Death and Dignity: Making Choices and Taking Chargeby Timothy Quill Book review by Brian Jackle
In spite of its rather innocuous title, Death and Dignity is a revolutionary book dealing courageously with one of the most controversial, heart-wrenching medical issues facing us today, physician-assisted suicide, as manifested by the defeat of Proposition 173 in 1992 by California voters. Dr. Quill begins his book with a reprint of his famous 1991 New England Journal of Medicine article in which he described publicly the case of "Diane" who contract-ed a nearly-always fatal type of leukemia. She requested and received from Quill a prescription for barbiturates so that she could end her life before becoming totally dependent and debil-itated. For his public revelation, criminal charges were brought against him (the most serious being manslaughter) which could have led to a 15-year jail sentence, but were dismissed by a grand jury. What makes this book so powerful and convincing is that Quill is no dry academic medical ethicist developing an argument in support of assisted suicide. This doctor is speaking out of his own agonizing experiences with patients, and the clinical criteria he proposes emerge out of these frontline experiences. Quill lauds the two main directives of the Hippocratic oath: to prolong the lives of patients and to minimize their suffering. Quill's main thesis is that when one is treating a dying patient, minimizing suffering must take precedence over life extension, even though this contradicts traditional medical training and practice. Substituting the term "comfort care" for "hospice," Quill writes, "Comfort care puts a higher value on relieving symptoms, human contact, and care of the person than on treatment of the underlying disease or medical intervention. Comfort care focus-es its energy more on the patient's quality of life, personal meaning, and symptom al-leviation (lessening suffering) than on prolonging life or treating disease." Legally, doctors are not allowed to facilitate death intentionally, even if death is the only way to relieve a patient's overwhelming suffering. Physicians may withhold or withdraw life-sustaining medical treatment such as respirators at the patient's request (this is called "passive euthanasia") or use the "double effect" by prescribing increasing amounts of narcotic medicine which alleviate pain but also "unintentionally" shorten a patient's life. Quill makes clear that a huge majority of terminally ill patients are treatable with comfort care, though as much as 10% of incurably ill patients suffer tremendously in spite of physicians' attempts to provide comfort through pain medication. It is this group that primarily interests Quill. Physician-assisted death includes both physician-assisted suicide (in which the patient commits the final act by him/herself) and voluntary active euthanasia (in which the doctor is the direct agent of death). Although this distinction is critical for medicine (in the first case it allegedly remains "untainted"), Quill reminds us that such distinctions can become more illusory than real: "Why is it considered ethical to die of 'natural causes' after a long heroic fight against illness filled with 'unnatural' life in prolonging medical interventions and unethical to allow patients to take charge at the end of a long illness and choose to die painlessly and quickly?" Quill supports the legalization of physician-assisted suicide, but not voluntary active euthanasia, because the physician's power over the patient is enormously increased as in the risk of error, coercion or abuse, even though incurably ill patients unable to swallow pills or to move, under these criteria, could not be helped to die by assisted suicide. Quill's guidelines have many safeguards built into them, and overall his approach is conservative compared with Dr. Jack Kervorkian and his suicide machine or Derek Humphry and his Final Exit. Quill is quite critical of both of them. Quill shows us through some disturbing clinical examples that sometimes death is the only escape from intolerable suffering. Quill argues that enhancing patient choice and control is the most convincing reason to support assisted suicide, while other consequences of the current system such as uncontrolled suffering, increased dependence on physicians' values (rather than the patients'), secretive behavior on the part of the doctor, and patients abandoned to die alone (so as not to incur the wrath of the legal system), also argue for a change in policy. Throughout the book, Quill provides compelling case histories of his own patients (some with AIDS) and those from medical literature to reinforce his ideas. Finally, Quill strongly urges patients to sign both living wills and health care proxies (comprehensive sample forms for both are given in the appendix) to avoid, in advance of acute illness, the pitiful agony of unwanted prolongation of suffering. Paradoxically, having a living will and a health proxy outlining one's medical philosophy about end-of- life treatment might free a dying person to live more fully in the final months, as one will not be haunted by the fear that one will linger in a dependent, debilitated state prior to death. Quill attempts to balance a reverence for life with the belief that death should come with dignity, peace and without losing control and independence, the lack of which is more frightening to many patients than even physical pain itself. This book should be required reading for persons with AIDS (PWAs), their caregivers, family members and medical staff. Although Quill does not acknowledge the fact, AIDS has brought many of these suicide/euthanasia issues to the forefront of the medical community. Unquestionably, this book provides the most persuasive and meticulously reasoned arguments in favor of assisted suicide. However, Quill could have bolstered his theses even more forcefully in two ways. First, there is almost no discussion on the moral and religious arguments against assisted suicide and how one might counter these often compelling attacks. Secondly, Quill does not say why medicine refuses to acknowledge its limitations or why it sees death as both an enemy and a failure. Nor does he consider how being a death-denying culture or a technology- addicted society influences our attitudes toward euthanasia. These historical and sociological questions would not nullify Quill's case but would shed light on how to deal with the thorny moral and ethical issues this topic poses. Quill writes movingly that "going gently into that good night with one's dignity and sense of self intact is certainly as morally acceptable as raging against the dying of the light." After reading his book, it will be hard for any reader not to see both the logic and the compassion behind the statement. We can only be thankful for Quill's bravery in bringing this painful subject to public awareness so the debate on its merits can finally begin! Death and Dignity: Making Choices and Taking Charge by Timothy E. Quill. W.W. Norton & Company, New York. ©1993, 255 pages, $21.95. Reprinted with permission from San Francisco Sentinel, January 12, 1994.
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