Vol. 4 No. 8 (August, 1994) pp. 99-101

DEATHRIGHT: CULTURE, MEDICINE, POLITICS, AND THE RIGHT TO DIE by James M. Hoefler with Brian E. Kamoie. Boulder: Westview Press, 1994. 291 pp. Cloth $49.95. Paper $16.95.

Reviewed by Richard Pacelle, Department of Political Science, University of Missouri-St. Louis

Many of the earliest studies of public policy came to the separate conclusions that unanticipated consequences and outright failures were the rule in policy making rather than the exception. In their book DEATHRIGHT: CULTURE, MEDICINE, POLITICS, AND THE RIGHT TO DIE, James Hoefler with Brian Kamoie show that the right-to-die as an issue faced an almost unprecedented array of obstacles (policy restraints) to its emergence and development. DEATHRIGHT is a comprehensive analysis of the development of the right-to-die issue in American politics. The task of explaining and analyzing what the authors call policy mediation is complicated by the fact that the right-to-die a multidimensional issue, which varies according to the competency of the patient, the extent of the condition, and the types of treatment or assistance that are sought (whether to withhold treatment or take an more active role in ending a life), and that there is no unified policy, but the policies of fifty state governments.

The book is a detailed case study of the significant forces that kept the right-to-die issue off the policy agenda and constrained and shaped its eventual emergence. The forces of policy and social activism (the agents of change) not only had to overcome the normal inertia that restricts issue evolution, but cultural and religious forces that were deeply imbued in individual and collective beliefs. The confluence of policy and social activism created a momentum that eventually overcame some of the restraining factors to yield what are often disjointed right-to-die policies in many jurisdictions. This analysis of the right-to-die issue has implications for students of federalism, judicial and legislative behavior, and public policy.

The book is very well-written and this is no mean task given that the authors introduce discussion of scientific and medical advances. The authors do an good job of integrating a series of case studies of victims and their families and demonstrate how the experiences tend to contribute cumulatively (if imperfectly) to the forms of policy mediation. For those interested in the right to die as a specific issue, this is an indispensable study that spans the broad panorama of factors that affect the way Americans look at death and the impact of the myriad factors on the public policy concerned with the issue. The book is a remarkable in-depth case study of the range of religious and cultural (and pop culture) forces that make Americans reluctant to face death and admit mortality. The authors bring an impressive battery of evidence to explain attitudes toward death and how technology has transformed this from a private matter to a societal concern. The range of material shows a great deal of creativity, including data on cryonics, pet cemeteries, greeting cards, and health food. The sources of data are appropriate, although they may be over exploited in places. As a study of the obstacles that have inhibited the formation of a coherent right-to-die policy,

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the book is first rate. The book makes appropriate use of historical analysis to show how the treatment of death has changed in the United States during the twentieth century. In addition, the book draws selectively on some comparative analyses to demonstrate how death is viewed and accepted in other cultures. Governments in societies with cultures and religions that are more comfortable with the idea of mortality have had an easier time dealing with these controversial issues.

The forces of policy restraint were effective barriers to the emergence of policy to deal with the deathright issue. Like the relationship between the lawyer and her client, the doctor-patient relationship is inherently unequal. Such an inequality, as in the legal realm, presents its own set of obstacles to the construction of policy and regulations that might affect that relationship. Some of the major forces of policy activism have flowed from changes in the doctor-patient relationship. More general environmental factors have also served as the impetus for policy activism. The well-documented emergence of a "rights culture" has had spillover effects. The development of the right to privacy and the expansion of group (race and gender, among the earliest) litigation have created the conditions for other groups and issues to develop.

One of the strengths of the book, its multifaceted look at the popular and cultural forces that shape the way Americans view death, is so detailed that it is also the major weakness of the study. The narrative discussing the cultural, historical, medical, and religious factors almost detracts from the broader perspectives that could contribute to the building of theory and future hypotheses for the emergence and transformation of issues. As a study that can contribute to the literature regarding the emergence and evolution of public policy, the book leaves a bit to be desired. It is perhaps unfair to hold the book to that standard because that was not the primary stated mission of the authors.

The preface, albeit brief, is one of the strongest parts of the book. It discusses a broader context for analyzing the chapters to come. As the authors note: "We can understand right-to-die policy better if we think about the `policy forces' of restraint, activism, and mediation: pressures and stresses that push, pull, and shape policy into one form or another. Using this approach, one can understand the outcome of right-to-die policy at any given time, in any given place, as a product of a struggle -- a mediated resultant that emerges when the forces of activism overwhelm the forces of restraint, forcing mediators to act" (p. xiii). This is a useful way of looking at this issue, the forces that constrained its development, and the factors that may overcome the inertia. The general propositions may be useful in examining the development of other issues. The discussion in the Preface and the terse definitions of the key terms should have been further developed and placed in a more prominent place in the book. If a reader misses the Preface, he/she would lose some important analytical perspective.

The other criticism of the book is related to this: the subsequent, substantive chapters could do a better job of integrating the forces of restraint, activism, and mediation. Instead, each chapter deals with

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one aspect without adequately developing the broader relationship to these forces. The major shortcoming of the book is that the connections between the details and the broader context are only implicit until the brief conclusion Chapter 9. This last chapter finally gets around to examining the broader perspective explicitly. For those interested in integrating this case study into a broad conceptualization of public policy development, the Preface and Chapter 9 will be the most valuable resources.

The last few substantive chapters deal with policy mediation: the role of the courts and legislatures in providing "the tangible policy response." The analysis provides an interesting contrast between the treatment of the issue by the two branches. The pattern of policy mediation of the right-to-die issue has been similar to that of other polycentric, controversial issues of the past half-century: the courts have been leaders on the issue, while legislatures have done their best to avoid the issue. The authors succinctly discuss the diffusion of policy innovation among state courts and state legislatures.

Because the right-to-die issue involves the question of privacy, the abortion issue is in the background although the authors deal with the connections only implicitly. Many of the forces that oppose the right to an abortion want to limit the right-to-die. In particular, the role of the Catholic church in opposing and then structuring (and helping to weaken) the deathright legislation when it was clear that it would eventually pass lends an interesting perspective to the analysis. Therein lies one of the problems for those who support liberalizing the right-to-die: there are strong opposing forces that were mobilized for other issues, most notably opposition to abortion rights. Many of the pro-choice groups, however, have shown no particular interest in right-to-die issues. The Supreme Court, state courts, legislatures, and interest groups have taken great pains to separate the two issues and avoid the baggage that abortion carries (see Rehnquist's opinion in CRUZAN V. DIRECTOR, MISSOURI DEPARTMENT OF HEALTH).

Ultimately, much of the policy activism for a deathright comes from the grassroots level, from people who have experience with family members whose lives were prolonged past a meaningful existence. In fact, the case studies of states that passed deathright legislation showed that key actors in the process were often moved to action by family circumstances. The range of social, cultural, political, religious, medical, and scientific forces made policy mediation a complex process. The authors are able to overcome the barriers and concisely trace the development of the right-to-die issues. As technology advances, virtually everyone will know someone confronted with the issues and politics surrounding the right-to-die. As the authors acknowledge, this fact suggests that policy mediation will continue.

REFERENCES

CRUZAN V. DIRECTOR, MISSOURI DEPARTMENT OF HEALTH, 110 S.Ct. 2841 (1990)