Death Is That Man Taking Names: Intersections of American Medicine, Law, and Culture - Hardcover

Burt, Robert A.

Hardcover

ISBN 10: 0520232828 ISBN 13: 9780520232822

Publisher: University of California Press, 2002

Synopsis

The American culture of death changed radically in the 1970s. For terminal illnesses, hidden decisions by physicians were rejected in favor of rational self-control by patients asserting their "right to die"―initially by refusing medical treatment and more recently by physician-assisted suicide. This new claim rested on two seemingly irrefutable propositions: first, that death can be a positive good for individuals whose suffering has become intolerable; and second, that death is an inevitable and therefore morally neutral biological event. Death Is That Man Taking Names suggests, however, that a contrary attitude persists in our culture―that death is inherently evil, not just in practical but also in moral terms. The new ethos of rational self-control cannot refute but can only unsuccessfully try to suppress this contrary attitude. The inevitable failure of this suppressive effort provokes ambivalence and clouds rational judgment in many people's minds and paradoxically leads to inflictions of terrible suffering on terminally ill people.

Judicial reforms in the 1970s of abortion and capital punishment were driven by similarly high valuations of rationality and public decision-making―rejecting physician control over abortion in favor of individual self-control by pregnant women and subjecting unsupervised jury decisions for capital punishment to supposed rationally guided supervision by judges. These reforms also attempt to suppress persistently ambivalent attitudes toward death, and are therefore prone to inflicting unjustified suffering on pregnant women and death-sentenced prisoners.

In this profound and subtle account of psychological and social forces underlying American cultural attitudes toward death, Robert A. Burt maintains that unacknowledged ambivalence is likely to undermine the beneficent goals of post-1970s reforms and harm the very people these changes were intended to help.

About this title

About the Author

Robert A. Burt is Alexander M. Bickel Professor of Law at Yale University. He is the author of The Constitution in Conflict (1992), Two Jewish Justices: Outcasts in the Promised Land (California, 1981), and Taking Care of Strangers: The Rule of Law in Doctor-Patient Relations (1979).

From the Back Cover

"This book is enormously important, beautifully reasoned and written with crystal clarity by an author of wide scholarly experience, brilliant insights and extraordinary erudition. It is the first book length study I've seen that reasons from the individual psychology of all stakeholders. It ultimately provides the only truly revealing way to understand the personal and civic conundrums surrounding dying, which have always been characterized by irrational thinking, inconsistencies of behavior and paradoxes of personal viewpoints."―Sherwin Nuland, M.D., author of How We Die

"Once you acknowledge the profound and inescapable ambivalence that shapes our attitudes toward death, what can we learn about our death-dealing policies and practices, from end-of-life care and assisted suicide to the death penalty? Robert Burt's Death is That Man Taking Names provides extraordinary insights in eloquent and elegant prose. All thoughtful people who are seriously interested in the deeper roots and broader implications of our policies concerning death should read this remarkably original and provocative book."―Thomas H. Murray, President, The Hastings Center, and author of The Worth of a Child

From the Inside Flap

"This book is enormously important, beautifully reasoned and written with crystal clarity by an author of wide scholarly experience, brilliant insights and extraordinary erudition. It is the first book length study I've seen that reasons from the individual psychology of all stakeholders. It ultimately provides the only truly revealing way to understand the personal and civic conundrums surrounding dying, which have always been characterized by irrational thinking, inconsistencies of behavior and paradoxes of personal viewpoints."—Sherwin Nuland, M.D., author of How We Die

"Once you acknowledge the profound and inescapable ambivalence that shapes our attitudes toward death, what can we learn about our death-dealing policies and practices, from end-of-life care and assisted suicide to the death penalty? Robert Burt's Death is That Man Taking Names provides extraordinary insights in eloquent and elegant prose. All thoughtful people who are seriously interested in the deeper roots and broader implications of our policies concerning death should read this remarkably original and provocative book."—Thomas H. Murray, President, The Hastings Center, and author of The Worth of a Child

Reviews

Robert Burt has written a provocative and disturbing book that should be read by all professionals involved in end-of-life care. He suggests that dying patients, their families, and their physicians are "all vulnerable to unruly psychological forces unleashed by the imminent prospect of death" and that self-determination by patients is an inadequate safeguard against the many surrounding "forces of evil." He uses the legal and clinical examples of physician-assisted suicide, abortion, and capital punishment to illustrate his thesis. Although I disagree with some of his conclusions and examples, the central themes deserve serious consideration. His first theme is that all persons facing end-of-life decisions are inherently ambivalent, with mixed emotions and motivations. Therefore, the notion of rational self-determination is an illusion in this context. However, the inherent limitations of rational decision making are relevant to all major medical decisions, not just those at the end of life. Because we are not purely rational beings, informed consent is always influenced by subjective and emotional factors. Yet it does not necessarily follow that informed consent and the self-determination of patients should be abandoned. Choice by individual patients, in and of itself, certainly does not preserve patients' autonomy any more than it encourages true informed consent. Clearly, the best end-of-life decisions are made as a result of the collaboration and mutual informing of the patient, the patient's family, and the physicians, each sharing his or her own expertise to help the patient make the best possible decision (often in the worst possible circumstances). Burt's second theme is the danger of secrecy, especially with regard to complex decisions that may give rise to ambivalence. This danger is particularly worrisome when the illusion of rationality is proposed as a safeguard. For example, decisions about do-not-resuscitate (DNR) orders used to be the exclusive province of physicians, until we learned that this secretive process was applied inconsistently and that physicians were unconsciously influenced by such factors as race, sex, and age. A more open, regulated practice was then developed, involving informed consent and creating additional challenges by putting more of this medical decision into the hands of patients. DNR decisions are still approached with ambivalence and are often influenced by irrational forces, but an open process ultimately offers better protection against nefarious forces than does overly simple reliance on patients' self-determination or physicians' beneficence. The third theme is that death has an "inherent aura of wrongdoing" and that it is "inherently evil." From this ominous perspective, considering death as a natural, inevitable part of the life cycle deprives it of its gravity and creates an illusion of moral neutrality. Death, it is argued, should not be accepted and certainly should not be chosen or consciously assisted. Extreme individual suffering should only be addressed by acts that involve "structured ambivalence" and not by acts that would explicitly and consciously hasten death. Burt further suggests that the psychological and spiritual toll taken on physicians by the regular confrontation of extremes of suffering and death explains some of the dark sides of medical practice, such as the seemingly irrational undertreatment of pain and the overuse of invasive medical technology in dying patients. He uses a selective reading of Freudian psychoanalysis to argue that physicians may punish patients in order to meet some unconscious psychic need to inflict added suffering. In support of this argument, he cites a study in which physicians maintained the use of paralytic drugs when they were withdrawing life support. Their motivation, in his view, was in part to protect the staff and family from witnessing the patient's struggle to breathe, but also, unconsciously, to punish the dying patient. I find the latter interpretation far-fetched. My belief is that the primary motivation for maintaining paralysis would be to help the dying patient, who is heavily sedated, to die more comfortably and quickly. Conversely, I would argue that one reason that paralytic drugs are sometimes discontinued in dying patients when life support is being withdrawn is so that ambiguity is injected back into the act, rather than because of any notion regarding protection of patients from suffering. In fact, dying patients are frequently undersedated when ventilators are being withdrawn, in order to create the kind of ambiguity that Burt is encouraging. Several examples from the broader field of end-of-life care also require the illusion of moral clarity in the face of ambiguity. For example, the rule of double effect requires that the sole intention of physicians be to relieve suffering, and that death, even when inevitable and desired by the patient, can only be foreseen and not intended by the physician. When a patient is ready to die and accepts the sedation that comes with increasing doses of pain medication, how can it be said that death is completely unintended? Similarly, when a patient is sedated to the point of unconsciousness to escape awareness of suffering and then is not provided with food or fluids, can it be realistically said that assistance in causing death is entirely unintended? Should not the patient and family be informed that death will be inevitable once the process has been started? The huge variation among hospice programs in the incidence of terminal sedation (ranging from 0 to 50 percent of deaths) should give us pause about the desirability of "structured ambivalence." One could argue that physician-assisted suicide is a much more ambiguous act than terminal sedation. After all, the physician's intent in prescribing the medication might be in part to help with sleep or to provide the reassurance that the patient could escape, but with the hope that he or she will choose not to do so. Thus, Burt's approach of creating "structured ambivalence" also carries the potential for self-deception and for manufactured ambiguity when clarity and honesty would better serve patients and families. In Death Is That Man Taking Names, Burt reminds us that irrational forces come into play in all end-of-life practices and that we deny them at peril to our patients and our profession. He persuasively argues that processes governing such practices should be open, that those involved should be accountable, and that standards should not be so unrealistic and idealized as to force the true complexity of these decisions to go unacknowledged. Although Burt applies his analysis mainly to physician-assisted suicide, abortion, and capital punishment, it has broad applicability to other aspects of end-of-life care. Timothy E. Quill, M.D.
Copyright © 2003 Massachusetts Medical Society. All rights reserved. The New England Journal of Medicine is a registered trademark of the MMS.

Edition details

• Publisher: University of California Press
• Publication date: 2002
• Language: English
• ISBN 10: 0520232828
• ISBN 13: 9780520232822
• Binding: Hardcover
• Edition number: 1
• Number of pages: 256