Book Review

Hospice or Hemlock? Searching for Heroic Compassion

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

Article

Hospice or Hemlock? Searching for Heroic Compassion
By Constance E. Putnam. 209 pp. Westport, Conn., Praeger, 2002. $44.95. ISBN: 0-89789-921-0

This book explores the values shared by both sides in the emotionally and politically polarized debate around end-of-life care. Putnam finds common ground in the compassion expressed by advocates for palliative care, or “hospice,” and for physician-assisted suicide, or “hemlock.” Compassion entails responding to what patients and their families want and expect from their physicians as they approach the ends of their lives. For Putnam, compassion means making both hospice and hemlock available, allowing individual patients to choose how they die.

In building her case for shared values, Putnam draws on history, classic legal cases, and philosophical concepts, addressing, among other topics, the medicalization of dying, the growth of hospice, the right-to-die movement, and the legalization of physician-assisted suicide. Notably absent are public-policy and economic perspectives. Her critiques of incomplete or ineffective arguments are insightful; however, she does not adequately address the shortcomings. Particularly interesting is a discussion of the concept of rights based on the work of philosopher Judith Jarvis Thomson. Woven into the historical references are instructive and entertaining profiles of several visible and key persons in the debate, including modern hospice founder Dame Cicely Saunders and Hemlock Society founder Derek Humphrey.

Though it contains little new information or analysis, Hospice or Hemlock? offers a comprehensive review of the literature and a useful summary of the debate. Putnam's lopsided conclusion in the final chapter, however, is disappointing after an evenhanded treatment of both sides of the debate. Indeed, to some her conclusion may appear to be a capitulation to hemlock advocates rather than a heroic exercise of compassion, as implied by the title of her book. Moreover, her use of the term “physician-aid-in-dying” rather than “physician-assisted suicide” strongly suggests that she favors the hemlock side; the language has been as hotly contested as the issue itself.

Hemlock advocates do not oppose hospice but, rather, believe that it may not be enough or appropriate for everyone. Physician-assisted suicide, they argue, offers an additional option, available to those who desire it. With self-determination as their guiding value, the solution for them has always been both hospice and hemlock. For hospice advocates, the choice itself is impossible. Valuing respect for life and expressions of caring above all, they argue that physician-assisted suicide is wrong for a number of philosophical, legal, and practical reasons. Thus, the dispute cannot be resolved by choosing hospice or hemlock or even both. Although each side is concerned about human suffering and esteems patient-centered care, offering hemlock and hospice is not a mutually acceptable compromise. The solution may yet arise from the common ground that Putnam has identified but failed to build upon.

Putnam achieves her goal of making this well-written and easy-to-read book accessible to a wide audience. Whether she also succeeds in providing “a guide to how one might go about finding one's own answers to some of the myriad questions that end-of-life decision-making provokes” is a matter for each reader to decide. For this reader, the proper questions and answers lie deeper. In the end, the dichotomy that Putnam establishes with her title remains, and the search for heroic compassion seems only to have begun.

Felicia Cohn, Ph.D.
University of California, Irvine, College of Medicine, Irvine, CA 92697
fcohn@uci.edu