Journal ofMedical Ethics 1996; 22: 183-189

Book reviews

The Least WorstDeath

Margaret Pabst Battin, New Yorkand Oxford, Oxford University Press,1994, 305 pages, £30 hb, £14.95 sb.

English speakers have only one wordfor self-killing: suicide. Germans havefour: the traditional terms Selbstmord(self-murder), Selbsttotung (self-killing), the scientific term Suizid andthe literary Freitod (free or voluntarydeath). The first two have negativeconnotations, the third connotationsof mental illness. The last, Freitod,has positive connotations, beingadmirable and even heroic (page 264).As Battin puts it, "[i]t is associatedwith voluntary individual choice andthe expression of basic, strongly heldpersonal values or ideals, especiallythose running counter to conventionalsocietal norms, and suggests thetriumph of personal integrity in theface of threat or shame" (page 261).The term itself dates from Nietzsche,but the idea goes back to the Stormand Stress movement in Germanliterature, in particular Goethe's TheSorrows of Young Werther (page 262)."Freitod itself is conceived of as an

individual, intensely personal, andthus characteristically solitary act ....

Nor does the German term suggestthat one would be guided in one'sdecision by professionals or familymembers. It is an act in which one

insists on choosing a different, indi-vidual course contrary to ordinaryexpectations; it is in this sense that it isa 'free' death. This has its advantages:almost by definition, Freitod cannotbe socially 'expected', required bypolicy, advised by counsellors, or inany other way the norm, and hence itmay be more resistant to abuse" (page265). The Least Worst Death is aboutFreitod.

Understanding euthanasia beginswith understanding suicide. If that isso, Margaret Pabst Battin is singularly

placed to write on euthanasia. Herbook, Ethical Issues in Suicide, pub-lished in 1982, is a classic. Twochapters from it are included in thiscollection of 14 essays writtenbetween 1977 and 1992. The LeastWorst Death comprehensively coversthis important philosopher's views onsuicide and euthanasia. For anyonewith an interest in ethical issues at theend of life, this volume is essentialreading.The essays cover a variety of issues

surrounding the end of life but severalthemes weave through the book. Firstand foremost is the view that a desireto die can be rational. Rational desiresare "autonomous, informed, stable,considerate, uncoerced and in accordwith [a person's] basic valuesIrrational desires are "ill-considered,incoherent, unstable, misinformed,rooted in depression, unrealistic"(page 275). In "Assisting in suicide:seventeen questions physicians andmental-health professionals shouldask", Battin provides a practical list ofquestions aimed at examining therationality of a person's desire to die.

Battin argues that we have a basic,fundamental right to kill ourselves akinto the right to life, liberty, freedom ofspeech and worship, education, politi-cal representation and pursuit ofhappiness (page 279). These otherrights are rights "to do certain thingsjust because doing those things tendsto be constitutive of human dignity"(page 280). Sometimes, Battin argues,dignity requires that a person end hislife ("Suicide: a Fundamental humanright?").

Battin shows more reserved supportfor active voluntary euthanasia. Thissupport derives from three relatedconsiderations ("Euthanasia: the fun-damental issues"). Firstly, mercysometimes requires euthanasia. Somelives, she claims, are racked byunrelievable pain. While such peoplecould be sedated to the point ofunconsciousness, this, she argues, istantamount to causing death.

Secondly, if we are to respectpeople's autonomy this will sometimesrequire the practice of euthanasia orassisted suicide. Battin points to thewell established right of patients torefuse life-saving treatment, that is,passive voluntary euthanasia. Thisright is grounded in respect for auton-omy. But "full autonomy is notachieved until one can both choose andact upon one's choices" (page 112). Insome cases, patients may choose to dieby active means but not have theknowledge or access to methods toeffect this choice. Respect for auton-omy then requires physicians to helppatients achieve easy, painless death.The third argument for a policy of

permitting euthanasia is that sucheuthanasia can promote distributivejustice. There is a separate chapterdevoted to this theme: "Is there a dutyto die? Age rationing and the justdistribution of health care". Battinargues for "voluntary but sociallyencouraged killing or self-killing of theelderly as their infirmities overcomethem" (page 76). Some of Battin'spredictions appear grim. She seesmany services to the infirm elderlybeing restricted: "CAT scans orMRIs, renal dialysis, organ trans-plants, hip replacements, hydrother-apy, respiratory support, totalparenteral nutrition, individualisedphysical therapy, vascular grafting,major surgery" (page 64). Even hospi-talisation and hospice care might go.The important premise in Battin's

argument is that spending money onthe elderly is inefficient. The youngbenefit more. If patients were allowedto cut short their lives when deathbecame foreseeable due to illness, thiswould free up considerable resourcesfor more effective deployment atearlier stages of life. This wouldmaximise each person's chance ofreaching a ripe old age.

If this is the justification, the prac-tice is not age-rationing at all. It isrationing according to cost-effective-ness. Indeed, Battin rejects a fixed age

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limit. Rather, she advocates thatresources be restricted as oneapproaches death. "It is not old ageitself which is medically expensive; it isthe last month, six months, or year ortwo of life. Variation in costs and effi-cacy of treatment are not so much afunction of time since birth as time todeath" (page 75). This argumentrequires that care to the young berestricted when that care has littlechance of success. Battin, invoking a"veil of ignorance", argues that wewould not spend money on severelydefective neonates or catastrophicallydamaged accident victims (page 62).This, however, is a consequentialistargument about maximising benefits,together with the premise that theelderly near death often do not derivemuch benefit from more medical care.On reflection, it is not so frightening.It is an application of currentlyemployed health economic principles.

A problem-oriented approachThis collection is particularly timely.Battin writes, "[M]any observers arepredicting that euthanasia willbecome the social issue of the nextdecade" (page 163). While this claimis a little hyperbolic, our practices arechanging. In November 1994, citizensin Oregon approved The OregonDeath with Dignity Act which permit-ted physician-assisted suicide (PAS).This has been subject to a legal chal-lenge. The Northern Territory inAustralia has just passed the first legis-lation in the world legalising activevoluntary euthanasia (AVE).But Battin's work is timely in

another way. Battin is not only a goodphilosopher, she is a practical philos-opher. She adopts a problem-orientedapproach to bioethics, selecting aspecific issue and always attempting toprovide circumspect and reasonedsolutions. For example, in "Fiction asforecast: euthanasia in Alzheimer'sdisease?", Battin finds that traditionalphilosophical approaches (from theperspectives of mercy, autonomy andjustice) fail to provide a definitiveanswer as to whether we should pro-long the lives of patients withAlzheimer's. Battin claims that whenthe stakes are high, sometimes socialpolicy cannot "wait for philosophersto sift through these questions" (page152). She turns to novel thoughtexperiments to help people to decidenow for themselves whether theywould want to be treated in such astate. In "The least worst death", thefirst essay, Battin shows how unin-formed refusal of medical treatment

can lead to a painful or undesirabledeath. She then explores the waysphysicians can help patients to choosethe best available death by exercisingtheir right to refuse life-sustainingtreatments within current law.

Students and many philosopherscan learn from Battin's practice ofconsidering the strongest version ofher opponent's objections. Foremostin her mind are the slippery slopearguments that permitting euthanasiawill lead to abuse. Indeed, in"Voluntary euthanasia and the risks ofabuse", she claims that "it is morallyresponsible to advocate the legalisa-tion of euthanasia and assisted suicideonly if one can conscientiously argueeither that abuse would not occur orthat it could be prevented" (page165). She offers a range of thoughtfulsuggestions to prevent interpersonal,professional and institutional abuse.An interesting and effective strategy

employed by Battin to examine howassistance in dying works in practice iscross-cultural comparison with coun-tries with more liberal aid-in-dyinglaws. In "A dozen caveats concerningthe discussion of euthanasia in theNetherlands", Battin examines theDutch practice of tolerating AVE. Sheis critically sympathetic to the Dutchsystem, but illustrates the significantproblems of instituting a similarsystem in the US because of differentrelationships with primary care, differ-ent levels of universal health insuranceand social equality, and different legalsystems.

In "Assisted suicide: can we learnfrom Germany", Battin offers a fasci-nating historico-linguistic analysis ofsuicide in Germany. Germans have adifferent attitude to suicide thanEnglish-speakers, reflected in the con-cept of Freitod. Germany permitsassisted suicide but not AVE. Althoughassisting suicide is not illegal, physi-cians in Germany are rarely involvedbecause they have a conflicting legalduty to rescue their patient. "Fear ofeuthanasia and suspicion of authoritar-ian physicians" result in most suicideoccurring in private. Suicide wasassisted by the German Society forHumane Dying, DGHS, until arecent scandal involving cyanide-profi-teering by the founder. The challengepresented by the German system is:what should be the role of the physi-cian in assisted suicide?The very notion of "rational sui-

cide", Battin argues in "Manipulatedsuicide", invites abuse. Unremittingpain in the face of terminal illness is areasonable ground for suicide. But

"[o] ld age, insanity, poverty, andcriminality have also sometimes beenregarded as grounds for rationalsuicide in the past; given a societyafraid of demands from increasinglylarge geriatric, ghetto, and institu-tional populations, one can see howinterest in producing circumstantialand ideological changes, in order toencourage such people to choose the'reasonable' way out, might be verystrong" (page 200). We are caught onthe horns of a dilemma. If we admitthe concept into ordinary use, we willadmit the possibility of manipulation.If we don't admit the concept, we willbe linguistically ill-equipped to allowindividuals in intolerable circum-stances to die. The second is worsethan the first, Battin claims, so weshould admit the concept.

PAS v euthanasiaI began reading this book firmlybelieving that euthanasia should belegalised. I finished less sure. This is aresult of the even-handedness ofBattin's approach. Throughout TheLeast Worst Death (chapters 5, 6, 12),Battin provides arguments for thepreferability of physician assistedsuicide (PAS) over active voluntaryeuthanasia (AVE). Battin wouldreserve non-voluntary euthanasia onlyfor those cases in which a patient is"permanently comatose or otherwiseirretrievably inaccessible" (page 123).The argument is based on the privi-

leged position of the patient to knowthat her suffering is worse than death.A physician may misinterpret whather patient is saying. This, togetherwith the risk of manipulation andcoercion, suggests that patientsshould initiate the choice to die (page123). The physician should check forevidence of mental and emotionaldisturbance, and whether pain andapproaching death are present (pages123-4). Physician assisted suicide hasother advantages. It requires lessinstitutional change and lessens thepossibility of development of stan-dardised routines. It would slow theslide down the slope of involuntary"thrift-euthanasia".This is one of Battin's most import-

ant conclusions. Although sympa-thetic to the reasons for AVE, I havewondered why we need such practicewhen patients can kill themselves.One objection not considered in detailby Battin is that some people are sodebilitated that they cannot kill them-selves. However, virtually any compe-tent person can swallow a cyanide pill.If death is unpleasant by this means,

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once the pill has been swallowed, thepatient could be assisted with sedationor anaesthesia. Perhaps some patientscannot swallow. We could limit AVEto these patients. But in the context ofcompetent patients communicating adesire to die (the battleground ofAVE), such patients could communi-cate a desire to refuse food and water.Once they had clearly decided to dothis, there is much that medicine cando to support them during the dyingprocess. But it is central to PAS, asBattin stresses, that the patient initiatesthe train of events that lead to death.

Battin's argument is empirical,based primarily on worries aboutabuse. There are other conceptualreasons for preferring PAS to AVE.The matter of whether one lives ordies should be settled by oneself. Ifone chooses to be killed, it is oneselfwho should do the killing, or at leaststart it. There are various ways of sup-porting these claims. One route is toclaim that getting another to kill one-self is not self-rule, but rule byanother. Active voluntary euthanasiafrustrates autonomy; PAS promotesautonomy. To be sure killing one-self is difficult. But in other difficultdecisions in life, autonomy requiresdoing the difficult things oneself. Apatient who handballs responsibilityfor his death to his physician shirks aduty to himself.

Consider a parallel betweenpatient-physician and physician-nurserelationships. It might be argued thata physician who delegates to a nursethe administration of a lethal dose ofmorphine to a terminally ill patientavoids responsibility. He should givethe lethal injection himself, as doctorsin the Netherlands do. This view iscontentious. In a health care team, inwhich each member knows the patientand the decision is a shared one, itmay be appropriate for a nurse to givethe injection, if she is willing. But adoctor would be avoiding responsibil-ity if he made the decision to end thepatient's life and asked a nurse to per-form such a procedure without awritten order. He must act so as to setthe ball rolling. In the patient-physi-cian relationship, it is the patient whomust perform this initial act. We needa reliable signal of resolve. That signalis action. As a reliable barometer ofresolve, actions speak louder thanwords.

Making choicesAnother major theme that percolatesthrough several essays is that patientsshould make choices when they are

competent about when and how theywant to die. Battin objects to ourpassive acquiescence, accepting the"favourably regarded" progression todeath: aggressive initial treatment,followed by palliative care, withdrawaland withholding of care and finally donot resuscitate orders. "Dying in 559beds: efficiency, 'best buys', and theethics of standardisation in nationalhealth care" argues that both nationalhealth services and free marketsystems preclude a person "having adeath of one's own". It is only when aperson makes active choices aboutdeath that death can be good for theperson whose death it is ("Euthanasia:the fundamental issues").

Active choice has other advantages.We have already seen how makingchoices to limit treatment would savescarce resources. It would also facili-tate altruism. As patients becomeincompetent, they are treated accord-ing to what is in their best interests.Yet if they were competent, theymight make altruistic choices. Theymight choose to die earlier for thesake of their family or others. Such analtruistic choice cannot be made bysurrogates. Hence, not making one'sown choices during times of compe-tence precludes altruism ("Theeclipse of altruism: the moral costs ofdeciding for others").An important instrument of active

choice is the advance directive. Battinexpresses reservations about these(pages 161-2). However, she arguesthat completing an advance directiveis the most realistic way of limitingtreatment to patients with Alzheimer'sdisease.

Valuing the lives ofcompetentpatientsIf we are to permit assisted suicide orAVE, we need a clear procedure forvaluing the lives of competentpatients. We need a clear sense ofwhohas a good reason to die and who doesnot. What makes continued life goodfor a person? Is the value of life sub-jective, relative to that person's ownevaluation of its worth? Or is it objec-tive, independent of that person's ownevaluation of its worth? On one simpleversion of a subjective conception ofvalue, continued life is good if theperson whose life it is believes that it isworth living. Continued life is of valueon an objective conception if it hassome objective quality, such as thecapacity to experience meaningfuilhuman relationships. My own opinionis that such evaluations must take theobjective perspective. My one major

disappointment with The Least WorstDeath is that Battin is unclear abouthow we should value the lives of com-petent patients. Indeed, at times sheoffers apparently conflicting views.At some points, Battin appears

sympathetic to subjective evaluation.Thus she writes that whether con-tinued life is a benefit or a burden "isa function of subjective preferenceand choice" (page 106). Battin claimsthat "when a suffering person is con-scious enough to have an experienceat all, whether that experience countsas a benefit overriding the sufferingor not is relative to that person andcan be decided ultimately only byhim or her" (page 106). "We cannotobjectively determine whether life is abenefit to a person" (page 107).

Subjective evaluation results in thecollapse of a principle of mercy(beneficence) into respect for auton-omy. If I desire to die, then on a sub-jective conception of the value of life,my life is not worth living. Battinclaims that "... the principle of mercyis conceptually tied to that of auton-omy ..." (page 107). But they are dif-ferent concepts. A person mayautonomously desire some end that isnot good for him. Subjectivists ruleout paternalism by definition: if Iprefer death to suffering, then death isbetter than suffering.The glitter of subjective evaluation

often arises from a conflation of twodifferent questions: (1) what shouldwe do to this person? and (2) whatwould it be best for this person to do?If a person autonomously desires todie, we might not compel her to stayalive. But we can still claim that itwould be better for her to live. What aperson ought to be compelled to do isdifferent from what a person ought todo.

Elsewhere Battin more openlyembraces objective evaluation. Hermost detailed philosophical examina-tion of evaluating a person's desire todie comes in "Suicide: a fundamentalhuman right?". She begins with acontrast between two suicides. One isan 80-year-old woman in a nursinghome who was blind, had metastaticbowel cancer and chronic pain. Theother is a 15-year-old boy whojumped off a bridge because hisfavourite TV programme, BattlestarGalactica, was axed.

Objectivists have no trouble locat-ing a problem with such BattlestarGalactica suicides. The problem isthat the desire is not worth satisfying.Dying because Battlestar Galactica wasaxed is not a good reason to die. Such

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a response is not open to subjectivists.If there is a problem with such a desireto die, the problem has to do with theway the desire is formed.

Battin's analysis of these two suicidesappeals to evaluation of the object ofthe suicide. She differentiates betweentwo kinds of suicide. "'Miolent'suicides [are] desperate, aggressiveacts, that display both contempt andhatred for oneself and for others aswell". The other kind is "nonviolent"suicide. These often involve "cessa-tion" rather than "obliteration andannihilation", are often anticipated andplanned in a purposeful way, are some-times sacrificial to another person orcause, do not seek to punish or retaliateagainst oneself or others, and are oftenout of self-respect (page 284).

Battin's appeal to an objectiveconception of value is in places moreexplicit. The youth's suicide "pre-cludes indefinitely continuing life"while the elderly woman's suicideprecludes "inevitable death by anothermore painful or degrading means"(page 284). The notion of dignity itselfis an objective conception: "... it ... isa notion rooted in an ideal conceptionofhuman life, human community, andhuman excellence ..." (page 280). Theyouth gave up "love, purposeful occu-pation, social contribution, and theattainment of ideals" (page 281). Theelderly woman faced only "humandegradation" (page 282) or loss ofdignity: "increasing debility, depen-dence, financial limitation, loss ofcommunication and affection; increas-ingly poor self-image; increasingdepression, isolation ... blindness andpain" (page 281).

Battin thus appears sympathetic tothe objectivist conception of value oflife. Indeed, it is hard to see how wecould criticise the youth's desire to dieon a subjective conception. The desirecould be rational, in that it could be"autonomous, informed, stable, con-siderate, uncoerced and in accordwith his or her basic values ...". In thesame way as some people believe thatfreedom is worth dying for, thisindividual could, in his own solitaryway, believe that the continuation ofBattlestar Galactica is somethingworth dying for. Of course it is not,and that shows the limitations of thesubjectivist account of value.A subjective conception of value

severely constrains the role of discus-sion and advice at the end of life. Onthe subjective conception, discussionof end-of-life issues is limited to dis-cussion of how a judgment arose,what information was available, how

the person thought about the issues,and so on. It precludes discussionof the person's reason itself - forexample, that the axing of BattlestarGalactica is a very bad thing.

It also fails to take account of thefact that people can be mistaken aboutthe value of their life. We have nohesitation in saying that some lives ofincompetent people are worth living.For example, John has mild retarda-tion but lives a happy and productivelife, has many friends, and so on.Imagine some new treatmentimproves his cognitive abilities. Hebecomes competent. But he now alsomore clearly sees the negative aspectsof his life. He comes to judge it notworth living. The life itself - theexperiences, the relations, and so on-have not changed. Why change ourevaluation of the life? It is moreplausible to say that John is mistakenin his evaluation.

Battin suggests that a person is thebest judge of the value of his life (page107). That may be true. But it doesnot imply that he is an incorrigiblejudge. Nor does it mean that the valueof his life is relative to his own judg-ment.

In places, Battin seems sympatheticto this objectivist view. Thus shewrites, "... [T]he principle of auton-omy is dependent on the principle ofmercy in certain sorts of case" (page111). "When there is no evidence ofsuffering or pain, mental or physical,and no other evidence of factors likedepression, psychoactive drugs, oraffect-altering disease that mightimpair cognitive functioning, an exter-nal observer can accurately determinewhether life is a benefit: unless theperson has an overriding commitmentto a principle or a cause that requiressacrifice of that life, life is a benefit tohim or her" (page I I 1).

However, Battin has reservationsabout full commitment to objectiveevaluation. If a person chooses deathrather than pain, Battin claims that wecannot demand "independent, objec-tive evidence" that death is better thanpain. The incessantly pain-rackedperson is better placed than anyoneelse to make such an evaluation, givenher intimate acquaintance with thepain and her own beliefs and fearsabout death (page 111).

Indeed, Battin appears hostile tothe offering of advice about the valueof life. She has admiration for Freitod,which she describes as "a solitary,profoundly individual choice" (page265). Battin objects to those withterminal disease, severe disability or

old age being directively counsellednot to suicide or be killed (pages174-5, 271-2). She believes coun-selling should be non-directive,exploring a person's desire to die.

Battin could be interpreted asclaiming that an individual is oftenbest placed to make judgments of thevalue of his own life. He should beassisted to make the best judgmentpossible. Advisors should be aware oftheir own limitations in determiningthe relevant features of a person's par-ticular situation. However, if this isher argument, it is not an argumentagainst directive counselling per se,but against ill-founded or overambi-tious directive counselling.Although decisions at the end of life

are deeply difficult, we do believe thatthere is a place for directive adviceabout whether to live or not. A rebelcaptured by a vicious, suppressiveregime might be given a cyanide pill bya sympathetic guard. "Tomorrow, youwill experience unspeakable tortures,"the guard explains. "You should takethis pill now. You will be better offdead." Such advice is not out of placeand may be right. Sometimes, othersdo know what is best.

Free choice need not be solitary.One's death is not unfree if onereceives considered counsel, advice orargument about what is best. Indeed,to make a fully rational choice or achoice which is positively free, oneneeds to evaluate not only informa-tion, but the arguments of others as towhich is the best course. Perhapsrationality does not require that aperson agree with others, but it doesrequire that he at least consider theplausible arguments of others.

Battin is concerned that people willbe manipulated into killing themselvesby others promoting objective idealsof the worth of life, or "ideologicalmanipulation". This concern shouldnot be so great as to push us to sub-jectivism. The promotion of an idealdoes not necessarily constitute manip-ulation. It can constitute good advice.Many people now have an ideal ofphysical fitness, but that does notmean that they have been manipu-lated into valuing physical fitness.

Moreover, on some conceptions ofvalue, people may become convincedthat they were mistaken in wanting todie and that their lives are really worthliving. (The sanctity of life doctrine,although I do not support it, is anobjective conception of value.) Battin'sconcern about such abuse seems morejustified on some conceptions of objec-tive value rather than others.

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Such ideological manipulation ismost likely when objective evaluationis incomplete. Manipulation is some-times based on the invalid move from"Xness in life is a good reason to die"to "Xness in life makes life not worthliving". Extreme pain is a reason todie, but it does not necessarily makelife not worth living. Other features ofthat life may provide stronger reasonsto live. Severe disability is a goodreason to die; but it does not neces-sarily make life not worth living.

Evaluation of the quality of life of acompetent person's life is not relativeto that individual's own judgments ofthe worth of that life. It is in this sensenot subjective. It is in important waysobjective. Battin displays loyalties toboth camps, though her view is com-plex. I have not addressed Battin'sapproach to valuing the lives of non-competent patients ("Fiction asforecast: euthanasia in Alzheimer'sdisease?"). That also seems to meproblematic. My hope is that Battinwill clarify her approach to valuing lifein the future.

ConclusionA book that fails to stimulate discus-sion is unlikely to be saying anythingsignificant. This book says much thatis significant, and there is much moreto praise than to criticise. It is a fineexample of scholarship, a richresource of historical and contempo-rary examples, and US case law. Forthe second time in a decade and a half,contemporary bioethics owes a debt toMargaret Pabst Battin.

JULIAN SAVULESCUSir Robert Menzies Medical Scholar,

Clinical Ethicist,JYohn Radcliffe Hospital,

Oxford

Concepts andMeasurement ofQuality of Life inHealth CareEdited by L Nordenfelt, Dordrecht,Kluwer Academic Publishers, 1994,283 pages, £58.50.

In the introductory essay to this editedcollection Lennart Nordenfelt sug-gests a number of questions, amongstwhich are the following: what is thepurpose of measuring quality of life?;is its aim to determine the extent towhich resources should be allocated,for example, to health care in general,

or to some patients rather thanothers?; or is it instead to be used tomeasure the relative success of dif-ferent medical interventions?; giventhe relevant aim(s), which aspects ofindividuals' lives bear upon theirquality of life?; and, finally, howshould the values and tastes ofindividuals, as patients or voters, fig-ure in the selection of those aspects?Such questions have considerablephilosophical interest, and should bematters of urgent political concern.Each contribution to the collectioncontains views relevant to some or allof these questions. They are, withoutexception, thoughtful and seriousdiscussions, though philosophicallyinformed readers may find much ofthe territory they traverse familiar.The volume is divided into three

sections, the first of which addressesthe concept of quality of life in general,and contains essays by E Ostenfeld,P Cattorini and R Mordacci, P Liss,T Moum and S Naess, as well as theeditor himself. The second beginswith a sociological essay, by M Bury,suggesting reasons why quality of life isnow so widely discussed amongst stu-dents ofhealth. It is followed by papersfrom A Fagot-Largeault, P Sandoeand K Kappel, and A Musschenga.These examine specific ethical prob-lems arising for judgments about qual-ity of life in the context of health care,and include one particularly illuminat-ing account of how changes in anindividual's preferences might bearupon changes in her health status. Thethird section contains papers by RFitzpatrick and G Albrecht, S Bjorkand P Roos, A Aggernaes and MKajandi, and focuses on problems ofmeasurement. These are not, how-ever, merely technical investigations,but include, amongst other things, avery helpful discussion of the moralproblems involved in extending qualityof life measurement to various deci-sion-making contexts in health care.One of the collection's prominent

themes concerns the extent to whichstandards of interpersonal compari-son should depart from the objectivedimension of individuals' lives, con-cerning their biological functioningand basic capabilities, and encompasssubjective aspects, such as the extentto which their lives are successfulaccording to their own lights. Giventhe centrality of this problem, morereference to post-Rawlsian criticismsof so-called welfarist metrics, whichfocus on preference satisfaction,would have been welcome. For manycontemporary political philosophers

argue that whilst subjective standardsare appealing for liberal reasons(since they lessen the need to rely oncontroversial judgments about whatgoods individuals should care about)they may be deficient for otherreasons; for example, because of theexistence of malformed or expensivetastes.The absence of reference to such

discussions is indicative of a moregeneral feature of the collection,namely the extent to which it tends totreat judgments of health-relatedquality of life in a normative vacuum.Although references to utilitarianismare quite widespread, it would havebeen desirable to explore the way inwhich different conceptions of qualityof life might be embedded in distinctmoral and political theories concern-ing the just distribution of health care.That omission is striking given that, asnoted, Nordenfelt himself suggeststhat one of the reasons to measurequality of life is concerned withresource allocation. Readers inter-ested in those issues would do betterto consult the very useful collection byNussbaum and Sen.'

References1 Nussbaum MC, Sen AK. The qual-

ity of life. New York: ClarendonPress, 1993.

ANDREW WILLIAMSDepartments ofPhilosophy,

and of Politics and InternationalStudies,

University of Wanwick

Primum non NocereToday: a Symposiumon PaediatricBioethicsEdited by G Roberto Burgio andJohn D Lantos, Amsterdam, ElsevierScience BV, 1994, 175 pages,US$ 142.75, 250 DFL

This book is an edited record of theInternational Symposium on PaediatricBioethics held at Pavia in May 1994.Eleven (including paediatricians, anacademic lawyer, an anthropologistand three bioethicists), of the maincontributors were from Italy. Twocontributors came from Chicago,and one each from France, Germany,the Netherlands and the UnitedKingdom. The proceedings make astimulating and enjoyable if ratherexpensive read.

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