Almost everyone does — misunderstand assisted dying, that is. This is particularly evident in several recent articles, both in Canada in the UK. I’ll just discuss Derek Miedema’s “My right to life trumps your right to die“, and Matt Gurney’s “Euthanasia’s foes, out of arguments, settle for fear-mongering” in this post. The first one, obviously, opposes assisted dying, the latter supports it; both are misunderstandings.

The main problem lies in the fact that Miedema makes a number of claims about the danger of assisted dying, and Gurney accepts that these are genuine dangers, but insists that they can be overcome by careful legislation. But he needn’t have taken Miedema’s arguments at face value in the first place, and by doing so, distorts both the nature and the purpose of assisted dying. This distortion is present in almost all the polls that have been done in order to gauge the level of support for assisted dying in most jurisdictions, and is based on the idea that the only reason for assisted dying is serious and uncontrollable pain at the end of life. This is a misunderstanding of what people who are demanding that their right to assistance in dying be recognised are saying, and allowing for assistance in dying only for those who are terminally ill and in great pain is not an adequate response to those demands.

Let us consider, first, the terms which will be of most importance in the discussion to follow. Assisted dying is a general term which includes both assisted suicide and voluntary euthanasia (and may include other acts as well, including the withholding of treatment, the withdrawal of treatment, palliative or terminal sedation, or other acts or omissions which lead to the death of a person for whom life is no longer worth living). Assisted suicide is the provision of the means for another person to take their own lives (or to die by suicide). According to the Report of the Royal Society of Canada’s Expert Panel on End-of-Life Decision Making, voluntary euthanasia “is an act undertaken by one person to kill another person whose life is no longer worth living to them in accordance with the wishes of that person.” That seems to me a bit cumbersome, but it makes the point clearly. The word ‘kill’ is sometimes used deliberately to overload the issue emotionally, but it is used here in a morally impartial way, without suggesting neither approval or disapproval. I will generally use the term ‘assisted dying’ unless more specific terms are demanded by the context. But it important to note that assisted dying takes place only at the request of the person concerned, and is based upon that person’s assessment of the value of their continued life.

It is important to note that Miedema is listed as “a researcher at the Institute for Marriage and the Family,” which is supported by James Dobson’s radical Christian fundamentalist Focus on the Family, whose stated mission, according to Wikipedia, quoting from “Focus on the Family’s Foundational Values”, is

… nurturing and defending the God-ordained institution of the family and promoting biblical truths worldwide.

This is important, because Miedema does not bring up the issue of religion, and yet religious reasons are arguably the primary underlying reasons for his opposition to assisted dying, even though apparently based on purely secular grounds.

First of all, he uses his twin brother as an example of someone whose life would be likely to be terminated on the basis of the legalisation of assisted dying.

Due to complications at birth, [Miedema writes] he is still in diapers and fed via a feeding tube even though he’s 39. He gets around in a wheelchair only when pushed by someone else. He can’t talk, and yet, he has taught me more about what it means to be human than anyone else I know.

Since he can’t talk, there is no reason to think that Miedema’s brother would be a candidate for assisted dying. Yet it is surely reasonable to wonder whether, if he could talk, he would wish to go on living in that condition. And since his condition is due to complications at birth, it is hard to understand why Miedema suggests that he has a 50/50 chance of ending up in the same condition. Moreover, I am always sceptical when someone says that they learned so much about life from those who have not been “euthanised.” It’s a bit like an antisemite saying that some of his best friends are Jews. This reminds me that Lord Sacks, Chief Rabbi of the United Hebrew Congregations of the Commonwealth, wrote of his father’s death that, though he died in misery, Lord Sacks himself learned so much about being human from the experience. What his father learned from the experience is not recorded.

However, the other examples Miedema uses are cases in which people can make their own decisions regarding the perceived value of their lives, and whether or not, as he argues in one of his “research” papers, some people in those situations can in time find value in their lives and reach a “new normal” in terms of which life can again be seen as not only worthwhile, but full of joy. It is important to notice that forcing people to stay alive in conditions in which they feel life not worthwhile is effectively, as Ronald Dworkin has pointed out, to enslave them. The case of Ramon Sampedro (the subject of the movie The Sea Inside) a quadriplegic who fought a thirty year battle for the right to die, is not one of the cases that Miedema considers, and his claim that Daniel James chose to die because he was depressed is simply without foundation. I am reminded that Wesley Smith stated, without any foundation, that my wife Elizabeth died because she was depressed, a claim for which there is no basis whatever, and certainly not based on anything that Smith could have known. And even if she had been, depression does not in itself indicate a lack of competence to appreciate the reasons and consequences of one’s decisions.

And it is just here that Matt Gurney’s response to Miedema goes astray. He simply accepts, without argument, that Miedema is right about the dangers posed by the legalisation of assisted dying for people like Daniel James or my wife Elizabeth. He appreciates that “choice and personal autonomy are at the very heart of the euthanasia debate,” but when he says that

The many valid concerns raised by euthanasia foes can be accommodated — reasonably, as is the Canadian way — without trampling on the right of others to choose a quick painless end to what could otherwise be a long, agonizing struggle.

And then he lists Miedema’s concerns:

Take the objections raised by Miedema. Doctors euthanising patients without their explicit consent, patients opting for euthanasia when their psychological fitness was in question, the sick being pressured to choose death, people in Oregon getting their legally mandated second opinion from a pro-euthanasia advocate with a medical license.

These are, one and all, ersatz concerns. Take the matter of people being “euthanised” without their consent. Holland is the usually the chief whipping boy when it comes to this. Very often people like Miedema speak of “involuntary” euthanasia here, but usually this concerns people during the last few hours of life who are no longer fully conscious, but are clearly undergoing great suffering and pain, most of whom have spoken about assisted dying, and who are eased out of life in situations where the conditions of double effect are fully present. That is, medication is given to the patient for the sake of relief, knowing that it may shorten life. Many doctors (as results in Belgium show) do not consider this euthanasia, and do not list it as such, but it comes under that rubric according to the wording of the law, so in anonymous surveys these cases turn up. In such cases, physicians consult other physicians, and respond to the wishes of family members to have their loved one’s pain relieved, and the result (although not the assured result) is the hastening of death. Miedema is not the only one who uses cases like this to pad his lists of those who have been “killed ” without request. José Pereira, a palliative care physician in Ottawa, who is opposed to assisted dying, classifies every such case as “involuntary” euthanasia, in an effort to arouse even more fear and concern. Gurney does not have to accept Miedema’s concerns without further consideration.

Now, let’s take Miedema’s other concern, that patients are being helped to die “when their psychological fitness was in question.” Miedema doesn’t provide any evidence for this, and, since it probably concerns patients in Oregon who are also thought to be “getting their legally mandated second opinion from a pro-euthanasia advocate with a medical license,” we can use the evidence from Oregon here. The last first. In Oregon, as in most jurisdictions where assisted dying has been legalised, there are some physicians who are dead set against assisted dying. In order to provide physicians who are at least supportive of assisted dying, Compassion and Choices, the pro-assisted dying organisation in the US, provides consultant physicians for those who cannot find a local physician willing to prescribe a life-ending medication. Why is this a problem? Of course, the doctors prescribing medication are “pro-euthanasia”. What else would they be? Doctors who are not willing not prescribe medication! As to the second, there is some evidence that a few patients in Oregon who have received prescriptions for a life-ending drug, have had bouts of (transient) depression. However, it is not at all clear (i) that approaching death is not a reasonable reason to be depressed, and  (ii) that depression does not necessarily affect a person’s ability to make a reasoned, autonomous choice, and (iii), it is important to note that doctors prescribing the medication are only required to refer a patient for psychiatric examination if, in their view, the patient’s condition is such as to raise questions as to the person’s ability to make a reasoned autonomous choice, so there is no obvious reason why these few cases should cause concern. Indeed, were I in such a situation, seeing a psychiatrist would be the last person I would want to see. Who is a psychiatrist to say what is and is not a reasonable state to be in at the end of life? In Harvey Chochinov’s research into dignity and dying and what he calls “dignity therapy”, a full 10% of his research subjects still would have preferred assisted dying to psychiatric intervention, and the number of people opting for assisted dying in Oregon is far below 10% of those dying in that fortunate place. And when you recall that dignity therapy (so-called) was given to people who did not have the option of assisted death, one can only say that there is something macabre about the research itself. Imagine giving dignity therapy to dying patients and asking them whether or not they would still choose assisted dying, when no such option is available, and ask yourself whether this is not, in itself, an attack on the dignity of persons.

Lastly, consider the idea that patients will be pressured into choosing death. Opponents of assisted dying make a big song and dance over this, and then say, in a voice heavy with the sense of threat and doom, that the elderly and the disabled and the vulnerable will be put at risk. This is simply nonsense. The belief is based on the idea that someone else is going to assess the continued value of the life of the person receiving assisted dying, as the Nazis did in their notorious T4 programme, where so-called racial and eugenics experts decided whose life was not worth living (lebensunwürdig Leben). It is also based on the desperation that people who oppose assisted dying feel when faced with the fact that they are not able to use their favoured reasons, namely, that God is the one who decides when we are to die, and so each person should be required to leave dying up to God. The ridiculousness of this idea is immediately evident when we consider that, if dying is up to God, then, in curing ourselves of diseases we may, as John Donne said in his work on suicide, frustrate God’s purposes, since God may have intended us to die of the disease in question.  Roman Catholics speak of “natural death”, as though it is possible to speak of natural death if we do not also speak of natural life, that is, a life in which no intervention by means of technology is made in order to prolong it. “Natural death” is only a silly mantra that religious ethicists at the end of the argument repeat, because they have nothing further to contribute to it. Instead of that, they have recourse to the idea that the vulnerable will be pressured into choosing assisted dying.

Of course, there is no question that some people might come under such pressure, but are we to infantlise adults in such a way that we simply hold that they are unable to make autnomous choices? If so, they are not able to make a choice to have treatment withdrawn or to refuse treatment either. This is not only silly, it is contemptible and dehumanising as well. The elderly, and those with disabilities, and any others who find their condition a less than valuable a way to live, should have the same choices as anyone else. Why should they be thought incapable of making decisions? Daniel James, for example, of whom Miedema states, without a shred of evidence, that he died because he was depressed, and that many people like him have been able to achieve a state which he calls the “new normal,” and have even found joy in life, may be quite correct as to the latter, but is undoubtedly completely wrong about the former. Why shouldn’t people have the choice about whether they want to stay around to see whether they will achieve the “new normal”? Were I rendered quadriplegic — I’m telling you right now — I would not want to continue living, whatever the wondrous “new normal” might be. But I say that in full knowledge that there are people who are quadriplegic, and who find life of continuing value, and even those who find joy in their state of nouveau normalité.

At this point Gurney gets it right:

First of all, added pressure does not mean a choice has been taken away from anyone. … Added pressure means exactly that … added pressure to make a choice. Miedema seems blind to the fact that he is asserting that his right to an easier choice comes at the cost of denying another citizen any choice at all. [my italics]

That last italicised sentence is the key, and it is crucial. Why should anyone be forced to undergo the torments of hell just because that will place someone else in the position of having to make a decision? And not even that is necessary. There is no need that anyone raise the question of choice with a person who is disabled or in pain. It is up to them, but when they have raised it, why should it be thought that an adult human being would be placed under irresistable pressure to make a choice?

My belief is that the arguments against assisted dying are, one and all, without merit. The problem is not as serious as people think. Of course, assisted dying laws would have to be carefully drafted, but it should be remembered that, in the absence of laws governing decisions at the end of life, there is much unclarity. Are people not being pressured, now, to give up on futile treatment, even though the question of its futility may be open? Are patients not being pressured, even now, to accept treatment that is futile, which is only being used as a salve to the consciences of the medical staff? Are people now not being helped to die, even though there are no laws governing the practice? And what about doctors themselves? It is well-known, apparently, that doctors make arrangements for their own last days, to ensure that they will not suffer as much as they know that they may – familiar as they are with the kinds of suffering involved. Why should they be privileged in this matter, when others are not? It is time that people put their religious prejudices aside, and looked at this matter from the point of view of those who are suffering, and wish to die with less pain and more dignity, instead of dying in pain, covered in urine and faeces, as so many now do (if Julia Lawton’s descriptions in her book The Dying Process are anything to go by). We are not wards of the state, and the state should have no right to determine how we die. It’s time for the state to get out of the dying rooms of the nation, just as it got out of the bedrooms some time ago. And no one, but no one, should listen to religious opponents of assisted dying until they are prepared to give the real reasons for their opposition, instead of the constant filibuster of irrelevant complaints that simply interfere with clarity of thinking and charity of action.