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Book Review by Alan Branch, Ph.D., Pastor, Turner Memorial Baptist Church, Garner, NC
Final Victory: Taking Charge of the Last Stages of Life, by Thomas D. Preston, M.D. Roseville, CA: FORUM Publishing, 2000. Pp. 252.
The most notorious name associated with the subject of physician-assisted suicide (PAS) is Jack Kevorkian. His cadaverous appearance and crude methods, such as killing people in the back of a Volkswagen Bus, make him an easy target of ridicule. Kevorkian's antics noted, the real challenge to the sanctity of human life in relation to end-of-life decisions comes from health care professionals who are more subdued in their advocacy of PAS. Even most PAS advocates find death in the back of a VW van morally repugnant. The danger is those who come behind him and present a more benign face to institutionalized death. Part of their argument is that PAS must be institutionalized in order to restrain the fringe actions of people like Kevorkian. One such physician is Thomas Preston and his book, Final Victory, is a good example of how the PAS debate is being waged on a popular level. Final Victory is not an academic book. Preston's target audience is the average person who is concerned about a prolonged and painful dying process. Because of his target audience, footnotes are kept to a minimum and technical jargon is used infrequently. When medical terms are used, Preston adequately explains them. Furthermore, the format, with large block quotes highlighting important points, makes the book easily accessible to a broad spectrum of readers.
Preston says he wrote this book in response to the landmark 1997 Supreme Court decisions in Glucksburg v. Washington and Quill v. Vaaco which upheld bans on PAS in the states of Washington and New York respectively. In fact, Preston was a plaintiff in Glucksburg v. Washington. One reason the justices upheld the bans on PAS is that there are no legal barriers prohibiting a patient who is experiencing great pain from obtaining appropriate medication. According to Preston, "The reasoning of the Supreme Court justices may be the defining event that led me to write this book, as it helped me to understand that since there is no legal barrier to effective relief of suffering, the solution is within our means" (p. xv). He goes on to state that he hopes more effective pain management will make PAS less necessary. Of course, this begs the question, "Is PAS ever necessary?" Preston sidesteps all moral debate and answers the question in the affirmative.
On a positive note, Preston does point out some flaws in the way terminal patients are treated sometimes. He says, "When a cure is no longer possible, the physician often withdraws. To physicians this is not abandonment but a statement of their inability to cure and therefore the end of their role in care of the patient" (p. 107). Preston goes on to argue that the thoughtful physician will not abandon a terminal patient, but will offer palliative care in an aggressive manner. Final Victory also offers good advice for patients who are trying to absorb a negative diagnosis. For example, the author makes clear for the layperson the difference between a fatal and a terminal disease. While a fatal disease is one that in its natural, untreated course will be fatal, a terminal illness "means a fatal disease has advanced beyond the point of reasonable hope for a cure" (p. 82).
These good points notwithstanding, Preston's particular form of aggressive palliative care is the glaring weakness of Final Victory. While he does discuss different methods of pain management, he also discusses PAS as a viable option. Preston glosses over a very important distinction within medical ethics when he states, "In physician-assisted suicide, as well as in terminal sedation or withdrawal of life-sustaining therapy, the motive of the physician is to stop suffering, and the end result is the same--death of the patient" (p. 127). The distinction Preston overlooks is the principle of double-effect. This principle reflects a long-standing position within the Christian-Hippocratic tradition that says it is not immoral for a physician to administer pain relieving drugs, even if the drugs hasten death, as long as the intent is to relieve pain and not to cause death. In short, death is not desired, but is an unavoidable side-effect of good palliative care. Preston attempts to place his position within the same camp, but in reality they are very far apart. In PAS, the goal and the method of palliative care is to kill the patient. Furthermore, how does Preston know that all physicians who assist in suicide do so from benevolent motives? From a Christian perspective, the Biblical doctrine of sin should make us skeptical of tremendous power placed in the hands of an elite minority equipped with a technical expertise not available to the general populace.
Beyond his weak argumentation, Preston also glosses over the role of depression in requests for PAS and barely mentions the subject when he says, "If you feel more depressed than seems appropriate, talk to your doctor. There may be a way to help you this emotional problem" (p. 207). In reality, requests for PAS are frequently a sign of inadequately treated pain, which can lead to depression. Yet, Preston seems to play on the fears which lead to depression when he says, "If you stay with a doctor who is unsympathetic to your desire for the option of PAS, the strain on your relationship may be detrimental to your overall medical care" (p. 130). Preston limits a patient's choices to a pro-PAS physician who cares and an anti-PAS physician who is uninvolved. However, a third option is available: An anti-PAS physician who "digs deeper" in order to understand why a person may request PAS. Such a physician asks questions such as, "Does this person have fears about uncontrolled pain?" and "Does this person have feelings of diminished self-worth because of this illness?" In short, the patient needs a physician who treats depression aggressively.
Though never stated explicitly, the worldview of Final Victory is anthropocentric autonomy. Throughout the work, Preston urges patients to set their own course of action without any reference to a transcendent standard of morality. He displays his own anthropocentric colors when he says, "The key to spiritually and emotionally peaceful dying is connecting with your family before the end" (p. 192). In contrast, the theocentric position is that we must first be reconciled to God. Preston's book is an easily accessible argument for PAS. While Preston does a good job describing some problems with the current state of palliative care, his work is flawed by his uncritical advocacy of PAS as one viable and morally acceptable option among many others.