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Biomedical Ethics Reviews, Is There a Duty to Die?
  1. James Gilbert
  1. Consultant in Palliative Medicine Royal Devon & Exeter Healthcare NHS Trust

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    Edited by James M Humber and Robert F Almeder, Totawa, New Jersey, Humana Press, 2000, 221 pages, US$49.50.

    At the heart of this book is the idea that we would all be better off were we able to recognise the harder, slower, more expensive and more unjust dying which the continued development of modern medicine offers. The proposal is perhaps not so much a duty to die as a duty to refrain from unfair or excessive use of health care resources and to refrain from imposing excessive burdens at the end of one's life on family or friends. On the global scale, Battin invites us to consider a huge international deal to be struck between the wealthy First World and the developing Third World. Backed by figures on life expectancy in different countries and by some financial information, Battin is persuasive in identifying the wrong of excessive, expensive life-prolonging health care in a world where basics such as clean water, inexpensive vaccines, and ordinary family planning and reproductive health care are unavailable to so many. In short, “we ought to die sooner so they could live longer”. But this is only a part of the deal. The two other necessary elements are a) mechanisms to convey the savings from a person's earlier death in the First World to fund health care and related measures that would increase life expectancies in the Second and Third Worlds and b) the identification of the health-related obligations of people in the Third World to those in the First. We insist, for instance, that the rain forest ought not to be cut down, that the sea and the air should not be polluted in the way that happened in the developed world's early industrial development and that nuclear weapons should not proliferate. Although it is acknowledged that this line of argument depends on the future existence of effective international redistributive structures, our attention is drawn to this as a lack of vision, a lack of political will rather than a flawed argument. As Battin hoped, the deal outlined did strike this reviewer as more of a real challenge to our moral selves than a silly thought experiment.

    Of the subsequent eleven chapters, each written by a different author, six are sympathetic to the claim that there is a duty to die. At the national level it is suggested that public policy could achieve significant redistribution of resources and at the family level, emotional as well as financial burdens might be reduced.

    At least three contributors cast doubt on the existence of a duty to die and one (Tong) argues that it is not even safe to posit such a duty, given societal inequalities which might make any imposition of such a duty unfair. Having been taken on an interesting and for the most part well-written tour of this question, in the last two chapters a somewhat diluted and perhaps more plausible conclusion is offered; that although we may not have a duty to die, sometimes we do not have the right to something which is necessary to sustain our lives. Spellecy suggests a duty more akin to a debt of gratitude, which might be owed, but which it would be improper to demand. This book, the seventeenth annual volume of “Biomedical Ethics Reviews”, achieves its aim of discussing in an accessible, enjoyable and informative way a question of importance to most of us.

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