ISSN 1062-7421
Vol. 12 No. 1 (January 2002) pp. 34-37.
DYING RIGHT: THE DEATH WITH DIGNITY MOVEMENT by Daniel Hillyard and John Dombrink. New York: Routledge,
2001. 304 pp. Cloth $85.00. ISBN: 0-415-92798-6. Paper $22.95. ISBN: 0-415-92799-4.
Reviewed by Thomas F. Burke, Visiting Professor, Robert Wood Johnson Scholars in Health Policy Program, University
of California-Berkeley.
After debates about living wills, do-not-resuscitate orders, Jack Kevorkian, Karen Ann Quinlan, and the Hemlock
Society, Attorney General John Ashcroft's recent announcement that he considers the federal Controlled Substances
Act to forbid the prescription of death-inducing drugs under Oregon's physician-assisted suicide law is just the
latest salvo in what might be called "the politics of death." Inevitably, in a nation in which, according
to one source, 70 percent of all deaths occur after discussion to forgo or withdraw treatment (p. 17), the management
of death has become a matter of great political struggle.
DYING RIGHT is a rich and well-researched account of one aspect of this struggle, the debate over physician-assisted
suicide for the terminally-ill. Although it discusses developments in other parts of the world, the book focuses
on ballot initiatives, legislative battles and several state and federal court cases in the United States. Along
the way, DYING RIGHT offers insights into such varied concerns as the role of issue framing in politics, the medicalization
of American life, the ongoing contest for power between doctors and patients, the politics of deviance, and American
rights consciousness.
The introductory chapter puts the controversy over physician-assisted suicide in the context of the broader history
of efforts to grapple with the sometimes-pernicious consequences of life-extending medical technology. Beginning
with an elite effort in the early 20th century to legalize some forms of euthanasia, and continuing through the
media circus provided by Jack Kevorkian, the authors describe the growing interest in the management (and mismanagement)
of death. Where much of this management has centered on the withdrawal of medical support (resuscitation, ventilators,
feeding tubes) and the prescription of pain medication that may result in death (the so-called "double effect"),
physician-assisted suicide is an explicit and active approach to curtailing life. Thus it represents a momentous
turning point, a
reversal of "two thousand years of Western medical ethics and law" (p. 98).
The second chapter analyzes the defeat of two citizen initiatives legalizing physician-assisted suicide in Washington
and California. Chapters 3 and 4 trace the victory of the Oregon Death with Dignity Act, and the subsequent defeat
of an initiative to repeal it. Chapter 5 covers a series of court battles, most famous among them the Supreme
Court's consideration of a constitutional "right to die" for terminally ill patients in WASHINGTON v.
GLUCKSBERG and VACCO v. QUILL. Chapter 6 examines the implementation of Oregon's law, and legislative attempts
both at both the state and national level to derail
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it. Chapter 7 surveys developments in other states and around the world. Chapter 8 places these developments
in the context of several theoretical perspectives, notably the sociology of deviance and the politics of "frame
alignment," the attempt to frame political issues along the lines of widely shared cultural values and beliefs.
The authors conclude that, although opinions vary widely about how death should be managed, all sides now converge
in believing that the "good death"-a death without unnecessary suffering and the indignities of excessive
medical technology-is the proper goal.
DYING RIGHT'S greatest strength is its careful reconstruction of the arguments advanced by participants in the
battle over physician-assisted suicide, the strategic considerations that went into the framing of arguments, and
the techniques they used for diffusing their arguments. The authors obtained access to the files of the campaign
consultant for the pro-assisted suicide initiative campaign in California, Washington and Oregon, and make great
use of this material.
The main challenge of proponents was to reframe the image of patient seeking suicide. Instead of a lonely, depressed,
incompetent person whose wishes are a symptom of her disease, proponents portrayed terminally ill people as competent,
thoughtful adults and urged compassion for those dying painfully amidst tubes and medical equipment. The second
main argument for proponents, reminiscent of ROE v. WADE, was autonomy or, that as one television ad put it, a
person with a terminal illness should have the choice "to die on my own terms in a dignified manner"
(p. 51). Finally, proponents argued that assisted suicide was already happening "underground" through
conscious overuse of pain medicine, and that it would be better to legalize the practice to better regulate it.
Opponents countered with claims that legalizing physician-assisted suicide would only encourage abuses. The poor
and disabled, they charged, would be pressured to take the suicide option whatever their own wishes, particularly
in an era of managed care. Further, opponents argued that the measures did not have sufficient safeguards to stop
overzealous doctors and families from trampling the rights of the terminally ill. Worse, opponents warned of a
slippery slope from physician-assisted suicide for the terminally ill, to euthanasia for those troubled by chronic
illness, to, eventually, coerced euthanasia for the incompetent and unwilling. Opponents invoked the (controversial)
experience of the Netherlands, a nation that had stopped prosecuting physician-assisted suicide in the 1970s, and
a nation that some observers argued had begun a slide into more troubling forms of euthanasia. Finally, many opponents
of assisted suicide argued that the real solution to
the problems of terminally ill people was more appropriate medical care, especially pain management. Physician-assisted
suicide would short-circuit hospice reforms, and in the process deform the medical profession by turning doctors
into killers.
DYING RIGHT describes how both sides found the themes that would best resonate in the ballot campaigns, usually
on the basis of public opinion polling and focus groups. The resulting picture is not pretty. The television
ads are sometime horrifying, the low points provided by the aptly-named campaign consultant to the anti-assisted-suicide
side, Chuck Cavalier. One of the Cavalier ads features a young, apparently healthy man in what looks like a doctor's
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office. The voice-over forecasts his fate if proponents of physician-assisted suicide get hold of him, playing
on fears that medication used to prescribe death would not work:
"Billy won't die right away. He'll choke on his own vomit, in painful convulsions, and linger for days"
(p. 106).
Another ad portrayed a ghoulish-looking man holding a syringe behind an elderly, confused woman. "You're
about to see a secret suicide meeting," says the narrator, "and unless you note no on 161 [an assisted
suicide measure] it could happen to someone you know or love."
Because DYING RIGHT combines analysis of judicial, legislative and initiative struggles over the same issue, it
has the ideal design to compare these three modes of politics, and the authors might have made more of this. As
the example of Mr. Cavalier suggests, the differences in the quality of deliberation among the three modes are
hard to miss. The authors portray judicial consideration of the right to die as principled, thoughtful and balanced.
The oral argument at the Supreme Court in the right to die cases shows the Rehnquist Court at its best. By contrast,
participants in the initiative battle are governed by the perverse incentives of the process: it's
hard to change voter's minds about matters of principle, but much easier to scare them about details of a proposal,
or to connect the other side of the debate to some controversial group. Thus in place of debate about the proper
limits of autonomy or the alternatives to assisted suicide, we get "Billy" and ads criticizing the Catholic
Church. The authors highlight the differences between the ballot and judicial conflicts, but they don't connect
them to the ongoing debates over policymaking by citizen initiative and judicial review, or to the literature on
democratic deliberation.
Similarly, while the authors cite the works of Helena Silverstein (1996) and Michael McCann (1994) on the politics
of rights, they do not engage theories about rights mobilization very deeply; they do not say much, for instance,
about how the story they tell supports, undermines or modifies theories about the usefulness of rights claims for
the mobilization of social movements.
The authors attempt to explain the outcomes in the cases: a victory for proponents of assisted suicide in Oregon,
losses in Washington and California (as well as the Supreme Court). They emphasize the California and Washington
campaign's narrow focus on public opinion polling, and contrast the Oregon campaign's more extensive effort to
create a coalition of medical and legal elites in favor of the initiative. However, there are many other differences
among the cases, as the authors acknowledge, not least of them the fact that Oregon is comparatively unchurched
and libertarian state, prone to social policy innovations such as this one. That said, the author's conclusions
tell us something about the nature of reform-by-ballot initiative: that at least when implementation of a ballot
measure depends on professionals and institutions, those parties have to be drawn into the process of negotiating
the details of a new law.
Rather than focus on a few narrow questions, or adopt a theoretical perspective that drives their narrative, the
authors chose to write a broad overview of the battle over physician-assisted suicide. In this they succeed admirably.
For anyone seeking to understand an increasingly salient aspect of
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politics, the politics of death, DYING RIGHT is an invaluable source.
REFERENCES:
McCann, Michael W. 1994. RIGHTS AT WORK: PAY EQUITY REFORM AND THE POLITICS OF LEGAL MOBILIZATION. Chicago: University
of Chicago Press.
Silverstein, Helena. 1996. UNLEASHING RIGHTS: LAW, MEANING AND THE ANIMAL RIGHTS MOVEMENT. Ann Arbor: University
of Michigan Press.
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Copyright 2002 by the author, Thomas F. Burke.