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Volume 1, Number 1, 2001


The Right to Die With Dignity: An argument in Ethics, Medicine And Law
Raphael Cohen-Almagor

New Brunswick, New Jersey and London: Rutgers University Press, 2001, 304pp.



Cohen-Almagor's book is an important contribution to the medical literature on euthanasia since he argues for a liberal position that is balanced between the sanctity-of-life and quality-of-life. Cohen-Almagor argues that patients have an absolute right to determine whether or not to die within certain medical situations. Every patient has different ideas as to what constitutes effective health care if (s)he becomes terminally-ill. Some patients believe that effective health care occurs if the patient dies with dignity while others believe that effective health care occurs when the physician does everything in his/her power to keep the patient alive.Thus, every patient has a right to choose for him/herself how (s)he will die. In this book, Cohen-Almagor presents a carefully reasoned argument in favour physician-assisted suicide in some limited cases in which the patient asks to die with dignity. To ensure that a patient's rights are respected at the end of his/her life, the physician must exercise caution when "labeling" patients in certain ways. In other words, there are some key terms, such as brain dead, persistent vegetative state, and terminally-ill, which when consistently used by physicians to describe some medical conditions can cause negative implications for effective patient care. For instance, if a patient is labeled as "terminally-ill", certain medical procedures may not be administered because they may be regarded as "futile". The implications resulting from physiciansU language may be harmful to patients, and some of the terms used are offensive and degrading. If human life and the dignity of the patient is the first priority for physicians, then physicians should use neutral terms to describe the patient's situation without offending or degrading that patient. The preservation of dignity involves listening to a patient's complaints, helping cure his/her diseases, or at least helping him/her control pain. It also involves making an effort to relieve a patient's anxieties and distress, demonstrating sensitivity to the physical indignities that occur in severe  illness, and maintaining a patientUs sense that (s)he is a human being, not a case study or worse, a body that occupies a bed. To prevent abuse when deciding whether or not to perform physician-assisted suicide, the following procedural guidelines should be carefully followed by physicians.  First, the physician should not suggest assisted suicide to the patient but instead the patient should have the option to ask for such assistance if (s)he considers it important to die with dignity.  Second, the request must be voluntary, without outside pressures. The patient should state his/her wishes several times over a period of time. Third, the patientUs decision must not be biased by severe pain. Thus, proper pain management must be administered at all times. Fourth, the patient must be clearly informed of his/her medical situation and the prognoses for both recovery and escalation of the disease. Fifth, the patient's decision should never be a result of familial and environmental pressures. Sixth, the diagnosis must verified by getting a second opinion to minimize instances of misdiagnosis. Seventh, requests  for physician-assisted suicide must be reviewed by other consultants. Eighth, prior to the physician-assisted suicide, the patient must be examined by a psychiatrist in order to verify that the patient's wish is of sound mind and uncoerced by third parties. Ninth, the patient should be able to rescind the request to end his/her life at any time and in any manner. Tenth, physician-assisted suicide should only be performed by a doctor in the presence of another doctor. Eleventh, physician-assisted suicide may only be conducted through an oral, lethal injection. Twelfth, physicians must not demand a special fee to perform the assisted suicide. Thirteenth, there must be extensive documentation in the patient Us medical file, including the disease diagnosis and prognosis by the attending and the consulting physicians. Fourteenth, pharmacists are required to report all prescriptions for lethal medication.  Fifteenth, physicians must not be coerced into taking actions that contradict their conscience and understanding as physicians. Sixteenth, the medical association should establish a committee whose role will be to investigate the underlying facts that were reported and unreported cases of mercy killing. Lastly, licensing sanctions should be administered to punish physicians who violate any of these guidelines. In conclusion, I found this book to be hopeful since, given the complexities of the positions on euthanasia, few theorists have taken on the challenge to include as many checks and balances to ensure that abuses do not occur.  Being an advocate of the autonomy view myself, I recognize how important it is for patients to decide for themselves about end-of-life issues; however, so much can stand in the way of effectively achieving this. Cohen-Almagor addresses some of these issues in a cogent and complete manner. Irene Switankowsky, University of Wales, Lampeter.