Death, Dying, and the Biological Revolution: Our Last Quest For Responsibility by Robert M. Veatch (review)

BOOK REVIEWS 155 Death, Dying, and the Biological Revolution: Our Last Quest For Responsibility . By RoBERT M. VEATCH. New Haven and London: Yale University Press, 1976. Pp. 323 including index and bibliography. This book's three major themes are: (I) establishing the category difference between technical questions of medical feasibility and ethical questions of moral legitimacy; (2) defining ' death ' and ' dying ' so as to elucidate the difference between medical treatments which support life and those which "prolong dying "; and (3) showing the difficulty of articulating a public policy-not to mention an established medical ethic-about the dying and the recently dead in a society so pluralistic as almost to be antinomian. Veatch knows that these are questions of the first complexity, and avoids stating his views as dogma, occasionally leaving his own opinion on the issues unclear. Properly, he also avoids mechanically spinning out theorems based on axioms of ethics. The book's greatest value is the critical sensitivity with which it exposes and dissects the levels of these problems. Relations between ethics, policy, and medical feasibility are often uneasy, and Veatch appreciates this fact. He is also well-informed concerning both recent law on the topics and the current state of the medical art. The most philosophically interesting section is Veatch's analysis of four competing definitions of ' death '. His novel position is that it is as morally offensive to treat dead individuals as living as it traditionally has been to treat the living as though they were dead. His choice of definition is the " irreversible loss of capacity for social interaction "; his justification for this choice, in contrast to the " capacity for bodily integration ", is the neurologic fact that the autonomic, medullary controls for fluid circulation and for some reflexes (e.g. yawning) can persist in a person whose EEG is irreversibly isoelectric for what Veatch calls the higher functions, such as thought, reason, and emotion. (His note on " permanent back ward psychotics or senile individuals " needs amplification, though, since they aren't brain stem cases and equally clearly have no capacity for social interaction.) His meticulous analysis of the medical and legal options in defining death supports his thesis, put rhetorically: "How could medical research possibly discover that death should be pronounced when brain function rather than heart function has stopped irreversibly? " (Italics added). The book's focus-especially seen in chapters 3, 4, and 5-is on the results of this definition of death in the realm of public policy. He begins with an exploration of some of the concurrent problems: active vs. passive euthanasia, " slippery slope " consequences, and " extraordinary " medical intervention. His decisive move is to recast all these arguments from the perspective of the patient who acts as agent in his own behalf. "... To view the moral 156 BOOK REVIEWS issue from the standpoint of rights and obligations of the patients rather than from the moral alternatives of physicians ... changes the character of the discussion. The consequences are predictable. The patient (or his agent) should decide what interventions are acceptable, whether extended respiratory support for a cerebrally dead patient is "extraordinary", and so on. Veatch is in the " reasonable man " camp with this sort of guideline, and as many reasonable man theorists are, he is compelled quickly to admit legal recourse in deciding" reasonableness " (and, similarly, " grave burdensomeness " of treatments). Given the spectrum of judicial good sense and lack of it which Veatch recounts, one wonders how the practical consequences of his principle will improve on current policy. He reviews the refusal-of-treatment cases, including the Jehovah's Witness blood transfusion cases and the Down's syndrome infants with intestinal blockages, and discusses the Quinlan matter most astutely, concluding, in parallel with the New Jersey Supreme Court, that "refusal of death-prolonging treatments should be seen as radically different from and normally more reasonable than refusal of lifesaving treatments." (As noted above, Veatch appreciates that " gravely burdensome treatment " has almost as much of a subjective element as does the "reasonableness " of a refusal.) While Veatch's section on definitions of death suggests that patients choose between cardiopulmonary, bodily-integrative, and social-competence definitions , but not outside these, no such guide for " reasonableness...