Richard Dawkins has put up a new essay on assisted dying over at richarddawkins.net, in response to the High Court’s decision in the case of Tony Nicklinson and someone named simply AM, who is in a similar situation to Tony Nicklinson. He begins it with these words:

I can hardly bear to see poor Tony Nicklinson’s face as he hears the news that he is not allowed to die. I am ashamed of my country and its laws.

The question is: how can anyone see Tony Nicklinson’s face as he breaks down at the news that his judgement about the value of his continued life will not be respected, and that he must find some other way to end his torment?

The crucial decision of the court is expressed in these words:

78. A court hearing an individual case, concentrating rightly and inevitably on the dire circumstances of the claimant, is not in a position to decide such broader questions, but its decision would create a precedent which would affect many other cases.

79. As to constitutionality, it is one thing for the courts to adapt and develop the principles of the common law incrementally in order to keep up with the requirements of justice in a changing society, but major changes involving matters of controversial social policy are for Parliament.

And then the judgement goes on to quote “ample support for that proposition.” Amongst the supports is the judgement by

Lord Reid [who] said in Shaw v DPP [1962] AC 220, 275:

“Where Parliament fears to tread it is not for the courts to rush in.” [para 79]

That, however, is a remarkable statement, for the courts are there precisely to protect citizens in the case that Parliament fails to act in respect of issues that concern matters of justice, defence or rights and compassion. Parliament has so far failed to act. There is absolutely no reason within the common law that a precedent could not be set, and the precedent, as I suggested yesterday, could have been protected from uncontrolled ramifications by giving Parliament the time and the opportunity to act in respect of issues raised by the judgement. That is precisely what Madam Justice Lynn Smith did in the Carter decision in British Columbia, thus showing that she was much wiser than the judges of the High Court in London. Justice Smith made a limited judgement that Gloria Taylor had legal permission to receive help to die, and gave Parliament a year to adjust the law to reflect the protection of rights that is now being denied to those who are in Gloria Taylor’s situation. What the High Court could have done, and, in my view, should have done, is to have given Tony Nicklinson and AM the relief that they sought, while at the same time putting Parliament on notice that they must bring the law up to date in such a way as adequately to protect the rights of others so situated, whilst at the same time protecting those who might, in the opinion of some, be put at risk by the recognition of such rights to die.

The High Court, as well as others who have published opinions on this matter, clearly did not understand the issues at stake. Sarah Wollaston, a physician herself, and Tory MP for Totnes, has an opinion piece in today’s Guardian which shows conclusively that she simply misunderstands assisted dying, and has, besides, a very inadequate grasp of the facts. Her article is entitled “Assisted dying: the harm in helping.” The subtitle is: “Making assisted dying legal would alter the way society weighs the value of human life forever.” Quite aside from the fact that nothing is forever, the fact that Tony Nicklinson’s autonomy and decision regarding his life was not respected, shows clearly that the way society weighs the value of human life is already deeply flawed.

Let me try to put this as simply as possible. The trouble with people like Sarah Wollaston is that they do not seem to understand what a human life is. They think, for some reason, that human life is simply a biological reality, the fact that a body is breathing. The human life that we value is very different. A life is a continuum of sorts, with a unity of conception. I do not want to enter into the philosophical problem of identity, but the important thing about a well-lived life is that it has a sense of overall consistency and coherence. That is why we respect people’s autonomy, the right to make their own decisions about life: what to do with their lives, who to marry, whether to have children, which vocation to pursue, and many other decisions that go to make up a life rich in experience and held together, so far as is possible, by a single, or at least a unified sense of what is appropriate for a life so conceived.

A life conceived in this way includes some of the most important decisions that must be made, and includes, as an essential part, how that person understands the part that death plays in life. Most of us do not think much about death, especially when we are in the midst of life, but the time will come when the issue of dying will loom very large indeed. To be unable to make decisions about dying is to put outside the scope of a person’s conception of life all those things that may befall them at the end of life. But, in general, we do not do that. It has been recognised, in the last few decades, that patients have a right to make binding decisions about their treatment, what treatments they will accept, and what treatments they want to have withdrawn, even if failure to treat, or withdrawal of treatment, leads to death. However, the end of life can be a harrowing experience for some, and there, for some inexplicable reason, people like Sarah Wollaston think that we value human life more if we refuse to let people make their own decisions about how they will die. Why they should think that, and yet think it perfectly appropriate to permit persons to make other decisions that will bring about their deaths, is simply unintelligible. And why they think that withdrawing the right to make decisions at that point is to honour and value human life is simply foolish. How do you value a human life by simply ignoring their own judgements and decisions regarding that life?

I have already quoted, in an earlier post (yesterday, in fact), from Beauchamp and Childress’ book, Principles of Biomedical Ethics. In speaking about the supposed moral distinction between killing and letting die, they point out that very often this is a distinction without moral significance. Letting someone die in misery, instead of helping them on their way as they would wish, is not valuing human life, especially when life has become an intolerable burden. And yet Sarah Wollaston wants to see such refusal as a valuing of the experience of suffering, of which the dying should not be deprived. Here is what she says:

In my time as a doctor, I cared for many people who were dying. It was not uncommon, during a degenerative illness or cancer, for someone to ask me to help them to end their lives. Depression and hopelessness are a normal part of coming to terms with dying or a debilitating illness. During that time most people would have been able to weigh up their choices and have the capacity to decide whether they wanted to end their lives. But I also witnessed most of those same people come through the depression to reach a kind of peace before they died. Had it been easy and painless to take their own lives, how many would have been denied the chance to come through a sometimes lengthy adjustment?

So, some people would decide to forego “the chance to come through a sometimes lengthy adjustment.” What of it? Whose business is it that they should have this chance? Even knowing this — and there is no harm in the doctor saying: “You know, in the end, you may find that this is an opportunity. If you end it now, there is something important about yourself that you may never learn.” — it does not follow that we have a right to say to a patient that they must persevere until that point in their lives when they have experience this adjustment. And, indeed, Ms. Wollaston fails to mention that many people do not emerge from this period of adjustment with anything more than a longer period of suffering than they would otherwise have had coupled with the distress and despair that goes along with it.

Sarah Wollaston is being dishonest, for if she practiced as a physician for many years, she knows what other doctors know that — as Beauchamp and Childress put it:

Suffering and loss of cognitive capacity can ravage and dehumanize patients so severely that death is in their best interests. [183]

Wollaston says that allowing people in such circumstances to receive help in dying might have serious implications:

If society normalises such decisions about life and death, [she writes] how easy would it be to slide from believing it acceptable to allow doctors to prescribe lethal cocktails for their patients in exceptional circumstances to feeling it strange or even immoral that such patients be allowed to live?

Well, but this has not been the experience of those jurisdictions where assisted dying has been legalised. Of course, there must be controls, but what Wollaston seems to misunderstand — as practically every opponent of assisted dying does — is that the key element is the judgement of the individual patient, not the doctor, or anyone else. When life has become an intolerable burden is something that only the individual themself can say. Some people, as Wollaston says, will want to experience everything that life has to bring. They may have a religious sense of sharing their suffering with Christ, or some such thing. And no one has a right to make this decision for another person, unless that person has left durable power of attorney to make such decisions for them when they have become incompetent to make that decision themselves and their own views on the matter have been made very clear. But Wollaston and so many others simply misunderstand what assisted dying is about. It is about the right of people to make decisions regarding their own lives, so that the end of life will be an integral part of a life conceived as a whole. Aristotle said that we should consider no man happy (and that is a very shallow translation of what he meant by eudaimonia) until he is dead. For dying itself may make a retrospective comment on the whole of a person’s life, and it may make what had been, until that point, a well-lived and fulfilled life, something that, because of the immensity of the suffering, is much less valuable seen as a whole.

Wollaston has one other concern. It cannot be right, she suggests, to force doctors to kill their patients. This is one of the harms that, in her view, would be brought about by the legalisation of assisted dying:

People with capacity should have a right to make decisions for themselves – even if we don’t agree with them, except where those decisions harm others. Assisted suicide does harm others: it harms the doctors who take on the responsibility for killing their patients. There is a vast difference between the moral responsibility in doctors withholding treatment that will end life and actively prescribing with the primary intent to ensure death. [italics in final sentence mine]

Moral philosophers, however, have determined that there is not a vast difference here. Of course, some doctors may object to this on religious grounds, but it is hard to see that withdrawing treatment, or failing to start treatment, treatments which, if continued or started, would prolong life, is different from an act which would help a person die, because of their wish to escape the suffering, indignity and dehumanisation which is making of their lives an intolerable misery. The distinction simply does not stand up, even though doctors have been using this difference claim for many years as a rationalisation for their belief that helping patients to die is contrary to their responsibilities as physicians. The difference is a fig leaf covering some very nasty secrets, as Tess McPherson’s account of her mother’s death reveals. Besides, there are many physicians who believe that providing help in dying is one of their responsibilities, and on a continuum with other aspects of good medical care. Of course, no physician should be forced, against their deep convictions, to help patients to die. That may mean that patients will come to distrust them, but that is their affair. Nevertheless, they should have the obligation to refer their patient to a physician who will consider such a request for aid in dying.

As Dawkins said, many years ago now, in The God Delusion (and I am afraid I have mislaid my copy, so I can’t quote directly from it, or give a page reference — thanks to cafeeine for making the reference available: see Comment #1 below for the full quote and the reference), that he would like to “have his life taken out under anaesthetic.” That was an extremely helpful way of putting the point, for it makes it clear that dying is continuous with other things that happen to us in the course of our lives, and if we think it is appropriate to use anaesthetic during an operation, to protect from insufferable pain those who are undergoing surgery, what reason is there to oppose using every medical means available to protect from insufferable pain and distress those who are dying in misery? The problem with people like Sarah Wollaston is simply that they lack moral imagination.

Perhaps there is another thing that influences them when they talk about assisting people to die. They are themselves afraid of dying, and do not want to raise frightening issues too plainly, for, as John Schumacher says in his book, Wings of Illusion, about the underlying reasons for religious belief:

It was necessary for us to use an amplified state of consciousness to function within the realities of our situation. Simultaneously, however, it was also essential that we avoid perceiving reality for what it was — chaos followed by oblivion. That is as difficult as asking someone to see and be blind at the same time. We had to retain all the advantages of our new intelligence while being usefully “ignorant” enough of the same reality of which we needed to be aware. That sounds, and is, contradictory. But that is exactly what was required — namely, a creature of contradictions, of opposites. We became the genius ignoramus, the wise fol, the truth-hating seeker of truth, the chimeras as we now exist. We became what Bellow (Mr. Sammler) refers to as the “wretched, bleeding, needing, idiot genius of a creature.” [27]

It is this paradox that runs through all the objections to assisted dying. There is the knowledge of the terror that dying can be for so many, but there is the wilful hiding from that knowledge: the idiot genius at work. Religion is the name of the discovery that we could “live and operate in the clutches of our real condition while also believing our condition to be something different from what it actually was.” (loc. cit.) That is the mistake that is constantly being made, and dress it up in whatever clothes you please, it is the religious response to assisted dying that puts on the costume, and pretends that we are dealing with something else. Sarah Wollaston may say (as she does) that not only the religious oppose assisted dying, but, at base, her reasons are religious, even when she most protests that they are not; for religion is a matter of hiding from reality, and now, more and more people want to look a life squarely in the face, without the camouflage and pretence. That is hard, even for doctors, perhaps especially for doctors, because they are faced with the cruel realities of life on a daily basis. You might think that this would make them more compassionate, but, like everything else that requires facing ugly reality, it may just as well toughen them, so that they can look at the most terrible suffering without flinching, and then tell you, without any sign of human recognition, that in the end you will find the experience valuable.