Death and Dignity: Making Choices and Taking Charge.

Timothy Quill is the sort of competent, compassionate physician one would hope to find for oneself. Besides having a private practice in upstate New York, Quill teaches at the University of Rochester School of Medicine and Dentistry and occasionally contributes to the prestigious New England Journal of Medicine. As the former director of a hospice program, he seems to combine a commendable measure of medical expertise with a compassionate bedside manner. Why then is he someone to be uneasy about? His book gives the answers.

Death and Dignity begins with a reprint of Quill's 1991 NEJM article, "Death and Dignity: A Case of Individualized Decision Making." In that piece, Quill told the story of "Diane," a middle-aged, longtime patient of his who suddenly developed acute myelomonocytic leukemia, a rampant, painful, and terminal condition. At her request, Quill provided Diane with the know-how and the means to take her own life, should she decide she could no longer continue to live as she desired. Eventually, Diane did take her life, overdosing on barbiturates.

Quill's NEJM piece was an attempt to explain his actions and to legitimate them before the medical profession. Although he was not physically present at Diane's suicide, a la Michigan's Dr. Jack Kevorkian from whom Quill is at pains to distinguish and distance himself in the book the publication of Quill's article led to his eventual investigation by the New York State Health Department and by a grand jury. (In reporting Diane's cause of death, Quill had not indicated it was from an overdose.) Neither of these investigations led to actual charges being filed, however, and Quill remains in good standing. (Unlike Kevorkian, Quill seems to be highly regarded by his peers.) With the publication of his book, he is likely to become a sought-after guest on the talk-show circuit as well.

The case of Diane was formative for Quill and serves as the leitmotif of Death and Dignity. While Quill states that tough cases do not make good law, the thrust of the book is clearly the opposite. Quill's aim is to translate his experience with Diane into a model for legalizing physician-assisted suicide. He begins by claiming that cases such as Diane's are not the exception but the rule.

In the course of the book, Quill consistently argues from the particular--and the painful--to the general, with an eye on formulating public policy. He not only wishes to relieve the individual dying patient from a prolonged and agonizing death, but to free society from what are now its most conflicted and anguishing questions about the end of life. Unlike Kevorkian, however, Quill projects no Strangelovean image. He seems eminently reasonable and reassuring--up to a point. He writes, for example, that "physicianassisted suicide should never be contemplated as a substitute for comprehensive comfort care" (his term for pain management for dying patients). But a few pages later he shifts smoothly to different terrain, arguing that physician-assisted suicide should be considered "part of a continuum of comfort care options...." Seldom has the slippery slope been negotiated so adeptly.

Quill never attempts a full-scaled moral or theoretical argument for the legalization of physician-assisted suicide, never questions whether human life has value other than what we ourselves decide to give it. Instead, he relies on vignettes and the recollection of hard deaths he has witnessed to ease the reader toward his desired end. For Quill, as for the medical profession in general, the role of the physician is to be a provider: to facilitate, to heal, to enable, but never simply to stand by. If at the end of life the patient has had enough of anguish, pain, or despair, the role of the physician ought to be that of an agent who, in Quill's terms, helps the patient "over the edge into death." Rather than "abandoning" (a word that appears often in the book) the patient at the final stage, Quill argues, the doctor ought to facilitate as smooth an end as possible. (I am reminded of a semicomic character in the Audrey Hepburn film, Two for the Road. This fastidious American tourist keeps turning up on Hepburn's European holidays, making sure that everything is sprayed with Lysol and looks as neat as Disneyland.) The appeal and the danger in Quill's book is its combination of this blessed rage for order and tailored endings and his application of just-the-right-dose of "compassion." Death and Dignity is a strictly utilitarian argument driven by sentiment.

In a society that sees little earthly reason for enduring physical (or mental) suffering, and which fears "the loss of control" over one's life as a fate worse than death, Quill's radical medicine will go down relatively easily. The book's subtitle, "Making Choices and Taking Charge," combines two powerful political lodestars. In the United States, if you can't make your own choices and can't control your own destiny, you have, in effect, lost much of the impetus for living. A doctor who is steeped in this culture and who has already run out of technological fixes, will see little reason to persuade a patient to fight on longer. Thus, Quill says, "allowing someone a peaceful, dignified death can be a very sad, loving gift." ("Allowing" death, however, is something decidedly different from actively facilitating it, which is what Quill is proposing.)

Quill's language is consistently beguiling and misleading. "When I arrived at their house," he writes, "Diane indeed seemed peaceful." In fact, she was dead-- from the overdose he had provided. He states that Diane "taught me about the range of help" he could provide patients in similar circumstances. "Range of help" may be a Hallmarkean improvement on the term "physician-assisted suicide," but at least the latter is not misleading. (Quill's other euphemisms for physician-assisted suicide include "a controlled death" and a "nonviolent death.") Facilitating such timely and compassionate deaths, he says, ought to be considered "a fundamentally vital role for physicians." By turning even the word "vital" on its head, Quill has effectively delegated physicians as the final arbiters of power and control. It is a prerogative too many already feel is theirs.

As mentioned before, Quill stakes out his main premise early on: "Untreatable suffering prior to death is unfortunately not rare." But is this actually the case, and if it is, does it need to be? Quill provides no statistics, offers no surveys of hospitals, hospices, or nursing homes. Instead, he relies on anecdotes, mostly from his own practice. I asked a nursing supervisor who has worked with terminally ill cancer patients full-time over the last fifteen years what her experience had been. She told me that when it came to untreatable pain, she had run into such instances about once every five years. If that is the case, Quill's argument hardly amounts to a persuasive reason to legalize euthanasia-on-demand. What dissuades most of this nurse's patients from calling for a final, magic bullet? "Compassionate care makes them feel valued," she says. Compassionate care, for her, necessarily implies and includes skilled pain management.

A recent Catholic Health Association publication, "Care of the Dying: A Catholic Perspective" (The Catholic Health Association, Saint Louis), does provide some disheartening figures, ones Quill might have liked to quote. The study says that nearly 25 percent of cancer patients "die with severe, unrelieved pain." But the study then examines the reasons for this sad statistic--including doctors' lack of pain-management skills--and offers a wide range of practical policies and medical modalities that would dramatically lower it.

Instead of the patience and dedication such a course of treatment--already available-relies on, Drs. Quill and Kevorkian want to force the hand of death, to speed up its house calls. Death probably won't object, but care-givers ought to know and do better. When death comes before its time, some of life's best and most important moments are lost. When that happens, we and our loved ones are all diminished.