Choice in Dying

This has become more and more clear over the last couple years. Some people suggest that the Guardian keeps him on because his looney ideas attract hits, simply in order to comment (almost always adversely) on his looney toons articles. But this time he has really stuck his foot in his mouth. His latest article is entitled “Assisted Suicide is never an autonomous choice,” and that really is pushing the bounds of intelligibility. Let’s see why he thinks such a foolish thing; but before we do this, let’s ask this question: If assisted suicide is never an autonomous choice, is any choice ever truly autonomous in the sense desiderated? I think the answer to that is no, and because he cannot see this is the reason why it seems to me that Andrew Brown is now teetering inelegantly towards idiocy.

The subtitle of his article states: “There are many who consider their lives no longer worth living. Yet it’s fraudulent to ignore the part we all play in those feelings.” And this is just silly. We don’t have to ignore the part that we play in people’s feeling that the quality of their life is so low that they consider their lives no longer worth living, in order to hold that the decision to ask for assisted suicide can still be a perfectly autonomous decision. If a person cannot make this decision autonomously, then the meaning of ‘autonomy’ itself is in question.

And that’s precisely the problem. The Roman Catholic Church believes that no one can make a rational decision to end their life, and this is a close neighbour of Brown’s view. The problem here is what is to count as autonomous. When I make a decision to get married, for example, is my decision autonomous? What would indicate that it was not? Certainly, someone standing over me with a shotgun (as in “shotgun wedding”) saying, “You got her pregnant, and now you’d better do the “honourable” thing, or else!”, would raise questions as to the autonomy of my decision to marry. But simply the fact that other people are counselling me to get married, encouraging me to see that I have a good thing going and I shouldn’t blow it, or being encouraged by someone whom I love, and who loves me, to take the next step: do these influences make my decision, if I make it, less autonomous?

What about my decision on a vocation? My family, say, have certain expectations of me. I have done well in school. I shouldn’t waste my life playing in a band, when I have the ability to make something of myself as a doctor or a lawyer, which will give me security and stability. When all the influences have been totted up, and I make a decision, say, to go to law school, with the years of university and apprenticeship that this is going to take, should it be said that I did not act autonomously, just because I have taken the views of others into account?

To ask the question is to answer it. We simply cannot escape the influences of others over our lives. They are going to play a role in the decisions that we make, unquestionably. But what conditions are necessary in order for us to suppose that these influences necessarily subvert the autonomy of a decision?

Brown begins his article in an odd way:

The arguments over assisted suicide are mostly conducted with obvious flaws on both sides. Defenders of the status quo are wrong about the sacredness of life; those people trying to change it are wrong about humanity.

The actual, practical issue is tiny. No one wants either to prolong the life of the elderly into a grotesque torture, or to bump them off as soon as they become inconvenient, although these spectres lurk in the shadows of the argument.

As a beginning this is not promising. Let’s not bother to argue for anything. Let’s just make some grandiose statements about everyone engaged in the argument, as though no one has said anything in particular that is of great value. The concept of the sanctity of life is just irrelevant, Brown says. Anyone who argues for this is wrong. Okay, fine. Let’s allow him this. But then he goes on to say that, in any case, those who want to change the law — which is in fact based, largely, on the concept of the sanctity of life — are simply wrong about humanity. About humanity, of all things! This is just too big a claim to make. Being wrong about HUMANITY, he gives us to understand, we can’t really get much “wronger” than that.

But the second paragraph holds the key to Brown’s doddering into senility. We don’t want to prolong life to grotesque lengths, he says. “Them” and “us” are not mentioned, but they’re hiding in the shadows of Brown’s “argument”: we don’t want to “bump” (his word) people off when their lives become inconvenient. What does this mean? This is simply a root-and-branch misunderstanding of the argument for assisted dying. It’s not a matter of “us” prolonging the lives of “them”, or of “us” bumping off “them” when “they” become “inconvenient to us”. (It really is difficult according rationality to the man who writes silly things like this, but let us try to be charitable. I know it’s hard.)

What’s the problem then? It’s got nothing to do with the sanctity of life or religion. It’s got to do with the nature of HUMANITY (writ large), he says. And then this (this, I gather, is about the nature of humanity):

The thing that worries me about allowing patients to choose is that this isn’t the kind of decision that we can reasonably make alone.

Well, since most of our decisions are not simply made in lonely isolation, and those towards the end of life are likely going to be made in consultation with others: loved ones, physicians, our own conscience, the general moral climate in which we live, our own sense of the worthwhileness of continuing with a life whose medical trajectory can be predicted with some degree of certainty (Brown tends to forget that assistance in dying has to do with disease and its consequences); it is no doubt true that we won’t make our decisions in a social or other vacuum. But does this mean that we do not act autonomously? I don’t think Brown has given us any reason at all to think so.

Let me give you an example. My wife Elizabeth, who had a fairly aggressive case of MS, knew, from consultation with her family physician, and her neurologist, that there was simply no more that scientific medicine could do. The likely trajectory of her disease, which had already rendered her seriously disabled (her body below her arms completely paralysed and spastic), and was threatening to disable her even more, would probably end up causing her not only complete paralysis, but complete paralysis with continuing painful spasticity. A drug which had helped with spasticity had already precipitated total liver dysfunction, which almost killed her, and there was nothing else that would relieve the pain of uncontrolled spasticity in her legs which, a few times, had thrown her completely out of her bed. Large doses of morphine helped a little, but had complicating side effects. She needed nursing care twice a week, because, having no bowel control, she had to be “toiletted” by public health nurses, and she was permanently catheterised, the catheter being changed every month or so. She could not walk or transfer herself to her wheelchair, since her arms were beginning to grow numb. She had to spend most of her time in bed, being turned from one side to the other to avoid bed sores. Even at night she had to be turned every two hours; she could not do this herself. The pain made it difficult to concentrate so, towards the end, she was no longer able to read with attention. And there are many other things that I could tell you about her condition, which was, to her, a source of deep existential anxiety.

Though she had said very shortly after her diagnosis that, when things got too bad, if they did, as it seemed very likely that they would, she would not stick around to await the end in total paralysis, as had happened to people that she knew, I continuously expressed my wish for her to try to stay alive, that life could still have good things, and she should not bring everything to an end too soon. At one point, almost three years before she died, I finally relented, and in a sense gave her my permission to go when she thought the time was right. It was our sixteenth wedding anniversary. She had been telling me for some time that if I loved her, I would let her go, something I was very reluctant to do. Watching her progressive decline, and her increasing desire to have the freedom to go, I finally said to her, in a letter which she framed and hung above her desk, that I would not hold onto her forever, and that, if she felt it necessary to go, she had my blessing to do so, though I urged her to live as long as possible, and to postpone any decision as long as she could. The next few years, though fraught with great anxiety, were yet ones of great intimacy and fulfilment in our personal relationship. We grew even closer together, though we were, since the first day we shared our love, so close that it was hard to imagine the relationship becoming more intense or the bond even closer and more firm, but it did. I believe that, had the option of assistance in dying been available to her, she would have lived longer than she did, and would have lived with more confidence that the future would not have to be the one prefigured by her disease.

Finally, however, she decided that the time had come, and without my knowledge took an overdose of sleeping pills and morphine. But even this was not the end, for some 36 to 48 hours later she woke up, very disappointed that she had not died, and then immediately resolved that she would go to Switzerland. She asked me if I would accompany her. I said that I would, and she immediately began making plans to go.

My point here is that there were all sorts of influences that were being brought to bear on her as she was making these decisions, but the decision, in the end, was hers, and there is simply no reason for believing that she did not act autonomously in the end, whatever influences were brought to bear. In Switzerland she was asked by a doctor whether this was something that she wanted to do, explicitly excluding me from the discussion. At the time of her “accompanied death” at Dignitas, she was repeatedly told that she did not need to go through with this, that she could come back at another time, that no one would think less of her if she changed her mind. But it was she who directed the whole affair, insisting, after some time, that she thought it was time that they were getting to work. She asked for the drugs to be mixed, and then, after waiting some time for the anti-nausea drug to take effect, it was she who insisted that enough time had passed for the drug to be effective and that it was time to move on to the next stage. There was nothing in all this to indicate that she was not acting autonomously. Indeed, she  had, over the years, consistently said that, if I really loved her, I would respect her decision to die, if that is what she decided to do.

And there was nothing, in all of this, that diminished her sense of self-esteem, something that Andrew Brown seems to think is a necessary prelude to terminating one’s life. It was, indeed, her own sense of herself, her decisiveness and care in living a thoughtful and ordered life, that led her, in the end, to want to die before her life had become an intolerable imprisonment in her own body. Brown seems to think that the moment the interests of others become involved, autonomy is ruled out. But this is nonsense. Certainly, it is true that there are thousands of old people whose lives are not valued, and who may, because of this, find death preferable to continuing to live. Well, that is a problem for society, not for assisted dying. If someone has decided to die because their lives are no longer valued by anyone else, and they accordingly hold their lives to be of very little account, then we should try to improve conditions for them, so that their lives are valued, and they can get to the point that they can, in turn, value their lives. There is no inconsistency in supporting assisted dying and arguing that conditions should be improved for the elderly, or for those who are terminally ill. Assisted Dying is a choice, and there is simply no reason it cannot be an autonomous one, although philosophers like Onora O’Niell think that the issues are too complex at the end of life for autonomy to be possible. I think she is wrong, but I will not expatiate on her arguments here. We are only considering here Brown’s rather simplistic way of approaching the issue of autonomy.

But there is no point in saying that, because they are not valued they cannot therefore make an autonomous decision to end their lives when they are imprisoned both by disease and loneliness. No one is going to accede to a request for assisted suicide only because a person is lonely and unvalued by those around them, and legalisation of assisted dying would not be premised upon such a foolish condition. In the case of someone asking for assistance in dying, the question of that person’s disease burden would be the first consideration, and if, in the opinion of medical professionals, the disease burden was not such as to make the possibility of meaningful life impossible, assistance would not, or at least not immediately, be granted, and hopefully the person’s social isolation could be remedied. However, we must not forget that this is not just about disease, but about a person’s assessment as to the value of life — which is why Lord Falconer’s recommendations do not go far enough. Just legalising assisted dying would make it more likely that the urgency of such improvement in an elderly person’s circumstances would come to light. But the idea that such a person is incapable of autonomous judgement is simply a red herring. The nature of humanity upon which Brown bases his opinion is also such that, when the parlous situation of someone who is old and alone is brought to our attention, we will, other things being equal, make some attempt to improve their situation.

Brown brings up the case of the serial killer Harold Shipman, who found old people a convenient target, because they were so often alone, and no one to check up on them. This does not mean that any of those old people could not make an autonomous judgement; it just means that their social isolation made them easy targets for a psychopath. But what has this got to do with assisted dying? Nothing at all. It’s just one more of Brown’s red herrings. The problem with so many arguments about assisted dying is that people think that any odd feature of the way society is organised, or about the way old people are treated, or practically anything else that strikes them as making assisted dying risky, is immediately addressed as in some sense a knock-down argument against legalisation, when they are really simply indications that, in other respects, we do not always care for people as we should.

For example, a lot of people suggest that, because we cannot make hospice or palliative care universally available, we should refuse assistance in dying, because, if palliative care were available, this would be an adequate remedy for the person who is asking for assistance. But this is simply nonsense. Yes, hospice care is often spotty and inadequate, but this is not a good reason to force people to suffer because we cannot provide them with adequate care. First of all, palliative care often is not sufficient to solve the problems which lead people to request assisted dying. But second, if we can’t provide them any relief, because services are inadequate, this is a reason to improve care, but not at the expense of that person’s suffering.

Brown says:

Let’s suppose that only one in a thousand of them thinks their lives are hardly worth living – and that’s a very low estimate. That still means hundreds of people who would take the chance of assisted suicide if it were offered without pain or condemnation; and if we treat their decisions as wholly autonomous there is no reason to argue with them.

It is probably true that no decision is wholly autonomous (whatever that might mean). We are social animals, and what we decide will be determined to some extent at least by what others say. But this still doesn’t mean that our decisions are not autonomous, and if that one in a thousand, whether cared for or not, is living in misery, and wants help to die, why should that be forbidden her? Because she is not cared for? Or because our palliative care is inadequate? That hardly seems a good reason to deny assistance to her. If, however, physicians think they can make things better for her, then, by all means, they should try, but if, after having tried, the person still insists that they want help to die, why should it be denied them?

The continuing stupidity of the arguments against assisted dying are a constant puzzle to me.  But Brown has not provided one good reason for denying assisted dying to those who are very ill and suffering greatly and have decided, whatever other influences have been brought to bear, that it is time to go. No one should be pressured into dying, and any law that does not correct for possible pressure would not be adequate; but no one should be pressured to go on living either, for living can be absolute hell, and no one should be forced to endure the pains of hell just because of Brown’s idea that he has plumbed the depths of our humanity and knows, within an ace of the bullseye, what it is all about.