The concept of ‘assisted dying’ is about two things: compassion for suffering, and respect for autonomy. People with a terminal illness who wish to shorten the experience of dying, which might be agonising or attended by profound indignities, are the focal case for help to a quiet and easeful passing. Some sufferers, desperate to shorten the approach of death, are not in a position to end their own lives. To deprive them of help is cruel. For those still with the physical competence to do so, the how and where they do it, together with the fact that the effort might fail and leave the sufferer in a worse state than before, reinforces the point that compassionate assistance is better than an imposed rejection of their need – which is the current situation: in jurisdictions where assisted dying is illegal, third parties are obliged to refuse help and thereby to condemn sufferers either to an extension of their suffering or to finding a way to end their suffering by themselves.
It is legal for people to take their own lives if they feel that there is an overwhelming reason to do so. If a severely depressed person contemplated suicide and sought help to do it rather than attempting it alone, he might meet with help and support that eventuates in his changing his mind and eventually recovering. If his desire were clear-minded (depression does not automatically remove rationality) and settled in intent, his autonomy is impugned if he is denied, and might turn more tragically to the resort of self-help. Refusing assistance to a desperate and suffering person in any other circumstance is cruel and oppressive; the same applies here.
I am on record as saying that people who cannot bear a life of disablement or the profound agonies of depression should be as entitled to help, if they really and autonomously want it, as someone terminally ill who seeks it. It is an absolute, and rightly so, that apart from such exceptional circumstance as long-term coma without hope of recovery, no-one other than the individual himself should make that decision on his behalf. It has to be the chooser’s own clear, settled and independent choice, uninfluenced by others, transparently arrived at, and authorised properly. It is right that there should be strict safeguards to ensure this.
It is obviously far better that people who feel that a non-terminal condition is intolerable should be given every help, every facility, to live in ways that are not merely manageable but fulfilling and welcome to themselves. Disability and depression are not in themselves reasons to die; far from it; on the contrary, a caring society should work hard to help people experiencing either condition to overcome them and to live well. But, however rarely – for the great desire of almost all of us is to live – the burden is too great. Recall the case of 23 year old Daniel James, an ardent rugby enthusiast who had played for the England youth side and was paralysed in an on-field accident that broke his neck. He made several suicide attempts because he felt, as he put it, that his body was a ‘prison’ and that his life filled him with ‘fear and loathing’. He eventually chose to go to Dignitas in Switzerland. One would wish that he could have found a way to live on, but ultimately the decision was his alone to make, and the thought that others should be allowed to force anyone to bear what they find unbearable is unconscionable.
Opponents of assisted dying in effect impose their belief that the mere fact of being alive trumps any considerations of the quality of life. But that cannot be right. Dying and suffering are acts of living, and can be hideously painful whether physically or mentally. Again: the vast majority of us prefer to be and stay alive; that is in almost all cases because however bad things seem to us, we retain hope that it can get better. For the terminally ill, and for some for whom merely existing denies them what was central to them and made life worth living, that hope is unavailable. To force them to continue in an existence that is unbearable to them, or to oblige them to try their own means of relief when a kind and easeful alternative is available, is cruel.
Many if not most people who work in medicine are opposed to, or at least ambivalent about, the idea of taking positive action to assist someone to die. In terminal cases the usual alternative is to withdraw life-support of one kind or another to let death occur ‘naturally’. But in essence there is no difference between ‘omission’ and ‘commission’ here, except that the former prolongs a process that might involve much suffering. The greatest difficulty for medical personnel is acting to end the life of someone who is not terminally ill. For this reason it might be best if assisted dying were the province of a medical specialism, governed by strict protocols, in which no other medical personnel are involved. A sub-specialism of anaesthesiology might be most appropriate for this.
I sometimes wonder whether those who oppose assisted dying understand what suffering can be. Even those who work in hospices, providing comfort and care for sufferers who wish to continue for as long as they can – and that would be most of us; and the comfort and care given in hospices is admirable – must see that palliation is not enough for the few who would rather choose to bring to a close the suffering and profound indignity of dependence they experience. I myself do not wish to linger in a drugged and helpless state for months, waiting for release; I should wish to make my farewells while still fully aware and able to engage, not a mere remnant of myself.
Assisted dying is kindness and respect; it is a tenderness to those who really wish it; it is an act of compassion and understanding. Its opponents urge a ‘slippery slope’ argument, as if wishing to help sufferers were a Trojan horse for allowing forced euthanasia, disposal of the disabled as the Nazis did, carte blanche for anyone who happens currently to feel miserable to access a fatal injection. This is nonsense. The disabled deserve respect and enablement, the depressed need help and support, no-one should force ultimate and irreversible decisions on others in any respect. This goes without saying. At the same time, to deny a sufferer help when it is clear both that and why he wishes it in his circumstances, is – the word bears repetition yet again – cruel. Opponents of assisted dying fear that some will be encouraged, tricked or bullied into seeking death; that must be scrupulously guarded against. On the other side of the argument, it might rightly be said that forcing someone wishing to die either to do it himself or otherwise to continue suffering, is in fact a form of abuse, and when considered as such, is one of the worst kinds.
Specifying safeguards is not difficult. Is the person seeking this ultimate form of help clear and settled in the choice, making it independently, and does not wish help or further help of a different kind that he knows about, understands, and is available? If the answers are clearly ‘Yes’, what are the grounds for saying to him ‘No’, or ‘Do it yourself if you can’? Put this way, the refusal to legitimise assisted dying amounts to its opponents’ saying ‘My belief or opinion entitles me to refuse you your autonomy and to require of you that you go on suffering’. That is unacceptable.
To repeat: the concept of ‘assisted dying’ is about two things: compassion for suffering, and respect for autonomy. Many opponents to it might have the former, but none have the latter when it comes to this as the ultimate assertion of autonomy. And it is to be hoped that some of those who have the former are not misleading themselves into thinking they have it, in case their appreciation of the depths of certain kinds of suffering are insufficient for them to realise why autonomy is so important too.