The recent defeat of a referendum to legalize physician-assisted suicide in Michigan (not to mention the performance of euthanasia on national television by a prominent pathologist) has underscored continued public interest in issues surrounding medical care delivered at the end of life. In a manner similar to its relative silence during the abortion debate in the 1980s, the medical community has been generally reticent to forward cogent arguments supporting viable models of end-of-life care. The group of essays compiled by Steinberg and Youngner are a welcome aberration to this disturbing trend.
Comprising 10 essays, this collection focuses on a variety of aspects of caregiving when death is imminent. The discussions regarding competence to refuse care, the legal status of treatment decisions, and the ethics of withholding care or actively hastening death are broad in scope, yet clearly written and quite current. In particular, Daniel Callahan's critique of physician-assisted suicide is outstanding, regardless of one's position on the issue. Though thematically organized, most of the chapters are clinically based, with case scenarios demonstrating applications of the concepts being discussed. The erudition and completeness of references to original research, literature reviews, and general texts are excellent.
The editors demonstrate an uncanny prescience with respect to those types of clinical settings in which many caregivers encounter their most acute philosophic and ethical dilemmas. Entire chapters are devoted to determining competence in the face of a suspected or confirmed diagnosis of depression, to barriers preventing effective physician-patient communication, and to the difficulties presented when the wishes of a patient's family match poorly with those of the patient (or with each other). The essays on the treatment challenges that arise with pediatric and AIDS patients offer valuable insights into considerations specific to a patient's developmental stage or psychosocial milieu, which should be borne in mind by caregivers.
Written primarily for psychiatrists, the essays often contain suggestions as to what role this specialty should play in facilitating better care for patients with terminal illnesses. One or 2 authors are of the opinion that such mental health intervention should be primarily the provenance of psychiatrists alone, stating, for example, that primary care physicians are rarely adequately trained to differentiate between the grief of terminal illness, organic mood disorder, and depression. Nonetheless, generalists will find this book widely informative, lucidly written, logically organized, and clinically applicable. As such, I recommend it without reservation for those primary care physicians who find themselves attending the medical care of patients at the end of their lives.