Tomorrow in the House of Lords Lord Falconer’s bill on assisted dying will be debated. The bill would allow those who are terminally ill and likely to die within six months to request life-ending drugs from their doctor for the patients to use as and when they see fit.
As might have been expected, there has been huge discussion over the bill, but most of the arguments presented so far are not new, and the same will probably be true tomorrow. But there is one I haven’t seen before, put forward recently by Giles Fraser: that assisted suicide is the ‘final triumph of market capitalism’.
Fraser begins with the description by the artist Marion Coutts of the last eighteen months of her husband’s life, which involved NHS case conferences where no one would take any responsibility for what was going on. This, Fraser says, is the ‘inevitable corollary to “patient choice”’. I haven’t read Coutts’s book, but nothing Fraser says suggests that this particular failure to take responsibility was the result of offering any choices to Coutts’s husband. And often, when choices are offered to patients, it is quite acceptable for them to ask for medical advice. Allowing someone greater autonomy isn’t really a failure to take responsibility oneself; indeed, when patients should be given a choice, not to give them a choice is a violation of their rights.
Fraser goes on to suggest that the reality of patient choice, in most cases, is that patient care is replaced by ‘another bloody questionnaire’. Even if he’s right, it’s misleading to imply that the failure of care is the result of offering the patient a choice. That is much more likely to result from mismanagement, under-resourcing, or negligence. Removing the opportunity for choice would make things worse, not better.
Fraser then offers the well-known argument against assisted dying that it will result in many terminally ill people choosing to die so as to ease the burden on their relatives, and because of the very nature of that choice being unable to let their loved ones know the real reason for their having made that choice.
It is undeniable that there will be such cases, and they may even involve the relatives putting unwonted pressure on the ill person to end their own life. Some people do horrible things to one another. But the state does not, and should not, police personal relationships in the crude way Fraser is advocating. Any responsible doctor is not going to hand over life-ending drugs without properly discussing the implications of the choice with the patient, and ensuring as far as possible that this choice is being made in an informed and uncoerced way. It’s also important to remember that not wanting to burden one’s relatives is a perfectly respectable reason for choosing assisted dying, and not one that the state is entitled to prevent an adult from acting on.
Fraser ends with the claim that ‘choice’ is now considered the only important value in medicine: ‘the moral language of the supermarket has become the only moral currency that is accepted’. And this is why assisted dying is the final triumph of market capitalism. Even in matters of life and death, he says, we have become ‘consumers’, and history suggests that it will be the most vulnerable who end up as losers.
This last part of his argument moves rather quickly. First, it seems quite implausible that the only value underpinning modern health care is choice – or ‘autonomy’, as one might prefer to put it. The very nature of the choices patients are asked to make demonstrates that: they are being offered options each of which in some way is expected to benefit them. So beneficence matters as well as autonomy.
What about the connection with market capitalism? It can’t be that Fraser is claiming that the idea that each of us has the right to decide when and how we die has emerged only in recent centuries – he will know the works of the Stoics as well as anyone. Rather, his thought must be that the rise of market capitalism, which involves enabling people to make choices within a market, has made it possible for societies to consider extending the right to choose into inappropriate areas.
Now this is not the argument sometimes used against practices such as surrogacy – that they marketize practices which should not be marketized. For assisted dying does not involve any commercial transaction. So the analogy between a consumer and the terminally ill person requesting assistance with suicide is also somewhat dubious. Further, even if you disagree with market capitalism and think it has had bad effects overall, it does not follow that the legalization of assisted suicide is bad. That would follow only if you claimed that every effect of market capitalism is bad, and – so far as one can make sense of it – this suggestion isn’t credible. And if you think the legalization of assisted suicide is a good thing, then its being an effect of market capitalism is at least one thing to the credit of market capitalism (even if otherwise market capitalism is a bad thing).
The analogy that really seems to matter for Fraser is that between the effects on the most vulnerable of market capitalism and of assisted suicide, and I’ve already discussed that. Few of us accept that society should be organized to maximize the well-being of the very worst off group, but we do think that their position should be ameliorated as far as possible. So any institutionalization of assisted suicide should, as I’ve suggested, seek to minimize the coercion of the terminally ill. But it is not appropriate for the state to do that by continuing to violate the rights each of us has over central aspects of our own lives.
Two doctors will need to sign a consent form to prevent abuse of the Act. Sound familiar? So is also the case under the terms of the 1967 Abortion Act.
Here are the criteria:
(a)that the pregnancy has not exceeded its twenty-fourth week and that the continuance of the pregnancy would involve risk, greater than if the pregnancy were terminated, of injury to the physical or mental health of the pregnant woman or any existing children of her family; or
(b)that the termination is necessary to prevent grave permanent injury to the physical or mental health of the pregnant woman; or
(c)that the continuance of the pregnancy would involve risk to the life of the pregnant woman, greater than if the pregnancy were terminated; or
(d)that there is a substantial risk that if the child were born it would suffer from such physical or mental abnormalities as to be seriously handicapped.
As everyone now knows, all a pregnant woman, under 24 weeks, needs to do is walk into a clinic and ask for an abortion and it takes place with scant regard to the terms of the Act.
If the Assisted Dying Bill is enacted, then after a few years we could see a rise in very unintended consequences.
Your point would hold water if the UK was the first civil society to enact Assisted Suicide legislation. As it stands, though, there are a few other countries who have come to this decision first, and any “unintended consequences” can be found from studying the after effects from the passage of their laws. So any reactionary rhetoric is completely useless here, unless you mean to say that the people of the UK are distinct from the peoples of these other countries or that their passed laws are isolated from this UK law?
Thx Andy and Airin. That’s a good point, Airin, though of course there’s a certain amount of dispute about what’s been going on in other countries. The analogy with the Abortion Act is also problematic in that it’s not clear that the consequences Andy refers to were unintended.
I think that Fraser is essentially right that assisted suicide is a triumph of market capitalism, although I would place the emphasis on how the arguments for assisted suicide have been almost exclusively confined to the rights of the individuals that wish to be killed by another person. The assumption is that once we have decided that patients have a right to assisted suicide they will be able to exercise this right by being offered a killing service provided by medical workers. The medical workers most people have in mind are doctors because they can make a “professional” decision. The fact that the vast majority of doctors in a recent RCP and RCGP poll voted against assisted suicide (73.2% and 77% respectively) is seldom raised as a problem. Things do not get much better when it comes to nurses who are 70% opposed. When we get to the hired help like care assistants, porters, administration staff, social workers, cooks, cleaners, and all the other hundreds of thousands of workers that run the NHS and other healthcare organisations, we find very little polling data about their beliefs because lets face it who give a fig what cleaners think? The customers’ rights and beliefs are what counts in a market economy and if they want to be killed by the NHS all workers should dutifully obey their orders and do as the customer demands. This is a triumph for the me, me, me society of modern capitalism.
I am by no means in principle opposed to assisted suicide, but I am amazed at how little thought and consideration has been given to the practicalities of how and who is going to be doing all this killing. The BMA accepts that doctors can have conscientious objections but, as it states: ‘Where conflicts arise between the interests of patients and a doctor’s freedom to exercise a conscientious objection or to manifest belief, in the BMA’s view they must be resolved in favour of patients.’ Would this stand when it came to killing their patients? If we respect the objections of the majority of doctors and other healthcare workers and allow them not to become involved, how are we going to get the minority to do the killing? Would dissenting doctors and healthcare workers have to make a referral to the minority killers? Obviously that does not solve the problem as they would no doubt still wish to object to be involved in such a procedure. The alternative, often advanced by some medical ethicists, is that dissenting doctors and healthcare workers should be compelled to engage in the decision-making process. That is also obviously unworkable and would greatly undermine the ethos of the NHS and the medical professions if enforced and could be subject to a legal challenge.
Having spent many years working in mental health and psycho-geriatrics, I have little faith in the abilities of doctors to make this type of decision because they do not have the knowledge, skills, information, time or indeed concern to properly assess patients and their situation. Your suggestion that the state does not have to do anything more than find doctors, presumably from the minority wing of their profession, to make this decision, because to do more would ‘violate the rights each of us has over central aspects of our own lives’, is remarkably complacent. Within this minority we could get a significant number of doctors that would be, to say least, unreliable decision-makers. I support the right to abortion, but also agree with Andy that many doctors do not adhere to the Act and that we should not expect doctors to perform any better when it comes to assisted suicide. The state does not have to micromanage our lives, it does however have a responsibility to ensure that the NHS is efficiently regulated and that no individual is coerced into terminating their lives (mistakes might happen but they should be diminishingly small in number). There is nothing in Falconer’s bill or anything presented by supporters of assisted suicide that comes close to a workable system the NHS could safely operate.
If and when we have a proper debate that includes the beliefs and rights of all involved in assisted suicide, I might be convinced that assisted suicide is both ethical and workable.
Thx Keith. This is a thoughtful and helpful response. A few points. (1) The notion of individual rights emerged well before market capitalism. I just don’t see the link here between the right I have over my own life and a particular theory of how goods should be distributed. (2) In suicide, one kills oneself. It won’t be the NHS, doctors, or indeed cleaners who kill the patient. (3) Many doctors are opposed to abortion, and are entitled not to refer patients for termination. Of course that right to refuse would and should be built into any system for assisted suicide. Many doctors would very much like to be able to help certain patients autonomously to end their lives with dignity and minimum suffering. (4) It’s understandable that Falconer and others have not yet worked out the details, but the general outline of a system is not difficult to imagine, especially if one considers arrangements in other countries. (5) I hope I’m not complacent in the way you suggest. Naturally I recognize that legalizing assisted dying would be a momentous change in medical practice, and that it would require carefully thought-through and transparent admininistration, and adequate training for those doctors involved. I hope also that your lack of faith in doctors in general is misplaced. My claim was not that the state’s doing more than merely finding doctors would violate patients’ rights. It is that the current system violates those rights. The state may indeed have a responsibility to minimize the coercion of individuals; but it should not be doing that by placing unwarranted limitations on the rights each of us have over our own lives.
Thanks for your reply.
(1) This is a big topic. I agree that recognisable individual rights emerged before the market economy, but most of the rights we have today and our understanding of rights are inextricably tied to the market economy. That’s not say they are linked to a ‘theory of how to goods should be distributed‘, they emerge from the practices of the market system, i.e. the stuff that excited the likes of Hume, Smith, Marx, Weber, etc.. It’s the stuff we do and the way we communicate that makes me believe that the present debate on assisted suicide (and other issues) is being conducted from a position that only considers the “customers” interests and rights. The poor bloody works don’t get a mention. (2) If that was so there would be no need for a change in the law to allow assisted suicide, dying or whatever you like to call it. (3) So you suggest that the killing is to be done by a minority of volunteer doctors. Again, will all the workers be able to exempt themselves from the procedure? What about referrals? And so on and so forth. (4) The devil is always in the detail and there really is no excuse for not addressing it earlier, indeed, it’s underhand not to do so. If a general outline is not difficult to imagine, why do we never get it? The issue of other countries is complex. All the countries and US states’ health services that have assisted suicide are much smaller than the NHS. Scaling is not another little detail, it’s a really big problem. (5) Fine. How about just making it legal to assist somebody in suicide? You can have the right but do not expect medical workers to assist you. But of course that would not work, so it is not just about your right over your life, it deeply effects others who might believe they have a right not to be involved in killing you (“involved” might mean being on a ward where killing takes place). I’m with Berlin that such conflicts are the stuff of life and that we have to recognise these conflicts and if they can’t be resolved we have to live with them. But please let us not underestimate the complexity of the problem of devising a system within the NHS that can deal with this conflict.
Finally, I think my somewhat jaundice view of doctors and medics in general is supported by research and their criminal conviction rate. At the extreme end, when it comes to harming and killing doctors and medics are in a class of their own. Of course this is confined to a small minority, but assisted suicide might attract some pretty strange types. This is why I believe doctors alone should not be consider suitable for this type of decision-making.
Hello Keith,
You might care to read JP Griffin’s “On Human Rights” for an intelligent and elegant exposition of the notion of rights. You might even change your view that it is “inextricably” linked to capitalism …..
Anthony
Read it. I said ‘market economy’ not capitalism. Can’t fully explain the distinction here, but the former precedes capitalism and goes back in one form or another to a time before the period, the late Middle Ages, that Griffin identifies as the beginning of natural rights (as indeed does MacIntyre). Property rights (which include of course our right to freedom) predate the Middle Ages, but there are, as I said, rights that are not closely linked to the development of the market system. However, I still stand by my claim the ‘most’ of our rights are inextricably linked to the market economy. As is so often case, there is no single correct interpretation of this problem and we have to cross over the same point from different directions. I am not saying Griffin is completely wrong and I am totally right, we just have a different view. No time to say more.
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