Assisted dying: 5 things to think about

Making sense of our lives means thinking about death. Some philosophers, like Martin Heidegger and Albert Camus, thought death was a crucial, defining aspect of our humanity.

Camus went so far as to say considering whether to kill oneself was the only real philosophical question.

What these philosophers understood was that the philosophical dream of living a meaningful life includes the question of what a meaningful death looks like, too. More deeply, they encourage us to see that life and death aren’t opposed to one another: dying is a part of life. After all, we’re still alive when we’re dying so how we die impacts how we live.

The Ethics Centre was invited to make a submission to the NSW Parliamentary Group on Assisted Dying regarding a draft bill the parliament will debate soon. The questions we raised were in the spirit of connecting the good life to a good death.

Simon Longstaff, director of the Centre and author of the submission, writes, “It is not the role of The Ethics Centre to prescribe how people ought to decide and act. Our task is a more modest one – to set out some of the ethical considerations a person might wish to take into account when forming a view.”

Here are some of the key issues we explored, which are relevant to any discussion of assisted dying, not just the NSW Bill.

Does a good life involve suffering?

The most common justification for assisted dying or euthanasia is to alleviate unbearable suffering. This is based in a fairly universal sentiment. Longstaff writes, “To our knowledge, there is no religion, philosophical tradition or culture that prizes suffering … as an intrinsic good”.

Good things can come as a result of suffering. For example, you might develop perseverance or be supported by family. But the suffering itself is still bad. This, Longstaff argues, means “suffering is generally an evil to be avoided”.

There are two things to keep in mind here.

First, not all pain is suffering. Suffering is a product of the way we interpret ourselves and the world around us. Whether pain causes suffering depends on our response: It’s a subjective experience. Nobody but the sufferer can really determine the extent of their suffering. Recognising this could suggest a patient’s self-determination is crucial to decisions around assisted dying.

Second, just because suffering is generally a bad thing doesn’t mean that anything aiming to avoid it is good. We can agree that the goal of reducing suffering is probably good but still need to interrogate whether the method we’ve chosen to reduce suffering is itself ethical.

The connection between a good death and a good life

There’s not always a solution to suffering, no matter what anecdote you try, whether it be medicine, psychology, religion or philosophy. Sometimes suffering stays a while.

When there is no avenue to alleviate someone’s pain and anguish, Longstaff suggests “life can be experienced … as nothing more than an unrelenting and extra-ordinary burden”.

This is the context in which we should consider whether to help someone to end their lives or not. Although many faiths and beliefs affirm the importance and sacredness of life, if we’re thinking about a good, meaningful life, we need to pay some attention to whether life is actually of any value to the person living it. As Longstaff writes, “To say that life has value regardless of the conditions of a person’s existence may justify the continuation or glorification of lives that could be best described as a ‘living hell’”.

He continues, “To cause such a state would be indefensible. To allow it to persist without available relief is to act without mercy or compassion. To set aside those virtues is to deny what is best in our form of being.”

A responsible person should have autonomy over their death

Most people think it’s important for adults to be held responsible for their actions. Philosophers think this is a product of autonomy – the ability for people to determine the course of their own actions and lives.

Some philosophers think autonomy has an intrinsic connection to dignity. What makes humans special is their ability to make free choices and decisions. What’s more, we usually think it’s wrong to do things that undermine the free, autonomous choices of another person.

If we see death as a part of life, not distinct from it, it seems like we should allow – even expect – people to be responsible for their deaths. As Longstaff writes, “since dying is a part of life, the choices people make about the manner of their dying are central considerations in taking full responsibility for their lives”.

The role of the terminal disease

Some proposed laws, like the draft NSW Bill, suggest a person can seek to end their own life when their terminal disease causes them unbearable suffering. So, if you’re dying of lung cancer, you can only end your life if the cancer itself is causing you unbearable pain. It is necessary to consider if assisted dying be restricted in this way.

Imagine you’ve got a month to live and the only thing that gives you meaning is your ability to go outside and watch the sunrise. One day, you break your leg and are bedridden. Should you now be forced to live for a month in a state you find agonising and meaningless because your broken leg isn’t what’s killing you?

Longstaff argues, “If severe pain and suffering are essential criteria for being eligible for assistance, then on the basis that like cases should be treated in a like manner, assistance should be offered to a person who meets all the other specified criteria – even if their pain and suffering is not caused by their illness”.

Who is eligible for assisted dying?

Many laws try to carve out special categories of people who are and aren’t eligible to request assisted dying. They might do so on the basis of life expectancy, whether the illness is terminal or the age of the patient.

In determining who should be eligible, two principles are worth thinking about.

First, the principle of just access to medical care. Most bioethicists agree before we can figure out who receives medical treatment, we need to have a broader idea of what justice looks like.

Some think justice means people get what they need. For these people, granting medical care is based on how urgently it’s required. Others think justice means getting the best outcome. These people think we should distribute medicine in a way that creates the most quality of life for patients.

Depending on how we view justice, we’ll have different views on who is eligible for assisted dying. Is it those whose quality of life is lowest? If so, it might not be terminal cases in need of treatment. Is it those who are most in need of treatment? This might include young children who many people are reluctant to provide assisted dying to. Until we’re clear on this principle, it’ll be hard to decide who is eligible and who is not.

The second principle worth thinking about is to treat like cases alike. This idea comes from the legal philosopher HLA Hart. He thought it was essential for ethical and legal distinctions to be made on the basis of good reasons, not arbitrary measures. A good example is if two people committed the same crime, they should receive the same penalty. The only reason for not treating them the same is if there is relevant difference in the two cases.

This is important to think about in terms of strict eligibility criteria. Let’s say we reserve assisted dying for people over 25 years old, which the NSW draft Bill does. Hart would encourage us to wonder, as Longstaff noted in The Ethics Centre’s submission, “what ethically significant difference lies between a 24-year-old with six months to live and who wishes to receive assisted dying and a 25-year-old in the same condition?”