Regulating How We Die: The Ethical, Medical, and Legal Issues Surrounding Physician-Assisted Suicide (review)

Linda L. Emanuel, ed. Regulating How We Die: The Ethical, Medical, and Legal Issues Surrounding Physician-Assisted Suicide. Cambridge: Harvard University Press, 1998. 304 pp. $39.95 cloth; $18.95 paper.

Linda L. Emanuel's collection of essays exploring physician-assisted suicide includes chapters written by prominent authors who have taken opposite sides in the public debate. For readers who have not explored the issues in depth, the book provides an excellent opportunity to acquaint oneself with the major arguments in favor of and against legalization. The book is organized with three authors presenting "considerations in favor" (Angell, Batton, Loewy), three presenting "considerations against" (Pelligrino, Wolf, Childress), three "perspectives" (van der Maass, and L. Emanuel, E. Emanuel, Annas), and a "final synthesis" (L. Emanuel). In general, the presentation is balanced, though the perspectives and final synthesis are dominated by those who are opposed to legalization.

For readers who are familiar with the debate, much of the material has been published elsewhere, and each author's perspective is well-known. Nonetheless, there is some exploration of relatively fresh ground that even those acquainted with the issues should consider reading:

1. Peg Batton explores the moral and clinical responsibility of those who choose to turn down requests for physician-assisted suicide. Virtually all proposed safeguards (Quill, Cassel, and Meier 1992), model statutes (Baron et al. 1996), and legislative initiatives have "opt out" clauses for physicians who for personal moral considerations cannot directly assist a patient to die even if they meet agreed-upon criteria. What are these physicians' responsibilities to the patients they turn down, and what are the moral implications of exercising this option? Other than asserting that such physicians have the right to refuse to participate, this question has remained relatively unexplored by both proponents and opponents of legalization. Batton examines the impact of such a decision on the patient-physician relationship, and challenges such physicians to find common ground with their patients whenever possible rather than abrogating responsibility.

2. George Annas presents a novel and somewhat idiosyncratic belief that the provision of a potentially lethal dose of barbiturates (such as I reported in Quill 1991) does not legally constitute physician-assisted suicide. The primary intent must be to reassure the patient that there could be an escape rather than to end life. "Only physicians who believe they are intentionally killing their patients with overdoses of drugs, and who would feel the same if they shot their patients with a gun--or provided their patients with a loaded gun with the intent that they use the gun to kill themselves--should change their behavior to comply with the laws," according to Annas. If others in law, ethics, and medicine concur with this belief, and would put such policy into writing so that this possibility could be predictably available, then we might not need to change the law. I remain unconvinced that I understand the mental, ethical, and legal gymnastics required to justify such a practice in this way, especially in the current legal and political environment. Furthermore, the honest and forthright discourse needed in such circumstances might be undermined with such hedging of intent and responsibility.

3. Susan Wolf challenges us to consider the suffering of medically ill children and adolescents, asking whether physician-assisted suicide has any role in the treatment of such persons who do not have the capacity to consent. Most proponents of legalization of physician-assisted suicide require that two substantive anchors be present in all cases: (1) voluntariness and (2) intolerable suffering. Certainly most children are not capable of fully comprehending such a complex decision, and therefore could not meet criteria for voluntariness. But children are fully capable of suffering, and there is a long history in medicine and society of underrecognizing...