Assisted Suicide and the Verbessem Brothers

Belgian twins, Eddie and Marc Verbessem, were euthanized at Brussels University Hospital last December. The brothers had been deaf since birth and had been recently diagnosed with a genetic form of glaucoma that would leave them blind. William Pearce comments that this case appears to mean the following holds in Belgian,

“Death is a logical and reasonable option if a person will become deaf-blind. By logical extension there are some disabilities that are a fate worse than death. One does not need to be terminally ill to be euthanized”, see Hastings Center Bioethics Forum .

In this posting I will argue even if death is a reasonable option it does not mean some disabilities that are worse than death. I will then examine if death is a reasonable option when, if ever, it is permissible to help someone die.

Pearce seems to believe that all voluntary euthanasia is wrong. In the rest of this posting I will assume voluntary euthanasia is roughly equivalent to assisted suicide and only use the latter term. There are of course some differences between voluntary euthanasia and assisted suicide but don’t I believe these differences significantly affect my arguments. Pearce suggests two reasons for the wrongness of assisted suicide. Firstly he points to research in Oregon where assisted suicide is legal which shows most people who chose to end their lives this way did so because of the loss of autonomy or dignity rather than unbearable pain. The implication of the above is he seems to believe loss of autonomy or dignity is not a good enough reason to justify assisted suicide. I agree loss of autonomy is not a reason that can be used to justify assisted suicide. However it is important to be clear what losing autonomy means. Losing the ability to participate in activities that made someone’s life enjoyable or a loss of her dignity is not the same as losing her autonomy. Losing autonomy means someone losing the ability to make decisions based on what she cares about. Secondly Pearce seems to believe that many of the conditions given as reasons for permitting assisted suicide can be alleviated and hence are not reasons that can be justified. For instance in the Verbessem case he points to the lack of skill centres devoted to the deaf blind. In response I would suggest one cannot say someone ought to do something on the basis of something that ought to be. The Verbessem brothers had to decide what to do on the basis of the circumstances that actually prevailed, not on the circumstances that ought to have prevailed. I of course accept it is possible a reason that is now used to justify assisted suicide may cease to be a reason if and when circumstances change.

It might be suggested that the Verbessem brother’s case implies that living with certain disabilities is worse than dying but this is not so. Clearly some people who are deaf-blind want to continue living and do not see this disability as a fate worse than death. Equally clearly some people would like to live as long as possible regardless of any disability or any disease they may be suffering from. It follows that any condition however bad or painful cannot be the sole reason to justify assisted suicide. What matters is someone’s attitude to her condition. For instance someone suffering from painful terminal cancer might just wish to die whilst someone else suffering from the same cancer might wish to continue living, perhaps for religious reasons. It would appear to follow what matters is someone’s attitude to her condition caused by disease or disability. It further follows assisted suicide is really being justified by someone’s preferences. However because, we do not have a reason simply to satisfy all of someone’s preferences, satisfying her preferences cannot be used to justify assisted suicide. It still further follows that Pearce is correct and neither loss of autonomy nor any condition, however awful someone suffers from, can be used to justify assisted suicide.

It seems to be if we can justify suicide that we should be able to justify assisted suicide. Clearly we have the capacity for rational agency. Joseph Raz argues we also have a duty to respect the exercise of this capacity by others within certain bounds because we value this capacity. Moreover he believes this exercise includes the option to determine when and how to end one’s life and that others may help us implement this option (1). I now want to consider two objections to Raz’s position. Firstly someone might object that euthanasia is not part of a rational person living her life. Raz might reply a rational person might nonetheless value she has the option to end her life, if it became meaningless and full of pain, whilst living her life. He might point out if someone values a right and the exercise of this right does not significantly harm others that we should respect her right. This could be classed as Mill’s position.

I now want to examine what is meant by significant harm in more detail. Firstly the fact that someone is offended, simply by another’s decision to commit assisted suicide, is not a great enough harm for her to fail to respect the other’s decision. The fact that someone is offended by another’s political views should not mean she fails to respect the other’s capacity to express these views. Nonetheless there are certain harms that would sometimes make the exercise of assisted suicide wrong. For instance it would seem wrong for a mother with dependent children to be able to be assisted to commit suicide. Or an aged parent who enjoys life but in spite of this enjoyment chooses to end her life solely to ensure her estate passes to her children rather than being dissipated on her care. However such examples don’t show assisted suicide is always wrong. They merely show, as Raz suggests, there are bounds as to when assisted suicide is permissible.

Should assisted suicide always be impermissible because of the harm it may inflict? In what follows I will argue assisted suicide should only be impermissible in specific cases due to specific harm relevant to the case in question. Let us accept that a complete ban on assisted suicide would prevent harming people such as those in the above examples. However I would suggest a complete ban on assisted suicide would also harm other people. For instance if someone who is terminally ill and in great pain, has no relatives, wishes to commit assisted suicide is prevented from doing so she is harmed. She is harmed not by the failure of society to permit others to help release her from the pain, someone else might well want to continue living even with the same degree of pain. She is harmed in two ways. Firstly she is harmed because society prevents her attaining something she values. Secondly and more importantly in my view she is harmed by the failure of society to recognise her as an agent. In this case she values something, which harms no specific person, but is nonetheless prevented from seeking what she values. It follows a complete ban on assisted suicide would harm some people. It further follows some assisted suicide is permissible.

The above suggests if all assisted suicide is impermissible some people would be harmed and if all assisted suicide is permissible others would be harmed. How is society to decide on which cases are permissible and which are not? I would suggest this decision should firstly be based on harm to others. I would further suggest this harm must be to those who depend on the person who wishes to commit assisted suicide, basically family members. However not all harms to family members make assisted suicide impermissible. Consider an aged woman, suffering from a painful terminal condition, who only has weeks to live. She wants to be assisted to commit suicide. In addition she is also a much loved mother and her adult children do not want her to commit suicide. However her children are not dependent on her any more and even if they will be harmed by her death I would suggest such harm is not so great to make her assisted suicide is impermissible.

Let us assume it is permissible for an autonomous person to commit suicide. If suicide is permissible for an autonomous person why should it be impermissible for someone to aid her to do so in some cases? In order to answer this question I will first consider what means to make an autonomous decision. An autonomous decision is not simply a rational decision. The rationality of a decision depends on how well it achieves the agent’s goals. In this blog I take a position similar to that of Harry Frankfurt. Autonomous decisions are decisions based on what an agent ‘cares about’. Caring about and autonomy are central to being a person.

“Can something to whom its own condition and activities do not matter in the slightest properly be regarded as a person at all. Perhaps nothing that is entirely indifferent to itself is really a person, regardless of how intelligent or emotional or in other respects similar to persons it may be” (2).

However sometimes someone may not be fully aware of what she cares about. She might make a decision based on what she believes she cares about but when she comes to implement her decision finds she cannot. Sometimes what someone cares about is shown more by her actions rather than her decisions. Accepting the above provides a reason as to why even if it is permissible for someone to commit suicide it is sometimes impermissible for others to aid her do so. Someone may make a decision to commit suicide but be unable to implement her decision. Accepting the above suggests if assisted suicide is ever permissible it is only permissible if someone makes an autonomous decision to commit suicide and is unable to implement her decision by herself. It further suggests if voluntary euthanasia is ever permissible it must be so only under the above conditions,

Does the greater certainty that someone’s actions are autonomous compared to her decisions mean we can never justify assisted suicide even for someone who makes, what we believe to be autonomous decision to commit suicide, but lacks the capabilities to implement her decision by herself. I accept that the conditions in which assisted suicide might be permissible are far ideal. Nonetheless even if these conditions are far from ideal I believe assisted suicide is permissible if someone makes a decision to commit suicide and is unable to implement her decision. My belief is based on centrality of autonomy to our lives, of seeing ourselves as capable of determining our own future. I would assume anyone who believes we should not permit assisted suicide does so for beneficent reasons. She believes in acting beneficently has priority over respecting autonomy, at least in this scenario. Some proponents of assisted suicide argue that, because we would not let animal suffer as we do some persons in some cases, we should permit assisted suicide. I have argued above that suffering alone does not provide a basis to justify assisted suicide. Nevertheless in much the same way I would suggest those who place greater emphasis on acting beneficently over respecting autonomy see persons in much the same way as they see animals. They fail to see, or only pay lip service to seeing, others as creatures who can determine their own future, see respecting autonomy and a flourishing society .

Accepting the above has three important practical consequences. Firstly, because our certainty about autonomous decisions is less than our certainty about autonomous actions, we must be extremely careful about assessing autonomous decisions. Unfortunately if autonomy is essentially a matter of someone’s will rather than her rationality this is far from easy to do. I have previously suggested this involves assessing someone’s satisfaction with her decision, see valid consent . Secondly it seems to me Brussels University Hospital can justify offering the Verbessem brothers assisted suicide. Provided the Verbessem brothers had made an autonomous decision to commit suicide which they could not implement. I am assuming in the above that anyone who is both blind and deaf would have difficulty in committing suicide. I do not deny that had there been more skills centres for the death blind might available to the brothers that they might have made a different decision. Unfortunately as I have argued above they had to make their decision in the light of circumstances in their case. Lastly and perhaps even more controversially assisted suicide might be offered to a broader domain of people than just the terminally ill. I have suggested myself that assisted suicide might be permissible for prisoners serving life sentences, see prisoners serving life sentences .

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1. Joseph Raz, 2013, Death in Our Life, Journal of Applied Philosophy, 30(1).
2. Frankfurt, 1999, Necessity, Volition, and Love, Cambridge University Press. Page 90.