Assisted dying – yes or no?

by Joseph Markus

This is a debate that has been re-ignited following the publication of a report by the Commission on Assisted Dying recommending a change in the law to decriminalise assisted suicide. The Commission recommends putting on a statutory basis a procedure by which those who are terminally ill—some have suggested a much broader group should be included—are able to receive assistance in dying.

The debate is one that has suffered from caricatures on both sides.

There may be some truth to the fear that older relatives may be bumped off—either directly or indirectly—by a younger generation eager to rid themselves of an unwanted and expensive care burden.

Equally, there is probably some truth in the fact that many people freely choose death.

On the Today programme yesterday, the Thought for the Day covered the topic of assisted dying. The thinker expressed the idea that merely because a person chooses something does not make that a good thing.

He is right, to a limited extent.

But when it comes to medical decisions, decisions about matters of pain, life, death and dignity, surely these must be for the person concerned. Otherwise what values do we look to in order to determine whether a decision is a good or a bad one? The community? The harm this person’s choice to die may have on others? A dogmatic moral attachment to life at all costs? And, in any event, there must be a distinction between what a person is able to do to his body—choose to smoke, choose to drink, choose to die—and whether that choice is a clever one, or even a good one. Simply because somebody disagrees with the health choice of another is, in most circumstances, no reason to try and prevent that other from exercising that choice.

On both sides, outlined above, the touchstone is an understanding of autonomy (assuming, of course, that autonomy is possible). Either you see the choice to die as an expression of a person’s autonomy and personhood, or you see the dangers of that decision failing to be made in an entirely autonomous manner. Really there is no other basis on which to assess the morality of the choice or, more accurately, whether that choice should be accepted or refused.

Autonomy is a difficult concept. It’s unclear to what extent an individual may be fully or maximally autonomous in any given context. It’s also unclear whether background conditions—such as poverty—which narrow the range of options a person is given could be argued to reduce that individual’s autonomy.

The question for the purpose of this debate is almost certainly a problem of line drawing: was there sufficient autonomy? Is it possible for us to guarantee that people will act autonomously in respect of this particular decision? I don’t think that those two truths—expressed at the top—are mutually exclusive. Some may be coerced or pushed into it and others, at the same time, may freely choose it.

If the debate is one of autonomy, then, the debate at this point must turn to safeguards and the role that these may play in protecting the autonomous nature of decisions made by the dying.

Various concerns include the risk of a levelling down in palliative care, perhaps a change in attitude towards the elderly and infirm, and potentially a slippery slope leading to the choice being opened up to those suffering from non-terminal illness, disability or, perhaps, even mental illness.

Much of this is sloppy argumentation. The slippery slope is an often ill-thought-out point. To be made properly it requires factual support, otherwise all we face is a hypothetical (and largely, it seems, unquantifiable) risk. It also surveys any potential slide from a perspective that precedes any relevant change, meaning that we ignore the significant factor of how that change may have affected societal perceptions of the area.

It’s also important to remember that proponents of assisted dying in no way seek to level down general palliative care. Again no compelling reasons have been given for suggesting that this would take place: not everyone will choose to die when suffering from terminal illness, and palliative medicine will always have relevance to other groups who are not the subject of the proposed legislation. In any case, palliative medicine has its limits.

The risk of coercion, and of changing attitudes towards death and old age, are equally hypothetical. There may well be a risk. This is an argument, though, to have effective safeguards: for instance, an investigatorial doctor who has known the patient for some time, a second opinion from an independent doctor, a waiting period, and so on. It is not an argument that can successfully deny those who are suffering, and in great pain, the final relief that they desire.

It’s useful, as well, to turn the argument round. These days, considering that assisted dying is not funded in the UK, those who want it must be able to afford to go abroad. This is not an expense that is open to everyone, and so the position is that those who can go to Switzerland and Dignitas, those who cannot remain in the UK and take the risk of prosecution for assisting suicide. This seems fundamentally unfair.

Additionally, we do already have state-sanctioned ‘killing’, but simply in a different form. Involuntary and non-voluntary euthanasia are already regular occurrences in the healthcare context. We justify these acts to ourselves through an elegant ethico-legal sophistry, and the artifice of ‘double effect’. In the end, we reach the proposition that the chosen death is not allowed, but the one that is imposed in an exercise of clinical judgment is.

One last thing, which it is important to recall, is that a frequent background supposition is the perceived undesirability—or inability to stomach—assisted dying. But this is no reason to deny to others—who can stomach this—the ability to choose it. An Abortion Act style opt out for individual conscience, could ensure that individual doctors are not forced to do something with which they don’t agree, and it avoids the charge that we would be imposing moral beliefs on others.

My view is that a compassionate society should do whatever it takes to reduce the pain and suffering of those in the end stages of terminal disease.

It seems wrong to deny this ultimate relief from pain when it is obviously and freely chosen.

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