The theme starts in the first conversation between main characters John Amherst, a mill operative, and Justine Brent, a nurse, about the condition of a mill hand about to lose his forearm after an accident on the job:
"And what will the company do for them when the wife is a hopeless invalid, and the husband a cripple?"Later in the novel, in a typical Wharton twist, Amherst's wife Bessy is paralyzed from the neck down in a riding accident, and Justine is her nurse. She consults a clergyman, a doctor, and a lawyer, all men, who all assure her that hastening Bessy's likely end would be wrong. Bessy's pleas, and the memory of that earlier conversation with Amherst, still convince Justine to administer the overdose of morphine. She never denies the act, but she doesn't tell Amherst or Bessy's family either. When they learn of it, she is effectively banished from the family. Far from approving assisted suicide for his own kind, Amherst is horrified by the fact--it's right for a mill hand who loses his arm, in his calculation, but not for a wealthy woman who becomes paralyzed.
Amherst again uttered the dry laugh with which he had met her suggestion of an emergency hospital. "I know what I should do if I could get anywhere near Dillon--give him an overdose of morphine, and let the widow collect his life-insurance, and make a fresh start.[...] In your work, don't you ever feel tempted to set a poor devil free?"
She mused. "One might...but perhaps the professional instinct to save would always come first."
"To save what? When all the good of life is gone?"
"I daresay," she sighed, "poor Dillon would do it himself if he could--when he realizes that all the good is gone."
"Yes, but he can't do it himself; and it's the irony of such cases that his employers, after ruining his life, will do all they can to patch up the ruins."
There are a few elements of the story that are of their era: Bessy's pain cannot be managed effectively, and she has one of those plot-friendly injuries that are both immobilizing and intensely painful, and still allow her to speak. There are no surgical or therapeutic options for her, either, although her scientific young doctor is fascinated by the "case," and hopes that he can keep her alive for a long time, at all costs, just to prove his theories and prowess (the doctor is abusing morphine himself). There's no real medical "system" at work: the doctors and nurses who appear are all hired and paid by the patient's family directly, and visit the patient at home--no hospital, no insurance, no ethics committee in sight.
And most critically, Bessy's personal autonomy is disregarded, because she is a woman. She has a living father and husband, and their word carries more authority than her own in serious matters; her wealth also complicates the situation. Justine feels justified in obeying Bessy's desperate pleas, in part, by a New Woman's sense of female solidarity. As Donna Campbell writes in the introductory notes to the 2000 edition from Northeastern University Press,
Defined as a rich woman whom Amherst has never been able to wean from the position of social parasite, Bessy is already, according to the laws of class and consumption, a useless body. Thus Bessy's accident intensifies but does not fundamentally transform her status, a status that according to the laws of class validates the right of the rich to be useless....Justine exposes the unwritten explosive principle that science or its representatives may kill the useless body of the poor but not of the rich. [xxvi-xxvii]The central section of the book, from the time of Bessy's accident to the moment of her death, is packed with discussions about bodies, and quality of life, and modern medical advances, and the responsibility of nurses and doctors. The plot was apparently inspired by Wharton's upset after a woman friend was paralyzed and died months after an accident, in pain similar to what she assigned to Bessy. This real-life counterpart is discussed at length in the big brand-new (2007) Wharton biography by Hermione Lee.
The last section of the book is aftermath--this isn't an assisted suicide tale where the death is the end of the story, a solution for all concerned. Instead, it's a moment that continues to haunt and twist and nearly destroy the survivors. It's not hard to see where Wharton's sympathies lie (Justine Brent is, after all, an almost too-perfect heroine), but she gives the subject a complex, unsettling treatment anyway. For that, the novel should be read and discussed. Even a hundred years later.