Selected and reviewed by James Park, advocate of the right-to-die.
Organized in the order of quality, beginning with the best.
Summaries of the contents are presented in black.
Comments and responses by this reviewer are presented in red.

---

1. Herbert Hendin, MD 

Seduced by Death:
Doctors, Patients, and the Dutch Cure

(New York: Norton, 1997)       256 pages
(ISBN: 0-393-04003-8; hardcover)
(Library of Congress call number: R726.H46 1996)

     A suicide-prevention psychiatrist turns a critical eye
on the Dutch experience of voluntary death assisted by a physician
and merciful death chosen for patients no longer able to give consent.
Hendin believed that too many abuses and mistakes
were taking place in the Netherlands
—and that the U.S. should not copy the pattern created by the Dutch.
Rather, we should provide better pain-control,
so that patients will not request death.

     Hendin discusses several cases of physician-assisted death
in which serious doubts could be raised:
In one case a woman was suffering
because of the loss of two sons to death
and the loss of her husband by divorce.
She had no further reasons to go on living.
When, after many attempts at psychological help,
all agreed that nothing was going to change her wish to be dead,
she was granted her wish to die on the basis of her mental suffering.

     On the basis of such cases and other controversial reports,
Hendin claims that the Dutch guidelines for voluntary death
with the assistance of a physician were routinely ignored.
Doctors were often doing what they thought best
—including shortening the process of dying—
without explicitly asking the patient or family
if death is the best choice.

     The best response to the worries and doubts raised in this book
is not to ban all voluntary death and merciful death
but to create safeguards that are more reasonable and workable
than those originally used in the Netherlands.

     For example, reporting assisted dying to the prosecuting authority
after the death had already taken place made no sense.
The Dutch police and prosecutors could not bring anyone back to life.
They could only punish the doctor for doing something illegal.
(What incentive does a doctor have to report assisted deaths,
if no good can come of such reporting
and the doctor might even be prosecuted?)
Furthermore, law-enforcement officials have no training or expertise
in the complex issues of making end-of-life medical choices. 

    Any such reviews by the prosecutor should be completed before
the voluntary death or merciful death takes place.
Then everyone involved can proceed with the knowledge
that no prosecutions will result from their decision
to proceed with a wisely-chosen death.

    (Since this book was published,
the Dutch system has been changed a few times.
Now instead of reporting to the police or the public prosecutor,
doctors are supposed to report their cases of chosen death
to Regional Review Committees
each of which has a lawyer, a doctor, & an ethicist.
Only a few cases each year are forwarded to prosecutors.)

     Hendin points out that the second doctor's professional opinion
is often routine and superficial,
based more on the first doctor's reputation and opinion
than on an independent assessment
of the condition of the patient.
A better system could be created to ensure
that the second professional opinion
is truly independent and designed to correct any mistakes
in the diagnosis and prognosis of the first doctor.

     Carefully considered waiting periods should be required.
Often patients ask for assistance in dying
immediately after learning that they have a terminal disease.
But many who were prevented from killing themselves
immediately after they were told about terminal illness
have gone on to live for a number of additional years.

     Should a long-married couple be permitted to die together?
This would save either spouse having to grieve the loss of the other.
But sometimes the dominant partner (often the husband)
is forcing the other partner to go along with a 'suicide pact'.
Careful safeguards would examine all options,
including the option of dying together.
But the physical condition of the healthier partner
should also be taken into account.
Here is a chapter by this reviewer
explaining how to counteract family pressure to 'choose' death,
including the danger of 'suicide pacts':
Protecting Patients from Family Pressure to Die.

     Another problem of the Dutch system is the requirement
that the patient remain fully conscious and capable
up until the moment of death.
This leads to some premature deaths
because the dying patients sometimes fear
that they will not be sufficiently lucid or rational later
to be able to consent to voluntary death with assistance.

    The solution to this dilemma is for the patient
to draw up a written request for death
—created when the patient was clearly in full possession
of his or her mental capacities.
This plan for death would specify what should happen
if and when the patient becomes unconscious
or otherwise loses the capacity to make medical decisions.
Such prior documented requests for death
should be honored everywhere in the world.
Proper safeguards would make sure that the prior request for death
was made while the patient was still clearly capable
of making a wise decision about the timing and means of death.
A well-documented advance request for death
once a certain point in mental decline has been reached
would remove most doubts in the minds of doctors and proxies
who now must make decisions for patients who have progressed
beyond being able to make their own life-ending decisions.
This would solve the problem in the Netherlands
sometimes called "assisted death without explicit request".

     Some Dutch doctors (as doctors everywhere) 
provide slight assistance in the dying process,
such as increasing pain medication,
in order to avoid going thru the formal process
of applying for an approved voluntary death.
Such life-ending decisions produce a slower death.
And such deaths are always reported as "from natural causes",
rather than cases of voluntary death with physician assistance.
A more user-friendly system of safeguards
would work better in such cases,
thereby avoiding some premature deaths that result
from secretive—often unarticulated—
decisions to shorten the process of dying.

     Hendin usually considers the worst possible interpretation
of each of the cases and situations he considers.
But such maximum skepticism must be considered
by all advocates of the right-to-die.
We must be able to address problems
that will be raised by rather rare and unlikely scenarios.
Wise safeguards are needed for the marginal situations
about which reasonable persons of good faith can disagree.
When we are in doubt about the wisest course of action,
we need a deeper investigation of the actual situation
and a fuller exploration of all the alternatives other than death.
Opponents of the right-to-die will use such marginal cases
to support their position that all chosen death must be outlawed
because of the possibility of mistakes and abuse.
No one should be put to death for the convenience of others.
Some disabled people fear this the most.
Can we create wise safeguards that are so comprehensive
that even (open-minded) disabled people will endorse them?

     The title of Hendin's book—Seduced by Death—
points to the danger of society too easily affirming the 'right-to-die'.
If we create a 'culture of death', irrational suicides will increase,
because people who have foolish 'reasons' for killing themselves
will get the mistaken impression that the society approves
of their 'decision' to commit irrational suicide.
Because Dr. Hendin has devoted his professional life
to preventing irrational suicide,
he is acutely aware of the dangers created
by glib talk about the 'right-to-die'.

    In affirming our right-to-die, we must avoid romanticizing death.
Voluntary death and merciful death should not be the first option
people consider when confronting difficult problems in life.
Rather, a wise and rational ending of life should be the last resort.

---

2.  Wesley J. Smith 

Forced Exit:
The Slippery Slope from Assisted Suicide to Legalized Murder

(New York: Random House: www.randomhouse.com, 1997)       291 pages
(ISBN: 0-8129-2790-7; hardcover)
(Library of Congress call number: R726.S576 1997)

    When he wrote this book, Wesley Smith was
the attorney for the International Anti-Euthanasia Task Force,
one of the strongest opponents of the right-to-die in the United States.  

    Like any good lawyer, Smith builds his case by citing situations
in which people took their own lives prematurely
—people who were assisted in dying before it was necessary
and former persons whose lives were ended by others
before they would have died from natural causes.
Smith wants to combat the worst abuses of the so-called "right-to-die"
by banning most life-ending decisions.  

    If society turns against the media-promoted cult of death,
then a few more premature deaths could be prevented.
Loud talk about the "right-to-die" encourages some people
with flimsy 'reasons' for ending their lives to kill themselves.

    Smith presents a very low threshold for continuing life-supports:
If the patient is still a living human being, no one should 'pull the plug'.
In other words, on most (perhaps all) of the famous right-to-die cases,
he would have argued to keep the former person 'alive'
even tho he or she was in a persistent vegetative state.  
Human life should be granted sanctity no matter what its quality.
All human life should be preserved as long as technologically possible.

    'Anti-euthanasia' advocates realize that one of the most common ways
for life to be mercifully terminated is to remove life-support systems.  
This method of managing dying is well-established in law and practice.  
The last-ditch resistance focuses on food and water:
If nutrition and hydration are provided by means of tubes,
then it looks like a medical treatment or a life-support system.
As medical treatments or procedures, such tubes can be withdrawn.
But if they are defined as comfort care (like keeping the patient warm),
then they cannot be withdrawn or withheld.  

    If the 'anti-euthanasia' advocates had their way,
food and water could never be withdrawn or withheld
—as long as the body is still 'alive'.
But it does not seem likely that such views will prevail.  
Just as fully-capable patients can refuse food and water,
similar choices can be taken for patients who can no longer decide.  
As least this means of merciful death can be used
when the patient has left a written statement  
requesting death when specified conditions develop.  

    According to the 'anti-euthanasia' advocates,
all efforts to expand the 'right-to-die' must be resisted
because of the slippery slope:  
If we allow relatives of former persons in PVS to 'pull the plug',
we will not be able to stop the rampage of killing.  
The next people killed without their consent will be the disabled
and others who can no longer contribute anything to society.
Every disabled person will be at risk
if we allow further advances of the 'right-to-die'.  

    Lest this reviewer be suspected of exaggerating Smith's position,
here is a quote from the bottom of page 50:
"Yet virtually every day, fellow humans are being deprived
of the basics required for life just because they are disabled."

    Lawyers tend to over-state their cases
because it has some persuasive power for the listeners.  
Smith wants to classify Nancy Cruzan as "cognitively disabled",
even tho she was in a persistent vegetative state.
Few people want to discriminate against the disabled.
But if a former person will never have another thought or feeling,
why keep that body 'alive' on 'life-support' systems?

    Smith does correctly warn against hasty diagnoses:
One patient who was thought to be permanently unconscious
woke up a week later and made a complete recovery.  

    Death-by-dehydration is another important theme
in the anti-euthanasia movement.  
Smith claims that death by means of withdrawing fluids is terrible.
He quotes one doctor who told him so in a private interview.
No further evidence is offered.
 
    Death-by-dehydration will have to be studied
and documented much more fully before the position
taken by the anti-euthanasia advocates will be sustained.  
This reviewer thinks the opposite will be shown:
That death-by-dehydration is a good way to end of one's life.
Here is a website supporting Voluntary Death by Dehydration.

    Smith points out that we would not cause
the deaths of dogs or horses by dehydration.
Why cause additional days of suffering?
When we decide that the end has come for animals,
we easily give them a lethal injection.  

    Smith warns that we will do the same for human beings:
If we allow death-by-dehydration,
why not shorten the process by giving a lethal injection?
To avoid sliding down the icy sidewalk on a hill,
we should avoid even getting close to that hill.
This means no death-by-dehydration.  

    Another common argument from the anti-euthanasia movement
invokes the specter of Nazi Germany,
which also used the concept "euthanasia".  
'Undesirable' people were put to death in concentration camps.
These included Jehovah's Witnesses and labor union leaders.
But most of the victims of the Nazi Holocaust
were killed merely because they were Jews.

    The Nazis also wanted to get rid of "useless eaters".
If the disabled and the dying could no longer contribute,
then they should be sent to the gas chambers.  

    The Nazi crimes committed under the name of "euthanasia"
should never be associated with the right-to-die.  
The victims of the Nazi killings had no choice.
They were killed for economic, political, & racist 'reasons'.

    Smith thinks that we should learn from the Nazi Holocaust
that we should never permit doctors to assist people in dying:
Just see what happened in Germany during the Nazi period.

    Such arguments have a strong emotional appeal.  
And there are probably some lessons we can learn from Nazi atrocities.
Safeguards are needed to prevent anything
even vaguely similar to the Holocaust from ever happening again.

    Governments should never be in charge of who lives and who dies.
Keep strangers out of the loop.
Claim the right-to-die should always be a personal, individual decision.
And when we are no longer capable of deciding for ourselves,
our prior wishes (best expressed in writing) should be honored.
When selecting proxies, we should choose people we trust,
who know our settled values, and who will protect our best interests.

    Because opponents of the right-to-die often use the Nazi Holocaust,
we who believe in the right-to-die should be ready to answer
the questions raised by the Nazi atrocities during the Second World War.
Strong and reasonable safeguards are needed
to prevent any killing for economic, political, or racist 'reasons'.

    The next chapter deals with the Dutch experience with euthanasia.
In the Netherlands, doctors are supposed to follow guidelines
in helping their patients to die.
But frequently they perform euthanasia with shortcuts.
For example, they sometimes ignore the requirements
for repeated requests for death from the patient
because the patient is already too far gone to make another request.

    In this reviewer's mind, this illustrates the need for safeguards
that can take such situations into account:
When the patient has become incapable of making medical decisions,
then specific proxies should be empowered to make such choices,
including the decisions that will end that patient's life.  
These proxy decision-makers should be selected by the patient
before he or she loses the power to make wise end-of-life choices.

    Smith cites some foolish reasons for wanting death:
a scar on one's face, fear of overeating,
fear of future health problems caused by AIDS,
& untreated psychological problems.  
When doctors have the power to decide death, mistakes will happen.

    Also under Dutch law and practice,
parents of defective newborns can request death for them.
If they can find a doctor who agrees, death will be the result.
Smith does not think it should be that easy.
He cites disabled people who are glad they were not killed in infancy.

    In several chapters, Smith warns against the so-called "right-to-die"
as a form of oppression against the most vulnerable in any society.
The poor, the homeless, those who cannot explain their wishes,
the most difficult patients who have no one to speak for them,
racial minorities, illegal aliens, criminals, etc.
are all in danger of being put to death if 'death culture' advances.  

    Sometimes doctors might be tempted toward euthanasia
in order to prevent malpractice suits.
The doctor might hope to cover up a mistake.
And if the patient is dead,
any economic award won in court will be much less
than if the patient will need life-long care.

    Disabled people are among the strongest opponents
of the so-called "right-to-die".
They fear that people who can no longer contribute to society
will be killed first whenever any "right-to-die" is allowed.  
So they think that the best way to protect themselves
in to resist all advances toward a 'death culture'.
All forms of chosen death should be prohibited
because of the danger to vulnerable people.  

    This reviewer agrees these worries should be taken seriously.
We do have the historical example of Nazi Germany,
where disabled people were put to death as "useless eaters".
Such things are not likely to happen again.
But good safeguards will make it absolutely certain
that disabled people will not be coerced or manipulated into death.  

    The right-to-die movement should seek to create safeguards
that will be approved even by disabled persons.  
Here is one example of a safeguard especially for disabled people:
When a disabled person creates a Medical Care Decisions Committee,
he or she could make sure to include disabled persons in that MCDC.  
Or an ethics committee of a hospital or nursing home
could be sure to include disabled persons on that committee.
Where medical decisions are routinely made for disabled persons,
there could be a regular committee
consisting entirely of other disabled persons.
Of course, these would have to be open-minded disabled people,
who are capable of going either way on questions of life or death.  
If a committee of disabled persons always said "no"
to all proposed life-ending decisions,
then, of course, there would be no point in having such a committee.  

    When able-bodied people try to make decisions for the disabled,
they often bring their own preconceptions to the process.
For example, if they could not imagine themselves
wanting to live with such severe limitations,
they might suggest death as an alternative to life-with-disability.  
But people who have already adjusted to disability
realize that it is entirely possible to have a meaningful life
even with a disabled body and/or mind.  

    Disabled persons might not be the only victims of a 'death culture'.
Sometimes a spouse wants to be free of responsibility
for a husband or wife who has become more a burden
than someone who is loved and cherished.
If too-easy choices for death were permitted,
spouses might use the "right-to-die"
as a means of freeing themselves of unwanted relationships.  

    In Chapter 8, Smith attempts to answer
several arguments for the right-to-die.
After each argument favoring the right-to-die is rebutted by Smith,
this reviewer offers a reply from the perspective of the right-to-die.

    (1) Opposition to the right-to-die is primarily religious.
Therefore the separation of church and state
should permit secular persons to choose death.
Smith cites non-religious people who oppose the right-to-die. 

    Right-to-die reply:  
People who object of choosing death on religious grounds
should follow their own consciences.
But they should not attempt to impose their morality
on the whole society by means of the law.

    (2) Safeguards will prevent abuses and mistakes.  
Smith cites the Netherlands and Nazi Germany
as places where safeguards have been circumvented.  
He believes that safeguards will never work.  

    Right-to-die reply:
The question of safeguards will be central
to the next decades of debate about the right-to-die.
Thoughtful advocates of the right-to-die
must create safeguards that will work so well
that even some of the opponents of the right-to-die
will eventually embrace such safeguards.  
At least many people in the middle will embrace workable safeguards.

    (Here are Fifteen Safeguards for Life-Ending Decisions
https://s3.amazonaws.com/aws-website-jamesleonardpark---freelibrary-3puxk/CY-10SG.html
And here is a website devoted to safeguards for life-ending decisions:
https://s3.amazonaws.com/aws-website-jamesleonardpark---freelibrary-3puxk/SG.html)

    (3) Voluntary death and merciful death will only be used as a last resort.
Smith says that it is never necessary to hasten death.
Better hospice care and pain-control will eliminate all requests for death.  

    Right-to-die reply:
Yes, all appropriate medical care should always be tried first.
Death should never be suggested as a substitute for medical care.  
But there might come a turning-point in many slow deaths
when shortening the process of dying
would be better in the eyes of all concerned
than keeping the body 'alive' as long as technologically possible.
Good safeguards will eliminate even the suspicion
that someone is being rushed into death
instead of being offered appropriate medical care.  
Prohibiting the right-to-die does little to improve end-of-life care.
Voluntary death and merciful death should only be considered
after all appropriate medical treatments have been tried.
Safeguards can ensure
that all relevant medical options have been explored.  

    In extreme cases, when cure is no longer possible,
Smith does endorse terminal sedation,
which will keep the patient unconscious until natural death.
In his view, being unconscious for the last few days
is better than being poisoned.  

    (4) When animals are terminally ill or hopelessly injured,
we have no problem "putting them to sleep".  
Why do we lack similar compassion for suffering human beings?
Smith points out that we have always separated
killing animals from killing people.
We should not use veterinary ethics for persons.  

    Right-to-die reply:
Yes, we should certainly give up this analogy.  
No human person wants to be treated like an animal.
What we want is wise and compassionate treatment
as we bring our distinctively-human lives to a close.  

    (5) Some advocates of choices at the end of life
are also advocates of choices at the beginning of life:
They approve of the right to have an abortion.

    Right-to-die reply:
Yes reproductive freedom should be separated from the right-to-die.
Different values are being protected in these different situations.

    (6) The majority of the population favors the right-to-die.  
Smith disputes this claim by pointing out
that such poling can easily be distorted by how the question is asked.  
The majority of people do not favor doctors helping patients to die.
And Smith points out the many failures of referenda on the right-to-die
when the question was put to a yes/no vote of the people.  

    Right-to-die reply:
Public opinion is moving slowly in the direction of the right-to-die.  
More high-profile cases of former persons kept 'alive' by machines
will convince more people to favor choices to end 'life' voluntarily.
And the people who will never agree to any form of chosen death
will not be forced to participate.
For the foreseeable future, 'natural death' will always be an option. 

    (7) The right-to-die is needed because
too many people are being kept alive on machines
for too many months before they die.
Smith says that the appropriate answer to this problem
is better Advance Directives and better implementation of them.  
An Advance Directive should specify
when life-support is appropriate and when it is not.  
Smith argues that Advance Directives should not be rigid.
Unforeseen circumstances might call for a different response
than imagined in the Advance Directive for Medical Care.  

    Right-to-die reply:
Yes, better use of Advance Directives will help all end-of-life choices.
And a very important part of any Advance Directive
is appointing the best proxies to make decisions
when the patient is not capable of deciding.
And comprehensive Advance Directives
should include discussion of the right-to-die.  
People who want the right-to-die should say so.
And people who want the maximum permitted medical care
should express that wish just as completely and explicitly.  

    (8) Only conservatives oppose the right-to-die.  
Smith disputes this claim by citing many people
who are very liberal on other issues
who nevertheless oppose any so-called "right-to-die".  
Liberals also can fear the abuses that might follow
any liberalizing of the laws surrounding the process of dying.  

    Right-to-die reply:
It does not matter who is lined up on either side.
We want wise policy achieved by democratic means, based on reason.

    (9) There is no difference between pain-control and choosing death.  
Such advocates of the right-to-die invoke the principle of double effect:
Pain-control measures are permitted
as long as the primary intention is to relieve pain and not to cause death,
even if shortening the process of dying
is a foreseeable consequence of the pain-medication.

    Right-to-die reply:
Only some advocates of the right-to-die use this form of thinking.
More forthright advocates say that we should clearly separate
decisions that are intended to relieve suffering
(with the hope of returning the patient to a normal life)
from decisions that are intended to end the patient's life.
Even 'terminal sedation' should be called a life-ending decision.
And when life-ending decisions are being considered,
all of the safeguards should come into play.  
If we play mind-games ("We are only relieving suffering."),
the value of safeguards for life-ending decisions is lost.
If it is only a decision about levels of medication,
who will raise the question of safeguards for life-ending decisions? 

    Does it seem to readers of this book-review
that Smith discusses only very weak arguments for the right-to-die?
Perhaps this is his lawyer's method:
Think only for one side.
Never acknowledge that your opponent has any valid ideas.
Attempt to make the other side look foolish.
Present and reply only to the weakest arguments of your opponent.
If you have discussed 9 arguments, the reader might get the impression
that you have looked at the whole case for the right-to-die.
Perhaps Smith has selected only these 9 arguments
because they give him occasions to support his own point of view.
Why has Smith not confronted the best arguments for the right-to-die?
For example, where does Smith discuss personal autonomy?

    A balanced book would allow each side to present its best arguments,
to which the other side would be invited to reply.  

    Smith's preferred mode of death is a natural death in a hospice.
We do not need to drink the hemlock.
Rather, we can get proper pain-control in a home-like setting.  
And then we will never be interested in the right-to-die.  

    Will Wesley Smith's views ever change?  Perhaps not.
But some less committed anti-euthanasia advocates
might revise their views by reading books supporting the right-to-die. 
In any case, the issues Smith raises all need to be addressed,
because they do in fact appear in the minds of many people.  

---

3.  Wesley J. Smith 

Culture of Death:
The Assault on Medical Ethics in America

(San Francisco, CA: Encounter Books: www.encounterbooks.com, 2000)       285 pages
(ISBN: 1-893554-06-6; hardcover)
(Library of Congress call number: R724.S57 2000)

    (Since this is the same author as the book just above,
this review will be somewhat shorter,
because the author makes many of the same points again.)

    A lawyer raises doubts about what he perceives as
a trend in modern medical ethics to decide in favor of death
rather than keeping patients alive as long as possible.  

    The major issues include:
giving up medical care 'too soon',
making value-choices regarding the quality of life,
mercy-killing and assisted suicide,
& pressuring people into dying so they can 'donate' their organs.

    Smith has no special expertise in the field of medical ethics,
but he wants to preserve or go back to
what he conceives to be traditional medical ethics.  

    Most of the review that follows will consist of replies to Smith.  
People who believe in the right-to-die (as I do)
should take the critics seriously,
especially those who base their arguments on reason
rather than mere ideology.  
Smith does give the best arguments he can construct
for each of the points he wants to make.  

    When Wesley J. Smith criticizes a case of premature death,
he usually frames the choice in life-or-death terms:  
These cases of 'mercy-killing' or 'euthanasia'
should not have happened.  
We should always choose life over death.  
But as mortals, we do not have those options.  
Rather, we must select death now or death later.  
And we should ask how much better a later death would be.  

    For example, consider a former person
who has been in a persistent vegetative state for a number of years:  
When there is no chance of recovery, the options are not life or death
but death this year or death in some future year.  
What would be the best year-of-death for this former person?  

    Smith has entitled this book Culture of Death
because he fears that medical ethics is now becoming ideological.
And that new ideology will always favor death over life.  
Or to put it more accurately, the new culture of death
will always favor death now over death later.  
He gives examples to prove his case.  
And some of these examples do seem to be premature deaths.  
However, we do not hear the other side of any of these cases.
As a lawyer, Smith presents only one side.  
In a court of law, the other side would be given equal time.  

    And even if there were a number of cases of premature death,
this does not mean that we should outlaw all chosen death.  
Rather, it means that we need wise and careful safeguards
that have the potential to prevent premature deaths.  
Under any system of safeguards, there will always be mistakes:
Some lives will be ended too soon.  
But under any system that prohibits all chosen deaths,
there will also be mistakes:  
Some individuals will be forced to suffer too long before death.  
And if these patients no longer suffer because they are unconscious,
those who care about them might be forced to endure
seeing them imprisoned by machines that are keeping them 'alive'.  

    All colors of medical ethics should be permitted in a free society.
Some patients and proxies will choose a later death.  
And other patients and proxies will choose an earlier death.  
Within reason, both options should be available.  

    Smith fears that a new elite of medical ethicists is emerging,
who have an ideology that says:
"When in doubt, always choose death now rather than death later".

    I do not see any such culture-of-death emerging.  
Ethical views of all colors are heard and heeded.
Do conservatives or liberals have the upper hand? 
A case for either claim can easily be made
by selecting only examples that support the chosen claim.  

    Smith deplores the fact that medical ethics
is no longer based on religious belief.  
When the 'sanctify of life' prevailed, then all life
(no matter what its quality) was preserved as long as possible.  
Smith fears that if we 'devalue' some forms of life,
we will not know when to stop.  
If we allow some forms of voluntary death or merciful death,
then other individuals with a low quality of life are in danger.  
 
    This is simply a foolish and absurd claim.  
Even ordinary people who have no training in medical ethics
can make quality-of-life choices for themselves
—and for the former persons they have loved.  
Permitting some life-ending choices
does not mean that we will always 'pull the plug'.

    In everyday medical practice, religious views are taken into account.  
And religious beliefs about life and death
should always be honored whenever possible.  
But religious beliefs should not dictate futile medical care.  
Some religious people believe that prayer will bring a cure.  
If they pray hard enough, God will perform a miracle.  
Nothing in medical practice should prevent praying. 
But should there be practical limits on how long to wait for a miracle?
Hospitals should not be required to keep hopeless bodies
on 'life-supports' indefinitely, waiting for a miracle.  
Let religious practices be parallel to medical practices.  
But do not let one dictate to the other.  

    Smith worries that bioethics sometimes makes wrong decisions:
Some doctors recommend non-treatment for defective newborns.
Late-term abortions should not be permitted.  
Sometimes medical experiments are performed on human subjects
without those subjects fully understanding the dangers.  

    Advocates of the right-to-die would reply:
Each example of a questionable decision in medical ethics
could have been handled by better safeguards
—and a more thoro application of safeguards already in place.  
The problems Smith cites call for better medical ethics
rather than for prohibiting the practices he discusses.  

    Has the principle of autonomy gone too far?  
Sometimes people wish to die when they get a terminal diagnosis.  
But if doctors refuse to cooperate with irrational suicidal urges,
some of these patients change their minds about dying.  
Paternalism is justified by the good results sometimes achieved.  
For example, sometimes the patient
might be hurried into choosing death mainly to benefit the family,
who will be freed of the burden of caring for the patient
and who might inherit large sums of money.  

    Careful safeguards surrounding all life-ending decisions
should be able to prevent almost all mistakes and abuses.  
Smith has performed a valuable service
for everyone considering the option of choosing death:
He has gathered doubtful cases
—situations in which valid questions can be raised
about the wisdom of choosing death at the time it was chosen.  

    Another chapter explicitly addresses the possibility
that discussing the 'right-to-die' will create a duty-to-die.  
Medical ethics uses the concepts of futile medical care and rationing.
Sometimes patients and their loved ones demand medical treatments
that have little or no chance of being effective.
Medical ethics does consider the cost and benefit of each procedure.
Smith does not think that money should ever be considered. 
   
    The state of Oregon created a priority list of treatments.  
Public funds went only for the procedures higher on the list.
Treatments with high cost and little benefit
were not offered to people who could not pay.  
Each year the cut-off point was adjusted to fit the money available.
This system of rationing assured that
simple and less-expensive treatments were available to everyone.  
But it did exclude complex and expensive treatments.  
Thus, some people did die sooner
because the public would not pay for their treatment.  
But many more people were saved from simple causes of death
because in Oregon basic medical care was available to all.  

    Smith worries that the duty-to-die mentality
will be reinforced by the need for 'donated' organs for transplant.  
Especially disabled people might be rushed into 'choosing' death
because it will benefit others who need their organs.  
Because of the possibility of abuses and mistakes,
is Smith suggesting that we terminate organ-donation?

    But a more reasonable approach would be
to apply the safeguards already in place more carefully.
The public needs to be convinced that the donors really were dead
before any organs were taken.  
Science fiction and sensational journalism like to focus
on the possibility of stealing organs from the living.
Public willingness to donate organs after death is very fragile.  
A few reports of questionable cases
(or cases that were not correctly reported)
can cause some people to revise their plans for donating organs
—either their own organs after death
or the organs of family members who have died.
  
    The public needs to understand brain-death more fully.  
Smith cites some cases when the diagnosis of brain-death was wrong:
The patient did recover and returned to normal life.
 
    Thus, independent doctors must repeat the tests
to make certain that the patient is really brain-dead
before considering donation.  
Understanding the specific way in which this brain died
and following the safeguards for proper waiting periods
can make the diagnosis of brain-death more certain.  

    Some ethicists favor PVS being an optional definition of death.
Smith does not agree: Persistent vegetative state is not death.

    The public will rightly resist such a re-definition of death.  
When the patient seems to be awake part of the time,
has reflex movements and breathes without mechanical assistance,
people without medical training often have great difficulty
understanding that this former person will never recover.  

    Another proposed new definition of death
that Smith resists is permanent unconsciousness. 

    Defective infants is another possible source of organs
for other infants who will otherwise also die.  
Especially when infants are born with their upper brains missing,
these could be defined as born permanently unconscious.
Because anencephalic infants lack most of their brains,
they will never have any reaction, emotion, or thought.  
But if their organs are working well, they make ideal donors
for other infants who were born with defective hearts, for example.  

    Smith also opposes any form of organ-selling.
He worries that the poor will be exploited:
Instead of being offered full medical care,
their relatives will be offered cash for their organs. 

    This is not likely to happen,
but even the fact that people can conceive of such a practice
shows the need to have strong safeguards to prevent it.  
Organ-selling does present real opportunities for abuse.  
So any organ-market should be carefully controlled.  

    Smith also points out the dangers of surgically removing organs
before the donor has been officially declared dead.
 
    Even if the donor has approved of such a practice in advance,
we should never harvest organs from living bodies.
No one associated with the present system of organ-donation
has approved such a practice.  
And it would be counter-productive because it would feed
public worries about stealing organs from the living.
This is called the dead-donor rule.
 
    Another element of modern medical ethics
that Smith disagrees with is the effort to limit 'futile' care.  
Smith worries that it is too easy for doctors to declare
that further medical treatment would be useless.  
According to Smith, economic and quality-of-life factors
should not be considered in making medical decisions.  
Ethics committees should be subject to review and reversal
—just like the decisions of judges.
And this would require making their deliberations public.  

    Smith worries that 'medical dehydration'
will be used inappropriately against disabled people.  
And defective infants should not be refused treatment
merely because they will have lives of low quality.  

    In summary, Smith has constructed the best arguments
he can think of to prevent medical ethics from devaluing human life.  
All human life is equally valuable and should be protected. 

    In the first few decades of the 21st century,
the most likely arena of this debate will be patients in PVS
and other patients who are permanently unconscious.
Smith always wants to keep such patients 'alive'.
Everyone who affirms the right-to-die
will have to confront the arguments presented in Culture of Death. 

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4. 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,
all pointing out 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:
Books Supporting the Right to Die:
https://s3.amazonaws.com/aws-website-jamesleonardpark---freelibrary-3puxk/B-RTDIE.html.

    The review of The Case Against Assisted Suicide
 grew so long that it was given its own file on this website:
https://s3.amazonaws.com/aws-website-jamesleonardpark---freelibrary-3puxk/B-HENDIN.html

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5. Margaret Somerville 

Death Talk:
The Case against Euthanasia and Physician-Assisted Suicide

(Montreal, CAN: McGilll-Queen's University Press: www.mqup.ca, 2014--2nd ed.)       433 pages
(ISBN: 978-0-7735-4376-8; paperback)
(ISBN: 978-0-7735-8915-5; ePDF)
(ISBN: 978-0-7735-8916-2; ePUB)
(Library of Congress call number: R726.S64 2014)
(Medical call number: WB65S696d 2014)

    A professor of law examines all of the issues surrounding
euthanasia and physician-assisted suicide.
Civilization should not permit the purposeful ending of human life.
But all forms of making end-of-life decisions
within standard medical care should be permitted. 

    Some chapters carefully analyze the process
of withdrawing medical treaments—including life-supports—
as a permitted method of choosing death,
even if that life could have been extended indefinitely
if the life-supports were continued.
This is allowing nature to take its course rather than euthanasia.

    Another method of dying permitted within modern medical care
is increasing pain-medication with the knowledge
that such additional drugs in the patient's system
will probably shorten the process of dying. 
This also is a recognized, standard method of choosing death,
entirely within the normal practice of medicine
and it should not be labeled euthanasia or physician-assisted suicide. 

    She briefly mentions terminal sedation,
recognizing this also as a valid and legal end-of-life treatment
that leads inevitably to the death of the patient.
Keeping the patient asleep until death comes
is also not a form of euthanasia or physician-assisted suicide.

    Because this book was put together from a set of articles
published over a few decades, there is some repetition
and some chapters that have little to do with the right-to-die.

    But it does show an opening in the thinking of people
opposed to euthanasia and physician-assisted dying.
Some opponents do allow medical methods of choosing death.
"Just say NO!" is no longer a useful response to the right-to-die.

---

6. Mary & Robert Schindler
with Suzanne Schindler Vitadamo and Bobby Schindler

A Life that Matters:
The Legacy of Terri Schiavo—a Lesson for Us All 

(New York: Warner Books: www.twbg.com, 2006)     251 pages 
(ISBN-10: 0-446-57987-4; hardcover)
(ISBN-13: 978-0-446-57987-2; hardcover)
(Library of Congress call number: R726.S34 2006)

    This book is written mainly in the voice of Mary Schindler
—mother of Terri Schiavo.
But Terri's father Bob, sister Suzanne, & brother Bobby
all have major comments included.
These four people are Terri Schiavo's family of origin.
And they were united in their opposition of allowing Terri Schiavo to die.

    Terri Schiavo's husband—Michael Schiavo—has written another book
—Terri: The Truth—which takes a very different perspective
on the facts and opinions surrounding the Terri Schiavo case.
Michael Schiavo's book is reviewed
in the bibliography Books Supporting the Right-to-Die.

    This reviewer will leave it to careful readers to decide
just where the objective truth lies between these two different accounts.
Even tho each book spins the 'facts' to favor a particular belief,
Michael Schiavo's book is probably closer to what really happened.
And after many years of battling in courts,
the husband's perspective finally prevailed:
Terri Schiavo had her feeding-tube removed after 15 years in PVS.

    The Schindler family members consistently 'see' more responses
from Terri Schiavo than observed by most medical experts.
And they found their own experts to support their observations.
The Schindlers always wanted to keep Terri alive
and to seek rehabilitation for her
so that at least some moments of awareness would be possible.

    And after Terri's final death in 2005,
the Schindlers established a foundation
to support patients who have lost many mental capacities.
They hope that the tragic case of Terri Schiavo
will make it possible for other patients like Terri to be kept alive,
who would otherwise be declared "vegetative" and allowed to die.

    The rhetoric of this book displays its point-of-view.
Disconnecting Terri's feeding-tube is consisting called
"starving and dehydrating" Terri.
The judge and the husband who chose this course of action
after it was determined to be what Terri would have chosen for herself
are called "murderers".
The most extreme statements by the Schindlers
say that the judge and the husband should both be in jail.

    The Schindlers were able to find their own Roman Catholic priests
to support their position that life-support should always remain in place
until natural death occurs despite the life-supports.

    (In his book, Michael Schiavo notes that Mary Schindler
did authorize the removal of her own mother from life-supports
at the end her mother's life.
But the experience of dealing with her daughter's death
might have changed Mary Schindler's mind about life-supports.)
   
    As the media began to pay attention to Terri Schiavo,
many right-to-life groups came to side of the Schindlers.
In many ways Terri Schiavo became their poster-child.
The demonstrators and public opinion
were largely on the side of keeping Terri 'alive'.

    The Florida legislature passed 'Terri's Law',
which allowed governor Jeb Bush to re-insert the feeding-tube,
even tho the courts had already decided she did not want it.
This law—which was set to last only 15 days—
was ruled unconstitutional because the legislature
does not have the power to change rulings of the courts.

    The U.S. Congress similarly tried to intervene
and the President signed a special bill,
but it also was unconstitutional.

    One take-home lesson from the Schiavo case
is that families can easily be divided about end-of-life choices.
No matter what evidence was collected by the courts,
even including the autopsy report,
the Schindlers continued to believe that Terri was alive and conscious
until she finally died in 2005 when her feeding-tube was removed.

    This shows the power of metaphysical belief.
The same people who believe that an embryo has a soul
believe that all remnants of life must be preserved
as human beings approach the end of their lives.
The same difference of opinion will happen in other families:
Some family members will believe their dying relative is still a person.
And other family members will believe that this human individual
has lost everything that made him or her a person.
Such possible conflicts should be avoided
by each person creating an Advance Directive for Medical Care,
stating exactly what should happen in case of PVS
or some similar condition from which the patient will not recover.
The Schindlers will create one kind of 'living will',
which will keep them 'alive' as long as possible.
The Schiavos will authorize the withdrawal of life-supports
when there is no hope of recovery.

    In the wake of the Terri Schiavo case,
many opponents of the right-to-die attempted to create state laws
that would mandate food and water for all patients in PVS
unless there is clear and convincing evidence to the contrary.

    This reviewer also read Michael Schiavo's book
in parallel—chapter-by-chapter with this book.
Michael Schiavo's book-—Terri: the Truth—
is reviewed in the bibliography on Books Supporting the Right -to-Die.
Both reviews end with the following paragraph:

    Whatever we want, if ever we are in a condition similar to Terri Schiavo,
we should state our wishes clearly and unambiguously
in our Advance Directives for Medical Care.

    To keep abreast of the thinking represented in this book,
go to the website of the Terri Schiavo Life & Hope Network:
http://www.terrisfight.org.

---

7. Ian Dowbiggin

A Concise History of Euthanasia:
Life, Death, God, and Medicine

(Lanham, MD: Rowman & Littlefield, 2005)       161 pages
(ISBN: 0-7425-3110-4; hardback)
(Library of Congress call number: R726.D688 2005)

    A good summary of the historical background of the right-to-die debate,
beginning in ancient times and brought up to the present. 
This book is definitely against "euthanasia".
An historian favoring the right-to-die
would have selected different facts to include
and would have presented everything with an opposite tone of voice.

    For example, Dowbiggin frequently notes
that people who favor the right-to-die
also favor of such godless things as evolutionary theory and abortion.
Nazi atrocities are associated with the "euthanasia" movement.
One reason God appears in the title is that Dowbiggin
believes that traditional religions will always oppose the right-to-die.

    Nevertheless, advocates of the right-to-die should read this book
to feel the assumptions operating in the minds of the opposition.

---

8. Kevin Yuill

Assisted Suicide:
The Liberal, Humanist Case Against Legalization

(Palgrave Macmillian: www.palgrave.com, 2013)       188 pages
(ISBN: 978-1-137-28629-1; hardcover)
(Library of Congress call number: R726.Y85 2013)

    Kevin Yuill wants to keep the laws prohibiting assisting suicide.
But he fails to distinguish between irrational suicide and
making wise end-of-life medical decisions.
Like many other books on 'euthanasia' and 'assisted suicide',
both those who favor the right-to-die and those who oppose
so often miss what is actually happening on the modern deathbed.
Life-ending decisions are important is perhaps half of all deaths.

    If proposed right-to-die laws used a completely different expression,
this might have been a completely different book.
If we outlaw 'causing premature death', then everyone can agree:
We do not want anyone to end his or her life before its proper time.
And we certainly do not want physicians to help us 'commit suicide'.

    The basic context for this book is the United Kingdom,
but the author also refers to right-to-die thinking
in other parts of the English-speaking world.

    The arguments against foolishly ending one's own life are well taken,
but the author does not tell us how he plans to meet his own death.
Will he resist any discussion of medical choices
that would shorten his process of dying?

---

    Please suggest additional books that should be included
in this bibliography of books opposing the right-to-die.
Send your suggestions to James Park: e-mail: PARKx032@TC.UMN.EDU
The reviews above fill about 16 pages of the bibliographies for
How to Die: Safeguards for Life-Ending Decisions.

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revised 4-22-2009; 9-13-2010; 2-9-2012; 4-1-2012;
4-18-2013; 7-3-2013; 7-5-2013; 9-5-2013;
5-13-2015; 5-29-2015; 6-15-2015; 6-22-2015;
8-14-2017; 3-17-2018;

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    See related bibliographies:

Books Supporting the Right-to-Die

Best Books on Voluntary Death


Best Books on Preparing for Death

Books on Terminal Care

Books on Helping Patients to Die

Medical Methods of Managing Dying

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Go to the Book Review Index
to discover 350 other reviews
organized into 60 bibliographies.

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Go to the Portal for the Right-to-Die.

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Return to the DEATH page.

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Go to the Medical Ethics index page.

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