Reviewed by James Park,
existential philosopher and advocate of the right-to-die.
The following book is number 4 on the list of books opposing the right-to-die.
But this review got so big that it was put into this separate room.
The room for the rest of the books opposing the right-to-die is:
http://www.tc.umn.edu/~parkx032/B-RTD-NO.html

---

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 Oregon and Washington.
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 on the Right-to-Die:
http://www.tc.umn.edu/~parkx032/B-RTDIE.html.

    In the following presentation and response,
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 whether we have gone too far
in the direction of 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 the harmful deaths from the 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 simply follow the recommendations of their doctors,
even if they do not fully understand
their medical problems and the options available.
Thus if the doctors could legally recommend
a voluntary death or a merciful 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 they make recommendations that would be simpler for themselves.
Sometimes they want to get rid of difficult patients.
And rarely doctors do commit murder under the guise of 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 also include the option of a voluntary death or a merciful death
if the patient cannot be cured.

    Leon Kass argues against allowing anyone to choose a voluntary death
because of the spill-over effect this would have on less obvious cases.
In other words, once voluntary death and/or merciful death
become available, legal 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 a voluntary death or a merciful 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 choices of 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 the 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 people 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 their patients to die. 
Especially when patients do not know their doctors very well,
there is a serious 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
voluntary death or merciful death instead of continued medical treatment.

    There are valid worries about the proper role of doctors.
Some potential patients already have irrational fears of doctors and hospitals.
And if it became part of the doctor's standard role to recommend death,
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 do not want to confuse patients about what medical care includes.
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 called in
to help explore the various options at the end of life.
This would allow society to follow 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 disease or condition.
Ending all treatments would still be an option
that could be considered by ordinary doctors.
But even the option of discontinuing treatment
needs to be protected from mistakes and abuses.

    One of these files 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, there is no person remaining to benefit.

    This reviewer would suggest reframing this question another way:
We are not confronted with the question: to die or not to die?
What we face is 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 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.
These would be the ideal places for anyone
to express his or her wishes with respect to end-of-life medical care.
This reviewer's own choices are contained in his own Advance Directive,
which is linked from the above outline.)

    I think Leon Kass began to write this article
with the established principle that doctors must not kill.
Then he proceeded to defend it to the best of his ability.
In my opinion, he has not met the arguments
of those who favor allowing (at lease 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 the doctor 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 legal 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 and obvious cases seem similar enough.
Since we cannot draw the line against mercy-killing,
we must resist all attempts to legalize new forms of socially-approved death.

    This is the slippery-slope argument:
If we allow even a few wise voluntary deaths and a few wise 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 of the safeguards proposed
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 attempt to 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 people who can be balanced in their approach
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.

    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 a premature death
for fear of losing the right-to-die 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 decision should be made by the duly-authorized proxies,
who will take the settled values of the patient into account
as well as all of the medical facts and medical opinions 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 cyber-sermon on this subject:
"Do I Lose the Right to Die When I Lose Consciousness?"
http://www.tc.umn.edu/~parkx032/CY-CONSC.html

    Doctors are also human persons with their own moral beliefs and 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 agree to assist a patient in choosing death.
And Callahan is right to insist that doctors have a right to preserve this integrity.
But the autonomy of such doctors 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 claim their right-to-die to other doctors,
who have different moral standards and ethical beliefs.

    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 for all involved.

    This danger illustrates the need for safeguards
that require more than convincing one doctor that death is the wisest course.
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 such that they could be reviewed
in various public forums
—and approved or disapproved depending on the facts.

    The family of the patient should also be involved when possible.
The best way to do this is for the patient to appoint official proxies.
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.

    This reviewer agrees with Callahan
that we must be careful not to create a "culture of death".
If it becomes too easy and casual to choose death,
then there will be additional irrational suicides.
But if we have open safeguards privately considered
—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 US 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 all agree that there is 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 will result in an earlier 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 the 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 can be turned 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 raises doubts 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, there are few public procedures for making life-ending decisions.
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 declined beyond choosing one way or another.

    This reviewer does not see that as a serious problem
—since we should not be required to be conscious and capable to the last moment.
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 deprive patients with Alzheimer's disease
(or similar problems that render patients incapable of deciding)
of their right-to-die.

    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 are other persons to know the truth about 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 voluntary death or merciful 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 this reviewer believes that 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-guesing:
The committee might decide that the patient's suffering today
is not intense enough to justify a voluntary death.
Let the people most closely involved consider the present and future suffering
and all the other options that might become available.

    Hendin points out that consultation with a second physician in Holland
is often ignored or treated superficially.
When the first doctor is not planning to report the death as 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 really considering the patient.
Thus, the second opinion 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 see how best to 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 very serious problem in the Netherlands.
Now that the right-to-die is well accepted,
some doctors merely go ahead with their practice of helping patients to die peacefully.
But they skip the paperwork by means of which they are supposed to report this death.
Rather, they record the death (incorrectly) as having been 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 would any doctor be inclined to report a voluntary death to law-enforcement?
No crime has been committed. 
And the public prosecutor can do nothing to bring the patient back to life.
Since only bad consequences for the doctor could follow such a report,
we can all understand why doctors do not do the paperwork after death
if they can avoid it.

    I suggest that the paperwork should be submitted before death.
Then if there are going to be any mistakes or abuses,
they can be prevented by the authority to which the coming death was reported.
The Dutch system has now been reformed
so that reporting goes to a local committee
—before the death has been achieved.
This should improve the rate of correct and honest reporting of voluntary deaths.

    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
—when specified conditions occur.
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 voluntary death.

    In this reviewer's opinion, this is a fairly meaningless and useless safeguard.
Is there any adult in the Netherlands
who does not already know about the right-to-die?
How would such a safeguard be enforced?
Doctor-patient communications are private.
Who is going to report that the wrong person
brought up the subject of voluntary death?
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 not have been the wisest course of action.
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 a trial period in a nursing home
would have been a wiser course 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 all will know that 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 voluntary death as the best course of action.

    Perhaps more than one wise person should be consulted.
But this person should not be a public official,
who would always be under public and media pressure
to decide one way or another.
And these neutral third parties should be genuinely 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
were known to recommend only 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 agree that death is not the best option.
Millions of people have recovered from grief
and gone on to live meaningful lives.

    But can we think of situations of mental suffering
where that would be sufficient reason to choose to end life?
Herbert Hendin and others professionally involved in preventing irrational suicides
would probably say that all mental reasons for choosing death are invalid.
Such a presupposition would lead to principles requiring physical suffering
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 not become involved
in deciding which reasons are valid enough.

    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 be able to 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 a choice 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 other family members,
safeguards should insure that the choice for death
is not only a wise choice given all the circumstances
but that it is a free choice by the patient who wants to die.

    Of course, 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 AIDS to take him.
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 he was not sick and dying at the time 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 should protect people
from their own 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 they 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
that should have been treated instead of granting their wish to die.
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 "Four Differences between Irrational Suicide and Voluntary Death":
http://www.tc.umn.edu/~parkx032/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 rational reasons for choosing death from the irrational 'reasons'.
The psychological professional could help separate
the choices which are genuinely helpful to the patient
from the choices which clearly are harmful to the patient.

    The purpose of the psychological examinations
should not be merely to 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 depressed victim of HIV
from choosing a premature death.
The psychological helper could help the patient to reframe the situation,
perhaps showing that death later would be a better choice than death now.

    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 irrational suicides 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 public awareness of the right-to-die movement.

    One small step might be the official recording of the deaths.
New laws could specify which deaths will be recorded as 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 of the right-to-die
will completely reject the concept of voluntary death.)

    Full honesty and openness about the real cause of death
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 voluntary deaths.
Full and honest reporting would record the underlying disease or condition
along with the fact that the patient chose a voluntary end to his or her life.

    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.
What was not included in any published reports
will always be open to speculation.

    This reviewer does not suggest making every case-file a public document.
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 how each safeguard has been fulfilled.
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 records should not be open to public scrutiny.
(That would only invite critics of the right-to-die
to examine each medical file for possible mistakes.)
But the private medical 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 reason to BAN all voluntary deaths and merciful deaths.
But this reviewer believes such would 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 insure 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 small group of 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 it is clear that the patient cannot benefit from hospice care,
then this safeguard could be skipped.
And the reasons for skipping this safeguard
can be briefly 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 will be easily pushed toward the option of death.
Hendin notes that hospice care is not widely available in the Netherlands.
Could this be because voluntary death and merciful death are 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 because of the lack of good alternatives.

    Also, I think we will 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 the Netherlands,
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 people will choose a few months of hospice care.
And more people will choose a voluntary death or a merciful death.
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.
Usually 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 made to feel that they were a burden on their families?
Were some complex interpersonal dynamics distorting the decision-making 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 not working very well
—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 disabled persons would be good proxies,
who understand the special circumstances of being disabled.
Disabled persons could select as their proxies
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 dislikes any talk about separated 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 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.

    Disabled 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 will soon 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 to 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 people to die
will harm groups of people who are not well-prepared to 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
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 do not yet know
what we as a 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 these criticisms
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.

---

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    As noted at the beginning of this file,
this review is just one of several reviews of books opposing the right-to-die.
The rest of the reviews are found here:
http://www.tc.umn.edu/~parkx032/B-RTD-NO.html

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    See related bibliographies:

Best Books on the Right-to-Die

Best Books on Voluntary Death


Best Books on Preparing for Death

Books on Terminal Care

Books on Helping People to Die

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Go to the Book Review Index
to discover 400 other reviews
organized into more than 40 bibliographies.

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