Ending Life: Ethics and the Way We Die (Review)

By Laura Purdy, PhD, Wells College (Aurora, NY), Journal of American Medicine, Feb. 15, 2006

BOOK AND MEDIA REVIEWS

Pages 830-831 JAMA, February 15, 2006—Vol 295, No. 7 (Reprinted)
©2006 American Medical Association. All rights reserved.
Downloaded from www.jama.com at University of Pittsburgh, on February 15, 2006

Ending Life: Ethics and the Way We Die,
by Margaret Pabst Battin, 344 pp, paper, $24.95,
ISBN 0-19-514027-3, NewYork, NY, Oxford University Press, 2005.

Margaret P. Battin's new book Ending Life: Ethics and the Way We Die is a collection of her articles and stories, about half from the last 5 years, the rest dating mostly to the early 1990s, although the two pieces of fiction were written in 1981 and 1975. The majority are reprints, although some items (including the fiction) appear here for the first time. Arguments about physician-assisted suicide are at the core of the book, although it also addresses a fascinating array of related issues.

The first of three parts looks at dilemmas about dying and contains six pieces. Several are particularly interesting. One reports on contrasting attitudes and practices in the United States, the Netherlands, and Germany. The material on the Netherlands includes analysis and refutation of claims about rampant non-voluntary euthanasia. It also shows how US wariness about overt euthanasia has led to practices regarded by the Dutch as more morally problematic than their own acceptance of euthanasia, eg, routine second-party decisions that bring about early death. There are also thoughtful explorations of the difficulties inherent in decision making about whether to end one's life when the course of one's illness is uncertain and of the nature and extent of physicians' duties to help patients achieve an easy death. Along fictional account explores the vagaries of mutual decision making about when to end life.

The second part focuses on historical, religious, and cultural concerns. Three of the five articles stand out. The first is an exploration of what facts or choices might have led to the apparent coincidence that John Adams and Thomas Jefferson both died on July 4, 1826. Another raises the question of whether there could be legitimate disagreement about the morality of self-sacrifice or martyrdom (in the form of suicide bombing) based on cultural differences. Most interesting of all, from my perspective, is Battin's pioneering study of some of the more outre´ practices tolerated or promoted by certain religions that increase risk of disease, disability, or death. Some do so indirectly, by requiring the refusal of specific treatments like blood transfusions or of all health care. But others do so directly, by recommending strychnine or handling poisonous snakes. Battin is concerned about what she describes as "coercion, impairment of rational capacities, manipulation, callousness, and deception" (p 214). She concludes that when church members are actually seeking their own self interest—albeit under what she describes as "a special set of metaphysical assumptions"—church leaders must (as is the case with any fiduciary relationship) follow secular moral principles that safeguard members' welfare. Hence, in the vast majority of cases, churches are culpable for encouraging or coercing individuals to engage in practices with serious health risks.

The third part, "Dilemmas about Dying in a Global Future," is something of a grab bag. Only one issue considered is explicitly global, namely, whether there might be a duty to die created by worldwide inequities in life span. Battin's treatment helpfully dissects the erroneous assumptions underlying any such positive claim, while emphasizing the imperative to develop institutions responsible for achieving more equitable health conditions internationally. The rest of the articles speculate about the future: the consequences of having genetic information that indicates how long one might live; the consequences of greatly increased human life spans; the consequences of disseminating information about independently controlled methods of ending one's life; the benefits of so-called "oppositional collaboration" for helping to resolve some of the highly polarized debates in bioethics; and how cultural change might reframe current widely accepted assumptions about choosing to end life rather than waiting for disease to take its course. In the first two papers, Battin goes well beyond the concerns that seem always to get aired when such topics are discussed (Gattaca scenarios, manic visions, horrifying Struldbruggian images of interminable life). An underlying theme in the rest is her optimism about finding less adversarial approaches to questions about ending life. For example, she believes that New Technology Research Group (NuTech) methods controlled by individuals rather than medical professionals could provide a compromise position satisfying those at both extremes by providing for self-determination while avoiding the slippery slope of physician involvement. Likewise, she wonders whether our culture might evolve in the direction of seeing the decision to end life as a positive act rather than, as now, a last resort to escape hellish suffering. She sees this possibility arising in part from a shift in our attitude toward death itself, where "dying is no longer something that happens to you but something you do" (p 324).

Overall, these papers are thought provoking, careful, imaginative, and well argued. Because the author chose not to revise the reprinted pieces, there is some repetition. However, this does not detract from an otherwise excellent collection. It should be especially helpful for those who are not primarily focused on euthanasia and physician-assisted suicide but who want to stay abreast of the issues and arguments connected with them.

Laura Purdy, PhD, Wells College, Aurora, NY, lpurdy@wells.edu

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