Assisted Suicide and a Life not Worth Living

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.