Closing time

Brian Scarlett, University of Melbourne

Roger S. Magnusson Angels of Death: Exploring the Euthanasia Underground Melbourne University Press, 2002 (342 pp). ISBN 0-52284-970-9 (paperback) RRP $29.95.

Some victims of loathsome diseases must also suffer cruel and avoidable torment from our harsh and unreasonable laws. In agony, without hope for other than the merciful release of easeful death, they are denied release. For absurd or shameful reasons the law denies these sufferers their only hope, condemning them to a life of torment with no positive value at all. Fortunately there are some brave and selfless people—medical, paramedical, and others—who risk legal and professional jeopardy for their good. These killers—‘angels of death’—are resolute, merciful, and rational in the face of the suffering of the weak and the tyranny of the law. That, at any rate is how the situation is often represented. But as Roger Magnusson clearly shows, euthanasia is not so simple an issue.

The core and principal strength of Magnusson’s work on euthanasia is an interview-based study of the attitudes and practices of a group of health professionals, community workers, and others caring for AIDS sufferers. Most of his subjects are confident of the rightness of their actions. But a substantial part of what Magnusson has discovered adds up to a catalogue of horrors. There is fairly widespread incompetence in killing, inadequate doses of supposedly lethal drugs giving way to suffocation (‘manual work’ one of them calls it). Patients are bullied into consenting to euthanasia. Euthanasia is performed against the clear wishes of the patient. Drugs are stolen. Medical trials are subverted. Death certificates are falsified. Bodies are rushed off to hasty cremations to destroy evidence of the cause of death. A funeral director sometimes assists in killing the patient before removing the body. Doctors are coerced by friends of the patient. There are financial conflicts of interest. Even where treatment is effective, painless, compassionate, and disinterested, it is sometimes grotesquely unprofessional. Consider the following case—Joseph, a prominent AIDS physician reports:

My hairstylist had a lover who was very sick…whose doctor wouldn’t prescribe anything… so he could end his life. Joseph adds that he had followed the lover’s disease process ‘through the perception of … the stylist to the point where…[although] I don’t like to prescribe things for people that I don’t know…in this situation I felt rather comfortable doing it.

In due course Joseph needed another haircut and was therefore able to review his patient’s progress.

I heard…that it was the most beautiful experience my stylist had ever had. It was Valentine’s Day and they had a lovely meal with champagne…and they held each other and then…his partner took his pills and was released.(p. 212).

Such is the world of the angels of death.

Remarkably, this damaging testimony was revealed in interviews with practitioners and supporters of euthanasia; not, as a casual reader might suppose, dredged up by people seeking to discredit the euthanasia campaign. Is it possible that Magnusson has got it wrong, or that he is playing an elaborate double game? We have no way of checking his highly confidential interviews, but equally, absolutely no reason to question his integrity and candour. The book reads like an honest and straightforward report. But what a report!

Most of his subjects are confident of the rightness of their actions.

Given the widespread and spectacular abuses it reports, what policy changes, if any, does the study suggest? Magnusson is in favour of legalisation. Advocacy is not his main aim and is far from prominent in the book. I do not think that he would regard the book as a convincing argument for legalisation, but I am sure that some of his readers will think that it is. Their argument might appeal to the American experiment in the prohibition of alcohol. Prohibition produced worse evils than it prevented. Better to have the supply and use of alcohol out of the hands of the gangsters, and in the public eye where suitable controls could be enacted, accepted, and enforced.

Similarly, in the euthanasia case, legal bans have not been effective in preventing euthanasia. Bans make the practice of euthanasia invisible to legal and professional scrutiny, providing a niche for people who should never be allowed within a day’s march of a patient. Well thought-out laws would remedy these evils. This is a familiar line of argument, and worth pursuing if there is an adequate case that the practice in question is not in principle immoral. Work towards that argument is the weakest part of the book, but set that aside. Suppose that there is no objection in principle to euthanasia. Do we have here the materials for a case for legalisation?

The book certainly takes the first step by establishing that the present situation is intolerable. But that is not enough. The gaps in the argument seem to me to be three. Two severe limitations in the empirical research make it unsuitable, on its own, as a guide to policy. Third is the lack of a convincing case that compliance would be secured if legalisation were to occur.

Magnusson appears to have carried out the empirical work competently, and the research is valid on its own terms. But it cannot stand on its own as a basis for policy development. In the first instance, the subjects of the inquiry are all on the medical treatment side of the situation. Magnusson interviewed no patients, though there are occasional indirect reports from the medical side, and he cites a survey of patients’ attitudes. This methodology is comparable to the recent media reports of the difficulties faced by the Mayne hospital group, events consistently represented in terms of clashes between managers and doctors. Hasn’t something been left out?

The exclusive concentration on AIDS workers and thus on a part of the gay community also limits the usefulness of Magnusson’s research for policy development. Policy will not be sound if based on the study of a limited group, where that group varies significantly and relevantly from the wider community. Are there such differences in this case? Magnusson thinks there may be. Specifically, he says that the gay subculture may not be representative of the wider community because homosexuals are more heavily committed to control of their lives and to a high quality body image than are heterosexuals. Further, one of his respondents claims that young gay men are more likely to feel miserable, which may account for their higher suicide rate.

Do we have here the materials for a case for legalisation?

Suppose some of this to be true; would the differences be relevant to the strength of the case for policy change? I think the relevance becomes clear if we consider the concept of intolerable suffering—one of the key ideas in both the Netherlands and Northern Territory euthanasia legislation. Intolerability is not a fixed quality of states of being. What is experienced as intolerable is relative to demands and expectations, and these in turn are not fixed. The horrific end of the continuum here is that patients are at risk of having their supposed carers’ ideas of the intolerable forced on them, with fatal results. Magnusson’s work shows that this is occurring now. This is a dramatic and chilling example of what he identifies as a privatisation and atomisation of our thinking about the nature of our being. But the main point is that if crucial attitudes about what can be tolerated vary between parts of the community, how can judgments derived from consideration of one subgroup support a policy covering all?

Thirdly, there is the question of securing compliance. The Prohibition argument supposes that compliance will ensue if the law allows euthanasia under strictly controlled conditions. One problem with this suggestion is doctors’ public claims to have violated the law have been a principal means of applying pressure for change to legislation prohibiting euthanasia. Further, Magnusson draws attention to a distinct lack of enthusiasm for legalisation on the part of some of his euthanasia practitioners, who fear that it will curtail their freedom of action. No doubt it would, but what reason do we have for thinking that this curtailment will be effective enough to eliminate the abuses he identifies? A fair reading of Magnusson’s results strongly suggests that some of his interviewees, contemptuous of any community abridgement of their freedom of action, will do what they like if they can get away with it. One of them refers to the leadership of the Australian Medical Association as ‘frumps’. Ethics committees are out of favour. In midnight wards and in private homes along quiet streets, they will defy any law that does not please them at the moment, and, especially if they overcome the widespread problem of incompetence in killing, they will be able to get away with a great deal.

But if Magnusson’s study fails to support the change in the law that its author favours, it remains a very valuable contribution to our knowledge of the topic. Its strength, as I said, is in the fieldwork, and the more theoretical parts of the book are stronger the closer they stick to reflection on that fieldwork. In particular the reflection on suicide as control metaphor is very fine and, had Magnusson played more to his strength, it might well have been expanded and given greater prominence, with, perhaps, some contrary examples examined. One such example is suggested by the book’s citation of The Hemlock Society, the web-site of which advises that it is ‘the oldest and largest right-to-die organization in the USA’. But any reference to hemlock invokes the memory of Socrates, to whom is attributed the following rejection of suicide and, by parity of argument, euthanasia:

The allegory which the mystics tell us—that we are in a sort of guard post, from which one must not release oneself or run away seems to me to be a high doctrine with difficult implications... The gods are our keepers, and we are one of their possessions.

The gods are our keepers, and we are one of their possessions.

Has the Hemlock Society not realised that ‘Saint Socrates’, as Erasmus called him, would oppose their project? One of Magnusson’s respondents claims that right-to-lifers are control freaks. No doubt some are: it is a weakness of our species. But Magnusson’s study suggests that some of his euthanasia practitioners are control freaks too.

There is evidently a lot for us to learn. We are not in agreement about what is most salient in our common human nature, and if we can’t get clear about that, good end-of-life thinking is out of the question. Socrates would repay study. So would the Buddha. So would Cardinal Newman, who moved in his own life from a model of control to one of acceptance. As he said,

Keep thou my feet: I do not ask to see
The distant scene; one step enough for me.

These, of course, are just a few of the suitable cases for study—a pre-Christian Greek philosopher, the founder of Buddhism, a nineteenth century English Christian—all relinquishing control. Does any of that make sense? Trying to find out might be more interesting and productive than trying to make an original contribution to the well-explored philosophical problems of the logic of intention and moral appraisal. These essential areas of inquiry need better treatment than Magnusson gives them. In particular his treatment of the Principle of Double Effect and the Acts and Omissions doctrine does little to advance the discussion, or to improve our understanding of the issues. It is unreasonable to expect excellence over such a broad inquiry—all the more reason for not trying to do so much.

This lack of a clear focus is the major editorial fault of the book, but not the only one. The expression ‘beg the question’ is misused. A theory is said to be ‘incredulous’. Passages of dialogue from the interviews appear and reappear when they could have been dealt with once and for all. Magnusson’s discussion of theoretical issues mirrors this repetitive approach, and the text slides from issue to issue and back again without satisfactory resolution. These flaws are great pity since they obscure the many virtues of the work, virtues that would have been more evident had Magnusson kept closer to his research on what is going on in those secret wards and rooms. He has a lot to offer us in our wrestling with these problems.

Brian Scarlett lectures in philosophy at the University of Melbourne. His interests include theoretical and applied ethics, philosophy of mind and history of philosophy.