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Death & Dying

Review of "The Modern Art of Dying"

By Shai J. Lavi
Princeton University Press, 2007
Review by Bob Lane, MA on Jan 13th 2009
The Modern Art of Dying

Euthanasia is discussed in churches, philosophy classes, pubs, street corners, homes, medical societies, nursing classes, hospices, law journals, and in legislative assemblies across the land. There is no shortage of information and opinion. Just as we debate what counts as the beginning of life, we also have changed the definition of the end of life over the centuries. It used to be that death meant the termination of breathing. Later physicians defined death as a total stoppage of the circulation of blood. This definition served well until recent technology made it possible to sustain respiration and heartbeat indefinitely, even when there is no brain activity. The need for still viable organs for transplantation has resulted in a refined definition based on brain wave activity.

Here is the question: is it possible for us as a society to recognize and assert the fundamental importance of life while at the same time recognizing and asserting the right of a terminally ill patient to die with dignity?

Advances in medical science have also had a stunning effect on social policy. Medical advances and technology have made it possible, for example, for us to cure pneumonia in a person suffering from terminal cancer by administering antibiotics; before this discovery that patient would have died of pneumonia. Cardiac arrest and kidney failure are no longer fatal with the appropriate technological intervention. AIDS has intensified the debate over assisted suicide. Palliative care has improved, and it is rare now to find a physician who is worried about giving too much of a painkilling narcotic to a suffering patient on the grounds that it may be habit forming. In the midst of all these changes in the art of medicine and care-giving there remains the moral question of, not what can be done, but what should be done?

Lavi's book contributes to this ongoing discussion by providing a valuable, thoughtful, and concise history of euthanasia in the United States. His book takes us back to the 18th century Methodists, to see how "the art of dying" gradually became "technique." He does a superb job of bringing together insights from several disciplines (history, religion, social science, law, philosophy) which help us to understand the issues involved by showing how art, technology, medicine, religion and social policy have contributed to the situation we find ourselves in today.  Several chapters and a complete set of notes, index, and an interesting appendix with a case history of mercy killing, make up the 225 page book. [Table of Contents]

Early in his book (13) he writes, "Euthanasia is an ethical question, but not in the sense that most professional ethicists would have us think. The ethical dimension of euthanasia does not lie in asking whether and under what conditions the medical hastening of death should be practiced." He goes on to suggest that the proper question for a study of ethics is not, "What are we to do?" but rather, "Who have we become?" Death, in short, is not something we can control, but, like birth, something that happens. "Death" he tells us in his early discussion of John Wesley, "is not only the last moment of life but also the essence of being alive." (22)

"The history of the art of dying can be told," he tells us, "as the story of the varying dispositions that surrounded the deathbed." Lavi shows how we have moved from religion to medicine to public policy in our attempts to deal with death.

Dispositions of the Deathbed (58)

Pre-Reformation

Post-Reformation

Modern

Bad death

Hopelessness as despair

Fear and doubt

Hopelessness and helplessness

Good death

Hope

Faith and assurance

Hope

Domain

Otherworldly

This-worldly

This-worldly

Lavi presents a careful and useful analysis of the sometimes slippery terms used in the discipline of medical ethics. He distinguishes among these phrases, which are often used interchangeably, lethal dosing, medical euthanasia, mercy killing, pain management drawing out the differences among the various practices. For example, he writes, "The growing use of lethal dosing to secure a painless death replaces the need for euthanasia and brings the technical control of dying to its ultimate conclusion." (129) The chapter on lethal dosing is an interesting review of how the practice started, how it escaped any legal assessment, and how it is justified by using the "double effect" principle.

Another virtue of the book is the chapter on mercy killing by which he means the taking of the life of an individual (often requested) by a person other than a doctor. Drawing on many actual cases he develops a description of the practice as flowing from a special relationship between the "victim" and the "care-giver". In most of these cases (Lavi provides an appendix of several actual cases) the person who provides the "easy death" is a family member and the act is seen as an extension of the obligation to provide care for a loved one.

We have made little headway in changing the laws even though poll after poll indicates a public acceptance of carefully controlled mercy killing laws. We seem unable to deal with the problem. Psychologically we seem not to want to know about death or about those elderly and incompetent who are stored in "homes" until released from their pain by death. Lavi discusses the "Death by Dignity" statute in Oregon and shows how this approach bureaucratizes death with committees, courts, and forms. Lavi's position throughout is that death is an essential part of human freedom and of the human condition. Whereas some ethicists, like Tom Campbell, present an interesting and subtle human rights argument, the conclusion of which is:

This is not a utilitarian argument for a human right in the sense that it depends on arguing that the greatest happiness of the greatest number will be enhanced by the reduction of suffering that euthanasia makes possible. That may be an argument for euthanasia, but not what I take to be a human-rights based argument. The human rights rational is focused on the fact that the lesser interests of the majority (fear of involuntary euthanasia, the consequences of changing the traditional medical ethos,, etc.) should be not be allowed to trump the greater interests of those who are in grave need of the euthanasia option. [Source]

Lavi wants us to consider an existential idea of being-in-the-world. Returning to the ethical challenge posed at the beginning of the study he writes, "The basic question is not whether euthanasia should be legalized. Starting off with this question overlooks the fact that euthanasia has become a reality even for those who oppose it. The rise of euthanasia as an option is an event that is in itself ethically significant …. Thus, we have been guided not by the fundamental question "What ought we to do?" but rather "Who have we become?" (169)

© 2009 Bob Lane

Bob Lane is an Honorary Research Associate in Philosophy and Literature at Vancouver Island University in British Columbia. Lane's contribution to the euthanasia debate is available here.

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