of a century.” She concludes, “That may be a good thing, or it may not.” Most of the other essays take up Mann's challenge, and whether they support or oppose legalization (and the collection is evenly balanced on this score), they examine the issues from this enlarged perspective with clarity and analytic rigor.

Margaret Battin envisions the prospect that legalized physician-assisted suicide would represent a fundamental shift in our cultural ideal of death and that assisted suicide would not be a rare event: “dying,” she says, “no longer [would be] something that happens to you but something you do.” Frances Kamm carefully dissects the current arguments advanced for physician-assisted suicide, rejecting the proposition that there are no moral differences between respecting a person's wish to refuse life-prolonging treatment and his or her wish for hastened death, but advocating legalized physician-assisted suicide on the ground that death can be rationally and morally chosen as “a lesser evil” in many specific circumstances. Don Marquis acknowledges that decisions to proceed with assisted suicide are not necessarily a product of clinical depression or misinformation but can be “rational choices made in accordance with an individual's fundamental values”; he nonetheless argues frankly for paternalistic restriction on this choice, because legalization “will make many of those in need of care worse off” and because laws can justifiably restrict the right to self-determination in order to protect people against “fundamental loss of well-being” (just as participation in the Social Security system is mandatory). John Arras maintains that individual morality is not the proper perspective for evaluating claims for or against legalized physician-assisted suicide but that predictable social harms require its rejection and, in any event, whichever policy is chosen will inevitably and tragically harm someone. The essays conclude with four chapters by theologians with different views about the moral evaluation of physician-assisted suicide that follow from the tenets of their various religions.

Not all the essays address the most fundamental questions raised by legalized physician-assisted suicide. Michael Teitelman, for example, maintains more narrowly that even if physician-assisted suicide is legalized, it should not be available in hospitals because its public character there would be likely to intensify the dangers of assisted suicide, which would be more controllable in other, noninstitutional settings. Bernard Gert, Charles Culver, and K. Danner Clouser make a case for legalizing the assisted suicide of competent, terminally ill patients by facilitating their refusal of food and water, as a preferred alternative to more extensive legalization of physician-assisted suicide. These essays too are distinguished by the clarity and care of their arguments.

The summaries in this review cannot convey the subtleties of argument and the refreshing lack of cant in these essays. This excellent collection, in short, accomplishes the goal proclaimed by the subtitle of the book: it succeeds in expanding the debate about legalizing physician-assisted suicide well beyond its current narrow framework.

Robert A. Burt, J.D.
Yale Law School, New Haven, CT 06520