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Human Life in the Balance.

The latest book by Glenn Graber and David Thomasma urges us to understand as "euthanasia' settings where anymore is killed by intent or passive acquiescence. In his own book, Human Life in the Balance, Thomasma argues that we should defend the sanctity of life, and its associated values and ideals, against a similar broad range of assaults in modern society, especially against "technology."

Euthanasia: Toward an Ethical Social Policy argues that much of the demand today for mercy-killing by physicians could be obviated by more use of hospices and better relief of pain:

At this time, there is little need for active euthanasia if more attention is paid to controlling pain and suffering, if more attention is paid to the patient's value system, if much firmer responses are made to patient requests to die, and if plans are made with the patient and family about the best way to bring about a kind and merciful death. (p. 201)

This point is well made. Nevertheless, one wonders about the obvious objection: what happens when the system doesn't work as it should? What happens when a physician refuses referral to a hospice, when a hospice doesn't provide proper relief of pain, or when a hospice won't take an uninsured patient? Why do thousands join the Hemlock Society? What about the case of "Diane," written about so eloquently by her physician, Timothy E. Quill? What does a cancerous patient do when she is too weak and feeble to assert herself?

On a different point, this book is confusing as to exactly what it means by euthanasia. It begins by quoting a definition of euthanasia as "the art of painlessly putting to death persons suffering from incurable conditions or diseases" (p. 2). A bit later, the book discusses the "range of euthanasia" and suggests that Gary Gilmore's capital punishment is a form of euthanasia (p. 4). Included under "the range of euthanasia" are: extraction of some fetuses when drug-induced superovulation creates too many (such that some fetuses must die so others can live); the Baby Gabrielle case (Canadian anencephalic whose heart was transplanted to another baby in Loma Linda Hospital); transferring terminal patients to hospices to die; and finally:

Social Euthanasia. Over 37 million people in the United States cannot gain access to health care because they are uninsured or underinsured. If we continue each day to ignore this problem, are we not just practicing a form of social euthanasia of the passive sort? (p. 10)

So this book is confusing as to its subject and scope. To many in medical ethics, euthanasia connotes (1) bringing about a death for (2) someone else who (3) has a terminal disease. Often, such a person is incompetent or only semicompetent. The book would have been improved by a clear, unwavering use of the word euthanasia. Perhaps the authors wish to deny that such a usage exists. If so, an argument is needed.

The general approach of this book might be described as balancing principles. Cases are described, some principles are invoked, and conclusions are drawn. But, where real cases don't neatly fit principles (as few do), the principles invoked seem ad hoc.

The seven chapters cover the Range of Euthanasia, Justified and Unjustified Euthanasia, Unwilling and/or Active Euthanasia, the Family's Perspective, Euthanasia and the Medical Community, Euthanasia and Society, and Treatment of Suffering. The chapters are followed by nearly a hundred pages of cases.

This reviewer often found it hard to read the text and follow the argument. The authors endorse assisted suicide, even where the patient is capable of carrying out her own death, as in the case of Elizabeth Bouvia. They say that the patient "is transferring his right to life" to the agent by his request. This neutralizes the general prohibition against taking another person's life. The expression "transferring his right to life" is a bit odd. Life doesn't seem to be the sort of thing that is transferable in this way.

Sometimes, one feels the real problems have not been faced. After advocating use of ethics committees to resolve conflicts about euthanasia within the medical community, the authors state:

All that is required is that, in working through the decision, the participants, the health providers, and in most cases, the family, work through each step so that they can more clearly ascertain exactly where they might disagree, if at all. (p. 150)

Is it really so easy to solve these conflicts? It's hard to think that "more rigorous thinking" is the panacea.

At the end of their book, when attacking medicine's dependence on technology and its temptation to look for a quick fix in mercy-killing, the authors also seem to duck the real problem in concluding: "The proper care of the dying requires a kind of loving community [sic] our society finds so elusive" (p. 201). True, but is it not also a bit naive? Perhaps many of the problems surrounding dying AIDS patients in the Bronx could be solved if hospitals and staff there were a more "loving community," but given limited resources and finite moral capacity, what do we do in the meantime while waiting for that community to evolve?

This book also has one methodological glitch. During the discussion on many pages, it directs the reader in the text to some of the cases described at its end. Although these cases are interesting to read, it is difficult to then turn back to the original page and connect the case to the point on the page. It is also difficult not to read the text without referring to the cases lest something of importance be missed. Some places in the book need better editing, although the lapses are funny: "Can persons donate organs even if they are not brain-dead at the time of harvesting?" (p. 7).

Thomasma's Human Life in the Balance is intended as a work of medical ethics and written as a defense of the "Christian vision of life" (p. 16). In discussing "our religious heritage from the Old Testament," it concludes that in Scripture, "respect is shown to the gods of foreigners, especially place gods, by honoring them as one honored the people whom the god represented" (p. 10). Thomasma wants to show that the equal, sacred value of each human life embodies the Judeo-Christian heritage. Is this claim really true? In Genesis and Exodus, Yahweh often does not respect gods of foreigners, nor the people who worship such gods. Chapter 20 of Exodus describes how Moses received the Ten Commandments (including "Thou shalt not commit unjust killings"), but 33:2 describes how Yahweh directs the Hebrews to kill the Hittites, Amorites, and Jebusites in the adjacent land. In Exodus, killing the enemies of the Hebrews is not only not banned but indeed required by Yahweh. Similarly, in a much later period of the Bible, Elijah has his followers kill hundreds of Baal's defeated prophets. Little "respect" for these.

Indeed, it seems difficult to argue that the Old Testament attests to belief in the sacred value of each human life--or for that matter, that Christians did either for 95 percent of their history. The irrefutable example of this is slavery, which Jews and Christians practiced for millennia and which is clearly condoned in Scriptures (Exodus 21:2-3, 31:7-8).

Thomasma's book implies that Christians have always been antiabortion (true) from the time of conception of the embryo (false). This is a half-truth. The belief that personhood and the right to life began at conception in Catholicism became popular only as recently as 1870, when Pope Pius XI declared himself and future popes to be infallible when speaking ex cathedra, and then declared that sanctity of life began at conception.

In Thomasma's book there is too much slang, careless writing, and ad hominem rhetoric: "ABORTION - The same forces of hatred, greed, destruction, laziness, and selfishness occur in the less global sphere of care for defective newborns and some of the other human life issues I will now discuss" (p. 155). The book lacks clarity about moral issues concerning procreation. While lamenting the 1.5 million "babies" aborted each year, the book also laments the skyrocketing numbers of babies born out of wedlock to teenagers (p. 155). Thomasma seems to think that a society which "encourages abortions" is somehow encouraging the increase of out-of-wedlock pregnancies. Yet a majority of teenage mothers claim they carried their babies to term in part because they are against abortion.

Most of Thomasma's book intends to develop a "new ethic" for dealing with "Technology." This "new ethic" is a "pro-life" view with "Technology" as the enemy. There is a confusion here that is seem in the works of many who write about "technology and values." It is almost impossible to use a vague word such as technology in discussions of values and morality and to mean anything definite. Empiricists such as David Hume taught us that when such words are commonly used, a particular image often stands for the general concept. In this book and the popular mind, one gets the impression that the image for "Technology" is Karen Quinlan on a respirator or Barney Clark in the grip of his Jarvik-7-driven air compressor.

It needs to be stressed here that thousands of things count as "technology," including hydrocortisone cream, nail clippers, specially reinforced Nike jogging shoes, Rolodexes, instamatic cameras, desktop publishing, motels with cable television, AZT for HIV infection, automated banking cards, formica counters, acid-free paper, community access cable programming, video cassettes of Field of Dreams, mail order pet products, UPS next-day delivery, reliable phone service, and electronic keyboards. Considering all these things, it is misleading to write that "we no longer design technology to serve the fundamental needs and aspirations of persons." Just who generates the demand for these things and services? Who buys them?

Second, to talk about "Technology" as the monolithic enemy seems confused on another level. What makes a certain piece of technology good, bad, or neither, is the result of human decisions in certain social contexts. Respirators are not inherently dehumanizing in medicine; rather, it is the American practice of putting patients on such respirators and never taking them off that is dehumanizing. Once we realize the huge range of things included under "technology," and the importance therein of human decisions, it is easy to see that most of the "technological" things included in the above list are neither "dehumanizing" nor lacking in human control. Indeed, as Thomasma and Graber correctly recommend, better pain management in hospices is a "technology" in need of more attention.

Also, one wonders if the tone and thesis of Thomasma's own book doesn't undercut his thesis in his coauthored book. Suppose a Christian physician agrees with Thomasma that the sanctity of life should be upheld and that physicians should never commit active euthanasia. Suppose he agrees with their usage of euthanasia as including any decision that hastens death. If so, wouldn't such a physician oppose adequate pain relief on grounds that to do so actively promotes death? Both books seem hastily written, and lacking in careful thought. Both alternate between slang and too-vague discussions of medical ethics. Both attempt to cover vast territories, but both get nowhere definite. Other than the point about better relief of suffering reducing the need for active euthanasia, little else of substance occurs in the jointly authored book on euthanasia. As for the second book, Professor Thomasma is obviously deeply and passionately committed to an ethics that respects life and passionately against dehumanizing medical technology, but it is difficult to understand what else he is for or against, and especially, why. In general, both books tend to assume arguments just where they need them.

Gregory Pence is professor, department of philosophy and School of Medicine, University of Alabama, Birmingham.
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Author:Pence, Gregory
Publication:The Hastings Center Report
Article Type:Book Review
Date:May 1, 1991
Words:1963
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