Book Review

Physician-Assisted Suicide: What Are the Issues?

N Engl J Med 2002; 346:1836June 6, 2002

Article

Physician-Assisted Suicide: What Are the Issues?
(Philosophy and Medicine. Vol. 67.) Edited by Loretta M. Kopelman and Kenneth A. De Ville. 256 pp. Dordrecht, the Netherlands, Kluwer Academic, 2001. $98.50. ISBN: 0-7923-7142-9

Since ancient times, people have disagreed about the permissibility of suicide, assisted suicide, and physician-assisted suicide. This book presents an overview of the issues involved in the debate about physician-assisted suicide at the end of the 20th century. It contains the papers presented at a bioethics conference on physician-assisted suicide that took place shortly after the U.S. Supreme Court ruled that people have no constitutional right to physician-assisted suicide. The contributors' various disciplines guarantee a broad array of philosophical, moral, legal, and professional reflections about a person's right to control the timing, manner, and means of his or her death. The book addresses not only physician-assisted suicide, but also a broader range of end-of-life care.

Opponents as well as advocates of physician-assisted suicide are represented, and they articulate the various moral controversies that define the debate on physician-assisted suicide and euthanasia. It is this disagreement about the fundamental moral questions surrounding life, suffering, and death that will preclude a rational resolution of the issue, as one of the authors states.

A much-discussed theme in the debate about physician-assisted suicide, and a recurring issue in the book, is the moral distinction between acts (physician-assisted suicide or euthanasia) and omissions (withholding or withdrawing treatment or “letting die”). In one chapter, for instance, the author challenges the view that withdrawing feeding tubes because the patient refuses further treatment is different in terms of causality or morality from physician-assisted suicide. It is argued that, in both situations, the physician has a causal role in the patient's death, and thus there is no distinction between passive and active practices that result in death.

Another recurring theme is the opinion that, as long as pain is routinely underdiagnosed and undertreated, physician-assisted suicide should not be an allowable alternative to living with unrelenting pain. In this view, increased attention in medical education, research, and practice to patients' pain and its control may reduce the demand for physician-assisted suicide. This view of the matter entails a plea for medicine to take a more humanistic approach than the current scientific one, which does not accommodate considerations of pain very well.

Opponents of physician-assisted suicide often warn that such a right may be abused or that its endorsement represents a “slippery slope.” In this book, an argument is presented that abuse and mistakes are more likely in practices in which surrogates make decisions for incompetent patients, as is more often the case with decisions not to treat or to provide pain relief or terminal sedation — practices against which there are no safeguards — than in cases of assisted death at the explicit request of the patient. Another chapter addresses the slippery-slope argument by asking whether the general acceptance of suicide would necessitate the acceptance of assisted suicide and euthanasia as well. It concludes that euthanasia cannot be justified by any simple, logical reasoning on the basis of the assumed permissibility of assisted suicide alone, thus rebutting the slippery-slope argument.

In addressing the question of whether physicians must play a central part in authorizing assisted suicide, another contributor discusses the empirical data concerning two major arguments for physician-assisted death — that it will enhance patients' personal liberty to decide how to die and that it will promote compassion. It is concluded that physicians should not have an explicit role in assisted suicide as long as they do not follow patients' directives carefully or use the most effective measures to relieve suffering. The claim that permitting assisted suicide will enhance autonomy and compassion is criticized from yet another point of view, according to which physician-assisted suicide is an unwanted medicalization of death. In this view, physician-assisted suicide should be prohibited for reasons of community, because people are part of a social network, so that assisted suicide is not simply and solely a personal choice. And if compassion is to be the motive for assistance with death, physicians should not be the first to be permitted to provide such assistance: “the reality that underlies even the nicest physicians' interventions is that after the death, unlike the real family, the physician will be paid, and then move along to the next patient.”

The book also offers some reflections about the future. One argument is that neither will the gradual expansion of the practice of physician-assisted death be stopped, nor will it become a common component of conventional medical practice, whatever the legal situation may be — whether there is a clear prohibition of physician-assisted suicide, whether it is allowed under limited circumstances, or neither. An exploration of the prospect of cultural change with regard to one's own role in one's death results in a divergent conclusion: both backward and forward motion may be possible.

The rapid pace and complexity of the arguments in some parts of the book may necessitate a thorough second or third reading, but other chapters are more straightforward and easier to read. To those who are familiar with the arguments for and against physician-assisted suicide, the book will probably not provide many new insights. Nevertheless, it offers a good depiction of the contemporary debate about physician-assisted suicide and is an interesting work.

Johanna H. Groenewoud, M.D., Ph.D.
Erasmus University Rotterdam, 3000 DR Rotterdam, the Netherlands

Citing Articles (1)

Citing Articles

1. 1

   (2002) Physician-Assisted Death. New England Journal of Medicine 347:13, 1041-1043
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