Thoughts on assisted suicide

There is another case in the news where someone is making a legal bid to allow his doctors help him to die. These cases are always heartrending. It’s a cliché that hard cases make bad law. But it’s a cliché because it’s true.

If we look at individual cases, there are often very strong grounds for considering that the compassionate response is to allow assisted suicide or euthanasia. But the difficulty is that  public policy and law must be designed to produce the best, the most just, the most compassionate outcome overall. This is why any legal or policy change must be made in response to a full consideration of all possible cases, and of wider effects upon society; there’s no such thing as simply allowing assisted suicide in law – any such law would have of course to be very carefully constructed.

And any law or policy is always enacted within a particular context; any choice for a freedom allowed within law is made within a particular context.

When we turn to examine the most compelling individual cases, there are certain things which stand out. One of these is the surrounding context of the patient’s request: often, full exploration of all medical options, a good relationship with a medical team, a loving family, years of careful thought. The request to die may be made carefully and for pressing reasons.

There is no doubt that there are serious conflicts surrounding this issue. If one were to summarise some of the main worries against making a change in law and policy to allow assisted suicide or euthanasia, these include concerns that some people will feel subtly pressurised to choose death over life. Arguments in favour of introducing new legislation quite rightly attempt to make provision to ensure that any choice of assisted suicide or euthanasia is freely chosen and autonomous.

But this then indicates that we need to do much more than consider legal changes. We need to ensure that any request to die is made in a social, psychological and economic context where there is equal value given to the choice to live. Here are some suggestions about what society needs to provide in order to provide a real choice for those suffering major illness or disability or nearing death.

·                State of the art palliative care, freely available to all. This therefore includes putting significant research funds into palliative care. Of course, this may not be a solution to all cases; but without such provision, the choice of euthanasia is surely to that extent made from a reduced list of options.

·                Careful consideration of the practice of medicine which often seems more focused on extending life without consideration of its quality. Many, although not all, requests for euthanasia arise because a patient’s life has been extended through the use of technology and medical care without regard to outcome for that patient. These are very difficult issues, of course, but they need to be carefully addressed.

·                A sea-change in attitudes towards the elderly, the sick and the disabled in society would not go amiss. There is not space here to do more than indicate the issues here, but a quick glance at how our elderly are valued should suffice – social isolation, poverty, enforced lack of economic and social productivity are the norm for many of our elderly. They are often seen as a group presenting nothing but problems and burdens to society. The message that our elders are a burden must be reduced, changed, or reversed – without this, we cannot be sure that the way such a group is seen does not influence decisions to choose euthanasia. There have been changes for the better in our attitude to people with disabilities in recent years. Let’s continue this and work to for changes in attitudes to the elderly, who have much to offer.    

·                Lastly, a persistent knot in my stomach tells me that it doesn’t seem very sensible to introduce a law allowing assisted suicide or euthanasia whilst we are in the midst of a recession and whilst the funding of the NHS is in such a precarious position. Maybe we should take care of the funding of health and social care first. Just a thought.

 

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14 Responses to Thoughts on assisted suicide

  • Peter Wicks says:

    A related issue to this is the huge amount of resources that tend to go into, as you put it well, “extending life without [much] consideration for its quality”, and it might be interesting to consider why this is the case. As you say, hard cases make bad law, and the essential reason in my view is that our emotional responses tend in such cases to overwhelm our capacity to reason. But there are also other reasons, which might shed useful light on our fundamental ethical intuitions,

    In particular, the sanctity of human life remains a highly pervasive idea in Western culture, even if in terms of the language we use it has now been largely replaced (at least in secular contexts) by the concept of a “right to life”. The risk that some people might feel “subtly pressurised to choose death over life” is a real one, of course, but to some extent I suspect that the fear is exaggerated because of our notion that life is sacred. And then, of course, there is our horror of death, which make us cling all the more tightly to the idea that life must be preserved at all cost, and with all means possible, not only without regard to qualia, but also without regard to the expense. This bias can clearly be seen in the characterisation of health policy decision-makers as “death panels”. Clearly we cannot solve all issues here, but I think a recognition of some of the cognitive biases that underpin our attitudes to health care can be helpful.

  • Eric Brown says:

    This is to Peter Wicks:
    I’m not sure that your opposition of reason to emotion does so much work here. First, for many of those who hold it to be the case, the notion that life is sacred, is more than a simple emotion, but part of an overall and reasoned worldview. That worldview might be erroneous (arguably it is), but the dichotomy of reason and emotion does not quite capture what is at stake. What I see, from my sociology armchair, is a change and rift in worldviews which place human beings, as such, at the center of things and one where that position is not occupied by anything in particular. With the latter, humanity has to make itself valuable to itself through its own social and cultural activity (a natural process, like beavers building a dam in my view). Neither is more “rational” than the other, if “rational” has any content independent of strong ties to the scientific worldview (which I think it must). Nor is opposing rationality and emotions warranted, at least in the strong way you’ve done.
    Additionally, in a particular case, the urge to avoid a prolonged and painful illness can be just as emotionally charged on the part of the person seeking euthanasia as those, say, loved ones, who urge her to reconsider because they love her, will miss her, and consider her sacred.

    • Eric Brown says:

      Final note, I just wanted to thank Paula for her opening post and Peter for his comment.

    • Nikolas Schaffer says:

      “Additionally, in a particular case, the urge to avoid a prolonged and painful illness can be just as emotionally charged on the part of the person seeking euthanasia as those, say, loved ones, who urge her to reconsider because they love her, will miss her, and consider her sacred.”

      The big difference of course being that it is her life, not theirs. Surely it’s obvious that it’s more selfish for supposed “loved ones” to seek to extend someone’s life against their will than it is for the “love object” to end her own life because she’s had enough.

  • Eric Brown says:

    This is to Peter Wicks:

    I’m not sure that your opposition of reason to emotion does so much work here. First, for many of those who hold it to be the case, the notion that life is sacred, is more than a simple emotion, but part of an overall and reasoned worldview. That worldview might be erroneous (arguably it is), but the dichotomy of reason and emotion does not quite capture what is at stake. What I see, from my sociology armchair, is a change and rift in worldviews which place human beings, as such, at the center of things and one where that position is not occupied by anything in particular. With the latter, humanity has to make itself valuable to itself through its own social and cultural activity (a natural process, like beavers building a dam in my view). Neither is more “rational” than the other, if “rational” has any content independent of strong ties to the scientific worldview (which I think it must). Nor is opposing rationality and emotions warranted, at least in the strong way you’ve done.
    Additionally, in a particular case, the urge to avoid a prolonged and painful illness can be just as emotionally charged on the part of the person seeking euthanasia as those, say, loved ones, who urge her to reconsider because they love her, will miss her, and consider her sacred.

  • Eric Brown says:

    Also, I was wondering if anyone had any thoughts about whether or not persistent and personally/socially debilitating mental illness should be included among those diseases and injuries for which voluntary euthanasia would be ethically and legally an option?

  • Peter Wicks says:

    Eric, I agree that the notion that life is sacred is not in itself an emotion, and it will sometimes be part of an overall and reasoned worldview, although most often it is more like a vague notion that we have picked up from our surrounding culture and which influences are judgements, without us necessarily being aware of it.

    In any case, my point about our emotional responses tend to overwhelm our capacity to reason in these so-called “hard cases” was a different one. The notion that life is sacred seems to me to be relevant in the context of discussions about assisted suicide, and in some respects problematic, but I still think that the main problem resides in the interplay between emotion and reason, and this indeed has relatively little to do with the notion of sanctity of life per se. It’s not that I am opposing the two – at least that was certainly not my intention, and it’s not immediately clear to me how my earlier comment implies that I am – but rather assuming that sensible decision-making relies on a back-and-forth between emotion and reasons that tends to break down when those emotions become too strong.

    Taking up your point (and exchange with Nicholas) about the urge of a patient to avoid a prolonged and painful illness being “just as emotional charged…as those, say, loved ones, who urge her to reconsider because they love her, will miss her, and consider her sacred”, I am in no way suggesting that because an urge is “emotionally charged” that we should consider it illegitimate. What is also clear, however, is that in making their decisions all involves are going to be influenced by the prevailing social attitudes, and are doing so in conditions of great emotional stress. It is essential for those social attitudes to be supportive, and essentially liberal. In any case, your example provides a good example of how the pressure to live can be far more pervasive – and arguably just as problematic – as the feared pressure to die.

    In summary, I am not saying that emotion and reason are opposed, only that the interplay tends to work best when the former are not so strong as to overwhelm the latter. And if there is an operational conclusion to draw from this, it probably has less to do with how we should approach the assisted suicide issue per se than with the moral obligation, mentioned by Will Crouch in “Doing Well by Doing Good”, to practise and promote mindfulness.

    • Eric Brown says:

      Thanks Peter and Nikolas,
      My point about the contrast between the suffering patient and her relatives was not to make a claim about who is or is not being selfish or who has rights, but to argue that making a simplistic distinction between emotion and reason might not help advance the debate. I think that a number of models of ethical decision making, like Haidt’s and Sonenshein’s [sensemaking-intuition], are best seen as iterative processes where rational (meaning especially reasoned discussion with and reflection on the attitudes and actions of others) and emotional factors are elements within an overall mechanism; emotion overwhelming reason is something that happens, of course, but I am not sure that sort of event is such a factor in the sort of ethical decision-making at stake in cases of voluntary euthanasia.Perhaps I’ve read too much into Peter’s response.
      I guess I see the thrust of Paula’s original post in this way: perhaps more important than legal issues surrounding voluntary euthanasia is a generally supportive social environment that allows all involved to develop their decisions and reconcile themselves as well as possible without pressures either to live or die predominating. Of course that’s an ideal, and I would agree with Nikolas that the “final” say should go with the patient.

  • Anthony Drinkwater says:

    Paula,
    Thank you for your post. I know only what I have read in the press about Paul Lamb, but from the reports it seems clear that Mr Lamb is not elderly, not partially conscious, not under «pressure» to die, and he seems to be in complete control of his mental faculties.
    The moral case seems clear : were he physically able to commit suicide when he thinks it is right to stop living, he would be able to do so. The fact is that he needs someone to help him do it with the minimum of pain and maximum dignity. That the law insists that his handicaps should prevent him from achieving his clearly thought-out desires is in my view immoral. In short, it is one permissible conduct for the physically able and another for others.
    I agree with nearly all the points you make, Paula, on palliative care, on medical priorities, about attitudes to the elderly and handicapped (but let’s not forget that «society’s» attitude to the elderly starts with each individual’s attitude to his parents, aunts, uncles…!)
    But none of these points appear to me to be relevant to this case.
    I’m not clear either why you should feel uncomfortable about addessing this issue in a recession : what’s the link? Or should we abandon every element of policy except those that directly address the economic crisis?

    To Peter, I’m not sure what «mindfulness» actually means : it sounds pretty egocentric to me. And this appears to me to be the opposite of what this type of situation needs, which I would describe as empathy or, as Paula suggests, love. (I know that this is not very fashionable in philosophy.)

    • Peter Wicks says:

      Wikipedia provides a good definition and description of mindfulness, where of course I am referring to the concept as co-opted by secular psychology (see the Wikipedia entry “mindfulness (psychology)”), not the original Buddhist concept.

      As Wikipedia notes, mindfulness is basically a technique for focusing attention and awareness, and more precisely for *controlling* the way we do so. Both my own experience amd empirical evidence suggest that it is helpful in all sorts of ways, especially combined with a clear idea of what one is aiming for (e.g. via clarification of one’s core values and appropriate goal-setting).

      I’m not sure exactly who you are using the word “egocentric” in this context. Certainly the awareness of self (but also its ultimately illusory nature) is a core component of mindfulness, and it can certainly help you also to control the extent to which you empathise or not. I’m sure mindfulness can be very useful for psychopaths as well. But for those of us who are not psychopaths, we will more likely use the technique to clear the (emotional, ideological, behavioural) path towards a more empathetic lifestyle. As Will Crouch noted in his post, we tend to underestimate the extent to which our interests are actually aligned with those of others. Practising mindfulness helps us to serve both.

      • Anthony Drinkwater says:

        Peter,
        If you had written that the concept of self is a construct, that it is vacillating, malleable, dependent, genetically determined, random, subject to free will, changeable, influencable, insignificant, determined by our upbringing, worthless, dangerous, valuable, essential, irrelevant, unimportant…..or had almost any other quality you might care to use, I might agree – or not, depending on which you chose.
        But that it is «ultimately illusory» ? ….
        Do you mean that it doesn’t really exist?

        And I don’t see how removing emotion, belief (ideology, as you put it) and behaviour from our path can possibly increase empathy.
        Empathy, and the actions necessary to turn it onto something other than moral wishful thinking, relies precisely on emotion, belief and behaviour. Or so it seems to me…. But there again, I’m not a Buddhist nor a psychologist.

  • Peter Wicks says:

    The self is, ultimately, a psychological construct; a fiction; a story we tell ourselves. After all, what do we really know about our past? We seem to remember things that have happened, and our memories seem to correlate (more or less) with other pieces of evidence. We remember that we left our car in the garage, and lo and behold, when we go to look for it it is there. But I write this only because I seem to have a memory of that kind of thing happening. At least I think I have written it.

    And if that seems like so much sophistry, consider what happens when you apply a many-worlds view to the future. Then, we don’t have one future, we have many, all existing in superposition. Each moment of experience is then to be regarded as a kind of “measurement”, in which some kind of collapse of the quantum state vector has taken place. We exist in the here and now; our experience of the past and future is more indirect, and ontologically less certain. But evolution has left us with the persistent impression that we are a single entity that evolves through time, so that the “me” that is typing these words is the same “me” that decided to respond to your comment a minute or so ago. As long as there is enough continuity of one’s mental state for such identification between our different “selves” at different moments in time we tend not to question this belief, which is clearly necessary in order to function effectively. But the scientific justification for it is weak.

    As for emotion, belief, and behaviour, of course I am not suggesting we should be trying to get rid of them! What mindfulness helps us to do is to stop them getting in the way of living in accordance with our values, as they so often (again, because of our evolutionary heritage) do. The ability to feel, without being overwhelmed by one’s feelings, to think, without assuming that our thoughts are necessarily accurate or helpful, and to exercise appropriate control over our behaviour: this is what mindfulness helps us to do, and therefore (again, combined with appropriate goal-setting) to lead the lives we actually want.

    • AnthonyDrinkwater says:

      «But evolution has left us with the persistent impression that we are a single entity that evolves through time, so that the “me” that is typing these words is the same “me” that decided to respond to your comment a minute or so ago. As long as there is enough continuity of one’s mental state for such identification between our different “selves” at different moments in time we tend not to question this belief, which is clearly necessary in order to function effectively. But the scientific justification for it is weak.»

      I would have said that the scientific evidence is, on the contrary, overwhelming that it is the same «you». And that if you reply, it will be, again, the same you….
      In case it is a different you, how will you/he/she know what you were thinking when you posted the first time? Has he/she/new you had to spend a lot of time getting up to speed? Or is there some form of telepathy between you both? And if «you» have been doing something else meanwhile, does this transmission work between the three of you?
      It must be difficult waking up tomorrow for the new you to sew up all the thoughts, experiences, emotions and beliefs of yesterday’s old yous…

      • Peter Wicks says:

        How do I know what the person who wrote the previous comment under the name Peter Wicks was thinking? First of all, I don’t. I know (at least I’m inclined to assume) that it was posted, and I have some memories associated with the event, but exactly what thought processes were involved is lost in the mists of time. Perhaps it’s not even a meaningful question to ask.

        Of course, the reason I have these associated memories is that the human organism that is actually typing these words has evolved in a more or less continuous manner since the previous comment was posted, and I am thus able to access those memories. Does that justify identifying with that previous commenter as “me”? Why?

        Have I had to spend a lot of time getting up to speed? No, I access the memories quickly and automatically, largely without conscious effort. This is essentially what creates the illusion of self, as a narrative evolving through time. No telepathy, just continuity of physical evolution, and the formation, retention and recall of memories. And no, the entity that posted the previous comment has not been “doing something else meanwhile”; that entity no longer exists.

        Obviously, I do not think like this most of the time. The narrative conception of self is, as that previous commenter noted, necessary in order to operate effectively in the world. Nor do I see the primary purpose of mindfulness as being to come up with subtle insights regarding the nature of identity. On the other hand, as we hurtle towards a future-shock world of brain to brain communication and other identity-challenging technologies, we will need to get comfortable transcending our naïve notions of identity and self-hood. And yes, mindfulness can help with that as well.

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