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The end of life: Euthanasia and morality
Soc. Sci..tied. VoL 24, No. I, pp. 95--96. 1987 Pergamon Journals Ltd. Printed in Great Britain
BOOK REVIEWS The End of Life: Euthanasia and Morality, by JAMES RACHELS. Oxford University Press, Oxford, 1986. 204 pp. £12.95 Hardback, £3.95 Paperback
"Non est vivere, sed valere vita est." ("Life is not to live but to be alive.") Thus the epigrammatic Martial two millenia ago on the quality-of-life theme that dominates Rachels' book. But the arguments adduced by the author are not easily reduced to epigram, however felicitous. James Rachels, professor of philosophy at the University of Alabama, first drew the attention of those concerned with medical ethics when his paper, "Active and passive euthanasia," appeared in the New England Journal o f Medicine (9 January 1975). In it he questioned, and rejected, the validity of the traditional distinction between death directly procured ("active euthanasia") and that merely permitted ("passive euthanasia"). His present book is largely an expansion of the views he articulated a decade earlier. Rachels opens, fittingly, with a helpful historical overview that synopsizes the evolution of Western thought on killing in general and euthanasia in particular. In Chapter 2 he discusses "The Sanctity of Life" both in the Eastern tradition, which accords reverence to all life (even invertebrate and plant), and in the Western, which concerns itself almost totally with human life. Rachels does not accept the absolute premium on life qua life, which he imputes to both traditions, and instead makes the nice distinction between living and having a life, between biological and biographical life. Sanctity of life arguments, he maintains, apply only to beings (human or otherwise), possessed of biographical life. In "Death and Evil" (Chapter 3) the author raises a fundamental query--"Why is it wrong to kill people?"--and contends that death is an evil precisely and only insofar as it eliminates the potential that inheres in a given biographical (vice biological) life. And "innocence", he maintains, is an issue that is irrelevant to the morality of killing (Chapter 4). Also irrelevant, in Rachels' eyes, is the traditional distinction between ordinary and extraordinary means of preserving life (Chapter 6) and between killing and letting die (Chapter 7). The book concludes with additional comments on the morality of euthanasia (Chapter 9) and describes efforts to legalize it (Chapter I0). Prominent in most discussions about legalizing euthanasia, Rachels notes, is the slippery-slope argument, which holds that to yield now on a small point of principle often leads to further compromise and eventual removal of all restraints. The Nazi experience is frequently cited as the paradigm of this tendency. Rachels is at pains to dissociate Nazi "euthanasia"--a euphemism for genocide---from the beneficent euthansia that he advocates. In the process he manages to treat the late Leo Alexander in a way that can only be described as cavalier. "Soon after the (Nuremberg) trial.., it occurred to an American doctor named Leo Alexander that the Nazi atrocities might be used to discredit proposals for euthanasia." The picture this conveys is that of an anti-euthanasia, ultra-conservative zealot seizing on Nazi horrors to promote his own partisan view. In point of fact, Leo Alexander was an active-duty officer in the United States Army, consultant in psychiatry to the Secretary of War, assigned to the Office of the Chief of Counsel for War Crimes in Nuremberg, and himself a participant in the proceedings. As a physician he could not fail to observe that small attitudinal changes in the professional ethic of preHitler German physicians had progressed to the quantum immorality laid bare at Nuremberg. Binding and Hoche, 95
after all, had published their treatise on "life devoid of meaning" in 1920, well before Nazism had come of age. Slippery-slope or not, Alexander's monition to the medical community still seems valid today. This demurrer aside. Rachels' book is a useful addition to the literature on euthanasia. By asking the hard questions he challenges conventional attitudes toward his topic and, whether or not he manages to convince, at least forces a healthy re-thinking of this troubling and recurrent issue. Thoracic Surgery Service Newton- Wellesley Hospital Newton Lower Falls, Mass., U.S.A.
EUGENE G. LAFORET
Social Controls and the Medical Profession, edited by JUDI~ P. SWAZEYand STEPHEN R. SCmZR. Oelgeschlager Gunn & Hain, 1985. vi + 268 pp. $27.50. In 1973, the American Medical Association officially recognized that as many as 10% of U.S. physicians might be professionally 'impaired' by drug addiction, alcoholism, or emotional disorders. Local hospitals, state medical societies, and state boards of medicine have tried, in various ways, to tackle the problem. Social Controls and the Medical Profession is a collection of papers that explores the nature of extant social controls in and of medicine and that raises interesting questions about how the public and the profession ought to think about the problem that is variously called 'impairment,' 'disability,' or 'sickness' among physicians. This book is the product of the Project on Social Controls and the Medical Profession, a two-year, interdisciplinary effort whose "goals were to explore and begin to define the range of social controls affecting medical practice, to begin assessing how the controls interact, and to consider how the presence or absence of these controls affects physicians, their patients, and the practice of medicine in American society more generally" (!o. 2). The faculty of the project included physicians, sociologists, lawyers, philosophers, and clergy, and all have contributed to this volume. The first section of the book contains five papers providing "Comparative Perspectives on Professions and Their Governance." The first two give overviews of the ways philosophy and sociology, respectively, think about the issue of social controls in professions. Following these are a very good discussion of the socialization of law students, a paper on impairment in the clergy that discusses changes in notions of 'impairment' that resulted from changing notions of clerical responsibility over the past several decades and that offers a 'spiritual model' for assessing clerical competence, and finally, a paper on social controls among scientists. A cross-professional view of competence and impairment is an odd way to begin a book about medicine, but this section will be of use to readers unfamiliar with the sociological concept of 'social control." The second section of the book contains papers specifically about medicine. Several of the articles are of the how-to-be-a-good-doctor variety. The best of these is by Michael Parmer, a practicing surgeon. Instead of writing a strongly normative piece, Parmer spends a lot of time describing what it is like to be a solo practitioner in medicine today. An admittedly exploratory project of this sort ought, in my view, to be more descriptive than judgmental or nor-
BOOK REVIEWS The End of Life: Euthanasia and Morality, by JAMES RACHELS. Oxford University Press, Oxford, 1986. 204 pp. £12.95 Hardback, £3.95 Paperback
"Non est vivere, sed valere vita est." ("Life is not to live but to be alive.") Thus the epigrammatic Martial two millenia ago on the quality-of-life theme that dominates Rachels' book. But the arguments adduced by the author are not easily reduced to epigram, however felicitous. James Rachels, professor of philosophy at the University of Alabama, first drew the attention of those concerned with medical ethics when his paper, "Active and passive euthanasia," appeared in the New England Journal o f Medicine (9 January 1975). In it he questioned, and rejected, the validity of the traditional distinction between death directly procured ("active euthanasia") and that merely permitted ("passive euthanasia"). His present book is largely an expansion of the views he articulated a decade earlier. Rachels opens, fittingly, with a helpful historical overview that synopsizes the evolution of Western thought on killing in general and euthanasia in particular. In Chapter 2 he discusses "The Sanctity of Life" both in the Eastern tradition, which accords reverence to all life (even invertebrate and plant), and in the Western, which concerns itself almost totally with human life. Rachels does not accept the absolute premium on life qua life, which he imputes to both traditions, and instead makes the nice distinction between living and having a life, between biological and biographical life. Sanctity of life arguments, he maintains, apply only to beings (human or otherwise), possessed of biographical life. In "Death and Evil" (Chapter 3) the author raises a fundamental query--"Why is it wrong to kill people?"--and contends that death is an evil precisely and only insofar as it eliminates the potential that inheres in a given biographical (vice biological) life. And "innocence", he maintains, is an issue that is irrelevant to the morality of killing (Chapter 4). Also irrelevant, in Rachels' eyes, is the traditional distinction between ordinary and extraordinary means of preserving life (Chapter 6) and between killing and letting die (Chapter 7). The book concludes with additional comments on the morality of euthanasia (Chapter 9) and describes efforts to legalize it (Chapter I0). Prominent in most discussions about legalizing euthanasia, Rachels notes, is the slippery-slope argument, which holds that to yield now on a small point of principle often leads to further compromise and eventual removal of all restraints. The Nazi experience is frequently cited as the paradigm of this tendency. Rachels is at pains to dissociate Nazi "euthanasia"--a euphemism for genocide---from the beneficent euthansia that he advocates. In the process he manages to treat the late Leo Alexander in a way that can only be described as cavalier. "Soon after the (Nuremberg) trial.., it occurred to an American doctor named Leo Alexander that the Nazi atrocities might be used to discredit proposals for euthanasia." The picture this conveys is that of an anti-euthanasia, ultra-conservative zealot seizing on Nazi horrors to promote his own partisan view. In point of fact, Leo Alexander was an active-duty officer in the United States Army, consultant in psychiatry to the Secretary of War, assigned to the Office of the Chief of Counsel for War Crimes in Nuremberg, and himself a participant in the proceedings. As a physician he could not fail to observe that small attitudinal changes in the professional ethic of preHitler German physicians had progressed to the quantum immorality laid bare at Nuremberg. Binding and Hoche, 95
after all, had published their treatise on "life devoid of meaning" in 1920, well before Nazism had come of age. Slippery-slope or not, Alexander's monition to the medical community still seems valid today. This demurrer aside. Rachels' book is a useful addition to the literature on euthanasia. By asking the hard questions he challenges conventional attitudes toward his topic and, whether or not he manages to convince, at least forces a healthy re-thinking of this troubling and recurrent issue. Thoracic Surgery Service Newton- Wellesley Hospital Newton Lower Falls, Mass., U.S.A.
EUGENE G. LAFORET
Social Controls and the Medical Profession, edited by JUDI~ P. SWAZEYand STEPHEN R. SCmZR. Oelgeschlager Gunn & Hain, 1985. vi + 268 pp. $27.50. In 1973, the American Medical Association officially recognized that as many as 10% of U.S. physicians might be professionally 'impaired' by drug addiction, alcoholism, or emotional disorders. Local hospitals, state medical societies, and state boards of medicine have tried, in various ways, to tackle the problem. Social Controls and the Medical Profession is a collection of papers that explores the nature of extant social controls in and of medicine and that raises interesting questions about how the public and the profession ought to think about the problem that is variously called 'impairment,' 'disability,' or 'sickness' among physicians. This book is the product of the Project on Social Controls and the Medical Profession, a two-year, interdisciplinary effort whose "goals were to explore and begin to define the range of social controls affecting medical practice, to begin assessing how the controls interact, and to consider how the presence or absence of these controls affects physicians, their patients, and the practice of medicine in American society more generally" (!o. 2). The faculty of the project included physicians, sociologists, lawyers, philosophers, and clergy, and all have contributed to this volume. The first section of the book contains five papers providing "Comparative Perspectives on Professions and Their Governance." The first two give overviews of the ways philosophy and sociology, respectively, think about the issue of social controls in professions. Following these are a very good discussion of the socialization of law students, a paper on impairment in the clergy that discusses changes in notions of 'impairment' that resulted from changing notions of clerical responsibility over the past several decades and that offers a 'spiritual model' for assessing clerical competence, and finally, a paper on social controls among scientists. A cross-professional view of competence and impairment is an odd way to begin a book about medicine, but this section will be of use to readers unfamiliar with the sociological concept of 'social control." The second section of the book contains papers specifically about medicine. Several of the articles are of the how-to-be-a-good-doctor variety. The best of these is by Michael Parmer, a practicing surgeon. Instead of writing a strongly normative piece, Parmer spends a lot of time describing what it is like to be a solo practitioner in medicine today. An admittedly exploratory project of this sort ought, in my view, to be more descriptive than judgmental or nor-