23 October 2011
On assisted suicide
From pre-history until today we know all too well that many people have had and will continue to have their lives ended by brutal and inhuman means as the result of wars, torture by oppressive regimes and other forms of violence. Causing the deaths of others is not at all unknown to civilisation and in some societies where such deaths are not infrequent it is commonplace to say that human life is cheap.
However, in recent times using the notion of human rights that civilised societies have devised we emphasise the value of human life and this is institutionalised through laws and conventions as a means of collectively protecting ourselves as individuals from arbitrary slaughter. This is one of the foundations for our potential to live lives worth living, free of misery, terror and anxiety. Placing such a high value on human life means a decision to end it is of considerable significance for the individual and those around him or her.
Historically the Christian churches, especially the Roman Catholic Church, have participated fully in the slaughter of innocents. From the persecution of pagans in conversion campaigns to the Crusades against Muslim infidels, from the burning of ‘witches’ at the stake to the Holy Inquisition to root out heretics, from the conquistadors in south America to pogroms against the Jews in Europe, the Catholic Church has been no stranger to murder. Until recently, that is, when it has transformed itself into the defender of life at all costs. So it is that clinical abortions and assisting in the suicide of terminally ill people have recently become among the most heinous sins imaginable. It is on the latter that I want to focus in this article.
Terry Pratchett’s recent TV documentary showing an assisted suicide at the Swiss Dignitas clinic has opened up the subject of euthanasia once again. This led to a poorly argued Mercury ‘First Person’ article by the Catholic priest Leon Pereira to which I replied in the letters page. Since then a torrent of letters have appeared with most, I think, favouring the introduction of a law permitting euthanasia.
I thought it worth looking again at the arguments and came across a detailed statement by the United States Conference of Catholic Bishops explaining their opposition. This was interesting. Apart from the arguments based on what might be called secular sociological and philosophical concerns they made their theological arguments (such as they are) explicit. This is helpful because for once we see the real foundation for Catholic opposition to euthanasia.
I will look at the reasoned arguments later but before I do it is worth running through these religious arguments:
· … Christian hope sees our final days as a time to prepare for our eternal destiny;
· … suicide is a grave offence against love of self, one that breaks the bonds of love and solidarity with … God;
· … to assist another’s suicide is to take part in an injustice [against God?] which can never be excused, even if it is requested;
· … life is our first gift from an infinitely loving Creator. The most fundamental element of our God given human dignity;
· … by assuming and sharing our human nature, the Son of God has more fully revealed and enhanced the sacred character of each human life;
· … palliative care allows patients to devote their attention to the unfinished business of their lives, to arrive at a sense of peace with God …;
· … as Christians we believe that even suffering itself need not be meaningless – for as Pope John Paul II showed during his final illness, suffering accepted in love can bring us closer to the mystery of Christ’s sacrifice for the salvation of others;
· … as disciples of one who is the Lord of the living we need to be messengers of the Gospel of Life.
It is my opinion that these religious arguments against euthanasia have no substance unless you are already a committed believer in the existence of the sky god so for the vast majority of rational people they can be safely ignored.
However, the bishops offer a number of more substantial secular arguments that cannot be ignored. Indeed, several are quite powerful and must be answered rationally by anyone who wants to see a reform of the law in this country to allow for assisted suicide in certain circumstances.
Personal autonomy v. protection of life?
First, the definitions used in this paper.
The relevant cases of people voluntarily making a current request for assistance to end their lives fall into three categories:
- ‘Assisted dying’ (AD) refers to a life-ending dose of medication being prescribed to a mentally competent, terminally ill adult who then administers the medication themselves. (This is the objective of Dignity in Dying and is supported by the BHA.)
- ‘Assisted euthanasia’ (AE) refers to life-ending medication being administered by a third party to a person with a terminal, degenerative or painful illness to cause a ‘gentle death’.
· ‘Assisted suicide’ (AS) refers to providing assistance to die to someone who wishes to die but who is not physically able to kill themselves. (They may be, though need not be, dying, terminally ill, or suffering from a degenerative or constantly painful illness.)
Earlier I dismissed the specifically Christian religious arguments against AD/AE/AS. By themselves they demonstrate how a religious ‘absolutist morality’ (i.e. unchangeable rules derived from some ancient text) clashes with the collective judgements of reasonable people about what laws should govern matters of life and death now.
A quasi-religious argument used by the bishops is to claim that AD/AE/AS supporters show a false compassion for sufferers from fatal illnesses. While the British Humanist Association (BHA) et al argue that it is compassionate to help a dying person to escape, at their request, from their misery, the bishops argue that the real meaning of compassion is to suffer alongside the victim, giving support and sharing the pain. This really is a metaphysical argument for only the individual sufferer is in a position to judge whether their life is worth living. Being able to gain ‘the moral high ground’ on who is being truly compassionate is clearly felt to be important in winning the war of words but in reality it is only when hearing the pleas of a suffering loved one to ‘help me die’ that anyone is in a position to decide which is being more compassionate – to help them do so or to say ‘No, but I’ll share your suffering’.
There is one final quasi-religious or metaphysical claim sometimes made that needs to be dealt with. This is the claim that AD/AE/AS should not be permitted because ‘life is better than no life’, or that ‘life’ is a fundamental human good. Taking this view, people who wish to die are obliged to keep living because life is a metaphysical ‘good’ regardless of the fact that the person living it is enduring daily misery or pain and seriously considers they would be ‘better off dead’.
Rationalists must reject such metaphysical notions of an abstraction (life) being better than ‘no life’. ‘Life’ is a term for the processes by which living things are animated so ‘no life’ means simply the absence of those processes. It is not a state of being so even the phrase ‘I’d be better off dead’ can only mean that the person finds their life unendurable rather than the idea that there is another state of lifeless yet conscious existence which would be less unpleasant. While from a pragmatic human rights point of view we need to have a presumption underpinning law that establishes as a first principle that human life has supreme value this is not the same thing at all as saying that ‘life is better than no life’.
The secular arguments
I now want to look at the non-religious arguments put forward mainly by the Catholic Church but supported by the Anglican Church and others too. (The Roman Catholic and Anglican Churches made a joint submission to the Lords committee on Lord Joffe’s ‘Assisted Dying for the Terminally Ill’ bill in 2004. That bill failed in 2006.) The Churches may be using these as a stalking horse behind which a theological motivation is hidden but we nevertheless need to deal with them as they represent, in the main, reasonable challenges to the AD/AE/AS positions.
Several of the arguments against legalising AD/AE/AS revolve around the socio-psychological effects on society and the people who might be considered potential candidates for it but who have no desire to kill themselves. It is suggested that acceptance of AD/AE/AS would have the following effects:
- creating a class of people who believe the value of their lives has been diminished because it implies that for them a death by legal drugs is acceptable as objectively good, or even desirable;
- by permitting AD/AE/AS for people of this class the legislature would be communicating the message that they may be better off dead;
- that the possibility of AD/AE/AS for people of this class would lead to pressure by able bodied people that they ought to take this option rather than being a burden on society;
- the expression of a wish to die by a member of this class would then be seen not as ‘a cry for help’ but as a reasonable response to a ‘meaningless’ life;
- those of this class who choose to live on with their problems might be seen as selfish or irrational and encouraged to see themselves in this way;
- all this reinforces the excessively high status our society places on being productive and independent and legitimises discrimination by the able bodied against those with disabilities and infirmities;
- even the apparently free choice of a dying person may be subtly influenced by the biases and wishes of others, so they may act under this pressure rather than making a genuinely free decision;
- by accepting the legalisation of AD/AE/AS society would then feel less inclined to fund decent palliative health and palliative care for the old and terminally ill;
- permitting AD/AE/AS devalues human life across the board. It is the start of a slippery slope where all manner of people (e.g. those with learning difficulties) may be included in the ‘life not worth living’ category, who may be encouraged to commit suicide or have their lives taken.
On the face of it these are reasonable points to make. In a democratic state social norms shape laws and future norms are, in turn, shaped by law. The standard response from the pro-AD/AE/AS lobby is that the right to personal autonomy trumps all of these worries. While I believe that the dangers are exaggerated, especially as the numbers taking up the AD/AE/AS options would be small, still its proponents must acknowledge the dangers and take steps to counter them. We must be concerned that any laws passed in this area do not have significant unintended or perverse consequences.
One way of pre-empting them would be to pass ‘balancing’ laws guaranteeing the right to nursing and hospice care right up to the end of life, however it might occur. This alone would effectively sink most of the arguments listed above.
The Catholic bishops accept that many people want to die through fear of being kept alive by burdensome medical technology while experiencing intolerable pain and loss of control over bodily functions. But they counter this by arguing that a society can be judged by how it responds to those fears. (In this context, of course, it is only the Churches who do the judging.) They argue that people in that state of mind are vulnerable and need to be shown more love and care by society to assure them of their inherent worth.
No doubt all would agree with this as far as it goes, but when this human response slips over, in the bishop’s mouths, to become a veto over personal autonomy it is nothing more than a variation of the ‘life is better than no life’ argument. It dismisses the considered opinion of the sufferer, and their right to autonomy, and says implicitly ‘sorry, but you just have to soldier on for life’s sake’. It is small comfort for the sufferer to be told they have ‘inherent worth’ when all they want to do is to escape into oblivion from what they are experiencing as a pointless life of misery. Kant’s principle that we should treat others as ends in themselves, rather than as a means to an end, implies, in this case, that we should not oblige people to continue living against their better judgement because it serves the metaphysical end of revering the life process above all things, because ‘life’ is ‘sacred’.
The bishops’ next argument is that allowing doctors to assist in suicide compromises the ethical integrity of medicine as it violates the Hippocratic Oath. This is a fair point though it should be noted that graduating doctors now take a variety of ethical oaths and only 14% of them forbid euthanasia! (http://www.bbc.co.uk/dna/h2g2/A1103798)
The oaths are a safeguard (though evidently not a complete one) against the reckless use of medical knowledge and drugs to end the lives of others. A refinement of the argument is that trust in health practitioners is paramount. If patients come to suspect that medical staff have hidden agendas, that advice or prognoses might be given on the basis that AD/AE/AS is an option then patients would increasingly distrust what they are being told.
A possible pragmatic solution to this challenge would be to permit the establishment of a charity or subscription funded body of non-medical volunteers outside the NHS who would be specially trained to administer lethal drugs under controlled circumstances, so freeing the medical profession from any conflict of objectives.
The final and most frequently wielded argument of opponents is that ruthless relatives who stand to gain an inheritance might manipulate vulnerable sick and elderly people into seeking AD/AE/AS. It is easy to see the point. There are hard-hearted people who would not hesitate for long in making it known to an infirm parent what a burden they had become and how much good their money could do if they passed from the scene a little more quickly. Only a rigorous procedure of checks and double checks can hope to minimise the danger – and these are in place in those countries where AD/AE/AS is already legal. And with AD/AE/AS not only would there be several legal requirements prior to the act but there can also be police investigations subsequent to it. Knowing the scrutiny they would attract ruthless beneficiaries are, in my opinion, as likely to arrange an ‘accident’ as they are to manipulate a vulnerable relative into choosing AD/AE/AS.
On this tack, in an interesting Lutheran Church submission (opposing euthanasia) to the Australian Commission on Social and Bioethical Questions (http://www.lca.org.au/resources/csbq/euthanasia3.pdf), the authors acknowledge the widespread support for the idea of autonomous decision making in end of life decisions but point out the evident difficulties of framing laws and procedures that cannot be abused. Examples are given of where euthanasia laws have not worked as well as intended.
Terry Pratchett believes he has the solution to the problem through the creation of tribunals to hear applications for AD/AE/AS. The tribunal panel would include a legal expert in family matters and a doctor with experience of long-term serious illnesses. The applicant would make their case and have to demonstrate that they were of sound mind and had given it proper thought, along with explanations of why the alternatives of palliative and hospice care, etc. were considered unsatisfactory.
While all the foregoing Humanist and rationalist arguments are persuasive in answering the bishops’ concerns I think they are, to a great extent, missing the point because they get emotionally dragged along by concern for the terminally ill. I now suggest an alternative approach that achieves many of the same ends but deflects much of the criticism and places the aim of personal autonomy for all at its heart.
A different approach
Globally, around 1 million people commit suicide each year (WHO). They use all the means with which we are familiar: drowning in river or sea, jumping under trains, in front of trucks, taking poison, overdosing with prescription drugs, hanging, slashing wrists, gassing, etc. They have numerous motives from disappointment in love to financial failure, from shame or guilt to clinical depression. The one thing they all have in common, however, is that they were capable of doing the deed without assistance. They were able-bodied. They were able to exercise their personal autonomy.
While many might have been dissuaded if a friend, relative or professional had had the opportunity to intervene at the vital moment, many would still have judged, as people are free so to do, that they no longer wanted to live.
An individual may conclude their life is not worth living at any time in their lives. While able-bodied they are able to do something about it – but with some anxiety that things might not turn out as intended and they might end up permanently disabled as a result. There are also potential unintended consequences of successful suicides where they involve third parties who may be traumatised as a result: for example, the train driver who sees the face of the person moments before they die, a vision that may haunt the driver in dreams and nightmares for the rest of their life, or even make it impossible for them to continue in the same employment.
In the light of the risk of abortive attempts or third-party trauma a case can be made that anybody suicidal should be allowed access to medical assistance and drugs to make sure death occurs as desired and nobody else is traumatised in the process. One of the problems with such a view is that almost everyone would find it abhorrent that society might facilitate the suicide of otherwise healthy young people who are acutely depressed through, for example, relationship breakdown or failure in exams.
Clearly, in both types of case we would want to prevent young people acting on their impulses because older and wiser heads know that such states of mind are perfectly normal – and temporary. We can objectively judge that a person early in life and facing a deep emotional crisis has every chance of getting through it (and ‘growing’ in the process) and as such is quite different from a person late in life facing a certain decline to an unpleasant death. People with clinical depression, such as sufferers from bipolar disorder, also often take their own lives when their mental state is at its bleakest. Again, most people would judge that such cases ought not to be aided as they can be managed relatively easily by medication and counselling, giving the sufferer a quality of life they find perfectly acceptable for much of the time.
What about those relatively fit older people who feel they have just had enough? They may say their lives are not as fulfilling as when they were younger when they played sports, travelled the world freely, went to parties and dances, etc. They are often tired, have aches and pains, their teeth are deteriorating, their hair thinning, they’re unable to play with the grandchildren, cannot trek across the fells, ski or play rugby as they used to. Is it not reasonable to accept their judgement that they feel the loss of their powers so badly that they no longer feel their lives are fulfilling enough to continue? Here they are, not depressed or emotionally disturbed, perfectly rational but feeling they have already had a good innings and are now tired of life – and there’s no amount of watercolouring, Scrabble or web surfing that can change their minds! Well, the fact is that if they seriously want to die they can take their own lives as easily as any younger and fitter person. This is one key reason we do not generally feel they have a case for assisted suicide.
However, much of the campaigning for assisted dying legislation in Britain and elsewhere aims to create a class of people – those with terminal, painful or debilitating illnesses – who are entitled to assistance even though they may be perfectly capable of throwing themselves off the Severn Bridge. I think this an important point for it makes a terminal, painful or debilitating illness not just a necessary but also a sufficient qualification to be entitled to receive assistance – even though they are quite capable of taking their own lives. It seems to me that this creates a very unsatisfactory situation. What could be the justification for such legislation that makes a distinction between people with equal capacity to take their own lives? Only that we as a society might conclude that people with terminal conditions are living lives not worth living despite many of them being relatively able-bodied.
In other words, such AD/AE/AS legislation would amount to society saying ‘we disapprove of suicide by able-bodied healthy people, but having a terminal or unrelentingly painful illness entitles you to special consideration regardless of the possibility that you might be capable of taking your own life’. This creates a privilege without any rational justification.
I believe that the key question we must keep in front of us is not whether a person is terminally ill but only whether a person is unable to complete the act of suicide reliably on their own. By following this route and restricting assisted suicide (AS) only to people who are incapable of carrying it out themselves we would be effectively categorising it as a support service for a person with a significant incapacity, putting them in an equivalent position to able-bodied people. The character of the act then becomes something quite different from AD and AE. Such an approach has the significant advantage of not labelling all people with disabilities as burdens on society. It simply establishes a level playing field for all. Anybody assisting would then only have to show that their motivation was unselfish and altruistic in fulfilling a person’s wish when they were unable to fulfil it for themselves.
In conclusion, then, my position is that people have the right to autonomy, to control their own fate. Therefore, people should face no legal impediment to taking their own lives at any time. Further, that where they are incapable of doing so and have freely and unequivocally expressed a considered wish to die (possibly before becoming physically incapable of carrying it through) they should be allowed third-party assistance without fear of prosecution of those who provide it. In this way their right to autonomous decision making is ensured.
The reader will note that this position is dissimilar to the general aim of euthanasia campaigns for AD/AE only to be available to anyone with a debilitating or terminal illness. I think that approach is a mistake for some of the reasons put forward by the bishops – specifically because it gives out the message that society believes their lives are not worth living. I favour assisted dying being permissible only for those who cannot realistically take their own lives by ‘standard’ means. This would include those who have previously stated their wish to die in those circumstances but are now unable to communicate, and those with ‘locked-in syndrome’ and similar where they are able to state unequivocally a wish to die but are incapable of carrying it out without assistance. (As with the current case of Martin, 46, who has suffered a massive and almost totally incapacitating brainstem stroke.)
The effect of my position is to do no more than disability rights legislation does generally – to place people with incapacitating disabilities on an equal par with able-bodied people. This position will subsume the cases of many people with terminal illnesses and/or in constant pain but those conditions should not, in my opinion, be sufficient in themselves to qualify. Nor should they be necessary conditions. As long as a terminally ill or chronically pained person is physically able to carry through a voluntary act of suicide they will be in the same position as any other able-bodied person. To create a special class of people who have access to assisted dying or voluntary euthanasia because they are terminally ill or in constant suffering and yet who are physically able to commit suicide is to discriminate in a very real sense against all other able-bodied people who might wish to commit suicide.
As to suicide as a disability right - your solution still means that to be allowed the privelege of assistance you have to qualify by being unable to DIY.
And presumably if assistance were allowed (and funded), you could expect it to be competent and effective, unlike the many bungled attempts of the able, often done in ways that cause dreadful trauma to others as you say. This means that the practitioners (medical or otherwise) would need training and standards – even a professional body. Presumably none of these are currently allowed. Should access to this knowledge and indeed advice and assistance - not be available to all, without the need for any disability, terminality or pain qualification?
Frank: I can foresee that the discussions at AS tribunals would revolve around the applicant's competence to DIY rather than alternative solutions like palliative care. Debates would be interesting until we got used to them, that's for sure - but in principle quite straightforward to decide.
I was tempted by the option of having AS available to all (as a human right) but my paper outlines several types of case where most people would be very uncomfortable with it. And it must satisfy most people, mustn't it? If you want to argue for a general right to AS at any age (or for adults only) then you should put your case - but if simply based on an abstract right I think it will lack persuasive power.
And in any case, should we always have to submit to the tyranny of the majority? Most of us don't choose to live in homosexual relationships. Does this justify banning them?
Disability rights are largely about autonomy - having access to a suitable toilet without having to ask for a special key, etc., and having assistance without negotiating or pleading for it every time. Tribunals simply are not part of this model. Yet we would find the idea of a walk-in dying service unthinkable. Perhaps we need to think about these things in an open-minded way before shutting down any of the possibilities.
I'm all for open-mindedness, as I think my paper demonstrates, and having given it all some thought believe that assisted suicide should be available to people who want to die but who are incapable of doing it themselves and which is subject to a tribunal procedure to ensure the decision is being made freely.
Anyone with the capacity to take their own life is free to do it at any time.
Wider discussion of assisted suicide as a right for incapacitated people would be welcome.