Abstract
By Guenter Lewy. New York: Oxford University Press, 2011, 250 pages, $46.36.
In Assisted Death in Europe and America, Guenter Lewy, a political scientist, reviews the four most established regimens of euthanasia and assisted suicide. The book includes an introduction, chapters that discuss the approaches of the Netherlands, Belgium, Switzerland, and Oregon, and a final chapter entitled “Assisted Death as a Last Resort.” Interestingly, Lewy is not a health care professional but an historian, and provides a reliable fact-based analysis of how euthanasia and assisted suicide have evolved in different societies. The author wisely follows the advice of Johanes M. Van Delden, whom he quotes: “While facts will not settle a moral debate, one cannot do ethics properly unless one knows the facts correctly” (p. 17).
The introduction is an historical review of how the subject of assisted death has been faced throughout the ages. From the ancient Greek physicians' practice to current right-to-die organizations, it shows the strong polarization brought by this debate. It also discusses the so-called slippery slope, the main argument against assisted death, which states that any attempt to legalize assistance in dying could lead to the elimination of the infirm and disabled. The introduction also examines several studies showing the existence of an American euthanasia and assisted suicide practice with impressive numbers: it has been estimated that 70% of the approximately 1.7 million people who die in hospitals annually die as a result of someone's decision to withhold or withdraw life-sustaining medical interventions and, according to a 1993 study, 13.6% of all oncologists had performed either euthanasia or physician-assisted suicide (PAS).
The first experience analyzed is that of the Netherlands. The 2002 law decriminalizing euthanasia and PAS was the outcome of a unique process, having evolved from a series of court cases, starting in the 1970s. The chapter describes the most important cases and how the courts, public, and medical professionals reacted to them. Although a bit repetitive, the cases demonstrate the development of acceptance and rules for assisted death in the Netherlands. The chapter also explores some local empirical data. According to 1995 studies, 37% of requests for assisted death were granted. The shortening of life was less than 24 hours in 17% of the cases, and less than one week in 42%. Only 9% had a life expectancy of more than one month. In 2005, 1.7% of all deaths in the Netherlands were due to euthanasia.
The following chapter focuses on Belgium, where voluntary euthanasia has been allowed since 2001. The process of legalization in this country was started by right-to-die organizations in the 1980s and was brought to legality by the legislature. It was characterized by strong political polarization, and neither the organized medical community nor the courts had important roles on the discussion. Apart from the historical background, this chapter analyses two ideas that came up during this process: the possibility of advance directives for euthanasia and the “palliative filter.” The palliative filter was proposed by the Catholic organization Caritas Flanders, which strongly supported the idea that a prior palliative care consultation should be included as a requirement. The draft bill did not include this requirement, but a separate bill stressing the importance of palliative care was adopted unanimously.
The most controversial experience described is that of Switzerland. According to the country's criminal code, neither suicide nor assisted suicide has been illegal since 1937. Switzerland is home to right-to-die organizations, especially Exit and Dignitas. The chapter explores the history and development of these organizations. The author highlights the lack of transparency in their operation and management, as well as the lack of controls exercised by experts as the most important reasons for the controversy around them.
The last experience analyzed is that of the state of Oregon and its Death with Dignity Act, a citizens' initiative passed in November 1994 in the first jurisdiction in the United States to allow PAS. Oregon's structured data collection and annual reports provide the source for this chapter's more detailed information on patients' characteristics and motivations when choosing PAS.
In the final chapter, “Assisted Death as a Last Resort,” the author summarizes lessons and presents a 1996 model statute for PAS written by nine specialists in the fields of law, medicine, philosophy, and economics. This chapter explores the idea that euthanasia, assisted suicide, and palliative care may complement each other. The author also proposes that “the choice we face is not the choice between having no euthanasia and making it legal: rather it is a choice between driving it underground (with all the concerns about lack of transparency and medical professionalism) and making it visible” (p. 159). Following this line of thought, the author states that an imperfect system of control is better than no control at all. He also stresses that “any such regime should indeed be a work in progress, with its mode of operation carefully studied on a regular basis and revised as problems are detected” (p.160).