2008; Volume 9, No 8, August

Roger Woodruff, MD


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Hospice Palliative Care Book Reviews

Book Reports

Is There A Case For Assisted Dying?

Mary Warnock and Elisabeth Macdonald
Oxford University Press, 2008
155 pp
ISBN 978-0-19-953990-1
RRP £12.00, $US26.00

This book is to be recommended to anybody involved with the debate about euthanasia, although not all will agree with what is said. Written by a moral philosopher (Baroness Warnock) and a retired cancer specialist, this book sets out to provide a balanced discussion of what would be necessary for the legalization of physician-assisted suicide in the UK, to define what the issues really are. It certainly adds some intellectual tenor to the debate, although my reading was more than a little troubled.

I started off a little off-side when I read that I was one of those who were standing in the way of ‘what society demands’, trying to ‘impose their convictions on the quiet majority’.  The 2007 public opinion poll that is cited is not referenced, but when I last reviewed the public opinion polls from around the world, they mostly boiled down to ‘Do you want to die in agony or legalize physician-assisted dying?’  I have had a handful of serious requests for assisted-dying in 30 years of working as a medical oncologist and palliative care physician, which doesn’t support what the newspaper polls tell us.

Then I stumbled at there being no morally relevant difference between killing someone and allowing them to die.  I would contend that there is a great difference between accompanying a dying patient, allowing them to die and not artificially prolonging their life, and giving them a premeditated lethal injection. I was quite unconvinced by their philosophical arguments that killing patients was really no different to what I now do and wondered whether theoretical moral philosophy should be confined within ivory towers and kept out of the clinic.

I tripped at their dealing with ‘the Dutch experience’—the 1000 patients who are euthanased without request each year.  This was to be neither a concern nor a reason not to change the law in the UK, because the figures were not reliable as information was hard to obtain; but if we had information on the 40-50% of cases of euthanasia that are presently not reported, the figure isn’t going to be less than 1000 patients per year and may possibly be much higher.  It was also implied that many of these cases were handicapped babies; my copy of the New England Journal of Medicine indicates that more than 50% of the patients subjected to non-voluntary euthanasia were 65 years or older in the 1995 and the 2001 surveys.

I baulked at their reassurance that there is no evidence of increased assisted dying for vulnerable groups (the disabled, elderly and those with psychiatric illness) in the Netherlands; as we only have information on a little over half of the cases, such a conclusion is speculative.  The reports from Darwin and Oregon reveal a preponderance of socially isolated individuals who could be described as a vulnerable group, but this is not discussed.

I was uncertain which way they wanted to go on the slippery slope business. Early in the book, they argue at length that slippery slopes don’t exist but later conclude that future legislation will only succeed if it has guarantees against such slopes.
Does it present balanced arguments? I think not. In the end, I felt this book was a bit of a wolf in sheep’s clothing and wondered whether there was a philosophical position on the honesty of wolves.


An Argument for Voluntary Euthanasia

Rodney Syme
Melbourne University Press, 2008
301 pp
ISBN 978-0-522-85503-6
RRP $A32.99, £22.50

Here is another book to be recommended to anybody involved with the debate about euthanasia and physician-assisted suicide, although many may not agree with what is said.  Rodney Syme is a Melbourne urologist who has been at the forefront of the push to legalise physician-assisted death in Victoria and has served as the president of the Voluntary Euthanasia Society of Victoria, now sanitised to Dying With Dignity Victoria.  The book recounts some of his clinical experiences over the years, from which he develops his arguments to challenge the legal and legislative fraternities and take a swipe at the palliative care community.

I was a bit put off by the style.  The clinical histories are described in a melodramatic way and I didn’t like the repeated use of exaggerated adjectives—anguished signature, progressive ravages, remorseless progression, etc.  And the blind lady who bid him farewell as he vanished into the darkness? 
I was a little more off-side when labelled a hypocrite because I didn’t agree that ‘the intention of a doctor [using terminal sedation] to relieve intolerable suffering is no different from that of a doctor who provides or administers medication that causes death quickly.’  I beg to differ.  He argues that patients treated by ‘pharmacological oblivion’ (his term for terminal sedation) should be subject to coronial enquiry.  I was unconvinced by his argument that terminal sedation, not possibly, but always hastens the patient’s death.  In contrast, he says our more enlightened Dutch colleagues acknowledge that voluntary euthanasia will hasten death.  Should do, if they do it right. 
I was a little confused on the autonomy thing, which is a strong theme that runs through the book.  He describes Philip Nitschke’s computerised injection technique as ‘allowing that person to control totally the delivery of the lethal medication.’  Not after they click on ‘Yes’. And ‘the Dutch experience’—the 1000 patients a year euthanased without request? I don’t think it was mentioned.
I was more confused by his attitude to palliative care.  He states on several occasions how much he supports it, but describes the palliative care process as intrusive for the patient and family, and palliative care professionals with ‘the mindset’ (not agreeing with his views) as hypocrites.  He describes as laughable Michael Ashby’s statement that ‘… intentional ending of life is not part of palliative care practice and is different in kind from all other clinical intentions.’
Overall, the book is rather predictable.  There are the usual references to polls, the surveys of professional behaviour (since discredited because of ambiguous questions), recounting of terrible end-of-life stories, and quotes from the usual suspects—Timothy Quill and Marcia Angell, for example. 
On reflection, Syme gives some good examples of why physician-assisted death should not be legalised.  Working alone, facing patients with severe suffering, he repeatedly admits feeling professionally inadequate.  What did he do when he visited the family friend, not under Syme’s care, dying of cardiac failure with severe breathlessness?  Ordered the nurse to draw up the large dose of morphine (written up by the treating doctor), which he immediately administered by intravenous injection.  What, I ask, will happen when doctors with less experience of end-of-life care than Syme are faced with similar suffering?
No sheep’s clothing here.

Dr. Roger Woodruff, Australia, IAHPC Board Member
July 2008

Note for authors: If you wish to have your book reviewed, please send to:

Dr Roger Woodruff
IAHPC Bookshop Editor
210 Burgundy St, Suite 9
Heidelberg, Victoria 3084

Note: Review copies become property of IAHPC and are not returned to the author. Only palliative care related books which are previously approved will be reviewed. Due to the large number of requests, we can't provide exact dates of when books will be reviewed.

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