I will get back to my series on Hitchens’ god is not Great. But for now, since assisted dying has been in the news both in Canada and the UK, I think it is a good time to address some of the most pronounced misunderstandings about assisted dying, and the reasons for them. Well, the reasons are mainly — almost exclusively — religious; but we can still take a look at specific recent instances of these misunderstandings being made, and how they stand in the way of further development towards humane laws which will allow people to choose the time and manner of their deaths. I have already suggested that, in my view, this should not be open to question, but there are people who make it their business to keep this alive, not because they really believe that it will be dangerous to allow people to make this choice, but because they don’t think that anyone should get to make this choice — ever. In this case arguments become a kind of filibuster, to put off the “evil” day as long as possible, and, if possible, to postpone it forever. And the foundational reasons for an absolute prohibition are based, quite simply, on religious premises having to do with God’s dominion over us, or, to use Locke’s way of expressing it, on the idea that we are God’s property.
Actually, John Donne, the metphysical poet and Dean of St. Paul’s Cathedral in London, in a book written by him, but which he never published (it was published after his death by his son), entitled Biathanatos, basing himself the law of nature (The First Part), the law of reason (The Second Part), and the law of God (The Third Part), considered not only that suicide might be a legitimate act, and that he had often thought of it himself, but suggested that helping someone in distress to die might well be an act of justifiable mercy. As he said, regarding both:
And good opinions concur that it is to do, ever without doubt, whatsoever is for ease or escaping painful passage out of this life; in such cases a man may more allowably do by his own act than a stranger may, for law of nature inclines and excuses him, but they are by many laws forbidden to hasten his death, for they are no otherwise interested in it than as parts of the whole body of the state, and so it concerns them that justice be executed. Yet we see, this and the other, of withdrawing the pillows, is ordinarily done, and esteemed a pious office.
There is quite a bit packed into that. First of all, a general view that it is appropriate for someone to do whatever is necessary for an easeful death. Second, that the prohibition against helping someone to die is based on the idea that individuals are parts of a whole. Third, that, even so, it is considered a pious office for someone to hasten a painful death, by, for example, removing the pillow, and thus speeding up the process by making it more difficult for the person to breathe.
Donne also points out that, regarding fulfilling God’s intentions for our lives, we might very well, by medicines, and even prayers, “resist a disease of which God hath decreed that I shall die.” And he goes on:
Yea, though He seem to reveal His will, we may resist it with prayers against it, because it is often conditioned and accompanied with limitations and exceptions. Yea, though God dealt plainly by Nathan — “The child shall surely die” — David resisted God’s decree by prayer and penance.
In other words, in response to those who speak about “natural death” as some kind of predetermined end to which we are all tending, Donne would say that this must apply to other things too in which we may interfere, or may already have interfered, knowingly or unknowingly, and frustrating God’s will thereby. So when we inoculate ourselves against diseases, we may be frustrating God’s purposes, insofar as nature is presumed to express those purposes. So, the pretence that, at the very end of our lives, when we are dying, or like to die, we should cease acting to intervene in nature so as to hasten the process of dying, and by refraining from doing so we are surrendering ourselves to God’s will, is a bit late in the day to think of obedience to God’s will, if, in the course of our lives, we have in fact been acting, so far as it is possible to know, in defiance of God’s will by using scientific medicine to delay death as long as possible.
The point, if it still seems necessary to express it, is that by taking refuge at the very end of life in something thought to be God’s purposes, is simply an arbitrary interference of religion and religious prescriptions at one point in life, even though what might have been God’s will and purpose might reasonably be thought to have been frustrated all along by our interventions in the natural progress of disease and injury in which God’s will may already have been expressed, we having ignored it by our guilty interventions to cure ourselves of diseases intended by God to kill us. Inserting concern for God’s will and purpose at the end of life is simply an arbitrary intrusion of religious concerns at only one point in life, while ignoring all the other occasions regarding which the question of God’s purposes could have been raised. It is, in fact, trying to hold onto the completely irrelevant consideration of God’s supposed dominion over life, when that dominion does not govern our attitude towards life as a whole.
The problem with most of the arguments used against assisted dying is that they think that drafting safe assisted dying laws is an impossibility, even though there is already an understanding, in the common law, that patients have a right to have treatment withdrawn or to refuse treatment, both acts of autonomous decision where, apparently, no one sees a problem at all. Problems only seem to arise when the question of actively hastening death itself is involved. But death is involved in many cases of refusal or withdrawal of treatment, and it is a bit silly to pretend that assisted dying is a more difficult decision to make than these, or that misdoing around assisted dying is more likely than it is around the withdrawal of treatment, do not resuscitate orders, or refusal of treatment. We are not dealing here with an entirely different kind of decision, and argue as you might about acts and omissions, killing and letting die, it simply will not do to try to draw a bold moral line between one kind of act and another.
Baroness Hollins, for example, in her Telegraph article “Sick people need help to live, not help to die,” makes the mistake in the title of her article. She makes a deliberate attempt to ignore the fact that there is a difference between sick people (who will get well) and dying people (who will not get well), and dying people don’t need help to live, because they are dying. Of course, she knows that it is about dying, but she deliberate mislead us by suggesting that it is still about getting well. In her long discussion of what it means to have the mental capacity to make a competent decision, it is almost as if she were talking about someone with a mental problem who, with careful psychiatric care, would be able to recover and go on living a full life. To use her words, she is talking about sick people who need help to live.
But this doesn’t play very well in relation to someone who is dying, as becomes very clear when she starts talking about what psychiatrists say about terminal illness and mental capacity. For example, she says this:
Dr Martin Curtice, a consultant in old age psychiatry, told the commission [the Commission on Assisted Dying chaired by Lord Falconer and paid for by Terry Pratchett] that there was “a big overlap between depression and terminal illness and chronic physical disorders”. The presence of such depression “does not automatically mean you lack capacity, but it’s highly likely to influence your decision-making”. The British Psychological Society said “it’s incredibly difficult to assess people with a life-limiting illness for depression and anxiety”.
Well, yes, you would think so, and did it need a psychiatrist to point it out?! The report itself, of course, as one might expect, has a lengthy discussion of mental capacity (pp. 225 ff.), and it simply will not do simply to say that, because a person is depressed — for, after all, it is hard to think of anyone who is dying not having a certain level of depression and anxiety — though it must be pointed out that in places where assisted dying is available there is less anxiety, because people know there is an escape clause, so that the threat of dying in painful and undignified ways is relieved; however, to continue: just because a person is depressed does not necessarily impair that person’s capacity of make reasoned decisions, although the depression might influence those decisions, as Dr. Martin Curtice told the commission.
So, what is the relevance of this pretty obvious point? Baroness Hollins goes on to say this:
Nor would many psychiatrists – I write as one myself – be comfortable with the idea of assessing patients for suitability to receive lethal drugs. We assess mental capacity for the protection and treatment of our patients, not to clear the way for them to commit suicide. We also know that reliable capacity assessment can only be made over time and involves getting to know patients and what lies at the root of their problems.
It’s a bit like a sick joke. The old, “Doctors treat patients to make them well, not to allow them to die,” simply won’t work here, because what we’re talking about is dying (or, in some cases, what someone might call a living death). When she says that a “reliable capacity assessment can only be made over time and involves getting to know patients and what lies at the root of their problems,” she is implicitly saying that the wish to hasten dying is a psychiatric problem that takes time to come to grips with, and there’s a comic opera aspect to this kind of claim. Is it really such a difficult psychiatric problem? Harvey Cochinov of “dignity therapy” fame would doubtless agree. But why should this be considered a psychiatric problem? Why is the desire of someone like Daniel James, completely paralysed and in pain, to die, assumed to be a psychiatric problem? Or, why should Debbie Purdy’s concern about how life might end with MS be considered a psychiatric problem? Is it not obvious that someone like James or Purdy might be both (i) depressed at their condition or anticipated condition, and (ii) reasonably convinced that dying would be preferable to living at some stage? As the Commission on Assisted Dying report points out, while some people feel that depression is a reason to claim diminished capacity to make decisions, we are not surprised to find a study that says that ‘most people with major depression retain competence to make medical decisions’. (233) People are often depressed for very good reasons. The problem here is that when a person is dying, and facing a period of decline many of whose nasty features can be predicted with a fair degree of accuracy, it is neither unreasonable nor surprising that some people will find that a depressing prospect. To turn round and say that, on account of the depression or existential anxiety which this anticipated future causes, the person does not have the mental capacity of make a decision to avoid that future, seems to be unreasonably perverse, and yet this seems to be what Baroness Hollins is in fact saying.
Hollins quotes the Royal College of Psychiatrists as saying, in 2006, regarding a proposed assisted dying law, that
… there should be two specialist assessments, spaced at least two months apart with offers of treatment for both depression and pain, so that there is time for the suicidal ideation to abate – since the ending of life is irrevocable.
There are a number of things that need to be said in response to this. First of all, palliative care physicians are also claiming that their speciality should be involved in making such assessments of patients who are asking for assistance to die. We could no doubt add other specialities here as well. When a person has reached the point where they are asking for assistance to die — many of them now, in the absence of legislative provisions for assisted dying, at a time when time for assessments spaced two months apart may simply not be available, because they are already on death’s very doorstep – what sense does it make to speak in terms of such specialist assessments? To add to this, can a person be required to undergo specialist assessment? Suppose that I can say, right now, that when the time comes, I do not wish to be assessed by a psychiatrist, or by a palliative care specialist, does anyone have the right to force me to undergo such assessment, any more than they have a right to force me to undergo treatment?
Hollins ends her article by saying this:
The issue is not about legalising a right to die: death will come to us all, whether we like it or not. It is about legalising the assisting of people to end their lives. Yet most of those in the professions that are expected to be the assisters have serious reservations. This is not professional conservatism. As Dr Curtice put it: “This is a serious business, because ultimately someone’s life is on the line”.
The opening part of that is simply misleading, perhaps deliberately so. When people speak about a right to die, they are speaking about a right to die as they choose to die, and not as their disease prescribes, and Baroness Hollins must know this. Secondly, however, it is of course simply a truism that someone’s life is on the line, and the person who is making the decision knows this, otherwise they wouldn’t be making the request. So, of course, it’s serious business. But why is this decision the only one of which it is thought that it ought to be fenced about with qualifications and required assessments, when decisions to marry, to choose a vocation, to have children, to make all manner of decisions in which an entire life is at issue, are not? Why is a person’s decision to die to be fenced, when we are perfectly free in practically every other respect to make the decisions that seem good to us? Is not an entire life of more consequence? Of course it is. And yet no one is suggesting that we fence decisions regarding how we are to live our lives with all sorts of qualifications and limitations, expert consultations and quandaries as to mental capacity.
This is an especially pointed question when, as Baroness Hollins knows very well, the issue of dying, and how we die, is one which, if assisted dying were made legally available, would be something that could be openly discussed and about which decisions could be made, long before the day when such a decision would be exercised. And is it not the case, already, that decisions upon which a life is staked, are made all the time, in the context of decisions to refuse treatment or to have treatment withdrawn? Why does everyone get into such a lather when it is a decision made by a person in circumstances when it can seem reasonable to practically anyone that someone in those conditions might find going on in those conditions intolerable, and that for one person to make that decision would put no one else under any obligation? There are other issues at work in the background, many of them, though I cannot speak for Baroness Hollins, religious issues, which have no place in this discussion, unless the person in question raises them. It is surely not beside the point, however, to mention that Baroness Hollins, besides being a psychiatrist, is also a Roman Catholic.