C.G. Prado: Choosing to Die: Elective Death and Multiculturalism.

Stewart, Robert Scott

C. G. Prado

Choosing to Die: Elective Death and Multiculturalism.

New York: Cambridge University Press 2008.

Pp. 224.

CDN$88.95/US$85.00

(cloth ISBN-13: 978-0-521-87484-7);

CDN$24.95/US$23.95

(paper ISBN-13: 978-0-521-69758-3).

This work extends Prado's earlier book, The Last Choice: Preemptive Suicide in Advanced Age (1990/1998), on the rationality of ending one's life. In both works, Prado insists that the moral permissibility of suicide (and, by extension, of assisted suicide and euthanasia) rests first on determining the rationality of suicide. But proving the rationality and hence moral permissibility of ending one's life has become more problematic in our postmodern age, which is dominated by multiculturalism and relativism. The problem these positions present, according to Prado, is that they relativize rationality itself to particular cultures, thus making cross-cultural claims about the rationality of ending one's life impossible. 'Contrary to this view, the book's objective is to articulate cross-cultural criteria to determine when ... [choices to die by a variety of means] are rational and hence possibly socially, morally, and practically permissible options, and when each is chosen on the basis of sound reasoning and acceptable motivation' (12).

Prado distinguishes between four types of suicide and euthanasia: preemptive suicide, surcease suicide, assisted surcease suicide, and requested or voluntary euthanasia. This taxonomy is not commonly used and hence requires explanation. Essentially, the distinctions are based on deteriorating health over time with the concomitant consideration of what one is capable of doing oneself. Think, for example, of the famous Canadian case of Sue Rodriquez. Shortly after being diagnosed with amyotrophic lateral sclerosis she petitioned the Canadian courts to be allowed assistance in her suicide at that time in the future when her disease would make it impossible for her to commit suicide on her own. If she had committed suicide before she began to feel the effects of her disease, but in anticipation of them, this would be a case of preemptive suicide. Had she waited longer, when she began to feel its effects but was still capable of committing suicide on her own, she would have committed surcease suicide. Assisted surcease suicide was actually what Sue Rodriquez requested (and eventually did despite loosing her court case), namely, 'suicide deliberated and done with help when a condition advances to a point where the individual is incapacitated to a significant degree' (29). Requested or voluntary euthanasia would have occurred later when she was so disabled that she could not have committed suicide even with help and had to have her life ended by another.

Prado makes these distinctions in part because he believes that passing the bar set by the 'rationality criterion' can be given more 'latitude' as we pass from preemptive suicide to, eventually, requested or voluntary euthanasia (Ch. 8). That is, very loosely speaking, the burden to prove that one's decision is rational is weightier for preemptive suicide than it is for euthanasia, because 'one's interest in survival declines in importance' (177) as one becomes more debilitated and closer to death. The distinctions are also made, however, because, as Prado says he came to see only after publishing The Last Choice, '[preemptive suicide is mainly the suicidist's own business, and so neither a social nor professional concern on the order of surcease or assisted surcease suicide considered and committed while under medical care' (5). I'll return to this point below.

The 'rationality criterion', which Prado discusses over several chapters, is ultimately formulated as follows: 'Autonomous self-killing as release from terminal illness is rational if the decision follows validly from true premises that include the pertinent facts and enacting it is judged in cross-cultural dialogue not to override interest in survival unduly' (132). Prado hopes that his criterion will allow a respect for difference between cultures while maintaining that cross-cultural assessment is possible. Briefly stated, he thinks we can do this by recognizing first that much of what is put forward as facts by people are actually culturally based beliefs. The rationality criterion requires that facts and beliefs be clearly differentiated and that only actual facts are put forward as such. Second, only people who can 'accept the priority of deliberatively established cross-cultural principles over their own culturally determined beliefs and values' (132) are allowed to be 'judges' in 'cross-cultural dialogue'.

There is much of interest and value in this approach to the morality of euthanasia and assisted suicide. Prado's rationalistic approach does raise some overarching issues, however. First, consider again Prado's claim that preemptive suicide is 'mainly the suicidist's own business'. In insisting that surcease suicide, assisted surcease suicide, and requested or voluntary euthanasia need to be rational in order even to have their moral acceptability assessed, Prado loses sight of the private nature of choosing one's own death, by whatever means. In classic liberalism, this means that one doesn't have to defend the rationality of one's decision: one has, in liberalism, the right to make bad choices over actions that concern him or herself primarily. Of course, assisted suicide and euthanasia involve others in one's actions and hence aren't private in quite the same way that killing oneself is. But neither is abortion purely private either since one can't perform an abortion on oneself: and yet we don't require that women prove that their decision to have an abortion is rational before it is determined whether it is morally permissible in her particular circumstances.

Finally, it is unclear to whom this book is addressed. In the Preface, Prado discusses the disappointing reaction he received from medical clinicians when he presented his ideas about end of life issues at a conference. In general, they thought that his work was not relevant to theirs and that his material was far too abstract (ix). Prado claims that this book was written in part as a response to those criticisms. In this, I think he has failed: whatever its merits --and it certainly has some--it will not appeal to health care practitioners working in the field. It is simply far too removed and abstruse for that. This is especially true as the physician-patient relationship has become less paternalistic. While health care workers need to ensure that their patients have sufficient information to make autonomous choices, they tend now to think that it is not their job to evaluate the value-laden choices of their patients.

Robert Scott Stewart

Cape Breton University