Books selected and reviewed by James Park,
existential philosopher and medical ethicist.
The following books are
organized in order of quality, beginning with the best.
The paragraphs in black
intend to present objective facts about each book.
The remarks in red are the evaluations of this reviewer.
Stephen Jamison, PhD.
Final Acts of Love: Families, Friends, and Assisted Dying
(New York: Putnam, 1995) 279 pages
book should be read by everyone who plans a
or who plans to help someone else in a voluntary death—doctors included.
It is a very careful guide for exploring all the dynamics associated
with choosing to die and helping others to end their lives.
Final Acts of Love is based on interviews with 140 different people,
who assisted in 160 voluntary deaths.
Only 10% of these were reported as suicides.
The rest were attributed to natural causes.
The helpers were usually not doctors, but family members and friends.
are several of the cautions raised in this comprehensive
1. Is the medical diagnosis and prognosis clear to all?
2. Have all the medical options been explored, tried, and then rejected?
3. Has a specialist in the disease given a second opinion?
4. Is the patient asking for better treatment
or for loving attention rather than death?
5. Is the patient's judgment impaired by the disease or the treatment?
6. Is the patient irrationally depressed or suicidal?
7. Is the decision to die caused by a medical crisis?
8. Is the patient being pressured or manipulated by others
for personal or financial reasons?
9. Is the patient manipulating others into helping
when the patient could achieve a voluntary death without help?
10. Does the patient have an irrational fear of nursing homes?
11. How many people have been involved in discussing the proposed death?
12. How many independent people agree that death is the best option?
13. What impacts will this death have on other people?
14. Has the patient's wish to die persisted over time?
15. How long a waiting period would ensure that death is a wise decision?
16. What special measures will be needed to make the death
appear to be "from natural causes" or a "private suicide"?
17. How will this death be reported and registered?
18. What people will be present for this voluntary death?
19. What roles will each take in the process?
20. Is one helper too enthusiastic about causing death?
21. What will the helpers do if the first method of dying fails?
22. Has concern for secrecy and the details of dying
obscured the possible meanings that might be realized from this death?
23. If I plan to help another to die, what are my own personal, ethical,
philosophical, or religious views about assisting a voluntary death?
24. What safeguards and limits would I put on my participation?
25. What will be the impacts on those who help with a voluntary death:
psychological, moral, professional, political, & legal?
A Decision-Making Guide for Health Professionals
Francisco, CA: Jossey-Bass Publishers: www.josseybass.com, 1997)
(ISBN: 0-7879-0873-8; hardcover)
(Library of Congress call number: R726.J357 1997)
Almost all doctors and nurses who work with dying patients
get asked from time to time to assist their patients to die.
This book directly addresses this dilemma:
What should the doctor or nurse do when asked to assist a dying patient
to achieve a peaceful and painless death?
'Assisting suicide' is still officially a crime almost everywhere.
But this book reports that such laws have never been used
against a health-care worker who has helped someone to die.
This book does not explore the reasons for death
as seen by the patient who is dying.
Those issues are in the background.
And it is assumed that the nurse or doctor
would not assist a patient to die
unless it was in the best interests of the patient.
Rather, the focus is on the decision-making process
within the health-care professional—the doctor or nurse—
who must decide how to respond to a request for help in dying.
The doctor is first supposed to do no harm.
And sometimes assisting a patient to die is a help rather than a harm.
But the doctor does not want to get a reputation
as someone who helps patients to die.
Will the doctor be present
when the patient takes the gentle
The doctor should not recommend death as a treatment option.
But when the patient brings it up,
the doctor needs to think deeply about what is best for the patient
and how best to protect all the people who might become involved
—including, of course, the doctor himself or herself.
Good communication between the doctor and the patient
should make explicit all the reasons the patient wants to die
—both valid reasons and invalid 'reasons'.
Here are some of the invalid reasons for choosing death:
Some patients want to die because they fear they will lose the power
to choose death at a later phase of their disease.
Some patients are emotionally exhausted by the whole process.
Some patients suspect they have additional medical problems
they have not been told about.
Some patients do not want to be an emotional
or financial burden on their loved one.
Some worry about isolation as they die.
Others feel in despair.
There are two extreme ways of responding:
(1) Absolutely refuse to assist the patient to die.
(2) Grant the wish to die immediately.
Every health-care worker has a right to refuse to help the patient die.
But when they refuse to help, they should refer the patient
to someone else who feels more open to choosing death.
In some complex cases, where various doubts might arise,
it could be wise to call in a psychological consultant,
who will assess the patient's state of mind
and abilities to make wise life-ending decisions.
Families of the dying often complicate the process.
Some family members might be opposed to any chosen death.
Some relatives feel guilty for having neglected the patient.
Sometimes parents did not know their sons were gay
—much less dying of AIDS and now asking for assistance in dying.
Before agreeing to assist a patient in dying,
the doctor should make certain that pain and other forms of suffering
have been addressed in the best possible ways.
What methods of assistance in death are available to the doctor?
1. The doctor can order increased pain medication,
but when the dose is out of line with general medical practice,
the nurse will notice that a secondary purpose is to bring death.
2. The doctor can discontinue the life-support systems.
Jamison does not call this a method of assisting death.
3. The doctor can cooperate with the patient
who decides to give up food and fluids.
This method of achieving a voluntary death is completely legal.
4. The doctor can order terminal sedation
—enough pain-killers to keep the patient unconscious until death occurs.
And the drugs will probably shorten the process of dying.
Because other means of assisting a patient to die were still illegal,
90% of the assisted deaths Jamison studied were reported as natural death.
The other 10% were reported as (unassisted) suicides.
Even tho many assisted deaths have been reported in the media,
almost no one has been prosecuted or sued.
But there is a small risk,
which suggests that knowledge of the real cause of death
should be confined to a small circle of people who can be trusted.
Assisted Suicide should be read by
all health-care workers
who might ever be asked to help a patient to die.
In general, it does favor the right-to-die.
But most of the book is taken up with cautions
that doctors and nurses should heed
when responding to requests for aid in dying.
Charles F. McKhann, MD
A Time to Die:
The Place for Physician Assistance
(New Haven, CT: Yale
University Press, 1999)
(ISBN: 0-300-07631-2; hardcover)
(Library of Congress call number: R726.R355 1999)
(Medical call number: W50M47847t 1999)
physician and professor at a medical school
discusses all perspectives on physician-assisted voluntary death.
First, some common situations in which the patient
wishes to reduce his or her suffering
by choosing the most appropriate time to die:
cancer, AIDS, Alzheimer's disease, pain.
The person who is inevitably dying
might not want to dissipate his or her estate in futile medical care.
Being able to pass some wealth to the next generation
sometimes means more to the dying individual
than a few more days or weeks of low-quality 'life'.
Sometimes patients ask doctors to help them to die for irrational
The full situation should be assessed before
discussing the best timing of death.
voluntary death should be explored first:
comfort care, pain relief, hospice care.
If such methods do not handle the situation satisfactorily,
then the doctor has some other methods
which will assist the patient to the desired goal
—a peaceful, painless, & dignified death.
Some of these methods of assistance are now legal:
The doctor can provide sleeping and/or pain medication,
which have as a known side-effect shortening the dying process.
This could even take the form of 'terminal sedation',
in which the patient is kept unconscious until natural death.
In the states of Oregon and Washington,
the doctor can even write a prescription for gentle poison
once several safeguards have been fulfilled.
(3) If the patient is being sustained by some form of life-support,
all concerned can agree to discontinue such supports.
Natural death will quickly follow.
If all concerned approve death by
then food and water can be withheld
and the doctor can order additional medications
which can eliminate the unpleasant aspects of this method of dying.
considering legal methods of assisting a voluntary death,
completely open discussions can involve
all who care about the life and well-being of the dying patient.
McKhann discusses the Dutch experience
of voluntary death with doctor assistance.
The experience of the Netherlands has uncovered several problems,
which can be corrected in any new legislation in the United States.
about people who have requested death
in an Advance Directive or other careful document
but who slip into a semi-conscious state
before they can request death one last time?
How realistic is it to require the patient
to be awake and capable up to the last moment before death?
Physicians are rightly concerned about
the legal aspects of helping their patients to die.
Not only is assisted dying against the law in most states,
but doctors might also be sued by a relative
who did not approve of the voluntary death.
Also, doctors avoid public association with assisted dying.
They have been trained to cure, not kill.
And most of the professional medical groups
are opposed to any physicians assisting in dying.
Dr. McKhann asked other physicians for their opinions,
most said that they would be more willing
to help their patients die in the last weeks of life
if it were legal, moral, & professional to do so.
public resists physician-assisted voluntary death
because of fears of abuse and mistakes.
Like all other human beings, doctors do sometimes make mistakes.
But the public does not call for an end to air transportation
because pilots sometimes make mistakes
that result in the deaths of everyone on board those planes.
However, most cases of physician-assisted voluntary death
are nowhere near the error zone.
There is no rush to achieve death this instant.
And if there are doubts about the wisdom of this voluntary death,
then other opinions can be obtained
—from other doctors and relatives not yet consulted.
people worry about greedy relatives,
who hope to get their hands on their inheritance a bit sooner.
But most can wait a few weeks for their money.
And if there is any such doubt,
the full situation should be brought into the open.
public also worries that the 'right-to-die'
will be applied first to vulnerable people.
But the facts point in the opposite direction:
The vulnerable people get little or no health care at all.
Neglected patients will not get any special attention from doctors
who want to help them to die.
With respect to less-favored groups of people,
doctors are already wary of providing sub-standard care.
McKhann reviews the standard safeguards for deciding death:
1. requests from the patient while still capable of making decisions.
2. doctors' opinions about prognosis and treatment options.
3. psychiatric evaluation of the candidate if there is any doubt.
4. waiting period to avoid impulsive death.
5. full reporting of all material facts.
safeguards can probably be improved,
perhaps even to the degree needed
to win over some opponents of the right-to-die
who raise the specter of people being put to death
for the benefit of the state.
The discussion of the right-to-die
should be kept completely separate
from the discussion about health-care costs.
present system of secret
assistance in dying
is open to mistakes and abuses.
Can we make choosing the best time for death
an open and rational discussion,
in which all concerned persons will have a voice?
Time to Die: The Place for Physician Assistance
is a wise and compassionate book
about the prospect of physicians helping their patients to die.
It does not break any new ground in the discussion,
but the fact that it was published
shows that we are more open to the possibility
of making reasoned choices at the end of life.
Dr. McKhann believes that it is only a matter of time
before physician assistance in voluntary deaths will be approved.
How soon will we all have this right to choose?
The Last Goodnights:
Assisting My Parents with their Suicides:
(Berkeley, CA: Counterpoint:
www.counterpointpress.com, 2009) 254 pages
(ISBN: 978-1-58243-488-3; hardcover)
(Library of Congress call number: R726.W47 2009)
Lawyer John West provided pills to
help his parents die in 1999.
Both were in their 70s and had been health-care professionals.
His father was dying of fast-advancing bone cancer.
His mother suffered from the early stages of Alzheimer's.
They did not die at the same time, which might have been suspicious.
Even tho this
book was published 10 years after the events,
it must have been based on careful diary notes,
since it gives specific dates for most of the events
and quotes conversations with all the family members involved.
In part because
these events took place in the last century,
complete secrecy had to surround the planning for these deaths.
The father had two hips replaced just before his (secretly) planned death.
The mother was trying to carry on as normal,
so that no one would question her death either.
The plans were
completely successful in both cases.
The family doctor had no suspicions about either death
and he signed the death-certificates without even seeing the bodies.
These deaths were reported as due to natural causes.
But the actual cause of death was massive amounts of pills
voluntarily taken by the two parents
with the planning and help of the son who wrote the book.
The father's death was more clearly a
because he was not expected to survive
the rapidly-spreading cancer for many more weeks.
And he was clearly in charge of his own death;
his mental capacities were not compromised in any ways.
It might be said he was a member of the One-Month-Less Club,
since he knew that his life held nothing further than more days in bed.
Because of the clear medical facts,
there was probably no need for any further safeguards.
He had been head of the department of psychiatry at UCLA.
The mother's death
might be more difficult to categorize
since she lacked a definite downward pathway.
She might have lived a few more months,
even tho she did not want to tolerate the mental decline
she knew she was experiencing.
She had been a clinical psychologist.
If voluntary death had been a more viable option in California at the time,
she might have decided to continue living a bit longer.
But she feared that she might lose the power to take the pills herself.
And her son was not willing to cause her death by himself.
Even tho the
expression "assisted suicide" appears in the title
and a few times in the text, it is not essential to the concept of this book.
(The author does refer once to his father "committing suicide".)
This reviewer would have preferred another term—"voluntary death".
Such a non-offensive term could easily replace "suicide"
wherever it appears in this book.
The right-to-die movement has definitely moved away
from using the word "suicide".
But the author shows little sign of being in contact with this movement.
And perhaps this misleading term appears
because the writing began a decade earlier.
It is also possible
that the publisher thought that "assisted suicide"
should appear in the title because that would sell more books.
And the Library of Congress
classifies this book as "Assisted suicide--biography".
"Assisted suicide" is a traditional term.
And it is the one preferred by opponents of the right-to-die.
But this reviewer recommends that it be replaced by "voluntary death",
which separates it from the thousands
of irrational suicides that take place each year.
Another option for
choosing a timely death,
which was legal at the time, was voluntary death by dehydration.
John West hopes that lethal injections by doctors will be permitted,
as it now possible in Holland and a few other European countries.
Other members of the family (and even close friends)
could have been included in the last days of these two well-loved people
if they had chosen an open way of ending their lives.
And the author would not have traumatized himself
by the months of secret planning
if they had decided to use legal methods of choosing voluntary deaths.
6. Timothy E.
Midwife Through the Dying Process:
Stories of Healing and Hard Choices at the End of Life
(Baltimore, MD: Johns Hopkins University Press, 1996) 239 pages
Dr. Timothy Quill became famous for disclosing
that he helped one of his patients to die by providing the necessary drugs.
This happens in only one of the nine deaths discussed in this book.
Midwife Through the Dying Process
traces the diseases and terminal illnesses of nine people
personally known by Dr. Quill in Rochester, New York.
The patients' families were almost always involved in the dying process.
Terminal sedation is the closest Dr. Quill is now willing to go
toward helping patients to die.
But the book contains many useful insights into the dying process
as seen thru the eyes of the doctor.
Created December 28, 2003; revised
several times, including 5-29-2010; 8-30-2010; 2-8-2012: 2-29-2012;