The title of this book reveals its purpose: deaths which a physician (or anyone) assists are by definition the deaths of others, and are therefore assisted suicides or euthanasia. Deliberate softening of those descriptors betrays an apologist, at times defensive stance. That is no great revelation, for the editors openly admit: ‘Our focus was...the practice of [euthanasia/assisted suicide]...we did not include authors...who find [it] morally unacceptable.’ The collection then was never intended to be a ‘balanced discussion’ of views; it is a series of justifications from ‘enthusiastically cooperative’ authors. (xxiii)

Twenty-four articles in favour of Dutch practice, in six sections, first discuss the historical or socio-political background, regulatory or legal requirements. Later, more clinically-oriented papers on quality assurance, learning and development of practice, give way to discussion of unbearable suffering and a final round-up. Overall, with a few more heavily weighted to moral matters, they detail a wide aspect of the development and practice of assisted suicide and euthanasia in Holland to date.

The editors' express the hope that this collection can be an important contribution to what is mostly (in my view) a polarising, low-level public debate, more often run on high emotion than facts, or deep questions about, say, the importance of life. Whatever position one takes on this vexed subject of euthanasia and assisted suicide, rendered as ‘EAS’ in this volume, at least it confirms the subject is a far more complex matter than is reflected in that public debate. Thus the editors' aspiration may be frustrated by a limited community of readers, and there is this rider: the collection has not ‘seen off’ some of the legitimate concerns raised in opposition to legal validation of such practices.

Several articles, for example, offer defences against the charge of a ‘slippery slope’ (once legalised, euthanasia is inexorably extended to those for whom it was never intended). Sauer and Verhagen, for example, argue there is no such incremental extension in the practice of the Groningen Protocol allowing euthanasia of severely disabled neo-nates. They do not consider the possible view that the protocol is already, of itself, evidence of that extension.

That authors are defensive of something they believe in is not a reason for dismissing the content of their arguments. However, neither is seriousness a reason for accepting those arguments or their consequences. The collection requires close reading to determine which, if any, of the views might stand up to scrutiny.

Chabot discusses the voluntary refusal of food and fluids (VRFF) as an option which can lead to a ‘humane’ death, given certain palliative interventions. (It has been one of the more emotive cornerstones of pro-euthanasia lobbyists that death by starvation, and particularly dehydration, is always a most cruel fate.) Chabot was found guilty but not punished by the Dutch Supreme Court after he assisted the suicide in 1994 of a woman who was not ill, though deeply grieving. Nearly twenty years on, he feels able to write that it is ‘within his professional duty’, ‘whether a patient has asked for it or not’, to advise anyone who ‘show[s] any interest in...a good and dignified death’ how to manage dying by VRFF. This is intended as an alternative for those who ‘do not qualify’ for EAS under Dutch law: he does not see any difficulty here, or whether his own practices might encourage, or even incite people who might be wondering, but with little or no real intention, to commit suicide by this method.

Yet, at time of writing (January 2014), Chabot has entered into the public debate about a mobile end-of-life clinic which has euthanized psychiatric patients who had ‘run out of options’ to meet their self-determined demands for euthanasia. Chabot argues the euthanasia of these psychiatric patients depends on a flaw in Dutch legislation which does not distinguish the psychiatric from the somatic, and therefore the law has been ‘derailed’. (http://www.nrc.nl/nieuws/2014/01/15/psychiater-chabot-euthanasiewet-is-ontspoord/)

As several articles in the collection point out in Holland, the doctor and person dying are supposed always to have a close personal relationship; and self-determination was not key to changes in Dutch law (the notion of a ‘right to die’ is nonsense in any case). Apparently, patients and practitioners cannot have formed such relationships in the practices of this ‘end-of-life clinic’, and regardless of intent, ‘claims’ for self-determination and ‘autonomy’ inevitably appear and have come out as a matter of practice in Holland, once the fatal step of passing permission to end lives into law was accomplished. Since neither outcome was the intention of Dutch law, they must therefore be extensions of it. Legalising EAS must always bring that generality which allows those whom the law does not consider as appropriate candidates for EAS, to ‘claim’ their specious ‘right’ to have an assisted suicide or euthanasia. That is the ‘slippery slope’ in action.

Youngner is already prima facie at odds with those authors arguing there is no such extension: ‘opponents argued we were heading down a slippery slope...They were right. Once we accepted the notion that death could be the least worst alternative...it was a matter of time until we considered the lethal injection.’ (xx)

Co-editor Kimsma takes a similar starting point, the ‘conviction that people at the end of their lives should not suffer unnecessarily’, which led him to ‘end the life’ of a patient in 1977 three years after he qualified. (xv)

While Kimsma authors or co-authors four chapters, we hear no more from Youngner directly. I would have preferred to know how he deals with the fact that EAS makes him ‘psychologically (or culturally) uncomfortable’, whilst still being ‘intellectually comfortable with its moral logic’. (xx)

Both their stated positions demand deeper moral questions.

In den Hartogh's analysis of ‘the underlying morality of ...Dutch law’ as providing a framework for assessing ‘the success of the system’ he finds that morality to be ‘completely traditional’, founded on a principle of mercy (again, rather than self-determination), and which does not conform to any revision of commonsense morality, whether proposed by Dworkin, Singer or any other philosopher.

It is not his purpose to explore their thinking directly, but perhaps it might have been, given the special position some philosophers have taken in driving the radical change of mind-set that some people might be judged as candidates for elimination; then to ‘help’ those people to die, even if at their own request, or sometimes take their life when no consent is possible.

EAS changes the fundamental nature of the relationship between the person dying and their doctor, which is a complex power relationship and demands patient safety as one of the fundamental principles of good clinical governance. But the collection does little, for example, to keep reminding us that taking the life of a human being is always a terrible matter. The preferred stance remains the indefeasibility, self-evidence, of ‘this person would be better off dead’.

This mind-set, once embraced as fully as it has been in Holland, allows little room for self-reflexive or retrospective questioning of the starting point, and facilitates the (false) move from ‘this person...’ to ‘all people like them...’. The criterion of ‘unbearable suffering’ is king, even though it is admitted at various points in the volume that the phrase bears interpretation and should be the subject of proper debate.

Den Hartogh, at least, draws out the question of whether it is ‘loss of meaning’ (rather than dignity) which constitutes such suffering as pushes people towards EAS. He thinks it is ‘fully possible to be mistaken’ about whether one has lost dignity vis-a-vis other people, so there is ‘no good reason for supplementing the requirement of unbearable suffering by loss of dignity’, a current vogue. (384) It is tantalising to glimpse some understanding that loss of dignity is, for example, only ignorantly equated with say, help in toileting. (If that were true millions of disabled people could have no dignity.)

Kimsma and Clark argue for a development of the close personal relationship between patient and doctor into ‘medical friendships’, employing ‘compassionate objectivity’ (sic). In their discussion of the ‘powerful unconscious thoughts’ and emotional conflicts that affect practitioners in their moral decision-making about euthanasia requests, they acknowledge that some physicians might be unsuited, given the possibility that ‘pettiness, callousness, laziness and neglect’ can all be features of daily medical practice. But though their sample was small, they still count this as exceptional: most doctors, in their opinion, can enter into these model friendships, despite deep moral dilemmas experienced by practitioners. They agree that the Dutch maintain ‘tremendous trust’ in their health-care system, but do not draw out the implications about whether patients should be so trusting, or what should happen if people realise that trust is/was misplaced.

Throughout the historical, socio-political discussions there is approbation, sometimes pride, in Dutch openness and the other conditions (e.g. coalition politics) which allowed the restraints against killing people to develop into a new practical ethics.

But there is no thinking about whether that pride is misplaced, whether thinking what was previously morally unthinkable is itself a proper thing to do, whether there is an underlying arrogance or even just some missed steps. In 1963 Rush Rhees wrote, we cannot say, in any general way, that ‘a life of unmitigated suffering can have no point at all’. This consideration, counter to the jumping-off point for enthusiastic contributors, is entirely absent here: in all fairness, it is absent from most discussions of EAS.

Questions about the value or importance of life are very difficult, but taking arguments ad absurdum as convincing, simply accepting a general conclusion that killing anyone who suffers unbearably is the only, right thing to do, cannot answer those deeper questions. This is especially true when, as acknowledged by several authors, there is no clarity in the idea of ‘unbearable’ suffering. When it is directly discussed at all, pain is generally taken to be a sensation with several caveats (throbbing, acute): but saying ‘pain is a sensation....’ tells us nothing at all about the concept of pain, and simply moves any questions one step backwards, so cannot help us decide questions about unbearable pain or suffering. The failure to get to these underpinning philosophical questions persists. Rush Rhees makes another important remark in this context, that just because we can intervene, does not mean ending suffering is ‘like getting off a bus’.

Not everyone is convinced the Dutch experience is without flaws: Esther Pans makes the important observation that the ‘Dutch “lesson”...must be thoroughly reconsidered before it can be applied elsewhere’ (71) since those changes in Dutch law rest on the social and medical preconditions peculiar to Holland beforehand and since. She has some insights into problems for practitioners in what to count as suffering, and how personal experience of pain can muddy the waters between what stands as a ‘well considered’ request when unbearable suffering is deemed present in the individual.

But then again, not everyone avoids shallowness. Margo Trappenberg offers the following:

Pity for the rest of us.

Also, without noticing the conflation and confusion of the ‘velvety pillow’ death she describes and the reality of choking to death on a cocktail of poison, or lethal drugs administered ‘by the needle’, and with no hint of irony, she has the collection's last word:

Smug indeed. A warning for the rest of us.