Book Review

In the Arms of Others: A cultural history of the right-to-die in America

N Engl J Med 1998; 339:1793December 10, 1998

Article

In the Arms of Others: A cultural history of the right-to-die in America
By Peter G. Filene. 282 pp. Chicago, Ivan R. Dee, 1998. $27.50. ISBN: 1-56663-188-2

Commenting on the narrow defeat of referendums to legalize physician-assisted suicide in Washington and California in the early 1990s, Peter Filene writes, “Fifteen years earlier — no more than a minute or two of cultural-historical time — Americans had been hesitant to legalize living wills. Now 46 percent voted to legalize not simply passive euthanasia but active euthanasia by doctors.” In the Arms of Others is a terrifically well written narrative of how we got from there to here. (“Here,” of course, now includes Oregon's statute on physician-assisted suicide, which has already been invoked in the suicides of several Oregonians.) Filene structures his narrative around the major court cases that have defined Americans' expanding legal right to refuse or terminate life-sustaining medical treatments, with the most detailed attention paid to the case of Karen Ann Quinlan. But In the Arms of Others is far more (and far more readable) than a recitation and analysis of medical facts and court opinions. Filene has a gift for bringing legal and ethical arguments vividly to life. He situates the Quinlan case, as well as the cases of Joseph Saikewicz, Infant Doe and Baby Jane Doe, Claire Conroy, and Nancy Cruzan, in their richly detailed, psychologically nuanced human contexts. And he places these family dramas in the still broader context of the political and cultural wars that swept over the United States in the 1970s and 1980s and that continue today.

Filene emphasizes in particular how the “right to die” became entwined with the abortion debate and how both issues “translated [patients' and families' private choices] into the ideologies of warring social movements. The dilemma of dying became political, absorbing the passions and anxieties of modern America.” Though he does not make this point explicitly, his account is a cautionary tale for bioethicists and palliative care advocates (including me) who aspire — in the words of the mission statement of the Project on Death in America — “to transform the culture of dying” in the United States. It would be naive, Filene warns, to assume that this task is simply a matter of convincing ethical arguments, evocative personal narratives, or savvy public relations. Each of these elements has an important role, as In the Arms of Others illustrates. Yet Filene also demonstrates that they are all played out in a highly contested cultural terrain, making the process of transformation complicated and unpredictable.

Certain trends do seem clear, however. For one thing, it is unlikely, according to Filene's history, that American society will hold the line much longer against widespread acceptance of physician-assisted suicide. In Filene's words, which continue the passage I quoted in my introduction, “Attitudes [toward suicide and euthanasia] were shifting with astounding speed; informal or extralegal behavior was moving almost as fast; sooner or later, legislation would surely catch up.” Oregonians have proved Filene right, though legalization came in the form of a referendum. Filene is ambivalent about this trend and, partly as a consequence, leaves the reader in something of a muddle. On the one hand, he enters the ethical debate on the side of those who deny a critical moral difference between passive and active euthanasia, or between withholding or withdrawing life-sustaining treatment and intentionally hastening death with a lethal injection. On the other hand, he worries that legalized physician-assisted suicide in the United States would not “function” as it does in the Netherlands (according to the benign interpretation) and could conceivably lead to the manipulation and coercion of vulnerable people, as “the direst opponents” of legalization fear. But if there is no substantial difference between what is now legal and what (except in Oregon) is not, why does Filene worry about manipulation and coercion only in the latter case? I think he should worry more about physician-assisted suicide than about withholding or withdrawing treatment and that they are morally different, but that is an argument for another occasion.

Finally, Filene makes a convincing case that Americans will continue to struggle over decisions at the end of life because our legal and ethical approach to the subject has been dominated by a preoccupation with autonomy and self-determination. In contrast, most people die from chronic, incurable diseases, and under these circumstances, decisions at the end of life require an emphasis on dependency and interrelatedness. To Filene it is ironic, but inevitable, that the “rights” propounded in the landmark cases involving Quinlan, Conroy, and Cruzan were justified on the basis of privacy and self-determination but had to be exercised on the patients' behalf by others on whom they had become utterly dependent. This, Filene reminds us, is the nature of frailty, decline, and death — and perhaps the hardest thing of all to assimilate in American culture in the late 20th century.

David Barnard, Ph.D.
Pennsylvania State University College of Medicine, Hershey, PA 17033