New England Journal of Medicine

May 2, 1996 Volume 334, Number 18    

   BOOK REVIEW

 A CHOSEN DEATH: THE DYING CONFRONT ASSISTED SUICIDE

by Lonny Shavelson, 240pp, New York, Simon & Schuster

1995 $23 

     The personality and varied talents of the author -- as journalist, photographer, and emergency room physician -- are evident in this remarkable book, which presents moving and thought-provoking accounts of assisted death and the decisions faced by five people.  These detailed stories of the ending of life, in which the author plays the parts of witness, confidant, and participant, show the complexity and moral ambiguity of assisted death.

     Shavelson's book challenges the simplistic thinking characteristic of much of the debate on this subject.  On the one hand, the claim that those who resort to this option are taking the easy way out, seeking death without enduring terminal suffering, is belied by the stories of Renee and Mary.  Both suffer from cancer, pursue and endure repeated aggressive efforts at cure or remission, including experimental therapy, and opt for assisted suicide by ingesting a lethal dose of medication only when they view lingering to the bitter end as intolerable.  On the other hand, those who advocate assisted death as the right of self-determining adults should be given pause by the story aptly titled "Freelance Euthanasia."  Gene, a mildly disabled retired cook, lonely and depressed, requests information from the local chapter of the Hemlock Society.  Sarah, the chapter president, responds by aiding Gene's suicide, procuring medication and applying a plastic bag.

     The notion that patient-initiated assisted suicide is superior to doctor-initiated active euthanasia is challenged by Shavelson's documentation of the difficulty dying patients have in accomplishing the former.  After an overdose of liquid morphine, Renee lapses into unconsciousness but continues to breathe for nearly 12 hours, before a friend completes the deed by placing a plastic bag over her head.  Mary, near death in a cancer ward, manages a final act of will to repress vomiting after swallowing an overdose of barbiturates.  If physician-assisted death ought to be permitted subject to adequate safeguards, then voluntary euthanasia by a physician giving a lethal injection in response to a patient's well-considered request -- the preferred means in the Netherlands -- may be better.

      Shavelson's narratives make clear that there are no hard and fast rules stating when assisted death is appropriate.  In some instances a request for it is irrational or premature; in others the request makes sense in view of the dire situation and the lack of reasonable alternatives.  Assisted death is not a solo act, but a fateful transaction between persons.  A critical element in the negotiations surrounding it is a careful assessment of the person's condition, his or her relationships with family and friends, and the available options.

     In the final chapter, "Hospice and Hemlock: A Plan," the author departs from the narrative style to advocate a policy for physician-assisted death that combines the hospice and Hemlock Society approaches.  The hospice movement to date has subscribed to the maxim of neither prolonging not hastening death.  Its partisans have contended vocally that this mode of palliative care obviates the need for physician-assisted death.  Shavelson supports hospice; the story of Pierre, a trapeze artist who died of AIDS, shows how competent hospice care can help people have a good death in the face of great suffering.  However, after witnessing the deaths described in the book and interviewing hospice clinicians, Shavelson argues that hospice care does not always ensure a good death.  All dying patients should have access to such care, and physician‑assisted death should be made available only as a last resort.  The final chapter is more a sketch than a fully developed plan, still needing the eligibility criteria for assisted death and procedural safeguards to be fleshed out, but it offers a promising framework for an ethically justifiable policy. 

     Conspicuously absent from A CHOSEN DEATH is a detailed examination of the role of physicians in negotiating and participating in assisted death.  Perhaps in the future Shavelson will devote his considerable talents to disclosing the ways physicians caring for dying patients have confronted this deeply controversial issue. 

     Franklin G. Miller, Ph.D.

     University of Virginia

     School of Medicine

     Charlottesville, VA 22908