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

• Author: Satz, Ani B.

THE CASE AGAINST ASSISTED SUICIDE: FOR THE RIGHT TO END-OF-LIFE CARE. Edited by Kathleen Foley and Herbert Hendin. Baltimore: Johns Hopkins University Press. 2002. Pp. xii, 371. $49.95.

CONTENTS I. INTRODUCTION: AUTONOMY, SUFFERING, AND A PARENT'S LOVE 1380 II. OVERVIEW 1382 III. PRELIMINARIES 1383 IV. ASSISTED SUICIDE AND PALLIATIVE CARE 1386 A. The Argument from Mutual Exclusivity 1386 B. Undermining Palliative Care? 1387 C. Forcing Death? 1390 V. AUTONOMY AND SUFFERING REVISITED: THE CONCEPTUAL CLAIMS 1393 A. The Role of the Professional Ethic 1395 B. The Actions and Omissions Distinction 1400 C. The Autonomy of Those Who Wish to Die 1403 VI. CONCLUSION: PRACTICE VERSUS POLICY--ANOTHER SOLUTION 1406 I. INTRODUCTION: AUTONOMY, SUFFERING, AND A PARENT'S LOVE

When the four horsemen came--schoolteacher, one nephew, one slave catcher, and a sheriff--the house on Bluestone Road was so quiet they thought they were too late.... Inside, two boys bled in the sawdust and dirt at the feet of a nigger woman homing a blood-soaked child to her chest with one hand.... What she go and do that for? On account of a beating? ... "What she go and do that for?"--Toni Morrison, Beloved (1)

In Toni Morrison's acclaimed novel Beloved, Sethe, a runaway slave woman on the brink of capture, gruesomely murders one of her infant children and is halted seconds before killing the second. Cognizant of the approaching men, Sethe's actions are deliberate, swift, confident, and unflinching. Afterwards, she sits erect in the Sheriff's wagon. The reader is left to struggle, situating the horror of the event within the context of the reality of slavery. Was this an act of mercy to prevent the suffering Sethe's child would know as a slave? Is loss of autonomy, even rising to the condition of slavery, sufficient justification for ending a life? Was this a desperate attempt to control an unjust situation?

These questions of suffering, self-determination, and control are similar to the ones raised within the context of the euthanasia debate today. The two primary justifications for euthanasia are often identified as the prevention of suffering and respect for autonomous choice to end one's life (or, for the incompetent person, respect for the guardian's autonomous choice, presumably supporting the interests of the incompetent individual). Certainly slavery is the extreme example of diminished autonomy, and arguably of suffering. Nevertheless, an intuitive response that Sethe's actions are morally wrong, or an emotive reaction of shock, is understandable.

Reflections about such an intuition or emotive response likely would reveal concern--not that Sethe ended the life of an infant or even that she ended the life of her own child--but that she ended the life of a healthy child who might have known a situation other than slavery. Further, even if Beloved lived her entire life as a slave, it is unclear that her life would have been one only of suffering. At the very least, the child could have known love and friendships, even within a situation of gross social injustice.

The killing of Beloved, though an instance of euthanasia, is different from assisted suicide, where individuals who are suffering intolerably from illness choose to end their lives and require assistance to do so. Consider the case of Carla, who received a physician's assistance to terminate her life.

Carla was 47 years old.... In 1988, Carla noticed a painful swelling in her lower abdomen and went to her family doctor. He referred her to a gynecologist.... A subsequent operation revealed that the pain had been caused by a large malignant tumour on one of Carla's ovaries. By the time the operation was performed, the tumour had already grown so large that it could not be totally removed Carla underwent chemotherapy and by June her condition had greatly improved ... [in] March 1990 ... it was found that the tumour had re-grown. Chemotherapy was tried once more, but this time it was in vain. By the middle of the year, Carla's pain had increased to such an extent that her family doctor had to prescribe opioids (morphine-like drugs). Her condition deteriorated quickly and it was not long before Carla had to be readmitted to [the] hospital.... She was vomiting constantly.... To prevent thirst, Carla received an infusion of a saline solution.... Carla lost a lot of weight and became extremely weak, unable even to move around in her bed. This made it very difficult for the nurses to prevent bedsores. While Carla lost weight, the tumour continued to grow and was soon obstructing the blood flow in her legs, causing them to swell painfully. (2) Many opponents of assisted suicide argue as if there is no moral difference between the death of Beloved and the death of Carla. They fear any action intended to terminate the life of a suffering individual. This includes actions by doctors within regulated schemes of assisted suicide for irreversible and terminal illness requiring informed consent, secondary medical opinions, and waiting periods. One's capacity to choose to die is not viewed as morally relevant. Opponents object to the assisted suicide of competent individuals as well as those who are in a persistent vegetative state. Support for these views purportedly stems from the potential for abuse within regulated schemes, the availability of other means to alleviate suffering, and the moral distinction between intending and foreseeing death. The authors whose work is the subject of this Review are no exception.

2. OVERVIEW

   The Case Against Assisted Suicide: For the Right to End-of-Life Care is edited by Kathleen Foley (3) and Herbert Hendin. (4) Foley and Hendin are medical doctors who present the self-proclaimed first comprehensive examination of the arguments against assisted suicide in favor of greater palliative care. The book, a collection of fourteen articles by distinguished contributors such as Daniel Callahan, Yale Kamisar, and Leon Kass, establishes the case against assisted suicide in four steps, comprising each of the book's sections, respectively. The first section argues that the philosophical and legal foundations for the right or interest in assisted suicide cannot be sustained. Broadly, the authors conclude that assisted suicide is inconsistent with autonomy, compassion, and rational choice. (5) Even if one believes the philosophical foundations for assisted suicide are sound, the second section emphasizes that, in practice, there are abuses within assisted suicide schemes, as the Dutch, American (United States), and Australian experiences demonstrate. The third part of the book addresses the implications of assisted suicide for vulnerable persons, with special attention to the concerns of the disabled. The final section argues for the importance of quality and more robust hospice and other palliative care, leading to the editors' favored solution in the conclusion of a states-based initiative to improve end-of-life care, avoiding the need for assisted suicide.

   The book combines the work of several authors to establish foundations for better palliative care and the prohibition of assisted suicide. It purports to show that assisted suicide should not be allowed because it increases vulnerability at the end of life, undermines palliative and other care, and is unnecessary to relieve suffering. The book thereby rejects the claims that assisted suicide supports autonomy of the affected person and is needed to relieve suffering at the end of life. While I do not believe the collection is persuasive on these points, its value lies in its approach to the issue: a philosophical-legal-empirical perspective on assisted suicide, advocating a practical solution.

   In order to dismiss the authors' case against assisted suicide, one must rebut the conceptual claims as well as account for the empirical data and anecdotal evidence presented. This Review focuses primarily on philosophical claims. This is accomplished, I believe, while taking seriously the editors' charge that philosophers and lawyers, removed from patient care, must account for the realities of clinical practice (pp. 4-5). Any philosopher writing in the field of medical ethics who is worth her salt must accept this task. I do not attempt to dispute the empirical data provided by the physicians in this book, but only to reveal problems with the conclusions and inferences drawn from that data. I have both macro and micro concerns, but first there are some preliminary issues to resolve.

3. PRELIMINARIES

   It is necessary to clarify what I mean by "euthanasia" and "assisted suicide." Different forms of euthanasia are often conflated in the collection. Euthanasia literally means "good death"; the prefix "eu" in Greek means "good" and "thanatos" means "death." The Oxford English Dictionary defines "euthanasia" as "[a] gentle and easy death," and this is the definition commonly used. (6) Either definition may include death not caused by illness. The Oxford definition, however, refers only to the mode of death or the way in which someone dies. Adopting the Oxford definition, opponents of euthanasia, including several of the authors of the collection, invoke the specter of Nazi concentration camps, where the gas chambers killed those unsuspecting of wrongdoing "gently and easily."

   When used in the medical decisionmaking context, however, a more sophisticated definition of euthanasia is necessary. Euthanasia is viewed as a gentle and easy death that is for the sake or the good of the person who dies. (7) This places the focus upon the purpose of death--the good of the patient--rather than upon the mode of death. (8) It is a more suitable understanding of what euthanasia is for ethical and legal purposes, as the relevant question is whether euthanasia is for the benefit of the one who dies, not whether the method used to terminate the patient's life is of a certain sort. (9)

   There are several types of euthanasia. (10) Voluntary...