End-of-life decision making: A cross-national study (review)

In End-of-Life Decision Making: A Cross-National Study, editors Robert Blank and Janna Merrick have assembled a series of articles examining end-of-life issues in a diverse set of countries, namely, Brazil, China, Germany, India, Israel, Japan, Kenya, the Netherlands, Taiwan, Turkey, the United Kingdom, and the United States. Each article discusses an overlapping set of questions meant to identify, analyze, and critique the death-related policies of each country. Categories of analysis include public attitudes toward death and dying, incidence and quality of palliative care, status of euthanasia and other death-hastening practices, permissibility and utilization of advance directives, and definitions of death (especially insofar as the operating definition influences organ transplant rates and policies).

The collection clearly represents a step toward developing a rigorous, informed, and culturally aware analysis of end-of-life decision making as an international issue. This is indeed the intended role of the book according to editors Blank and Merrick, who state in the preface: "This book should serve as a reference work on the status of death-related policies in these individual countries and a starting point for a more systematic comparative analysis of end-of-life policy making and health policy in general." Each article, and the work as a whole, may therefore be evaluated in light of this aim.

The collection is genuinely groundbreaking in its sheer scope and focus of analysis, specifically, in its inclusion of the perspectives of countries (e.g., China, Kenya, and Turkey) that have been under examined in mainstream bioethical discourse. The inclusion of the perspectives on end-of-life care in resource-poor countries was clearly a major concern for the editors. Blank writes: "Even the broader literature on comparative health policy has tended to include only industrialized, primarily Western, countries, thus giving a skewed picture of the problems and context" (7). Accordingly, the collection represents a capably realized attempt to promote a highly inclusive environment in the debate surrounding end-of-life decision making.

Certain shortcomings of the work, however, ensure significant limitations for the impact of the collection in academic and policy-making circles. Of primary concern are three particular weaknesses of the collection.

First is the conspicuous inconsistency in approach, focus, and quality of the individual works, which undoubtedly is due partly to the distinctive backgrounds, style, and expertise of the contributors. Some tend toward rather airy ruminations on the issue, others focus on the legislative and quantitative aspects, others attend to a more general analysis of the role of bioethics in their country, and still others (albeit very few) offer robustly theoretical critiques of current policies. Surely a lack of consistency is to be expected in a work that draws from a multitude of highly distinct perspectives, but nevertheless, these discrepancies detract from the contribution of the collection to the debates on end-of-life care.

A second issue concerns the repeated failure to address and in turn, to attempt to resolve, the ambiguous nature of certain key concepts in end-of-life discussions. Particularly striking is the lack of critical attention to the term "dignity." The majority of contributors deem the term sufficiently important to introduce to the discussion, yet it remains woefully under examined. For instance, Darryl Macer indicates that in Japan " . . .surveys show that people do want to die with dignity, but that there are difficulties in expressing these views to those around them" (118), apparently assuming that introducing the term in the context of life-sustaining treatment infuses it with sufficient clarity. Even more confusing is the explanation of Li Yiting et al. of their proposed "focal point" of end-of-life care, namely, pain relief. The authors equate patient dignity with adequate pain management. The idea, it seems, is that death becomes dignified by virtue of being "easy and peaceful" (37).

Given the relative lack of bioethical debate transpiring in some of these countries, however, it is perhaps an excusable...