This post is now available in Polish at Racjonalista — thanks once again to Malgorzata.
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A few days ago, over at the New York Times, a selection of letters in response to Ezekiel Emmanuel’s article on assisted dying, and to Ben Mattlin’s piece on his reasons for opposing the Death with Dignity law that is on the Massachusetts ballot today, were published. I want briefly to address myself to one of these letters, which in my view is particulary powerful. I copy the letter here:
To the Editor:
Dr. Ezekiel J. Emanuel uses a flawed rationale to challenge the legitimacy of assisted suicide. While he seems to agree that it would be acceptable in cases of severe, intractable physical pain, he suggests that it is not legitimate if motivated by emotional pain or depression. The appropriate response in such cases, he maintains, is to provide “counseling and caring.”
As a retired clinical psychologist, I must note that there is a vast difference between the depression of a terminally ill patient, who realistically perceives his situation to be hopeless, and a physically healthy patient suffering from clinical depression.
In the case of a physically healthy patient who is clinically depressed, feelings of worthlessness and hopelessness are the product of inaccurate perceptions of self and circumstances — mental distortions produced by the illness itself. For such patients, treatment can produce marked improvement.
The same cannot be said for terminally ill patients, whose feelings of hopelessness are, sadly, all too realistic and whose depression is often a normal response to a disheartening reality. While the “counseling and caring” Dr. Emanuel recommends can provide comfort to the terminally ill patient, they cannot change the reality of a patient whose quality of life has diminished to the point where each day is another round of frustration and pain, be it physical or emotional.
If I should become terminally ill, I would not want to cede to a third party the right to determine when my life is no longer worth living.
JAMES HAWTHORNE Baltimore, Oct. 29, 2012
I want to shout it from the housetops: Precisely! So much hand-wringing about assisted dying — and all the laws in the United States, unfortunately, get this wrong, and Scotland is about to get it wrong, too, if it passes the bill introduced by Margo MacDonald – is about the fact that people who are dying, or who are suffering from long-drawn-out degenerative conditions like MS and ALS, are depressed. Some will even add “clinically depressed,” just to make the point clear.
However, it has always seemed obvious to me — and it is an obviousness that does not move the opponents of assisted dying — that being in some situations, and finding them to be existentially distressful — what some choose to call clinical depression — is a perfectly reasonable thing to find. As James Hawthorne points out, with great clarity, dying people, and I would add, those suffering from degenerative conditions, or even, I would also add, those who are suffering from conditions or disabilities which they find intolerable (such as Tony Nicklinson or Daniel James), are people
whose feelings of hopelessness are, sadly, all too realistic and whose depression is often a normal response to a disheartening reality.
Why, I wonder, is this not obvious? Why is the distress or depression or existential angst of people who are dying, or who are living in what are to them intolerably painful or undignified or meaningless conditions, not recognised as perfectly natural? To think of these mental states as mental pathologies which bring into question the ability of those who have them to make autonomous decisions is simply perverse. And, I might add, to continue to confine the range of people to whom assisted dying laws apply only to the terminally ill is also perverse, for they are not the only ones for whom it is perfectly natural to have such feelings of existential despair.
Polls which suggest that people will support assisted dying for the terminally ill, but would not do so for those whose suffering is not terminal within a specified period, are not, I suspect, asking the right questions. The public response to Tony Nicklinson’s case suggests this, for it seems clear that a majority of people would have supported Nicklinson in his legal campaign to receive legal permission to receive help to die. And it is not, as so many people seem to think, that people like Tony Nicklinson want to die. They do not. But they know that death is the only way out of situations in life that have become intolerable and burdensome to them. Elizabeth might have lived for many years more in the complete paralysis which was soon to be her misfortune, and yet those years would have been years of torment that she did not want to experience. Her torment was already great enough, and she just wished that she could die.
To confine assisted dying to the terminally ill is not enough, and it should be seen to be not enough, and so confining it reflects such a lack of understanding of the reasons why people elect to die that those who support limited assisted dying of this sort need to have a short sharp shock to bring them to a recognition of the realities. They may be working within what are the political realities as polling numbers seem to reveal them to be, but they do not reflect the reality of people’s lives, and their reasons for choosing to die. It is high time that the death with dignity movement grew up, and stopped pandering to the religious forces of unreason which, at a stretch, can be brought to see that those who are already dying may be helped to hasten death, but who cannot be brought to see that other lives may be even more intolerable, because their torment will go on sometimes for years without remission. It is time that those who support assisted dying began to think beyond the narrow confines of their prison houses, where they have been locked away because of religious opposition to assisted dying, and to come to recognise that there are many other reasons, besides the imminence of death itself, why people may reasonably wish that they were dead.
I always make sure I keep updating my plans so that I will be in control. I am not counting on others (including the legal system) to understand or be supportive of my personal needs. Yes, I am dealing with justified depression as described in the letter above. Once things reach the point where my quality of life is totally down the drain, I , and not a helpful do-gooder, will decide what I will do next. My life, my business.
Excellent post, as usual!
I wonder if it’s because so many of our religious ‘leaders’ and politicians have been or are clinically depressed themselves that they shy away from the notion of linking assisted dying with depression? We’ve had several cases in Australia recently of politicians ‘coming out’ as depressives.
Stonyground
There is a song in the musical ‘Avenue Q’ about schadenfroid, the German word that means that we enjoy the suffering of other people. Hearing the song made me think about where I stand on this issue. I only enjoy the suffering of others when they have done something that means that they thoroughly deserve their misery. Those who have actively campaigned against the legalisation of assisted dying really do deserve to die in horrible pain. Firstly because such pain is entirely self inflicted. Secondly because, by their actions, they have inflicted such pain on thousands of fellow human beings.
It is also worth pointing out that those who base their moral outlook on their religion have close to a one hundred percent track record of being wrong.
Eric, i agree with all you say, as usual. Although my wife’s situation with terminal cancer falls into the category which could benefit from the proposed new law in Scotland, she and I both fully support expanding the categories to include degenerative diseases and permanent disability. Indeed, my personal view is that anyone over the age of consent and mentally capable should have the right to physician assisted death if they choose. Anyone who has a settled judgment that their life is intolerable (and only that person is capable of making that judgment) should be allowed a clean exit without having to resort to traumatising some poor train driver. If any medical judgment has to be involved, then it should be limited to mental capacity and whether or not there is a reasonable prospect of the illness/disability being cured.
Having said all that, basically to show where I stand long term, I have to support Margo MacDonald’s Scottish bill.
Maybe not, but we still have to work with these results. At a recent conference in Edinburgh, chaired by Margo MacDonald, it was stated that whilst 82% of the public favoured assisted death for the terminally ill, when permanently disabled were included in the question, the figure dropped to around 50%. I am at a loss to understand these figures and yes, they could be due to badly worded questions, but the figures are now out there. It is an uphill struggle to get parliamentary approval of assisted dying for the terminally ill alone, so for the moment this is the best we can hope for. I realise that if we get this legislation approved, and subsequently try to extend it, we will be accused of operating a “slippery slope”. However, it is my hope that once assisted dying is seen to operate safely, it will be possible to extend it. This may be naive on my part, but I see no point in failing to get any change at all because we try for a comprehensive law at the outset. The forces against us are too well organised and has been pointed out, it is easier for healthy people with long life expectancy to organise politically than it is for the disabled and dying.
One positive feature of the conference was the speech given by Revd. Scott McKenna, who came out strongly in support of assisted dying, with reasoned interpretations of the sixth commandment (You must not kill unlawfully), and also of the church’s version of “sanctity of life”, and their god’s choice of the moment of death. I won’t go into his arguments here, which incidentally go against the Church of Scotland’s official view. It is simply heartening to see a minister of the church stand up and publicly challenge this official view. Perhaps there is hope yet.
Haggis, I understand completely that you must support the bill that Margo MacDonald is putting before the Scottish parliament. That is not in question. However, the question whether the permanently disabled should be permitted to receive assistance in dying is simply not the question that should be asked, for most of the permanently disabled do not want to die, and do not consider themselves to be suffering. So, its not permanent disability which is in question here. It is those who are suffering intolerably that count, and that is not characterisable as a group simply denominated by ‘permanent disability’. We need some way of characterising the life of people like Tony Nicklinson, Diane Pretty, Daniel James, and put that question to people. But speaking of permanent disability is just waving a red rag around in front of the religious bullies, for this is the argument they are making, that these are the people who will be put in danger by a more generous assisted dying law, and they won’t be. But those who are disabled in such a way as to find their lives insufferable: that is a different category of people altogether, and they have a right to die as well as the terminally ill. That is why I say that the death with dignity movement must grow up, and stop accepting limitations imposed upon it by disabled rights groups, and the religious who are so quick to grasp onto this straw, that they have turned into a very secure handhold. It is important, therefore, that support for other measures, though important, needs to be qualified by a recognition of the rights of others who are suffering intolerably to die.
I am glad to hear that Scott McKenna of the Church of Scotland supports assisted dying. There are members of the Church of England who also do so, and I hope their numbers will grow. I am not hopeful. Religious opposition to assisted dying is too deeply entrenched, I am afraid, at least at the theological and institutional level, for the churches’ views to change greatly. I hope that I am wrong, but fear that I am not. I would certainly welcome, however, a conversation with Scott at some point.
Liz671. Absolutely. I understand why you would not have much sympathy for those who oppose relief for those who are suffering. Die Schdenfreude does mean joy or pleasure (Freude) at other people’s suffrering (from der Schaden, harm or damage), but I hope you do not really mean that you would take joy at anyone’s suffering. Opponents of assisted dying may deserve, in some sense of the word, to die painfully, but then, the argument really is that no one deserves to die so. Most people who oppose assisted dying do so for religious reasons, and have been hoodwinked by religion. They do not enjoy people’s suffering; they just have the unfounded conviction that this is what their god requires, and, of course, as you point out, there is no reason for thinking so. The track record of the religions is, as you say, a litany of failure and error from start to finish.
Yes, you are right, of course, & now I see why the wrong question is being asked. The criterion must be “intolerable suffering”, which, as has been said before, cannot be judged by anyone other than the sufferer.
Excellant point. There have been several mild efforts here in Oregon to expand the parameters of the Death with Dignity Act but these were quickly beaten back with cries of “slippery slope” and the like. Eventually these reforms may come but not soon.
And, speaking of depression, the Massachusetts initiative
was defeated yesterday. I don’t know whether it affected the outcome or not, but why the New York Times felt compelled to print two op-ed pieces opposing the ballot measure, in the week before the election, is beyond me.
Stonyground says:
We only use one email address at our house and since Mrs. Stonyground set up a social networking thingy on the other computer, even though it says Stonyground in that box down there, I now, for some reason, come up as Liz671. Presumably I will have to get around to setting up an extra email address to stop this from happening.
In reply, reading it back now, I think that I worded that rather badly. I don’t think that anyone deserves a horribly painful death and I certainly wouldn’t laugh about it no matter how much I disliked some one. Schadenfreude, I think, can only apply to milder forms of suffering. I tend to see opponents of assisted dying as misguided rather than evil, and even if they do end up suffering an unpleasant death, I shouldn’t have said that they deserve it, no one does. That is one of the potential problems of the religious mindset, if you believe in a just god, then it follows that people deserve things that happen to them.
Stonyground says:
Being only halfway computer literate now I’m a bit confused.