197. ASSISTED DYING - A Reasonable Adjustment to Make

Frankly, all I want to write about this week is how good the movie adaptation of Wicked is. But on Friday, MPs in England get to vote on an Assisted Dying bill and it seems remiss as a philosopher to not have some thoughts.

Of course, part of the remit of Philosophy Unleashed is that it doesn’t cover material that’s on GCSE and A-level exam specifications, and euthanasia discussions have long been a staple of Religious Studies GCSEs. In fact I think I have taught about ethics and euthanasia to at least one year group during every year of my teaching career. So is there anything interesting to say that takes this potentially tired debate beyond the curriculum?

For one thing, the curriculum discussions are steeped in current laws, and so the potential for a change in those laws is something the exam boards have yet to catch up with. But more importantly, in the Religious Studies classroom where these discussions usually take place (euthanasia is not one of the applied ethics topics in the standalone Philosophy A-level), the conversation is always tiredly framed around quality of life vs sanctity of life, with God looming large at every turn.  It would be nice, therefore, to think about this issue without dragging God into it for once. To take the position that religious views are actually irrelevant here: if you don’t want to engage in euthanasia for faith-based reasons, you don’t have to. No-one is forcing it on you. And if you don’t want to carry out euthanasia if you are a doctor with religious reservations, you don’t have to either. To consider the views of those opposed to euthanasia on religious grounds is like trying to base a policy on alcohol around those who believe God teaches only temperance, or plan a war that will please religious pacifists. We all know the position, and the position isn’t moving. Be it the war, the pub, or the lethal injection…these things aren’t for such people and never need to be. But for those of us who do think euthanasia might be a possible option, it’s worth thinking about the why and how of it all very seriously. After all, the alcohol drinkers and soldiers might not have religious objections to their inebriation or battles, but they still might recognise that there ought to be some limits on how much they can drink or when exactly it is ok to fight.

So should we have the right to assisted dying? Or, if not the right, the legal permission to get it done?

The issue, morally, lies in the assisted bit. We all know suicide is always an option, and not something you can be prosecuted for if you do it (if we are successful in committing the ‘crime’ of suicide then we are no longer in a position to be arrested for it!) but to assist someone in their suicide leaves a living aider and abetter of something deemed morally objectionable by law. It stops being suicide (taking one’s own life) and starts being homicide (taking the life of another). Or, if the assistant in the dying doesn’t actively kill the person who wants to end their life, then it at least becomes a form of manslaughter for their providing the means to a death that otherwise might not have happened.

Intention is a part of the law already. If I am the shopkeeper who unwittingly, but legally, sells you the pills you use to overdose, I am not assisting in a suicide and not culpable for charges of manslaughter. If, however, I knowingly give you more than the legal limit of pills, or, worse, do so in order for you to go home and overdose, then I am complicit in your death and a crime has occurred. But that crime is considered far less of a crime than if I crush up the pills and feed them to you myself! Yet even this scenario differs greatly if I do so in order to murder you, against your will, sneaking the pills into your food and tricking them down your throat, and if you have asked me to do it because you want to die but are too scared to kill yourself. My intention changes from murder to assistance, and your intention differs too. These different intentions become morally important.

Which brings us to the assisted dying bill. Because the bill is not attempting to legalise all forms of assisted suicide, only the assisted suicide of the already terminally ill. People who will be dying anyway within six months, but whose earlier death might save them weeks or months of terrible pain and suffering. And there are several reasons why such people might wish for assistance in their decision to end their life before their illness takes them, rather than simply killing themselves (because, remember, that option still remains currently legal). Theoretically, a patient can come straight from the diagnosis and go home and end their lives. But there are several key reasons why this is not desirable:

1. Suicide is a lonely, tragic business. It is a lot to ask of someone for them to willingly take their own lives considering how hardwired human beings are for self-survival. Besides the personal trauma of having to actually go through with such fatal self-harm, the current laws against assisting a suicide mean that anyone who is with you when you do it, if they know you are doing it and do not stop you, might be vulnerable to charges of assisted suicide. So you are either forced to kill yourself alone, or run the risk of getting your loved ones in trouble. Remember: all these people really want is to die with dignity, and avoid the unbearable pain and suffering of the latter stages of their disease. They do not want to forfeit their goodbyes with family and friends, or be forced to die in an even scarier way than their illness will eventually kill them. They want what the word euthanasia actually means: a good death. Not a painful one. Assisted suicide, by a professionally trained doctor, would mean a death that can be planned, and which can be relatively painless. A death surrounded by friends and family if wanted, or to take place after saying your goodbyes. This also saves those friends and families the pain of further weeks and months of watching you suffer, and the trauma of one of them discovering your body after suicide.

2. Another important reasons assisted suicide might be preferred to solo suicide is that to physically kill yourself (suicide) you need to actually be in a position to do it. You must be physically healthy enough to do whatever it is to yourself that will end your life. However the whole reason people given some of these terminal diagnoses want to end their lives is because of how bad things will be at the end. Not at the time of diagnosis. If they are healthy enough to kill themselves then they are not yet at the point where life is no longer worth living. At that point, their body will likely be failing them. Now that they are at the point of wanting to die, they may not be physically able to end their own lives. It is precisely at that point of physical incapacity that they would like suicide to be an option. Hence the need for a doctor to do it for them instead of being forced to do it by themselves, a lot earlier than they would like to die. An already premature life cut even shorter because of the laws against helping someone in need at the point at which they need that help.

So the reasons for assisted dying over solo suicide are there. Importantly, they are merely asking that those with terminal illnesses - and their families and friends - can be spared some additional suffering than would be caused by either the illness itself, or the perfectly legal act of unassisted suicide. In fact, one could even call it a ‘reasonable adjustment’ to ensure one’s universal ability to end one’s own life is not unfairly denied to people just because of a physical disability (a protected characteristic under UK law). Not allowing assisted suicide is discriminatory to those of us without the physical capability for killing ourselves.

It is not that simple, however. A further moral complication arises with the culpability of the doctor tasked with assisting the suicide. Solo suicide is a neatly resolved issue: the one who does the act takes full responsibility for their own choices and their own life. In a moral world where we are constantly told that the taking of another person’s life is a great wrong, and especially in the profession of medicine, based on healing not harming, to be suddenly told that part of your job involves intentionally ending the life of another human being is a radical disruption to your previous moral norms. Assisted suicide is not a solo endeavour. It drags the assistant into moral culpability and leaves behind someone living to bear the moral burden of what they have done in a way that solo suicide does not. I might have the right to do what I want to with my own life, including end it, but I do not necessarily have the right to force another person to help me do what I cannot achieve on my own.

And speaking of rights, it is worth noting that we do not really have a right to suicide. It is not a right because it lacks a correlating obligation. In fact, my obligation upon learning you are suicidal might actually be to try to talk you out of it. If you ask me for some rope, and I know the reason you wish to use it is for self-harm, it is my right to say no. We can kill ourselves - it is a terrible existential fact of the human condition - but to speak of it as a right seems wrong. Not only because it feels like the obligations we have to others require us to make obstacles to that so-called right’s fulfilment, but because we clearly don’t have any other rights around choosing how we die. Many of us will die behind wheels of cars, of sudden heart attacks and strokes, because of random accidents or acts of violence, and, yes, from terminal illnesses, and none of these are the ideal way we would perhaps have preferred to go out: peacefully in our sleep at a ripe old age. The vast majority of us will die at a time not of our own choosing and in a way we do not want. That is, sadly, life. So there is no natural right to a good death nor obligation for someone to fulfil it for us. We don’t get to choose when we’re born and we don’t get to choose when we die. In fact we don’t even seem to have a right to life, despite what other legislation might say. The means of life - food and drink - are kept behind a paywall under capitalism, and people die all the time of perfectly avoidable causes. You don’t need to bring God into the picture to suggest that when we live and when we die is not really something in our own hands.

The problem with the above argument is that all rights are created. No rights exist naturally until they are identified and then work put in to crystallise and manifest them in practical terms. Our so-called right to life exists precisely because life is so fragile. It is a practical safeguard established through convention to name the idea that avoidable deaths should be avoided. And it is predicated on the assumption that most people want their life preserved wherever possible. The existence of suicide suggests that this assumption may not always be universal, and that we sometimes accept someone’s right to waive that right to life. In fact we don’t even need to go as far as suicide. Many times people willingly risk their own lives for something they deem more important than their supposed right to merely exist. Whether it is an extreme sport, flying in a plane, riding in a car, working on a building site, we put our lives at risk in a million different ways. Unhealthy diets, bad exercise habits. We can do that all we want.

On the other hand, the physically healthy person’s ability to kill themselves becomes a sort of de facto right of its own. Our seeming obligation to try and talk them down rather than assist is more of a cultural convention than anything more serious. One could imagine in a world where assisted dying was the norm, our only obligation if we heard someone was trying to take their own life might be to kindly direct them towards somewhere they could get it done professionally and painlessly rather than be forced to do it themselves. Comparisons to abortion are obvious here. Abortion still happened before it was made legal and safe, but before it was legal to advocate for, and there were sterile and hygienic professional places where abortions could be carried out safely, it might be considered a taboo to encourage someone to get one. Once legal, and dangerous backstreet abortionists became unnecessary as safe procedures became available, the taboo goes away and our instincts change. Before legal abortion, our social convention upon finding a pregnant person attempting to self-abort might have been to try to talk them out of it.  Now, we would ask what they were doing to themselves when there are doctors available who can do it properly and safely for them.

Legalising assisted dying merely secures the de facto right to suicide for all, and removes the unnecessary further suffering associated with the current, clunky and painful, do-it-yourself methods of suicide available. If anything, the current bill, by limiting it to only terminally ill patients, doesn’t go far enough.

In terms of the physicians who will have to do the assisting in killing someone, they make life and death decisions all the time already. Although their focus may be on all the decisions and actions taken which lead to life, make no mistake, much of what is done in a hospital is knowingly causing its fair share of death too. Death is inevitable in a world of split-second decision making, limited knowledge and even more limited resources. The fundamental medical principle is not ‘save lives’ (and even where life-saving is involved, it is seldom ‘save all lives’ but rather ‘save what lives we can’). It is, in fact, ‘first do no harm’. But ‘harm’ is a word with many meanings. For a life which cannot be saved because the disease it suffers from is terminal, harm might be forcing someone to suffer needlessly for more months than were necessary before the inevitable. Harm reduction might mean pain reduction, and for a life already ending that might well reasonably include the ultimate reduction of pain: euthanasia.

Another social convention masquerading as morality here springs to mind: our reaction to heroin users. In places where the drug is illegal, our instincts when seeing someone shoot up with heroin might be to stop them, to ignore them and walk away, to call the police… but in places that recognise addiction as a disease and take an approach of harm reduction instead of punitive sanction, clean needles are handed out to users to enable to addicts to get high without the additional risks associated with dirty needles, and methadone might be administered to ensure a cleaner product is going into the body than whatever is being sold on the street. Hopefully with an aim to eventually end the addiction, but if not, to reduce the harm the addiction causes in the meantime. ‘Do no harm’ can mean enabling certain behaviours, deemed socially taboo, that would be otherwise even more harmful if carried out alone. And suicide is no different. People are doing it anyway. Doing it in terrible circumstances, much earlier than they would need to, and far from the people that they love. Allowing legal assisted dying takes away that harm and gives them back precious days, weeks or even months of life in order to get their affairs in order and say their goodbyes before a far less scary death than either their illness, or their own hand, would give them. That pet-owners across the country can help their sick and suffering animals in this way but cannot help themselves or their loved ones is a moral scandal that has been going on too long.

Concerns are also raised, however, about the pressure people might get from their families to end their lives instead of soldier through to a natural death. Just as some families do put their pets down instead of paying large medical bills for treatment, the classic scenario is a wealthy grandparent being worried about being a burden on their family and the family seeing the inheritance they would gain as a justification to encourage their assisted suicide. To me this objection misses several points. Firstly, with my anti-capitalist anarchist hat on, maybe we should be looking first at the kind of terrible economic system and entrenched social inequalities we have created which leads to this kind of venal thinking in the first place instead of using them as an excuse to add further suffering to our current existence? Likewise, that such people are considered a ‘burden’ speaks to the failures of our care system and an erosion of our social bonds more than it does a problem with assisted dying. But taking the anarchist hat off, such sentiments already exist. The grandparent just gets to think of themselves as a burden without the option to stop being so burdensome. The inheritance is still all the family are thinking about as they count down the days before the illness kills their grandparent or parent. The coercion to die is already there. Only the victim of the coercion is forced to die painfully (stopping taking medicines, denying themselves food, etc.) instead of painlessly. It is also a legitimate consideration to bear in mind that some people might be a burden or might wish they could just die and give their family an inheritance they feel they need. I think of my own grandmother who died at the age of 96 but had wished she were dead for at least four years before her body finally failed her. Or the grandmother on my other side, who told me three months before she died that she had no joy in her life anymore. Or my wife’s grandparents who both sat in their late 90s saying they wished they were dead. None of these people were coerced by their families to die, but we, their families, had to deal with the sadness of having our loved ones tell us quite clearly that they didn’t want to be alive anymore. Why not do people the respect of taking them seriously? Sometimes life really is not worth living any more and elderly people are simply waiting to die. Not all elderly people by any stretch of the imagination. But for those who are, and they wish they could just die and leave behind something for their children rather than spend it on housing and care they don’t actually want, what is actually wrong with letting them? Gladly, none of these personal relatives were ever burdensome to me. But if they were, and they wanted to die anyway, why can’t we allow them? We do, after all, allow them to commit suicide if they choose to. Only, in your late 90s, again, the physicality involved in suicide becomes too difficult. Age, another protected characteristic, might require this reasonable adjustment too in order not to discriminate people just because of their age from their ability to tap out on life when it gets too much.

I mention the very old for the same reason legislation looks at the terminally ill. The main reason we have that instinct to talk a suicidal person down from their ledge is that we all know things can look quite bleak one day and be totally different the next. The idea many of us hold is that the person who wants to take their life today might regret the decision a week from now, a month, a year. The terminally ill don’t have that hope, unfortunately. They will be dead in six months regardless of their feelings. Likewise, we know those in their late 90s will be dying at some point soon, even if it is not right now. Though they might regret having their lives ended at 96 if they would have lived to 98, does it really matter? To have lived to 96 is good enough. There is clearly something significantly different about the terminally ill or very old being assisted in their suicide and a depressed 20 or 50 year old asking for the same thing. While we might want to make a different sort of argument for allowing a ‘good death’ for those people too, instead of condemning them to the horror of having to kill themselves alone if they can’t get help, I can certainly see that this is not the priority of the state because there is much more moral greyness in the idea that anyone should be allowed to end their lives painlessly at any time. That’s a much harder case to make, for all sorts of reasons, but when it comes to the terminally ill, and those whose choices are either a slow, lingering death, or an assisted ‘good death’, to me it certainly seems a no-brainer that the law should change and allow assisted dying as soon as possible. Indeed, I would argue the lack of assistance for such people, by denying a reasonable adjustment to be made due to their physical disability or age, to allow them to commit the same suicides that younger or more able bodied people are legally able to, is a violation of the Equality Act of 2010.

Author: DaN McKee (he/him)

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