Book Review

The Case against Assisted Suicide: For the Right to End-of-Life Care

N Engl J Med 2002; 347:541August 15, 2002

Article

The Case against Assisted Suicide: For the Right to End-of-Life Care
Edited by Kathleen Foley and Herbert Hendin. 371 pp. Baltimore, Johns Hopkins University Press, 2002. $49.95. ISBN: 0-8018-6792-4

Few medical issues arouse such strongly passionate opinions among health care professionals and laypersons alike as the debate about physician-assisted suicide. This valuable and intentionally provocative book will add much light — and undoubtedly some heat — to the debate.

Foley and Hendin have assembled contributions from leading experts in diverse disciplines, all for the explicit purpose of making the “case against assisted suicide.” The editors are well qualified in their own right. Foley, a neurologist, is an attending physician on the Pain and Palliative Care Service at Memorial Sloan-Kettering Cancer Center, and Hendin, a psychiatrist, is medical director of the American Foundation for Suicide Prevention. The writing is of uniformly high quality, and the book achieves stylistic consistency while still reflecting an individual voice in each chapter. In addition, the clustering of chapters into sections, the appropriate use of cross-referencing among chapters, and introductory and concluding statements by the editors result in a well-organized, cohesive statement — a rarity for a multiauthored book.

In brief, this book's carefully reasoned and carefully written arguments flow as follows. The first section considers the ethical and legal arguments against assisted suicide. A major focus is the fundamental ethical argument used by proponents of assisted suicide — namely, respect for the principles of compassion and patient autonomy. Among the best in the book, these chapters posit that proper application of the principles of compassion and autonomy, within the context of the medical as well as legal professions, actually argues against assisted suicide.

One point made repeatedly is the “slippery slope” argument. The application of compassion and autonomy as demanded by proponents of assisted suicide must inevitably lead to the sanction of assisted suicide, not merely for the terminally ill but also for patients with chronic suffering from any cause, life-threatening or not. This section then segues to an examination of legalized assisted suicide in Oregon and of legalized assisted suicide or euthanasia in the Netherlands and (briefly) in the Northern Territory of Australia. The conclusions are that legalization does indeed result in physician-caused deaths beyond the narrow confines of purported safeguards and that, together with social and financial pressures, it actually limits the development or availability of proper palliative care for the dying.

Parts of this section depend on reinterpretation of the published data, an approach that leads to different conclusions from those made by the original authors. The reinterpretations are well presented, but some readers will differ and pose counterarguments. Much of this section also depends on vignettes involving particular patients or particular clinicians' practices. These stories are well told and are highly disturbing in precisely the manner intended. With any such vignettes, one wonders about information that is left out or shaped by the bias of the storyteller. Of course, concern about distortion is also paramount in interpreting the vignettes presented elsewhere by proponents of assisted suicide.

The next section offers several “reasons to be concerned” that condoning assisted suicide will adversely affect vulnerable populations. One chapter focuses on the rights of the disabled, noting how the public debate is (too often invisibly) influenced by society's prejudices against them. Another provides a thoughtful review of the role of depression and the will to live. There is also a chapter that usefully summarizes and rebuts key arguments made by proponents of assisted suicide. The final section introduces “a better way” — that is, hospice and palliative care. The editors conclude with their opinion that assisted suicide and euthanasia must be opposed, noting that the central objective must be to “stimulate the medical community . . . into accepting the challenge to provide better care at the end of life.”

Some detractors will criticize this work for not being what it is not. It is not a detailed explication of the principles and practice of palliative care. It does not present wholly new arguments against assisted suicide but, rather, collects these perspectives in well-organized and well-articulated form. It is not a scientific treatise on the shades of our uncertainty; rather, it only obliquely critiques the still scant empirical data on which to base discussions and implies, rather than sets, a research agenda to address the huge gaps in the literature. In addition, it is certainly not a balanced discussion among those with divergent views but, rather, a highly charged polemic.

Do we need such a polemic, however comprehensive and clear? I recall a recent case conference for medical students. The patient was an elderly nursing home resident who had been debilitated by strokes and other conditions. She had become acutely suicidal, a state of mind indisputably caused by the recurrence of severe depression. As with previous episodes of depression, she responded well to treatment and subsequently returned to a pleasurable life at the nursing home. I was dismayed to see many of the students' reactions to this case. Surely, they said, we should have respected this patient's “autonomy” and shown her “compassion” by allowing her to die as she initially (though no longer) wished, rather than treat her depression. Here was an instance of the “expendable elder” dynamic — one that I believe was strongly affected by the distorted public debate about assisted suicide.

I purposely reveal my own biases here, since each reader's views will exert a dominant influence over his or her responses to this book. Having said that, I believe that this book is sorely needed. Many will argue against its details, but it will be of tremendous interest to a wide audience both within and outside of medicine.

Jeffrey M. Lyness, M.D.
University of Rochester, Rochester, NY 14642
jeffrey_lyness@urmc.rochester.edu

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