ISSN 1062-7421
Vol. 12 No. 1 (January 2002) pp. 34-37.

DYING RIGHT: THE DEATH WITH DIGNITY MOVEMENT by Daniel Hillyard and John Dombrink. New York: Routledge, 2001. 304 pp. Cloth $85.00. ISBN: 0-415-92798-6. Paper $22.95. ISBN: 0-415-92799-4.

Reviewed by Thomas F. Burke, Visiting Professor, Robert Wood Johnson Scholars in Health Policy Program, University of California-Berkeley.

After debates about living wills, do-not-resuscitate orders, Jack Kevorkian, Karen Ann Quinlan, and the Hemlock Society, Attorney General John Ashcroft's recent announcement that he considers the federal Controlled Substances Act to forbid the prescription of death-inducing drugs under Oregon's physician-assisted suicide law is just the latest salvo in what might be called "the politics of death." Inevitably, in a nation in which, according to one source, 70 percent of all deaths occur after discussion to forgo or withdraw treatment (p. 17), the management of death has become a matter of great political struggle.

DYING RIGHT is a rich and well-researched account of one aspect of this struggle, the debate over physician-assisted suicide for the terminally-ill. Although it discusses developments in other parts of the world, the book focuses on ballot initiatives, legislative battles and several state and federal court cases in the United States. Along the way, DYING RIGHT offers insights into such varied concerns as the role of issue framing in politics, the medicalization of American life, the ongoing contest for power between doctors and patients, the politics of deviance, and American rights consciousness.

The introductory chapter puts the controversy over physician-assisted suicide in the context of the broader history of efforts to grapple with the sometimes-pernicious consequences of life-extending medical technology. Beginning with an elite effort in the early 20th century to legalize some forms of euthanasia, and continuing through the media circus provided by Jack Kevorkian, the authors describe the growing interest in the management (and mismanagement) of death. Where much of this management has centered on the withdrawal of medical support (resuscitation, ventilators, feeding tubes) and the prescription of pain medication that may result in death (the so-called "double effect"), physician-assisted suicide is an explicit and active approach to curtailing life. Thus it represents a momentous turning point, a
reversal of "two thousand years of Western medical ethics and law" (p. 98).

The second chapter analyzes the defeat of two citizen initiatives legalizing physician-assisted suicide in Washington and California. Chapters 3 and 4 trace the victory of the Oregon Death with Dignity Act, and the subsequent defeat of an initiative to repeal it. Chapter 5 covers a series of court battles, most famous among them the Supreme Court's consideration of a constitutional "right to die" for terminally ill patients in WASHINGTON v. GLUCKSBERG and VACCO v. QUILL. Chapter 6 examines the implementation of Oregon's law, and legislative attempts both at both the state and national level to derail

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it. Chapter 7 surveys developments in other states and around the world. Chapter 8 places these developments in the context of several theoretical perspectives, notably the sociology of deviance and the politics of "frame alignment," the attempt to frame political issues along the lines of widely shared cultural values and beliefs. The authors conclude that, although opinions vary widely about how death should be managed, all sides now converge in believing that the "good death"-a death without unnecessary suffering and the indignities of excessive medical technology-is the proper goal.

DYING RIGHT'S greatest strength is its careful reconstruction of the arguments advanced by participants in the battle over physician-assisted suicide, the strategic considerations that went into the framing of arguments, and the techniques they used for diffusing their arguments. The authors obtained access to the files of the campaign consultant for the pro-assisted suicide initiative campaign in California, Washington and Oregon, and make great use of this material.

The main challenge of proponents was to reframe the image of patient seeking suicide. Instead of a lonely, depressed, incompetent person whose wishes are a symptom of her disease, proponents portrayed terminally ill people as competent, thoughtful adults and urged compassion for those dying painfully amidst tubes and medical equipment. The second main argument for proponents, reminiscent of ROE v. WADE, was autonomy or, that as one television ad put it, a person with a terminal illness should have the choice "to die on my own terms in a dignified manner" (p. 51). Finally, proponents argued that assisted suicide was already happening "underground" through conscious overuse of pain medicine, and that it would be better to legalize the practice to better regulate it.

Opponents countered with claims that legalizing physician-assisted suicide would only encourage abuses. The poor and disabled, they charged, would be pressured to take the suicide option whatever their own wishes, particularly in an era of managed care. Further, opponents argued that the measures did not have sufficient safeguards to stop overzealous doctors and families from trampling the rights of the terminally ill. Worse, opponents warned of a slippery slope from physician-assisted suicide for the terminally ill, to euthanasia for those troubled by chronic illness, to, eventually, coerced euthanasia for the incompetent and unwilling. Opponents invoked the (controversial) experience of the Netherlands, a nation that had stopped prosecuting physician-assisted suicide in the 1970s, and a nation that some observers argued had begun a slide into more troubling forms of euthanasia. Finally, many opponents of assisted suicide argued that the real solution to
the problems of terminally ill people was more appropriate medical care, especially pain management. Physician-assisted suicide would short-circuit hospice reforms, and in the process deform the medical profession by turning doctors into killers.

DYING RIGHT describes how both sides found the themes that would best resonate in the ballot campaigns, usually on the basis of public opinion polling and focus groups. The resulting picture is not pretty. The television ads are sometime horrifying, the low points provided by the aptly-named campaign consultant to the anti-assisted-suicide side, Chuck Cavalier. One of the Cavalier ads features a young, apparently healthy man in what looks like a doctor's

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office. The voice-over forecasts his fate if proponents of physician-assisted suicide get hold of him, playing on fears that medication used to prescribe death would not work:

"Billy won't die right away. He'll choke on his own vomit, in painful convulsions, and linger for days" (p. 106).

Another ad portrayed a ghoulish-looking man holding a syringe behind an elderly, confused woman. "You're about to see a secret suicide meeting," says the narrator, "and unless you note no on 161 [an assisted suicide measure] it could happen to someone you know or love."

Because DYING RIGHT combines analysis of judicial, legislative and initiative struggles over the same issue, it has the ideal design to compare these three modes of politics, and the authors might have made more of this. As the example of Mr. Cavalier suggests, the differences in the quality of deliberation among the three modes are hard to miss. The authors portray judicial consideration of the right to die as principled, thoughtful and balanced. The oral argument at the Supreme Court in the right to die cases shows the Rehnquist Court at its best. By contrast, participants in the initiative battle are governed by the perverse incentives of the process: it's
hard to change voter's minds about matters of principle, but much easier to scare them about details of a proposal, or to connect the other side of the debate to some controversial group. Thus in place of debate about the proper limits of autonomy or the alternatives to assisted suicide, we get "Billy" and ads criticizing the Catholic Church. The authors highlight the differences between the ballot and judicial conflicts, but they don't connect them to the ongoing debates over policymaking by citizen initiative and judicial review, or to the literature on democratic deliberation.

Similarly, while the authors cite the works of Helena Silverstein (1996) and Michael McCann (1994) on the politics of rights, they do not engage theories about rights mobilization very deeply; they do not say much, for instance, about how the story they tell supports, undermines or modifies theories about the usefulness of rights claims for the mobilization of social movements.

The authors attempt to explain the outcomes in the cases: a victory for proponents of assisted suicide in Oregon, losses in Washington and California (as well as the Supreme Court). They emphasize the California and Washington campaign's narrow focus on public opinion polling, and contrast the Oregon campaign's more extensive effort to create a coalition of medical and legal elites in favor of the initiative. However, there are many other differences among the cases, as the authors acknowledge, not least of them the fact that Oregon is comparatively unchurched and libertarian state, prone to social policy innovations such as this one. That said, the author's conclusions tell us something about the nature of reform-by-ballot initiative: that at least when implementation of a ballot measure depends on professionals and institutions, those parties have to be drawn into the process of negotiating the details of a new law.

Rather than focus on a few narrow questions, or adopt a theoretical perspective that drives their narrative, the authors chose to write a broad overview of the battle over physician-assisted suicide. In this they succeed admirably. For anyone seeking to understand an increasingly salient aspect of

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politics, the politics of death, DYING RIGHT is an invaluable source.

REFERENCES:

McCann, Michael W. 1994. RIGHTS AT WORK: PAY EQUITY REFORM AND THE POLITICS OF LEGAL MOBILIZATION. Chicago: University of Chicago Press.

Silverstein, Helena. 1996. UNLEASHING RIGHTS: LAW, MEANING AND THE ANIMAL RIGHTS MOVEMENT. Ann Arbor: University of Michigan Press.

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Copyright 2002 by the author, Thomas F. Burke.