Angels of Death: Exploring the Euthanasia Underground (Hardcover)

From The New England Journal of Medicine
Roger Magnusson's Angels of Death describes the practice of extralegal assisted suicide and euthanasia by physicians, nurses, technicians, and other health care professionals who provide care to seriously ill patients and patients with AIDS who are dying. It is based on a snowball sample of 49 detailed interviews carried out over a period of three years with health professionals specializing in the care of patients with the human immunodeficiency virus and AIDS, principally in Sydney and Melbourne, Australia, and in San Francisco. This book is about cooperative euthanasia -- that is, physician-assisted suicide and euthanasia occurring underground, mainly among patients with AIDS at home and those in large, tertiary-care hospitals in the United States and Australia. It describes networking among sympathetic physicians, nurses, and other health care workers and traces patterns of referral. It portrays ways in which health care professionals provide advice about drugs, assistance to those who wish to obtain drugs (often from an underground pharmacy), and informal psychiatric assessments. It also describes how they manipulate hospital procedures, fabricate information when signing death certificates, and collaborate with funeral directors in the orchestration and general facilitation of assisted dying at the bedside. It describes ways they may support both the patient and the family as well as debrief the family after a death. In Angels of Death (the name given to informal groups of physicians and nurses known to be willing to provide assistance in suicide or euthanasia), Magnusson finds, as have other researchers, that cooperative aid-in-dying is easier and more direct in the community than in the hospital but that it frequently still occurs in hospital settings. Some occasions of cooperative euthanasia involve direct, deliberate, life-ending measures: "A common example of shared involvement was for one health care worker to access the patient's vein, while another injected the drugs." Other occasions involve stretching applications of the principle of double effect, particularly in deaths that involved "understood," deliberate overdoses of morphine: The physician in charge of Erin's unit . . . approached Erin [a nurse] about another distressed patient they were caring for. ‘Use as much morphine as you need,’ said the physician. ‘I'll sign for it.’ Erin was taken by surprise. ‘Do you know what I mean?’ said the physician. ‘I'm not sure,’ said Erin. ‘Do you want me to make him comfortable, or do you want me to make him ultimately comfortable?’ ‘Yes,’ replied the physician, ambiguously. The patient died that night. Magnusson, professor of law at the University of Sydney, and his associate, Peter H. Ballis, of Monash University, also in Australia, applied considerable skill in eliciting first-hand accounts from physicians, nurses, and other health care professionals working in legally delicate settings, and as a result they obtained very revealing interviews. They stress that the physicians involved in these cooperative networks are "not isolated and wild-eyed miscreants acting from the fringes of their professions" but rather respected, mainstream physicians. Underground euthanasia is a "culture of deception," and it is practiced everywhere, although Magnusson observes that it is "more deeply entrenched, with a longer and richer history" in California than in Australia. Angels of Death has several limitations. The study was limited to patients with AIDS in cities where large, interactive, and mutually supportive populations of gay men have helped shape the nature of health care. Its methodology involved reportorial interviews that were not cross-checked by interviewers of different background commitments. Most irritating, the book does not clearly identify the three-year period during which the interviews were conducted, so the reader cannot know when, during the years of the AIDS epidemic, the practices described were implemented, whether before or after the development of protease inhibitors and other drugs. The study is also presented with a certain sensationalism, which its title betrays. And it does not explore the philosophical issue of whether occasions of the "understood" overuse of morphine -- as in the example of Erin, noted above -- are conceptually closer to a "double effect" and hence legally permissible or, as Magnusson clearly believes, closer to euthanasia. Despite these shortcomings, Angels of Death is a comprehensive, compelling, and deeply responsible description and analysis of practices in contemporary health care, and it includes an extensive bibliography. A superbly thought-provoking book, it should be read by both opponents and proponents of the legalization of assisted dying. It is here that Angels of D