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Physician-assisted Suicide: Expanding the Debate
  1. John Keown
  1. Faculty of Law, University of Cambridge

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    Edited by Margaret P Battin, Rosamund Rhodes and Anita Silvers, New York and London, Routledge, 1998, 463 pages, £45.

    This substantial academic volume, which seeks to expand the debate on physician-assisted suicide, is a significant addition to the growing number of edited works on one of the most important issues in contemporary bioethics.

    The introduction observes that the essays illuminate the evolving, increasingly “nuanced” American debate in the wake of the landmark Supreme Court decisions upholding laws against physician-assisted suicide. Its twenty-three chapters are divided into five sections: “conceptual issues”; “those at risk”; “the practice of medicine”; “the impact of legislation”, and “religious perspectives”.

    How, then, is the debate said to be evolving? Conceptually, the editors claim, both proponents and opponents now appeal to the same values, such as autonomy, beneficence, and medical integrity. Politically, patients' groups have focused attention on the likely effects of decriminalisation, particularly on “vulnerable” groups such as the disabled and racial minorities. Medically, there is greater recognition of decision making by patients and relatives and of the inadequate provision of palliative care. Religiously, different denominations have extensively examined their respective theological positions. In short, it is claimed that the debate is not only “larger and louder” but also “deeper and more profound”.

    This well-produced book is certainly a worthwhile contribution to the debate. Margaret Battin is deservedly one of the most well-known writers on end-of-life issues and she and her fellow editors have produced what is, on the whole, an interesting, readable and topical collection of essays. Whether it succeeds in expanding and deepening the debate is, however, itself a matter for debate.

    On the one hand, a number of contributions do help to develop the debate, particularly Patricia King and Leslie Wolf's essay on the perspective of African-Americans, Patricia Mann's on the meaning of death, and the contribution by Margaret Battin herself, which questions the common assumption that physician-assisted suicide should or would be rare.

    On the other hand, the book risks giving a misleadingly narrow and rather one-sided impression of the debate.

    First, although the editors write that they aimed to produce a “fairly evenly balanced” collection, contributors in favour of physician-assisted suicide outnumber those against by around two to one.

    Secondly, only two essays oppose physician-assisted suicide in principle, and those for religious reasons. The book's failure to include a single philosophical contribution articulating and defending the traditional principle of the inviolability of human life mars the volume. This failure is all the more unfortunate not only because several essays criticise this principle, and those criticisms therefore are allowed to pass unchallenged, but also because the principle of the inviolability of human life was reaffirmed by the Supreme Court and underpins its reasoning. The volume could easily mislead a reader into believing that the principle no longer plays an important part in the current debate.

    Thirdly, moving from principle to practice, another omission is the Dutch experience of euthanasia and physician-assisted suicide, an omission which is all the more puzzling in the light of the significance attached by the Supreme Court to the dangers of the “slippery slope” and to the relevance of the Dutch experience in this context.

    Finally, contributions on the achievements and availability of palliative care, the Oregon law, and on the alleged distinction between physician-assisted suicide and euthanasia, would have been valuable. The book does, however, have useful appendices containing the text of the Supreme Court judgments; the “philosophers' brief” submitted to the court, and the Oregon Death With Dignity Act.

    In short, in some significant respects this volume serves to expand the debate. In others, however, it gives a misleadingly narrow impression of it.