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Easing the passing: Death booths, misrepresentations and the ‘Ugh factor’

Death is in the air. To stop us being engulfed by the ‘silver
tsunami’,  Martin Amis urges the
construction of euthanasia booths, and encourages the elderly to go to them for
a martini, a medal and a pharmaceutical nudge into the void. Terry Pratchett
talks cosily about ‘shaking death by the hand’ as he sits on his lawn, Tallis
on his IPod, drinking some modern Socratic hemlock washed down with vintage
brandy. He and his backers in the euthanasia industry shrewdly propose death
tribunals who, having heard evidence about individual cases, would sign or
withhold a death warrant. Such tribunals, they say, would obviate the risk that
vulnerable people might opt unacceptably for euthanasia. The opinion polls
consistently indicate considerable public support for a change in the law
against assisted suicide. The opponents of assisted dying are caricatured as
reactionary bigots, probably fuelled by otiose, antediluvian religious
prejudice: people who care more about some dogma of the sanctity of life than
about pain, fear, despair and autonomy. The crusade for assisted dying is a
campaign by the modern and enlightened against the mediaeval  and  benighted.

The arguments are old and tired. And this is no place to
rehearse them. Just two points amongst many.

First: stop to wonder why the would-be repealers of the
assisted suicide legislation can get none of the real experts on their side.
Lord Joffe would have loved the support of just one mainstream palliative care
physician. He couldn’t find one. And why’s that? Because the palliativists know
that it is vanishingly rare to have suffering that can’t be palliated. At the
very worst, you can sedate to unconsciousness. But that’s not what most people
think. And they are not being disabused of their error by the euthanasists. For
a lobby that contends that its main agenda is the autonomy of the patient, that
is shameful. Tell the truth: don’t generate and perpetuate fear for political

The classic example is the fear of choking in motor neurone
disease. It seems that a high proportion of MND patients who opt for assisted
dying do so fearing that eventually they will choke to death. If they think
that, they are misinformed. Their clinicians need to read the literature and
reassure them. It would cut down the number of flights to Switzerland.  I’m sure the point has been made much better
elsewhere, but a paper of mine outlines the problem: Misrepresentations about palliative options and prognosis in motor
neurone disease: some legal considerations
:  Journal of Evaluation in Clinical Practice
(2005) 11(1) 21-25:

Second:  Would you
want to be treated by a doctor who, before he saw you in the surgery, had
killed a couple of patients? If you wouldn’t, perhaps you think that the
solution is a special class of doctor or paramedic – a public executioner:
someone who got up, had breakfast, killed patients until lunch, had his
sandwiches, and then killed more people until he went to pick up his children
from school. But would you want to have the executioner round for dinner (other
than from morbid curiosity)? Probably the answer is that you would not. The
reasons are visceral, and hard to identify in terms appropriately rigorous for
an august blog platform like this. But they are hard to identify and discuss
precisely because they come from a place that is deep and old. They are woven
so tightly into our constitutions that it is difficult to tease them out and
put them under a philosophical microscope. I’ll call the reasons collectively the
‘Ugh factor’.

We ignore the ‘Ugh factor’ at our peril. It tells us some
things that are worth hearing, and that we won’t hear from anything else. In fact
we live by it a lot of our lives, but feel that we should disregard it when we
write academic papers. Even those papers, though, are often ruled by ‘Ugh’,
particularly if we are lawyers. When we talk about the views of ‘all
right-thinking people’, we are appealing to it. We’re just embarrassed to go
further, look harder at the reasons for our distaste, and try to describe them.
That description, if accurate at all, would probably be more passionate and
poetical than propositional, and therefore not the sort of thing that would get
past the referees. Which is no doubt yet another reason why the ‘Ugh factor’
deserves particular respect.

If ‘Ugh’ gives us a creeping chill when we’re drinking tea
with a professional killer, we might want to wonder if a society that pays his mortgage
might not be an icy place too.

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5 Comment on this post

  1. I suspect that most people wouldn’t mind too much knowing that such-and-such a person were a “professional killer”; even in the context of human euthanasia there’s a difference between murder/torture and killing a consenting sufferer. The anti-abortion lobby consider doctors who offer abortions as murderers but the rest of us don’t mind sitting down for meals with them. We’ll quite happily eat with vets who might spend their whole days euthanising animals, but might think twice about eating with someone who tortures animals for fun.

  2. I have no wish to caricature Charles Foster as a reactionary bigot fuelled by otiose, antediluvian religious prejudice, but I don’t appreciate his seeking to travesty those who use arguments which he does not approve.

    As for the two non-old and non-tired arguments presented :

    The first presents as a matter of fact that many of those who wish to be assisted in suicide are mislead into thinking that their condition cannot be palliated.
    Two comments – is this really a matter of fact other than in a few cases ? If so, where is the evidence ? (Does it for example apply to Mr Pratchett?)
    Secondly, what is meant exactly by palliation ? If it means, as it seems from the post, reducing a person progressively to a state of unconsciousness, then this is exactly what I do not wish to happen to me, for a whole host of reasons. And if I can’t end my life myself at that time, I would like someone else to help me do so.

    The second argument is interesting : I agree that the “Ugh” factor can tell us something important about what is happening in our minds. But does Charles Foster have the same feeling whan he takes his cat or dog to the vet, knowing that the same vet may just have terminated the life of a similar pet ?

  3. Whilst being aware of the ‘Ugh factor’, I think we need to be equally aware of the ‘Hmm factor’ in this current chapter of the assisted dying debate.

    Martinis? Vintage brandy? Shaking death by the hand? Hmm. The arguments might be old and tired but whilst I believe that Ughs function productively to refresh such arguments and keep them relevant, Hmms can, on the other hand, render us ethically blind as we are seduced by the power of such poetic narratives. A group of wise, just and well-placed individuals making a fair and compassionate end of life decision? Hmm. A musty courtroom tribunal making judgements at snail pace through a bureaucratic and dehumanised legalistic process? Ugh. Pass me the tubes and life support machine, please doctor.

  4. Anthony,
    Re evidence:
    (a) There are, for very obvious reasons, no decent studies that set out the conclusion that I suggest is right. The evidence is necessarily anecdotal.
    (b) Some of that anecdotal evidence is summarised in the paper mentioned in my post.
    (c) The fact that no or no significant numbers of palliativists endorse assisted dying suggests strongly that my conclusion is correct. If assisted dying were clinically necessary for the alleviation of suffering, palliativists would endorse it. They do not. People still ask for assisted dying: a significant (but not, you’re right, the only reason) must be that the request is made for reasons that are clinically misfounded.
    (d) Don’t know about Pratchett.
    Re definition of palliation: My post was very short and very limited in its scope. It did not purport to answer all the arguments for assisted dying. It was directed only to one argument – that which very often features the Dr. Cox case or the fear of choking in MND, and says: ‘Assisted dying is necessary in order to stop that sort of obscenity’. The evidence about that is unequivocal: it is not necessary. In the tiny number of cases where orthodox palliative techniques fail, sedation to unconsciousness is available. There is always a complete clinical answer to that argument. So by ‘palliation’ I mean ‘the control of symptoms to a degree necessary to ensure a physically comfortable death.’ Yes, I acknowledge that there are other issues in play – notably autonomy. Those issues will be particularly vocal in Pratchett-type cases. I appreciate too that the practice of sedation to unconsciousness impinges on autonomy interests. I have discussed autonomy’s involvement in these problems at inordinate length elsewhere (‘Choosing Life: Choosing Death: Hart (2009), if anyone is interested), and didn’t feel that I should subject readers of the blog to yet another sermon on that subject.

  5. Anthony,
    I should have answered your point about the vet.
    No, I wouldn’t feel that about the vet. That is because the vet would have killed an animal, not a human. The same point is perhaps better made another way: I have many friends who eat cows: I have no friends who are cannibals.

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