Writing in theconversation
Lidia Ripamonti asks
if assisted dying became legalised who should decide if a life is
worth living. She is assuming that assisted dying would become available
to those who have a life not worth living. It might be argued because of
dangers of pressure being put on disabled people, the aged and those suffering
from mental illness that any such decision should not be solely up to the patient.
If not the patient who else can say her life isn’t worth living? Her medical
team, her priest or a bioethics committee? Others telling a patient she has a
life worth living when she has already decided her life is not worth living
seems to be unacceptably arrogant. In philosophy how we frame a question is
especially important if we want to draw meaningful conclusions. In this posting
I will frame the above question slightly differently. I will then argue that in
certain situations we should simply accept the patient’s decision.
If we simply accept the framing
of Ripamonti’s question then it is possible to conclude that there may be
dangers for the disabled, the aged and the mentally ill if assisted suicide
became permissible. I now want to suggest that her question might be better
framed Perhaps the question might be framed as follows. If assisted dying is
legalised, who gets to decide if someone’s life contains unbearable suffering rather than her
experiencing a life which isn’t worth living? It might be argued that if
the permissibility of assisted dying is based on unbearable suffering that
disabled people and those suffering from mental illness would be better
protected because they can live enjoyable worthwhile lives. It might be
suggested that others, such as a patient’s medical team, might be able to give
an objective answer as to whether the patient is suffering unbearably.
Unfortunately it seems impossible to give an objective answer as to whether
someone’s suffering is unbearable. One person might find some suffering
bearable whilst similar suffering would be unbearable to someone else. Whether
suffering is unbearable is a subjective question. Others telling a patient that
she doesn’t have unbearable suffering when she has already decided her
suffering is unbearable seems to be unacceptably arrogant. It might be
suggested that this difficultly might be addressed by replacing unbearable suffering in our amended question
by unbearable pain. Perhaps we can measure pain objectively. I’m
doubtful whether this might be possible but let us assume for the sake of
argument that pain can be measured objectively. However even if this was
possible it doesn’t help solve our problem. What matters to some is not the
degree of pain alone or how long it will persist but someone’s reaction to it.
As with suffering someone might find a pain bearable whilst someone else might
find the same degree of pain unbearable. It appears to follow if we don’t want
to be accused of arrogance that we cannot replace a ‘life not worth living’
with either ‘unbearable suffering’ or ‘unbearable pain’ in an attempt to
reframe Ripamonti’s question.
Ripamonti is concerned that
letting the patient solely decide if she has an unbearable life endangers the
disabled, the aged and the mentally ill if assisted suicide became available. I
accept that Ripamonti is correct provided assisted dying became available
across a broad domain. I will now argue that in a restricted domain her concern
seem much less pressing. No one is suggesting assisted suicide should be available
to anyone who finds her life not worth living. Medicine is concerned with
illness not social problems. Let us assume that assisted suicide should only be
available to terminally ill patients capable of making a competent decision. If
we strictly restrict the domain of patients who could avail themselves of assisted
suicide in this way the disabled, the aged and the mentally ill would appear to
have little to fear from the legalisation of assisted suicide. Unfortunately
this restricted domain appears not to be restricted enough, some terminal diseases
may kill someone but can take a long time to do so. For instance Stephen
Hawking was diagnosed with motor neurone disease MND in 1963 but lived a highly
productive life until his death in 2018. Perhaps then the domain of patients
who should be limited to those who are autonomous with a terminal illness and who
are expected to live less than six months. Accepting such a domain should
protect those suffering from Alzheimers, the disabled, the aged and those
suffering from mental illnesses.
However accepting this strict
domain causes additional problems which are not easy to resolve. If the domain
is restricted to autonomous persons then this restriction protects those
suffering from Alzheimers. We don’t, or can’t fully understand what it means to
suffer from Alzheimers. But does it always protect children? Consider two
patients suffering from terminal cancer both of whom suffer identical pain and find
their lives not worth living. Let us assume that assisted suicide becomes
permissible but is restricted by the above domain. Let us also assume that the
first patient is an adult and as a result is able to end her suffering using
assisted suicide. Let next assume that the second patient is a child who
because of her suffering also wishes to relieve her suffering by ending her
life. Children are not usually considered to be fully autonomous and we have
restricted the domain of patients who can avail themselves of assisted suicide
to those who are fully autonomous. It might be questioned whether we are really
protecting the child. We certainly aren’t protecting her from pain and suffering.
I have argued that autonomous adults
with a terminal illness with a prognosis that they will live less than six
months and who believe that their life isn’t worth living should have a right
to assisted suicide. However because I argued that assisted dying should only
be available to autonomous patients creates difficulties and doesn’t protect
some patients from pain and suffering. What sort of responses might be made to
these difficulties? One response might simply be that I am wrong and that the
decision as to whether a patient’s life is not worth living should not be
solely up to the patient. Accepting this response would mean Ripamonti’s
question becomes pertinent again, who should decide. However I would be
reluctant to accept this response because of the reason given above. If someone
who is expected to live less than six months believes her life isn’t worth living
then it might be asked what pertinent reasons could have others advance to say
her life is worth living? Of course others might advance other reasons
pertinent to the impermissibility of assisted suicide but these reasons are not
pertinent as to whether someone’s life is worth living. It would appear that
the decision as to whether a patient’s life is not worth should be solely up to
the patient. A second response might be to drop the requirement that the
terminally ill patient must be autonomous. Of course how a decision is made to
request assisted suicide matters. If such a decision needn’t be an autonomous
decision should be replaced by a good decision, I have argued elsewhere that
autonomous decisions need not always be good decisions wooler.scottus
. Let us accept that a good decision is not simply some decisions regarded as a
good decision by the decision maker. Others must also be able to regard the
decision as a good decision. However if we accept the above the following might
occur. The patient might make a decision that her life is not worth living
which she believes is a good decision whilst others believe her decision is a
bad one and not in her interests. Once again we might question whether the
reasons others give for her life being worth living are pertinent. If others
cannot give such reasons then there replacing an autonomous decision by a good
decision becomes meaningless. I have argued that if assisted suicide became permissible that initially it should only be
made available to autonomous adults with a terminal illness and a prognosis
that they will live less than six months and who believe that their life isn’t
worth living. I have further argued that who decides if a life isn’t worth
living is the person living that life.
What can we learn from the above except
that applied philosophy is a messy business? Can any practical conclusions be
drawn from the above discussion? First I would argue that the discussion shows
how a question is framed matters. Secondly a tight restriction on the domain of
people who can avail themselves of assisted suicide gives rise to difficult
questions. Such a restricted domain would protect the disabled from exploitation whilst enabling
those disabled who meet the criteria to avail themselves of assisted suicide.
However such a tightly restricted domain would not protect other vulnerable patients from
suffering such as children and those suffering from dementia. None the less I
would argue that it is better to protect a limited number of people from
suffering than none. Perhaps more work might enable us to extend this tightly
restricted domain to others but extreme caution would be needed.
