Hospital bed - imaige: US DOD, Public Domain
People should decide for themselves what is valuable and live their lives in accordance with that decision. In so doing, they are the authors of their own lives, forming them through voluntary decisions and taking responsibility for what they do and become.
This is the ideal of individual autonomy, and it plays a central role in our ethical and political thinking. A core commitment of liberal political philosophy is that people should have the chance to enjoy autonomous lives. That also means that they should have control over the time and manner of their deaths. If self-authorship matters at all, it matters especially when we are approaching death. The law should recognise this by ensuring that people have the right to end their lives, with help from others if needed.
This is a familiar argument for legalising assisted suicide. Most writers on this topic agree that respect for autonomy counts in favour of legalisation, even if they ultimately reject it on other grounds like the danger of abuse or the psychological cost to family and physicians. For the record, I find those qualms unpersuasive. Neither the difficulty of designing safeguards nor the squeamishness of bystanders justify condemning our co-citizens to such pain and disempowerment. I think the case for legalising assisted suicide is unanswerable.
Still, I won’t repeat that familiar argument here. I want to make a point which is often missed by opponents and proponents of assisted suicide alike. Legalisation wouldn’t only give people the right to die. It would also have transformative effects on many other decisions. Some of those effects would be good, and some bad. A proponent of assisted suicide must explain how to secure the former while minimising the latter.
I recently saw a talk by Melanie Reid, the distinguished Times columnist, who has been severely disabled since an accident in 2010 left her tetraplegic. Reid spoke in harrowing terms about what it was like suddenly to be incarcerated in her own body. She frequently longed to die. A measure of freedom came from one piece of good fortune: she has gradually regained control of the thumb and first finger on her right hand. This helps her manage her disability, but it also means she can end her own life, with the help of a journey to Switzerland and Dignitas. Not everyone is so fortunate.
Reid’s observation wasn’t a declaration of suicidal intent. Her point was that the option of dying transforms the character of her other options. She is no longer compelled to endure, but makes an active choice to live, in the knowledge that there is a way out if she needs it. The option of dying empowers her, even as she chooses not to exercise it for now. It liberates her from the fear of being trapped.
So many people suffer fear and powerlessness as they approach death. I work with staff at the Prince and Princess of Wales Hospice in Glasgow, and one day I asked: what do your patients fear? The answer was: pain, of course, but powerlessness more. People fear the indignity of dependence, and losing control as they reach the end of their lives. They fear the loss of autonomy.
This gives a second powerful reason for legal reform. The right to die empowers us even when we do not choose to exercise it. It guards against the fear of pain and powerlessness, and guarantees a dignified death even if we can’t afford to fly to Dignitas.
Here’s a worry, though. Autonomy doesn’t just mean shaping your life through free choices, including the choice to die. The character of those choices must also reflect one’s values, ambitions and goals. To borrow terminology from the Barcelona-based philosopher Serena Olsaretti, those choices must be voluntary. We act non-voluntarily when we choose to do something just because there are no acceptable alternatives. In such circumstances we don’t actively author our lives, but merely react to a hostile context, choosing something we’d avoid but for the fear of something worse.
This poses a problem for the advocate of legalising assisted suicide. When people seek death it is almost always because they want to avoid unacceptable alternatives: physical pain; isolation and powerlessness; anguish for friends and family. So, most decisions to die are non-voluntary. Far from being a final expression of individual autonomy, they represent the last resort of someone trapped by appalling circumstances.
This doesn’t mean we shouldn’t legalise assisted suicide. We would hardly support people’s autonomy by giving them no choice at all. Rather, we must change the context of those choices to remove their non-voluntary character. This means pursuing legal reform in parallel with changes to palliative and geriatric care, to ensure that people’s other options are also acceptable. The point isn’t to dissuade people from assisted suicide: that decision is up to the individual. Rather, we should empower the individual by making sure that their decision is a reflection of their genuine values and life goals, rather than a non-voluntary response to unbearable circumstances.
This highlights the importance of palliative care. We must ensure that people have relief from pain (when that’s medically possible) and help to manage their pain (when it’s not). There’s much we can do alleviate pain’s tendency to control people’s lives; the more we can do, the more we can ensure people don’t seek death for fear of unacceptable suffering.
We must also find ways to deliver palliative and geriatric care that don’t leave people dependent and disempowered. That means giving people more control over how they are supported, resisting the tendency to sequester the ill and elderly, and making reasonable adjustments so they can still contribute to social and civic life. Recent experiments in the Netherlands which combine creches or student accommodation with old people’s homes offer imaginative possibilities. If we can alleviate disempowerment and isolation we will eliminate the aspects of old age and terminal illness which people most fear.
The autonomy-based case for legalising assisted suicide is compelling, but legal reform must be accompanied by reforming palliative and geriatric care along the lines I have suggested. That will hopefully ensure that people can remain autonomous and continue as their authors of their lives in illness and old age. It will also be vital for ensuring that their autonomous is respected if, as is their right, they choose to bring their lives to an end.
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