John Keown's informed and powerful argument against euthanasia features both an excellent exposition of its pitfalls and a strong confrontation with a question that remains controversial abroad: Are there circumstances in which withdrawal of treatment should be considered euthanasia? American readers of this book, who consider the question settled and are unfamiliar with cultural and legal differences in the way European countries and the United States have dealt with end-of-life issues, may be puzzled at first as to why this University of Cambridge lecturer in the law and ethics of medicine wants to address this question. But Keown's exposition will make even such readers, who believe we have wisely avoided many of the dilemmas Great Britain and other European countries are forced to face, realize that there are some dilemmas we have not escaped.
To evaluate euthanasia, Keown examines its actual practice. He carefully provides evidence to show that legalization of voluntary euthanasia cannot be regulated and that it leads increasingly to involuntary euthanasia and to patients who are not ready to die or whose suffering could be alleviated by palliative medicine. Such a study relies heavily on the Dutch experience, since not only has the practice been legal in the Netherlands for some time, but two Dutch government-sanctioned studies (in 1990 and 1995), in which physicians participated anonymously and with impunity, have shown us what the actual practice entails.
The Dutch studies play down a fact they cannot help but reveal, namely, that thousands of patients have their lives ended without their consent. The studies report 3,600 deaths in 1995 from assisted suicide and euthanasia and officially acknowledge between 900 and 1,000 involuntary deaths. But they refuse to describe as euthanasia, or involuntary (when a competent patient does not give consent) or nonvoluntary (when the patient is deemed unable to give consent) euthanasia, the 1,350 patients in 1990 or the close to 2,000 patients in 1995 whose physicians gave them large doses of pain-killing medication with the primary aim of ending their lives. In the course of my own studies of euthanasia in the Netherlands, I asked Paul Van Der Maas, the principal investigator of the Dutch government-sanctioned studies, why, if patients had consented to the drug overdose, these should not be considered euthanasia cases. He conceded they could be--the only difference was that the patients took longer to die. When asked why, if patients were put to death who had not consented (about a third of the patients), these cases were not considered nonvoluntary or involuntary euthanasia, Van der Maas could not give a reason, but he was not willing to consider recategorizing them.
When one realizes that in one-quarter of the cases in which Dutch physicians give medications intending to end patients' lives, they do so without the patient's consent, that a third of Dutch doctors admit to having done so, that half of Dutch doctors feel free to suggest euthanasia to their patients, and that 60 percent of Dutch euthanasia cases are not reported to the authorities, one is inclined to agree with Keown that this is a system out of control.
Keown is also concerned, however, that the data on the many thousands of Dutch cases where treatment (including tube feeding) was withdrawn without patient consent do not permit us to know whether the doctor was merely stopping a futile or burdensome treatment or intended instead to end the patient's life--referred to as "passive euthanasia." This is an issue that has also troubled Keown in his own country because British law since the landmark Bland case has condoned passive euthanasia. Most of the concluding chapters of Keown's book deal with his concern with passive euthanasia and reflect some of the differences in approach to end of life care between Europe and the United States.
In 1989, Tony Bland was left in a persistent vegetative state after being crushed by a crowd at a soccer game. …