Book Review

A Merciful End: The Euthanasia Movement in Modern America

N Engl J Med 2003; 349:2277-2278December 4, 2003

Article

A Merciful End: The Euthanasia Movement in Modern America
By Ian Dowbiggin. 250 pp. New York, Oxford University Press, 2003. $28. ISBN: 0-19-515443-6

Euthanasia is one of the most controversial bioethical issues in many Western societies. The Netherlands and Belgium have recently legalized euthanasia as a medical act under specific conditions, particularly the persistent voluntary request of the patient. In other countries, the question of what physicians are allowed to do in caring for people at the end of their lives is a recurrent theme on the moral agenda of public and political debate. In A Merciful End, Dowbiggin shows that at least since the late 19th century, active euthanasia or mercy killing has been advocated as an acceptable policy. He carefully outlines how, from the start, diverse motives and approaches have been at work. History can therefore explain some of the complexities and ambiguities of the recent debate.

In the early decades of the 20th century, euthanasia emerged as a public health measure in the broader context of Progressivism. Euthanasia was advocated as an individual right and, at the same time, as a socially beneficial practice. In this respect, it was closely intertwined with the eugenics movement. The freedom to choose death coincided with the evolutionary duty to die. Dowbiggin describes the 1915 Bollinger case, in which a handicapped newborn did not receive surgery, to demonstrate the connection among mercy killing, social reformation, and utilitarian goals. Between 1920 and 1940, social support for euthanasia increased in American society, with growing media attention and frequent mercy-killing trials, and culminated in the 1938 establishment of the Euthanasia Society of America.

In this period, euthanasia was associated not only with eugenics and sterilization laws but also with early advocates of birth control and the women's movement. It was part of the broader agenda against traditional ethics and organized religion of humanism, an ideology that developed in the 1940s. Dowbiggin shows how this agenda combines the argument in favor of individual autonomy with the argument that euthanasia saves taxes and satisfies biologic requirements for social engineering. Voluntary and involuntary euthanasia were necessarily connected, and it was exactly this connection that discredited the movement in the subsequent period (1940 to 1960) when the Nazi atrocities became known.

In the 1960s, the use of life-prolonging medical technology instigated a new cultural interest in death, terminal illness, and relief of suffering. Euthanasia again began to dominate the public agenda, but this time, as expressed in catchphrases like the “right to die” and “death with dignity,” the emphasis was primarily on patient autonomy and individual rights. However, the focus was ambiguous: for many, euthanasia referred to the right to refuse treatment; but for proponents of the euthanasia movement there was no distinction between passive and active euthanasia. Dowbiggin describes the resulting change of tactics: if “letting die” was ethically permissible and in need of legalization, the logical next step should be legalizing active euthanasia. But even within the euthanasia movement itself, the historic legacy continued to be divisive. The focus on individual choice, as exemplified in the advocacy of living wills, was often combined with social justifications, such as the need to eliminate “accidents of nature.” This double focus finally destroyed the unity of the movement and led to the founding of new organizations (e.g., the Hemlock Society in 1980) and the emergence of palliative care.

Dowbiggin's book is a lively and readable demonstration that the commitment to relieve human suffering has a long history and that the issue of euthanasia tends to reduce the complexities involved. Nobody will reject the notion of death with dignity, but disagreement will persist over what it entails. Is it active or passive euthanasia or both? Is euthanasia voluntary, nonvoluntary, or involuntary — or all three? Such disagreement is not accidental but intrinsic, as this book shows. Self and society, individual freedom and the common good, are necessarily related.

Henk A.M.J. ten Have, M.D., Ph.D.
University Medical Centre Nijmegen, 6500 HB Nijmegen, the Netherlands