L van Zyl. Ashgate, 2000, £40.00 (hb), pp 230. ISBN 0-7546-1231-7

• Van Zyl L. Death and Compassion: A Virtue-Based Approach to Euthanasia

Can virtue ethics tell us what to do? And has principlism had its day? These are two of the questions that van Zyl’s text seeks to answer in the affirmative. Van Zyl wishes to encourage an approach to medical practice that draws upon the requirements of virtue ethics, in preference to principlist (primarily deontological and consequentialist) ethics. Her account then relates these twin themes to one concrete realm of medical practice, decisions taken at the end of life.

Van Zyl believes that the process of modernisation has not only affected medicine, in its evolution from an “art” into a “science”, but also medical or bio-ethics, in its move to a principlist ethic, which demands the application of universal, rational, objective rules to “cases”. Such shifts account for some dissatisfaction with the medical focus, since it is just that, while the patient’s wider “suffering” passes unnoticed. Virtue ethics—that is, the approach that might account for such suffering, meanwhile, has been relegated to—at best—a “place on the sideline”. In contrast to such popular, but bare and impersonal, principles as beneficence, non-maleficence, and autonomy, the author employs an Aristotelian approach to reintroduce three related virtues: compassion, benevolence, and respectfulness.

The virtue of compassion encourages an empathetic identification, and hence engagement, with the patient and his or her suffering. Benevolence encourages truly beneficent, helpful actions, which will result from this fuller understanding of the patient’s predicament. Finally, respectfulness encourages full respect for the patient as a self-realising individual. A dialogue conducted in accordance with this virtue will result in shared decision making, as opposed to the doctor or patient-directed approaches presumed by, respectively, paternalistic and autonomy-based models.

In line with the expanded (patient-directed) conceptions of “harm” and “benefit”, the goal of medicine is conceived in terms of promoting patient welfare. Applying her thesis to euthanasia, Van Zyl contends that where this goal cannot be achieved, and where continued life might even be harmful, euthanasia might be permissible, in either an active or a passive sense. Euthanasia, as a last resort, can therefore be justifiable as a compassionate, benevolent, and respectful response to a patient’s suffering. Although Van Zyl draws some tentative conclusions as to situations of justifiable euthanasia, she also accepts that there will be numerous cases that are not so amenable to resolution; in these the process of interaction between physicians, patients and patients’ families might be more important than the actual decision reached.

To get the inevitable pun out of the way, this work certainly has its virtues. Principally, the book succeeds in offering a useful counterbalance to the plethora of texts devoted to principlist accounts of morality, and the morality of euthanasia in particular. Moreover, Van Zyl’s account might cheer those who despair at the limitations of the contemporary focus on, and/or approach to, patient autonomy. On a more mundane note, the argument is also well sustained and accessibly presented.

Perhaps inevitably, however, a few vices warrant note. Primarily, Van Zyl’s argument might not in fact constitute an alternative because, in suggesting, for example, in the closing chapter, that virtue ethics can nevertheless found some “rules”, Van Zyl arguably strays onto the principlist ground she is so keen to avoid. More generally, although Van Zyl’s criticisms are often well aimed, the principlist objection might stand, since it is not certain that virtue ethics alone will determine the morality of conduct. How, for example, would it fit with current professional and legal obligations? Similarly, how are both practising and future doctors to be educated in the virtues? The sorts of institutional responses that are probably required would almost certainly need to have some principlist component. It is perfectly plausible that virtue ethicists can and will answer such questions. It is a shame, however, given her useful reconsideration of a much discussed concrete topic, that the author uses most of her text to set out her stall, when the practical applications of virtue ethics—as she concedes—need greater development.

These points need not be laboured, however, since Van Zyl’s text is a vital corrective to much contemporary theorising. The book is therefore recommended, particularly to researchers and students, although practitioners too might welcome this often refreshing perspective.