Reviewed by James Park, advocate of the
right-to-die.
The following book is one of the most important
opposing the right-to-die.
But this review got so big that it was put into this separate file.
The file for the rest of the books opposing the right-to-die is:
https://s3.amazonaws.com/aws-website-jamesleonardpark---freelibrary-3puxk/B-RTD-NO.html
Kathleen Foley, MD
& Herbert Hendin, MD, editors
The Case Against Assisted Suicide:
For the Right to End-of-Life Care
(Baltimore,
MD: Johns Hopkins UP: www.press.jhu.edu,
2002) 371 pages
(ISBN: 0-8018-7901-9; paperback)
(Library of Congress call number: R726.C355 2002)
(Medical call number: W32.5AA1C337)
This is a
collection of articles and essays by several different authors,
exploring possible problems with the
right-to-die
such as the physician aid-in-dying now
available in several states.
Johns Hopkins University Press also
published a similar collection
that took the opposite point of view:
Physician-Assisted
Suicide:
The
Case for
Palliative Care and Patient Choice
edited by Timothy E. Quill, MD &
Margaret P. Battin, PhD.
This book is reviewed in the companion
bibliography:
Best Books Supporting the Right-to-Die:
https://s3.amazonaws.com/aws-website-jamesleonardpark---freelibrary-3puxk/B-RTDIE.html.
In the following
presentations and responses,
the ideas of the authors are
presented in black
and the responses of this reviewer are
presented in red.
These are further distinguished by
being in different paragraphs.
Also within
the responses by this reviewer,
there are several links to safeguards
for
life-ending decisions.
This comprehensive website
explores over 30 specific safeguards,
describing each in detail and
explaining how it will discourage
irrational suicide and other forms
of premature death.
Horizontal lines separate the reviews of the
different chapters.
Only the most insightful and original chapters are reviewed.
Chapter 1: "I
Will
Give No Deadly Drug":
Why Doctors Must Not Kill
by Leon R. Kass, MD, PhD.
People who are old
and sick can sometimes be persuaded
that death is the best option
for them.
It relieves them of any further
suffering.
And their families are also relieved
of the further stress of their disease
and dying.
Kass wonders: Have we gone too far with
patient
autonomy?
Just because a patient 'wants to die'
does not mean that death is the best
choice.
The
answer to this worry is to make sure
that more
people than just the doctor and the patient
are involved in
every life-ending decision.
If several
open-minded and thoughtful persons
are involved in
examining all of the options,
then the best
decision is more likely to emerge.
But society
should not go so far as
to prohibit all
voluntary deaths and all
merciful deaths
because of the
worry that some
chosen deaths
might be coerced and/or manipulated.
We need wise
ways to separate harmful
deaths from helpful
deaths.
Here are more
than 30 safeguards,
many of which call for the opinions of other persons.
Kass points out
that the doctors already have
overwhelming power and
authority in making medical
decisions.
Often the doctor has a strong
recommendation,
based on past experience with similar
cases.
And many patients follow the
recommendations of their doctors,
even if they do not fully understand
their medical problems and the options
available.
Thus, if doctors
could legally
recommend choosing
death,
how many patients and families would
resist
and ask for a second medical opinion?
How many suffering patients and/or their proxies
can really make independent choices at the end of life?
One way to counter-balance this
great
power of doctors
is to make sure
that other knowledgeable persons
are involved in
the decision-making process.
When only one
doctor and one patient are involved,
and if the
doctor can recommend death
as the best option,
how many dying
patients will have the courage to resist?
We should not
automatically assume
that doctors
are always acting in the best interests of their patients.
Sometimes their
recommendations are simpler
for themselves.
Sometimes they
want to get rid of difficult
patients.
And rarely
doctors do commit murder
disguised as medical care.
But the correct
way to restrain this overwhelming power of doctors
is not to prohibit any discussion of
the option of death
but to make
sure that other
wise persons are also involved
in the process
of making thoughtful medical decisions,
which should include the option of a
timely death if cure is not possible.
Leon Kass argues
against allowing any
voluntary deaths
because such permission would spill-over to less obvious cases.
In other words, once voluntary death and/or merciful death
become available options for every patient to choose,
then some people who should
not
be helped to die
will be encouraged to commit
irrational suicide
because they know about others who have chosen death.
Kass thinks that even the obvious cases involving a wise choice of death
should be prohibited because some less-wise cases will
follow.
If we allow the voluntary
choice of death by the patient and/or the
proxies,
how much longer will it be before involuntary choices of
death
are imposed on patients and families
who have little power to resist
medical authority?
This reviewer
is not convinced.
By the use of careful
and
comprehensive safeguards,
we can
say "yes" to wise and
compassionate plans for death
and we can say "no" to foolish and
ill-considered choices of death.
We need safeguards to prevent
manipulated-death,
not a blanket ban on all forms of
chosen death.
Here is a list of possible
forms
of abuses and mistakes,
linked to specific safeguards
to avoid those distortions of the right-to-die.
One of the most
basic and comprehensive of Kass's objections
to doctors helping their patients to die
is that this will fundamentally
change the doctor-patient relationship.
Even doctors who never participate in life-ending decisions
will have their role tainted
by the fact that
some doctors are
involved in the process of helping patients to die.
Especially when patients do not know their doctors very well,
will they worry that their
doctors might too easily recommend
death?
When patients put their lives into the hands of doctors,
they do not want the additional worry
that their doctors might be considering recommending
some form of chosen death instead of continued medical
treatment.
There are valid
worries about the proper role of doctors.
Some potential patients already
fear all doctors and hospitals.
And if recommending death became
part of the
doctor's standard role,
then such irrational fears might
become worse.
Perhaps the proper response to
this worry is to keep
regular
doctors
far away from any practice of
advising about death.
We should avoid confusion
about the scope of medical care.
When the patient has exhausted
standard medical care,
and when death is being considered
as a valid option,
then specialists who deal only
with life-ending decisions
could be asked to help
explore the various
options at the end of life.
This would affirm
the dictum in the title of this chapter:
"Doctors must not kill."
Most doctors would be
confined to
their healing roles.
They would recommend various
options for treating the problem.
Ending all treatments would still
be an option
that could be considered by
ordinary doctors.
But even the option of
discontinuing treatment
should be
protected from mistakes
and
abuses.
One of these essays deals specifically with this
question:
"Preserving
Good Doctor-Patient Relations:
Will My Doctor Decide to Kill Me?"
Kass argues that death can never be a benefit
to the
patient
because once death has come, who stands to benefit?
This reviewer
suggests reframing this question another way:
We are not confronted with the
question: to die or not to die?
Rather, we face dying now or dying later.
When is the best time to die?
What are the best
circumstances?
Which is the best pathway towards death?
There is no pathway that avoids death.
We must all die one way or
another, at one time or another.
When we reframe the question this
way,
some of the experiences we might
have to undergo
between now and death might better
be avoided.
Each of us can ask: What is
the ideal way for me to die?
I, for one, do
not want to be kept 'alive'
if there is no meaning for my continued life.
Meaningless existence should be
shortened in my case.
I wonder if Leon Kass really wants
his existence as a former person
extended as long as medically
possible.
(This reviewer has written a book encouraging
everyone
to create an Advance Directive for Medical Care:
Your
Last
Year:
Creating Your Own Advance Directive for Medical Care
Eight Questions in PART III deal with life-ending decisions.
An Advance Directive would be the ideal place for anyone
to express his or her wishes concerning end-of-life medical care.
This reviewer's own choices are found in his Advance Directive,
which is linked from the outline above.)
Perhaps Leon
Kass began to write this article
with the established principle
that doctors must not kill.
Then he proceeded to defend this
principle to
the best of his ability.
In the opinion of this reviewer,
he has not met the
arguments
of those who favor allowing
(at least some) doctors
to have some role in
helping their patients to die.
He does not offer a better
approach to dying.
He merely says that doctors
should always strive
to
keep their patients alive.
In Chapter 3 Daniel Callahan also argues against
allowing doctors to recommend death.
Allowing physicians to participate in death
(even when there is obvious benefit to the patient)
will inevitably lead to practices we all regard as evil.
Even if we create good safeguards to prevent abuses and mistakes,
the logic of the argument for permitting the option of death
will still persuade some people who should not die now
that death is also the best option in their cases.
Patients and doctors so convinced will evade any safeguards
because the marginal cases
are similar enough to the obvious
cases.
Since we cannot draw the line against mercy-killing,
we must resist all
attempts to legalize socially-approved
death.
This is the
slippery-slope
argument:
If we allow even a few wise
voluntary deaths and merciful deaths,
then unwise deaths will follow.
Several years of experience with
the Oregon Death with Dignity Act
show that no foolish deaths have
followed the wise ones.
For several years in Oregon,
physicians have been prescribing life-ending drugs
for people who were already dying
—and
no further chain of horrors
has followed.
Callahan criticizes some safeguards as arbitrary and
legalistic.
For example: The patient must be suffering and competent.
If we allow the principle of patient autonomy to be paramount,
how do we limit the right-to-die to people who are suffering?
And what kinds of suffering qualify?
How severe must the suffering be?
This reviewer
agrees that safeguards should not limit the right-to-die
to people who can claim to be
suffering in some sense.
Suffering is always subjective to
some degree.
Rather than requiring some kind of certification of suffering,
we should allow any
and all
reasons for dying to be
offered and argued.
Then other open-minded people should examine
the reasons
offered
by the patient and/or the
proxies
to determine their degree of validity.
An open-minded analysis of
each case
will lead to saying "no" to some requests for death and "yes" to
others.
Such decision-making has been organized in ethics
committees
within some health-care organizations that take care of the dying.
Requiring
the
patient to be conscious and capable to the very end
is not a
wise safeguard
because it will encourage some patients to choose death prematurely
for fear of losing the capacity to choose death at some later time.
Wiser safeguards would allow the patient's wishes to be carried forward
even after the
patient has lost the ability to make wise medical
decisions.
Then the life-ending
decisions shift to the duly-authorized
proxies,
who will take the settled
values of
the patient into account
as well as all of the medical
facts
and recommendations they can
gather.
The proxies should have the same options that were available to the
patient
when the patient was still clearly able to make medical decisions,
including the decision to end medical treatments
and to choose a wise pathway towards death.
This reviewer has written a essay on this
subject:
"Do I Lose the Right to Die When I Lose Consciousness?"
https://s3.amazonaws.com/aws-website-jamesleonardpark---freelibrary-3puxk/CY-CONSC.html
Doctors are also human persons with their own
ethical standards.
And few doctors comply with every wish of their patients.
The autonomy and integrity of the doctor should also be preserved.
Under most
systems of safeguards,
doctors have a right to refuse to participate in life-ending decisions.
If I were a doctor, I also would
want to be completely convinced
that death at this time is the best option for the patient
rather than waiting for death at a later time.
But some doctors believe that it is never better to choose
death now
over continued efforts to treat the patient.
Such doctors would never assist a patient in choosing death.
And Callahan insists that doctors have a right to preserve
this integrity.
But the autonomy of the
doctor should not become an absolute barrier
to the autonomy of the
patient to choose a wise pathway towards death.
Doctors opposed to any form of the right-to-die
should refer patients who wish to exercise this final right
to other
doctors, who have different moral standards and ethical beliefs.
Callahan believes allowing
physicians to help their patient to die
will change our culture for the
worse.
Because the doctor-patient relationship is private,
safeguards will be ignored
whenever it seems convenient.
This danger
illustrates the need for safeguards
that require more than convincing
one doctor that death is best.
The reasons for choosing death
now rather than death
later
should be reasons that could be examined in a court of law
if there is ever any question that a harm has been committed.
Even tho courts should not be asked to rule on every case,
the reasons
for choosing death should be stated in writing
to accommodate any possible future judicial review.
Even tho the public should never become involved
in the decision-making process at the bedside,
the principles by
which medical decision are made
should be open to debate in various public forums.
The family of the patient should also be involved
when possible.
The patient should appoint official proxies or agents.
If there are no family members willing and able to participate,
then other
groups of wise adults should be called upon
to review the life-ending decision before it is carried forward.
An institutional ethics committee would be a good example.
This reviewer agrees with Callahan
that we must be careful not to create a "culture of death".
If we become too easy and
casual about choose death,
we will increase the number
of irrational
suicides.
But if we have open
safeguards privately fulfilled
—as we now have for all medical decisions—
then there should be no fundamental change in our culture.
Our culture will still strongly affirm life.
Chapter 4 by
Yale Kamisar traces
the rise and fall of the 'right' to assisted
suicide.
The U.S. Supreme Court found
no right to assistance in dying in the
Constitution.
But there is a continuing right
to privacy,
which includes the private right to choose death.
In a New York case, it was argued
that the principle of equal
protection of the laws
should extend the right-to-die to patients who are not on life-supports
because this right is already assured
for patients whose lives are sustained by machines.
Patients on respirators, for example,
can choose to die now
rather than later
by turning off their life-support systems.
This argument did not prevail on appeal.
Such subtle
legal distinctions are lost on most patients
who are suffering on the way to death.
We have no right to require a
physician to help us to die.
But we do have the right to refuse
any further medical treatments,
even if such withdrawal from
medical support would result in death.
Thus patients and doctor can cooperate in choices
that legally fall within the right to refuse treatment.
Also it is completely legal for the doctor to increase
pain-medication,
even if everyone can foresee that this will shorten the process of
dying.
It would be very difficult for our culture to retreat to some position
in which no medical
decisions could be taken
that would have any impact on
the time and place of death.
Some of the right-to-die cases reviewed by the
Supreme Court
were decided by a one-vote margin.
This means that new facts, better arguments, & better safeguards
would allow the Supreme
Court to go the other way next time.
And even now, the high court clearly allows the states
to enact their own laws regarding the right-to-die.
Yale Kamisar
argues that the public will turn against the right-to-die
when doubts are raised about the
details of the proposed laws.
In general, the public does
affirm the right-to-die.
But when a complex bill is offered, people turn against it.
Some worry that the proposed
safeguards are too loose
and others worry that the safeguards
are too restrictive.
The proposed law in Michigan had 12,000 words.
Public opinion turned against it
after pre-vote polling said it would win the referendum.
This chapter mainly worries about the fall-out
from liberalizing laws.
Many commentators
think that
we will not be able to
restrain bad consequences
if we allow even a few people to exercise their right-to-die.
Thus we need
easy-to-understand
safeguards
that everyone agrees would prevent
the vast majority
of possible
mistakes and abuses of
the right-to-die.
It is better to have a law with (even difficult) safeguards
that require careful
examination of all the options
than to have no law and no
safeguards at all.
At present, we have few guidelines for making end-of-life decision.
Thus, unreported and unexamined decisions for death
will continue and expand—until
some reasonable order is created.
In Chapter 5
Herbert Hendin examines the Dutch experience.
Hendin worries about the spill-over effects of allowing the
right-to-die.
Doctors feel justified in doing things that are not strictly legal
because other similar actions
are permitted by law.
For example, in Holland the patient is required to be
conscious and capable up until the last
moment of life.
But sometimes doctors go ahead with a planned death
even if the patient has lost consciousness
and/or the capacity to make medical decisions.
In the Netherlands about 5% of all deaths
were achieved by means of physician assistance.
But Hendin shows that some of these were actually
chosen by the doctor and/or the family rather than by the patient
when the patient's thinking capacity
declined below any meaningful form of choosing.
This reviewer
does not see that as a serious problem
—since
we should
not be
required
to be awake and able at the end.
As
long as the decision for death
was a wise decision,
the
mental capacities of the
patient at the last moment should not matter.
Also such requirements exclude
patients with Alzheimer's disease
or similar problems that render
patients incapable of deciding.
Another problem
with the Dutch law and practice
is that it requires the patient to be suffering intolerably.
But what about patients who refuse medical care
and thereby increase their
suffering to an intolerable level?
The law permits all patients to refuse treatment.
If they begin to suffer beyond what they can endure,
they are permitted to request death.
But they are not required to accept any medical care
that might reduce or eliminate their suffering.
For this and
other reasons, this reviewer does not believe
that intolerable suffering
should
be required
as a condition for requesting death.
Suffering is always subjective.
How can other persons evaluate the
patient's suffering?
Strangers should never be called
upon
to evaluate the suffering of
patients they have never met before.
Let everyone who is suffering
explain as fully as they wish.
But do not require a certain level
of suffering before
death is permitted.
Under Dutch law, even mental suffering
is permitted as a reason for choosing death.
Hendin points out some problems that might easily arise here.
Mental
suffering is even more subjective than physical suffering.
And people who commit irrational
suicide
almost always have some sort of
mental torment.
Certifying suffering does not seem
to be a workable safeguard.
And sometimes
people choose death now
because they fear some
future suffering.
Hendin does not approve of this 'reason' for choosing death.
But future
suffering is sometimes a valid reason.
Let all the facts and opinions be presented.
If the patient will never
recover
and can only be expected to
suffer more deeply,
then the patient should take his or her future suffering into
account.
This would be especially relevant
when the patient has a well-known
disease like cancer.
When future suffering can be predicted with accuracy,
it should be considered as an important factor
in choosing the best time to die.
In many life-choices we rightly consider future
suffering.
Divorce would be a prime example:
If the marriage is only going to create more misery and suffering,
then it is better to end it now
than to wait for the suffering to become intolerable.
If present suffering were a requirement,
it would always be subject to second-guessing:
Some committee might decide that the patient's suffering today
is not intense enough to justify a voluntary death.
Let everyone involved consider the present and future
suffering
and all forms of treatment that might be relevant.
Hendin notes
that consultation with a second physician in Holland
is often ignored or treated
superficially.
When the first doctor is not planning to report a chosen
death,
97% of the time the first doctor does not ask for a second opinion.
And even when there is a consultation, it is often perfunctory.
The colleague merely signs a form without examining the
patient.
This becomes a meaningless
exercise in seeking
signatures
rather than a genuine attempt to prevent mistakes and abuses.
This reviewer
agrees that the second
professional opinion
must be thoro—and
genuinely
independent.
And we might even require
consultation
with a hospice
physician.
Let's make sure
that this safeguard actually
makes a difference.
Sometimes the second physician
will notice some facts
or suggest some options not considered by the first physician.
Hendin shows
that under-reporting is a serious problem in Holland.
Now that the right-to-die is well accepted,
some doctors merely help their patients to
die peacefully.
But they skip the paperwork for
reporting a chosen death.
Rather, they record the death (incorrectly) as due to
natural causes.
This reviewer
agrees that non-reporting of voluntary deaths
will be an almost inevitable result of liberalizing laws
to allow patients to choose death.
Originally under Dutch law, the doctor was supposed
to report the death to the public
prosecutor.
Why should doctors report assisted deaths to
law-enforcement?
No crime has been committed.
And the public prosecutor cannot bring the patient back to
life.
Since only bad consequences
for the doctor could follow such a report,
we can all understand why doctors avoided correct reporting.
I suggest that the plan
be
submitted before death.
Then if there are going to be any mistakes or abuses,
they can be prevented
by the authority which reviews the plan for death.
The Dutch system has now been reformed (2002)
so that doctors report their euthanasia cases
to one of five Regional Review Committees
(which consist of a lawyer, a doctor, & an ethicist).
These committees review the reports, sometimes ask for more details,
and only very rarely report a violating doctor to the prosecutor.
And before the death of the patient,
doctors can discuss difficult cases with euthanasia consultants.
Hendin next takes
up the problem of deaths
without explicit request.
According to Hendin about 1,000 deaths per year fall into this category.
Some of these
might be mistakes and abuses of the Dutch system.
But most of them are probably
patients
who had requested death when they
were still capable.
Also, several were probably deaths
approved by relatives
after the patient was unconscious
or otherwise unable to decide.
Safeguards better than the Dutch
system
would permit
us to request death in advance
—specifying
what conditions would justify merciful death.
And better safeguards would
permit
proxies
to
exercise the same powers of choice
that belonged to us when we were
still conscious and capable.
Hendin points
out that sometimes doctors
suggest voluntary death.
This is not supposed to happen under the Dutch system.
The patient alone is
permitted to start the discussion of choosing
death.
How meaningful
is it to require to patient to speak first?
Could any patient in Holland not know about the right-to-die?
How would such a safeguard be
enforced?
Doctor-patient communications are
private.
Who would report that the doctor
mentioned death first?
Who starts the discussion is not as important
as preventing
any coercing or manipulating of the patient.
And pressure from all people
should be counteracted:
friends, family, nurses, social workers, clergy—as
well as doctors.
Careful safeguards would make sure
that the
patient is really making a free, informed, & wise choice
to die
—without undue influence
from anyone.
Hendin has
investigated some cases in depth
in which the choice of death might have been premature.
One husband was 'forced' to choose death
because his wife could no longer care for him at home.
He had to choose between a nursing
home and death!
Often the family has
a stronger wish for death than the patient.
We need careful
safeguards
that avoid even the appearance or
suggestion of
coercion
or
manipulation leading
to a 'choice' of death.
Here the 'views' of the patient and the family will not be sufficient.
In the case cited, perhaps an experimental stay in a nursing home
would have been a wiser choice than going directly to death.
Then the patient would have known first hand
whether or not he could tolerate life in a nursing home.
He might even have preferred
a nursing home to living with his wife.
But if he finds his life in a nursing home intolerable,
then he still should have the right to choose a voluntary death instead.
At least he gave the
nursing-home
alternative an
honest try.
In cases of possible
manipulation or coercion,
we need the careful
opinions of third parties
who have no personal or emotional stake in the final decision.
Neutral third parties can hear all the facts and opinions
before urging caution about 'choosing' death
or recommending a chosen death as the best alternative.
Perhaps more than one wise person should be
consulted.
But this person should not
be a public official,
who would always be under public pressure to decide one way or another.
Neutral third parties must genuinely be open to either
outcome:
Either the patient
should be kept alive and given further medical care
or the patient should
be permitted to choose a voluntary death.
If any such 'neutral' third party only recommends one kind of action,
then he or she is not the appropriate person to consult.
Another case,
which became famous in Holland,
involved mental suffering
only.
The woman who wanted to die was grief-stricken by deaths in the family.
If her psychiatrist would not help her to die, she threatened to kill
herself.
Thus
presented, most people would reject death as the best option.
Many people have recovered from grief and continued meaningful
lives.
But can
we think of situations of mental
suffering
that is severe enough to justify death?
People professionally involved in preventing
irrational suicides
might say that all
mental reasons for choosing death are invalid.
Thus physical suffering
would be required
before a voluntary death would be permitted and approved.
This reviewer suggests that we ought to remain open
to all valid reasons
for choosing death.
And strangers who have never met the patient
should never decide the validity of reasons for dying.
Let
the patient
state his or her reasons for wanting
to die
as clearly and completely as possible.
(The reasons for death should probably be put into writing.)
Then others
who
know the patient well
will be called upon to express their opinions
about the validity or non-validity of the presented reasons.
All other options for responding to the problems
should be explored
before anyone concludes that death is the best remaining option.
Such an approach would respect mental
reasons
for choosing death as well as physical
suffering.
But when the suffering is 'merely' mental,
then we need to be especially careful
that all of the alternative
courses of action have been tried.
Strangers and the news-media will always
be able to
raise
doubts based on limited information.
But the legal deciders are the only ones who must examine
all the facts and opinions
before deciding what to do.
In another case
reviewed by Herbert Hendin,
the wife did all the talking
for the patient who 'wanted to die'.
Thus, there was no way to know
whether he had a different view of his own impending death.
This
illustrates the need for better safeguards
to prevent 'voluntary death' from being chosen by others.
Perhaps the best way would be to have a
document
clearly written by the patient, proven to be his of her own view
by as many means of proof as might be workable.
Especially when there might be any question
of pressure
from family members,
safeguards should ensure that the choice for death
is not only a wise choice
given all the circumstances
but also a free choice
by the patient who wants to die.
If the patient can no longer make a wise
and informed decision,
then the duly-authorized
proxies should have the power to decide.
In another case,
a man newly diagnosed with HIV
decided he preferred to die
now rather than waiting for death by AIDS.
His doctor explained that modern drugs
could insure him several more years of disease-free life,
But he still insisted on dying immediately.
The doctor honored this autonomous
wish.
This reviewer
agrees that just given these facts,
this seems to have been an unwise,
premature death.
This 'autonomous decision' to die might have been based
at least in part on irrational fears of a terrible death in the future.
But the patient with HIV was not sick and dying when he chose
death.
Perhaps he should have been helped to see
that choosing death later—when
he actually got AIDS—
would have been more rational than choosing death now
because he has the virus that causes AIDS.
Comprehensive safeguards can protect people from foolish decisions,
even if at the time they
believe that death is the best option.
Stated more broadly, safeguards should prevent irrational suicides.
All of the safeguards linked from the catalog
of
safeguards
explain in some detail how each would discourage irrational suicide.
In the
Netherlands, few requests for voluntary death
are referred
to
psychiatrists for
evaluation.
Hendin believes that some of the patients who chose death
were suffering from psychological
depression.
Psychological patients should
be treated rather than killed.
The Dutch statistics show
that the number of irrational suicides
when down when the
number of voluntary deaths went
up.
And the total of these two kinds of chosen death went up.
Such problems
with the numbers show the need
for clear lines separating voluntary deaths from irrational suicides.
(See:
Will this Death be an
"Irrational Suicide" or a "Voluntary Death"?:
https://s3.amazonaws.com/aws-website-jamesleonardpark---freelibrary-3puxk/CY-IS-VD.html )
This reviewer
agrees that the USA could see an increase
in both voluntary deaths and irrational suicides at the same time.
As the right-to-die is acknowledged everywhere,
some people who were already on the verge of irrational suicide
will be pushed over the edge: They
will commit irrational suicide.
The proposed safeguard of having a psychiatric
evaluation
would help to prevent some irrational suicides,
which might be committed under the guise of
voluntary death.
The psychological evaluation could help to separate
the wise reasons
for choosing death from the foolish
'reasons'.
The psychological professional could help separate
the choices that are genuinely helpful to the patient
from the choices that clearly are harmful to the patient.
The psychological examination should not merely
determine
whether
the
patient is competent to
decide,
which is often the case under some systems of safeguards.
But the psychological professional should help to examine
the rationality of the
process of deciding to die.
This could involve discussing the options with family members
and the medical doctors who are treating the patient.
At least in cases where there might be some
question
of the wisdom of choosing death,
a review by a psychological professional should be required.
This would prevent the victim of HIV from choosing a premature death.
The therapist could help the patient to reframe the
situation,
perhaps exploring the advantages of postponing death until
later.
And if the patient still insists on dying no matter
what other people say,
and if there are no further legal means to prevent irrational suicide,
then this self-killing should be correctly registered
as an irrational
suicide—not a
voluntary death.
And any such foolish choices of premature death
should not be blamed on the
right-to-die movement.
Also the right-to-die movement needs more forthright ways
of saying that we do not
approve or condone irrational suicide.
Perhaps there is little we can do
to prevent the spin-off of irrational suicides
that might result from advancing the right-to-die.
One small step might be the official recording of
the deaths.
New laws could specify which
deaths will be called irrational
suicides
and which deaths
qualify to be registered as voluntary
deaths.
We can expect to see 10 irrational suicides for each voluntary death.
Opponents of the right-to-die movement will say that
all chosen
deaths should be registered as irrational
suicides
because there are so few that are actually voluntary deaths.
(Some opponents completely reject the concept of 'voluntary death'.)
Full honesty and openness about the real method of
dying
has not been achieved either in the Netherlands or in Oregon.
Many death-certificates claim the death was from natural causes
even when the laws require reporting of all doctor-assisted
deaths.
Full and honest reporting would record the underlying disease
along with the fact that the patient chose a voluntary death
or the official proxies for the patient chose a merciful death.
This reviewer agrees that Hendin has shown
some mistakes and abuses in the Dutch system
for permitting voluntary death with the assistance of one's doctor.
But an even larger issue is the worry about mistakes and
abuses.
Critics will always be able to raise doubts
based on numerical reports
of voluntary deaths
or on very brief summaries
of the circumstances
surrounding the life-ending choices of a particular patient.
Whatever was not
included
in any published reports
will always be open to speculation.
This reviewer does not suggest opening case-files to
the public.
But there should be comprehensive
private medical records,
which could be reviewed by appropriate legal authorities
in case mistakes and/or abuses might have occurred.
These private records would document each fulfilled safeguard.
And if a crime was committed under the guise of the right-to-die,
then a false paper-trail will disclose who committed the crime.
The death-planning records
should not
be open to public scrutiny.
(That would only invite critics to examine each file for possible
mistakes.)
But the private death-planning records should be available to the courts
just in case some crime was
committed
under the cover of some recognized right-to-die principles.
Critics of the right-to-die (such as Hendin)
point to the mistakes and abuses (and even crimes)
as good reasons to BAN all
voluntary deaths and merciful deaths.
But this might be an over-reaction to the
problems.
Reasonable
and
workable safeguards should be possible
which will satisfy at least some people on both sides of the debate.
Herbert Hendin
points out that in the Netherlands
consultation with a second physician has not worked as a safeguard.
The reason such safeguards are in place
is to ensure that some mistake was not made by the first physician.
But in the close-knit community of doctors who work together,
such 'consultation' easily becomes the routine signing of documents.
Dutch doctors who want a 'consultation'
know which other doctors
will approve almost any choice of death.
Sometimes the second doctor
does not even examine the patient.
Some safeguards require that the second doctor
have no professional or personal connections with the first doctor,
but such provisions are very difficult to enforce.
What prevents a few doctors from become easy collaborators in death?
Hendin also points out that the second doctor
is not required to have any specialized knowledge of palliative care.
All doctors know about palliative care,
but only a few practice easing
the problems of dying on a daily basis.
Perhaps one of our safeguards might be requiring
a
period of hospice
care
before any life-ending choice is permitted.
Hospice experience often shows that people who initially wanted to die
lost that desire when they began to receive good hospice care.
Since some doctors might be too quick to recommend death,
should we require an actual
stay in a residential hospice
before the option of voluntary death or merciful death is considered?
Merely consulting
with a palliative-care specialist might not be enough.
If adopted, this could be known as the hospice safeguard.
Of course, there will be some cases
—such as former persons in persistent vegetative state—
in which the medical condition is well known
and in which no amount of even the best hospice care
will bring the former person back to conscious awareness.
If the patient cannot benefit from hospice care, skip this safeguard.
And the reasons for omitting this safeguard can be stated in
writing.
And once hospice care has begun,
the hospice staff should
have no veto power over
any right-to-die decisions that might later be taken
by the patient and/or the proxies for the patient.
The most
open-minded hospice programs
will offer both
excellent supportive care and pain-relief
for those who wish to live as long as possible
and the option of
making life-ending decisions
for those who decide they have lived long enough
and who then choose a slightly shorter pathway towards death.
Under a hurried
system, insisting on a quick decision,
the immediate choice might seem to be between suffering and death.
Where there are no meaningful efforts to relieve suffering,
the patients and their families might too easily favor the option
of death.
Hendin notes that hospice care is not widely available in the
Netherlands.
Could this be because chosen
death is readily
available?
Are some Hollanders being rushed into death
because that is more
convenient for everyone else?
In the United
States we do have public funding for hospice care.
And the hospice movement seems likely to expand
as this option for end-of-life care
becomes better known and more widely accepted.
Thus it will be less likely that people in the USA
will be hustled into death for lack of good alternatives.
Also, will we see greater
cooperation
between the well-established hospice movement
and the growing right-to-die movement?
Hospices could even be created committed to allowing patients
to choose among all of the
legal options at the end of life.
Which hospices have already moved in the direction
of allowing
greater freedom of choice at the end of life?
Now that
palliative care is becoming more common in Holland,
some doctors who helped their patients to die
have expressed regret
that they did not know about
such methods of relieving suffering earlier in their careers.
Hendin believes that better hospice care will reduce
the total
number of deaths in the Netherlands by voluntary choice.
But in the
United States, this reviewer expects to see
both forms of end-of-life care increase:
More patients will choose a few months of hospice care.
And more people will choose a voluntary death
or have a merciful death chosen for them.
Often people choose both
hospice care
and later some form of chosen death.
Chapter 6 "The
Oregon Experiment"
by Kathleen Foley, MD & Herbert Hendin, MD
The authors raise doubts about a few cases in Oregon
about which some information was disclosed to the public.
Were these patients really able to make wise decisions?
How meaningful were the psychiatric
evaluations,
especially if the family kept looking for a new psychiatrist
until they found one who would say
that the patient was competent to make a life-ending decision?
These authors do not think that psychological
depression
was taken seriously enough—and was usually not treated.
The psychiatrist was asked only to evaluate
the competence of the patient to make medical decisions
—including the decision for death.
Better use of such psychological services would ask
the professional to
evaluate the reasons for choosing death.
Is the patient suffering from some irrational fears
about doctors and dying in a hospital?
Is the patient attempting to avoid repeating
a terrible death observed in
someone else?
Were some of the patients encouraged to choose death
because they were a burden
on their
families?
Were some complex interpersonal dynamics distorting the process?
Should patients who are choosing death
be allowed to keep this plan secret
from their
families?
Were financial
pressures motivating the decision for death?
The Oregon safeguards do more to protect the doctors
from adverse consequences
than they serve to prevent
mistakes and abuses
of the system for requesting help in dying.
The authors conclude that the Oregon safeguards are
weak
—in part because there is no way to
enforce them.
It all depends on the 'good faith' of the doctors.
Chapter 10 by Not Dead Yet founder Diane
Coleman, JD
addresses the special problems encountered by disabled people
when they face death.
She believes that society
does
not value the lives of disabled people
in the same ways it values the lives of able-bodied people.
And this attitude is sometimes transmitted to the disabled themselves:
They do not value their own lives.
And especially when they are dependent on machines
and/or other extensive medical supports,
they are sometimes easily persuaded that they should choose death
rather than remain a burden on themselves,
their families, medical personnel, & the financial resources of
society.
Often newly-disabled people need time to adjust
to their new physical and/or psychological limitations.
They are especially vulnerable to talk of the 'right-to-die'.
Perhaps the
best protection for the disabled would be good proxies,
who understand the special circumstances of being disabled.
Disabled persons could select as their advocates
other disabled persons who are in sympathy with their situation.
Also disabled persons could include in their Advance Directives
a consultation
with a representative of the disability community
before any choice of death could be approved.
Able-bodied
people, including doctors and judges,
are often unable to imagine
themselves wishing to live
with the severe limitations sometimes tolerated by disabled persons.
But this
reviewer does not agree with Diane Coleman
that the best response to the problems of the disabled
is to prevent all persons
from exercising their right-to-die.
Diane Coleman
resists talk that separates persons
from non-persons.
She believes this is a way of devaluing some human beings
so that they can be handled differently from full persons.
For example, human beings in persistent vegetative state
should not be regarded as former persons.
When anyone is given a lower status,
this supports discrimination against them.
And all disabled individuals should be protected against discrimination.
This reviewer
believes such thinking goes too far.
Former persons in PVS should
be treated differently.
We need careful criteria and tests for determining
when an individual has permanently become a former person.
Protecting all individuals in PVS—keeping
them 'alive' indefinitely—
is not the best way to protect
disabled persons.
Classifying
former persons in
PVS simply as "disabled"
is a
mistaken attempt to
protect full persons who are
disabled.
Disability groups resist talk of the right-to-die
because they fear that they will be coerced into 'choosing'
death.
Such thinking is a form of slippery-slope
worries:
If some people are permitted to exercise the right-to-die,
then disabled people might be manipulated into 'choosing' death.
The best response to such worries is careful
safeguards,
which prevent anyone from choosing a premature death.
And if disabled persons fear they will be discriminated against
in any system of permitting choice in dying,
let them suggest additional
safeguards to be fulfilled in their own
cases,
which will assure even the strongest advocates of the rights of the
disabled
that choosing death now
is better than insisting on a natural
death.
Disabled persons (and all persons) should always have the right
to say "no" to the option of voluntary death.
Wise and careful safeguards will protect this right
to refuse all options that disabled persons do not want.
But no individual should be denied the right-to-die
in order to protect some other vulnerable
persons.
Chapter 11 is called "Vulnerable People:
Practical Rejoinders to Claims in Favor of Assisted Suicide"
by Felicia Cohn, PhD & Joanne Lynn, MD.
These authors worry that allowing physicians to help
patients to die
will harm groups of people who cannot defend
themselves.
They list 9
common beliefs they regard as incorrect:
1. People want
the right-to-die.
But when patients know more about
palliative care,
they lose the urge to choose death.
2. The
right-to-die is a fundamental human right.
But there is no right to be assisted by a doctor.
3. When
medicine has done all it can, then death is next.
We can make much better use of modern terminal care.
4. Suffering
demands death.
No, there are better
alternatives than going directly to death.
5. We all have
the right to refuse medical treatments.
This includes physician
aid-in-dying.
No, these two can be separated:
The right to decline medical care does not imply
the right to demand that physicians help us to die.
6.
Pain-medication is close to help in dying.
No, the intent of pain-medication is to reduce pain,
not to bring the patient's
life to an end.
7. Doctors are
the best professional helpers in choosing death.
No, doctors usually have no special training in bringing death.
8. Doctors are
already helping people to die.
No, according to these authors
the current rate of physicians helping their patients to die is low.
9. Laws can
prevent abuses.
No, the experience of the Netherlands proves
that official safeguards can easily be avoided or ignored.
These worries
by people who oppose the right-to-die
have all been addressed before.
Wise
and careful
safeguards should
be possible to create,
which will address each and every
one of these worries.
In
summary,
this collection of chapters
The Case
Against Assisted Suicide
criticizing various aspects of the right-to-die
should be read by all persons on both sides of the debate and
people in the middle who are uncertain about
what society should do concerning the so-called "right-to-die".
Each and every one of the objections raised by critics
can and should be addressed by advocates of the right-to-die.
The most important outcome of such discussions
will probably be better
safeguards for life-ending decisions.
We need safeguards that are simple
enough
for
everyone to understand
and which do
effectively prevent mistakes and abuses
of any new system for permitting voluntary death and/or merciful death.
revised
4-17-2009; 9-12-2010; 2-9-2012; 2-17-2012; 2-29-2012; 3-31-2012;
4-1-2012;
4-18-2013; 7-3-2013; 7-4-2013; 7-5-2013; 3-5-2017; 8-26-2017; 3-7-2018;
Go to the Book
Review Index
to discover 350 other reviews
organized into more than 60 bibliographies.
Return to the DEATH
page.
Go to the Medical
Ethics
index page.
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the beginning of this website
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Leonard Park—Free
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