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J Med Ethics. 2007 December; 33(12): 742.
PMCID: PMC2598208

Death's dominion—ethics at the end of life

Reviewed by J Coggon

Edited by Simon Woods. Open University Press, 2007, £19.99 (paperback), pp 192.

Death's Dominion is Simon Woods' addition to the excellent and thought‐provoking Facing Death series. Its timeliness is hardly at issue: the debate on euthanasia, end‐of‐life care and associated issues looks set to rage for some time. And it comes out at a time when the UK Parliament is debating a palliative care bill, designed to promote a duty of the state to provide palliative care to all who need it. The real concern with a work in this area is knowing whether it is worth reading. I think it is. Relatively few are the texts that deal with palliative care, and fewer still are those that deal with it in such a careful and comprehensive manner. No thorough analysis of issues regarding the roles of the state and health care in individuals' end‐of‐life decision‐making can afford to ignore the specialty, yet it is often left unmentioned. For anyone who wishes to know about it and to see it in a clear social and ethical context, this book will prove highly valuable.

The book is logically structured, consisting of eight chapters. Although these lead clearly from one to the next, the chapters may also be visited individually by readers wishing to revise specific areas. Woods begins by considering and evaluating the ethical concepts relevant to the debate before exploring in chapter 2 the idea of the “good death”. The next three chapters focus on the values that have been said and can be said to underpin palliative care, highlighting the inherent tensions between liberal approaches and “traditional” communitarian ethics. Particularly interesting are the arguments that are expounded in chapter 5 regarding the “relational account” of autonomy that has been developed and its interplay with palliative care values. This allows the reader to understand the importance—and legitimacy—of challenging the will of a suicidal individual. Woods does not deny the relevance of a “subjective” view of a (competent) patient's own “best interests”, but acknowledges also the importance of the “objective” view. Understanding the way these can be balanced out and being sure that the right view “trumps” in a situation is of absolute importance.

Chapters 6 and 7 move to areas of greater, or at least more obvious, controversy. First there is a fascinating account of palliative sedation (a term argued to be preferable to the familiar “terminal sedation”). The argument in this chapter is balanced and elucidating. It is acknowledged that the practice, which is often caricatured as a covert form of euthanasia, is indeed difficult to distinguish when it is performed with a conjoined decision to withhold food and water from a patient. However, if used appropriately—Woods appeals to the qualifiers “adequate” and “proportionate”—palliative sedation can be a legitimate intervention that can be consistent with the values of palliative care. Then, in chapter 7, there is a discussion of assisted dying, an umbrella term for practices generally thought to be contradictory to palliative care. Again, the analysis is carefully and thoughtfully brought out, and the conclusions reached are that some practices that are currently considered illegitimate would in fact be compatible with palliative care's own values. Finally, there is a short concluding chapter that usefully ties together the arguments that have been developed.

It is a thoroughly researched work. Woods' analysis is predominantly ethical, but he relates it to a clear, comprehensive, and—importantly, given the nature of the issues under discussion—balanced social and historical setting. As interesting as his moral argument are the great swathes of information on the development of palliative care. Woods manages to condense what he learns from a good many texts into a clear and easily followed account of the specialty, developing a convincing analysis of its history in three stages: the early phase—the modern hospice; the middle phase—from hospice to palliative care; and the late phase—post‐palliative medicine. Seeing its development presented as it is in Death's dominion allows the reader to understand the relation of palliative care to other areas of medicine and to the broader ethical debate.

The ethical argument is presented clearly without becoming simplistic. Particularly for those who enjoy bioethics but are not trained in philosophy (perhaps I think here most of lawyers and healthcare professionals), the book is well explained. The balance is well struck between what needs to be explained and what can be taken as known by the reader. And the ethical position that Woods develops throughout the book is itself intriguing. His modified account of autonomy accords in its thrust with others that we see, holding that people do not always know what is best for themselves. This is combined with an account of why at the end of life we should be more careful than in other situations because of the especial issues that arise. Woods argues that this means that we could justify imposing obligations on patients to receive palliative care before instigating any life‐ending provisions (ie, euthanasia or physician‐assisted suicide). This is interesting stuff, and the basis of fundamentally important questions. Should we force people to be patients to allow them to exercise their autonomy? Should we (can we consistently) limit an imposition not to be depressed to those in a position where we might otherwise condone suicide as a rational course of action? Even a reader who is not convinced by Woods' position will not fail to recognise the level of thought and reason that supports it. It is crucially important for any student or researcher who is seriously considering ethical and policy matters at the end of life to embrace and tackle intellectually the issues that Woods raises in this book. I would happily recommend it.


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