Hospice Palliative Care
Dr. Woodruff, MD
The Table of Contents for each book reviewed is available in the Bookshop at www.hospicecare.com/Bookstore
ENDING LIFE: Ethics and the Way We Die
Margaret Pabst Battin
Oxford University Press, 2005
RRP $US24.95. £14.99
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A Dutchman came to see me last week. He was in his 80s, but mentally very on the ball. Towards the end of our meeting, he said, ‘I want you to know that I am a very strong proponent of euthanasia.’ This, it turned out, evolved from watching his father die slowly over a ten-year period in a nursing home, blind and deaf. It sounded awful to me, but I avoided asking how many courses of antibiotics and other life-prolonging measures had been administered during that time. When I suggested that modern palliative care might go a long way to preventing the pain and psychosocial suffering associated with a terminal illness, he was unmoved. He was both a fervent autonomist and scared of dying the way his father had.
This book is about the way philosopher Professor Margaret Pabst Battin thinks we should now move on from the currently polarized debate about physician assisted-dying, and along the way she presents a lot of interesting information about the way people die. She starts with the present for-and-against debate, exploring some of the issues in depth. The middle section of the book describes the influences of historical, religious and cultural concerns, touching on a wide variety of topics from serpent-handling to suicide bombing. The final section is titled ‘Dilemmas about Dying in a Global Future’ and deals with issues related to increased life expectancy, genetic prognostication, and ‘NuTech’ methods for committing suicide, before coming to the predictable conclusion that physician-assisted dying will come to be accepted as our culture changes.
In her introduction, Battin urged me not to address the issues surrounding physician-assisted dying in ‘all or nothing’ terms. But I failed to reach the required standard. I felt that her description of the Dutch practices was somewhat selective. I was encouraged to pass over the ‘notorious 1000’ patients who are euthanised each year without current request or consent. The clinical facts, as published by the Dutch authorities, is that the true number is a multiple of this when you include deaths related to treatment of pain and symptoms given with the intention of hastening death and deaths related to withholding or withdrawal of treatment done with the intention of hastening death, many of whom were euthanised without request or consent. A more detailed appraisal of Dutch practices can be found in John Keown’s Euthanasia, Ethics and Public Policy (Cambridge, 2002) and The Case Against Assisted Suicide edited by Foley and Hendin (Johns Hopkins, 2002), but I couldn’t find reference to either volume. And just to set the record straight, the Australian data on physician-assisted dying published by Kuhse, which is quoted, was based on unethical and ambiguous questions and was discredited years ago.
On the other side is the possession of personal autonomy. I am somewhat bemused that this is such an important and central tenet in the physician-assisted dying debate when we all relinquish bits of personal autonomy all the time, every day, because we live in a society. And what about the data from Oregon , where it is legal to exert your personal autonomy and receive physician-assisted suicide? During the four-year period 1998-2001, there were about 20,000 deaths from cancer in Oregon . Now if 60% of Oregonians voted in favour of legalizing physician-assisted suicide that might lead to as many as 12,000 requests. But during that period there were only 70 deaths by physician-assisted suicide of patients with cancer – which is one-third of one percent. There are more complex issues at work.
And just a word about suicide bombing. Forgetting the historical context from centuries ago, should we really “see these actions as defensible cases of martyrdom” in the twenty-first century? This might be appropriate analytical thinking for philosophy departments, but I wonder whether a lot of people down here on earth would agree.
This book is well-written and certainly thought-provoking. I would not hesitate to recommend it to anyone with an interest in the debate about physician-assisted dying or the historical and cultural origins of the way people die. I learned a lot of interesting things along the way and was entertained by Battin’s fictional essays. But would something as simple as improving pain control lead to fewer and fewer requests for physician-assisted dying? My Dutchman expects perfect pain control and euthanasia. And was I swayed towards legalizing physician-assisted dying? Not a bit.
Director of Palliative Care, Austin Health,