Vol. 3 No. 12 (December, 1993) pp. 127-129

THE RIGHT TO DIE: POLICY INNOVATION AND ITS CONSEQUENCES by Henry R. Glick. New York: Columbia University Press, 1992. 238 pp. $32.50.

Reviewed by Robert L. Savage, Department of Political Science, University of Arkansas, Fayetteville.

It is a rare book that is more profound and provocative than the publisher's blurb proclaims it to be. Henry R. Glick's little volume, THE RIGHT TO DIE: POLICY INNOVATION AND ITS CONSEQUENCES, is such a rare book as to its profundity and perhaps even to its provocativeness. Glick, a scholar noted for his work on state court systems, initiated the present study simply as "the political story of the right to die," provoked by his own interests in the innovative potential of state supreme courts for policy making. Those initial efforts, however, revealed a much more complex story of the policy-making apparatus of the American federal polity.

This storytelling is largely cast in terms of the relative empirical theories of political agenda setting and the diffusion of policy innovations. The first focuses attention on how a social concern comes to be recognized by citizens (and groups) as an issue with potential for policy resolution. The latter points to patterns of adoption of such policies by public decision makers. While it is easy to slip into a simple assumption of a smooth temporal transition from agenda setting to policy adoption, Glick convincingly demonstrates that the political process is rarely, if ever, so neatly wrapped and tied in the real world. Indeed, in relating the evolution of right-to-die policy in America, he makes clear that today's policy adoption may be setting the policy agenda for tomorrow.

The story gets underway with a brief exposition of the sad case of Nancy Cruzan, who, following an automobile accident, existed in a vegetative state from early 1983 to late 1990. Her case exemplifies many of the key factors that have shaped the right-to-die issue in American politics: the role of technology in exacerbating a perennial problem, the need for litigation to resolve particular and especially non-routine controversies, the parts played by groups in choosing sides in such issues, and eventually the effort to legislate a general policy for routine application. From this vantage point, Glick goes on to provide pertinent definitions for the right to die, which extend along a continuum from withdrawal or withholding of treatment (least active/most accepted) to involuntary euthanasia (most active/least accepted). He reviews the origins and impact of the issue, an impact accelerated by recent developments in medical technology and recounts briefly the dilemmas and ambiguities that heighten and complicate the issue. Glick indicates the primary cleavage lines among political combatants; finally, he notes the larger issue setting of the potentially converging policies arising from contemporary medicine, including brain death, medical costs, and the increasing number of elderly people.

Having set the substantive stage, Glick turns in Chapter 2 to the conceptual scaffolding, the aforementioned agenda setting and diffusion of innovations. Among the important distinctions he points to are public versus governmental agendas, outside and inside forces serving to move items from the public to governmental agendas, and early versus later policy adopters leading to the possibility of reinvention wherein the "laggards" may actually put into place more rigorous and even far-reaching policies than the "innovators" who led the way. The chapter is a cogent review of the literature on agenda setting and innovation in state politics and aptly prepares the reader for the substantive analysis that follows.

The rise of the right-to-die issue is explored in detail in Chapter 3. In other words, the focus is on the movement of the issue to public agendas. Glick explores in turn the earlier efforts at accomplishing euthanasia legislation before and after World War II, the emergence of the right to die as an item for both professional and mass agendas (1950-1990), and the increasing public support for the right-to-die legislation. He is particu larly innovative himself in the location of his data sources across these periods, moving from historical documentary accounts to frequency counts of the issue in professional and mass

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periodicals and finally to opinion survey results. In charting the evolution of the agenda process, further confirmation is given to the proposition that professional agendas lead the mass agenda.

In the next three chapters, Glick again adapts methods to suit the statement of the problem, generally the adoption of right-to- die policies. He utilizes case studies of three states to explore closely the movement of the issue from public agendas to governmental agendas. Although the selection of appropriate cases is always problematic, his choices seem altogether appropriate. His choices are the first state to adopt a living will law (California), the state in which the first formal proposal for a right-to-die law was placed on the legislative agenda (Florida), and a state in which right-to-die proposals have figured actively in decisional agendas but with a limited and late adoption (Massachusetts). He finds that while all three states were acting on the issue in roughly the same time frame, though individual policy sponsors played key roles in each case, while oppositional groups were primarily Catholic Church organizations, and though state court decisions had pivotal impacts upon legislative action, they nevertheless passed very different laws. As Glick notes, "Once items are placed on the agenda, agenda maintenance, careful strategy, ideology, and political context are all important in moving a proposal toward policy adoption" (p. 132).

He goes on in the next chapter to review judicial action across the states. While there have been "stimulants" that would seemingly point to increasing uniformity in courts, Glick finds that variability has actually increased. The major stimulants have included the stronger citational impact of the New Jersey Supreme Court in the Quinlan and Conroy cases, policy statements by major national groups such as the American Medical Association, and the U. S. Supreme Court's decision in the Cruzan case. Nonetheless, judges have great freedom to interpret such models and, for that matter, legislative enactments as well. Consequently, judicial decisions reflect a growing decisional acceptance of right-to-die policies counterbalanced by much policy reinvention as particular cases are resolved.

Similar results are found in examining state legislation across all states. The return to statutory policy in Chapter 6 shifts from the focus on legislative process in Chapter 4 to legislative outcomes. Here, Glick can utilize more rigorous, quantitative comparisons across all states and does so by developing a state living will facility index for correlational analysis. He finds that characteristics of states often linked to a general tendency toward policy innovativeness are much less linked to this measure of specific policy innovation. The more important explanda are the relative size of the state's Catholic population, right-to-die publications in mass periodicals, and the number of court decisions in right-to-life cases. On the other hand, state laws are often amended. Glick finds that amendments to right-to-life laws have tended to make them more facilitative and, consequently, less related to conditions existing at the time of initial adoption. At the same time, laws across the states remain highly variable depending in large part on the relative strength of oppositional groups in attaching restrictions. Continuous innovation through policy reinvention creates a kaleidoscope of right-to-die policies across the nation.

Glick concludes with a brief foray addressing the question of a national right-to-die policy. To this point, action by the national government has been limited to the Supreme Court's approval of the rather restrictive requirements imposed by Missouri's highest court and to the Patient Self-Determination Act. The Congressional action is indirect support of the right to die inasmuch as it is intended to heighten awareness of state policies for medical institutions and patients. Glick does note, however, that with or without national action, there are strong currents pushing toward more facilitative policies across the nation. Those currents are nonetheless subject to the vagaries of the policy process and can be rechanneled or reversed as well as promoted.

THE RIGHT TO DIE: POLICY INNOVATION AND ITS CONSEQUENCES is a valuable contribution to diffusion research and to the understanding of policy making in a federal

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polity. It is also an insightful analysis of the evolution of an important social issue of our time, an issue likely to remain important for the American political agenda for a very long time. Henry Glick is to be congratulated for bringing his considerable conceptual and methodological talents to bear upon this vital matter.