Assisted dying has always been controversial, but lately, it seems ever more present in public and philosophical debate. The proposed expansion of Canada’s Medical Assistance in Dying (MAiD) program to those who want to end their lives due to mental illness made headlines globally, spurring numerous discussions around the potential for disability, poverty, and social marginalization to push people toward choosing to end their lives. News from countries like the Netherlands sometimes prompt unease about the seemingly ever-widening conditions for access to voluntary euthanasia. Yet, worries about the long-term effects of policies permitting some assistance in dying are especially difficult to address since most such laws are pretty recent, so observing trends and determining if fears about slippery slopes are justified might not be feasible right now.
Some jurisdictions choose to err on the side of caution by keeping assisted death illegal. But, campaigners, experts, and members of the public are challenging existing restrictive laws. A call for allowing people the option to ‘die with dignity’ when faced with terminal illness and the pain and suffering this can bring is often at the forefront of such initiatives to legalize assisted death.
While all the nations comprising the United Kingdom prohibit assisted dying, this picture could soon be disrupted by Scotland potentially becoming the first UK nation to legalize it, as the Assisted Dying for Terminally Ill Adults (Scotland) Bill is currently going through its first stage of debate at the Scottish Parliament. The neighboring nation of the Republic of Ireland will soon consider a similar law. These developments open the question of whether other parts of the UK or similar countries might head in the same direction. With assisted dying currently illegal across the UK, citizens can only access it by traveling to jurisdictions like Switzerland where it is permitted, and this seems to be an increasingly popular option.
Against this backdrop, the Guardian recently ran a special issue on assisted dying, with contributions from a variety of public figures voicing their views on the need for legal reform. For example, the television presenter and current Great British Bake Off [also known as The Great British Baking Show] judge, Prue Leith, emphasizes the importance of choice for those who wish to have control of how and when their suffering ends: “While I am healthy at the moment, I’d very much like to have a little lethal concoction sitting in a safe waiting for the right moment. And I’d rather it was legal.” The writer Julian Barnes, whose works often deal with themes of death and memory, argues for the legalization of assisted dying as a way of ensuring that people can ‘die as themselves.’ In his view, assisted dying arrangements could allow individuals to avoid the traumatic experience of losing their fundamental character to physical, and especially, mental decline: “Most of us want to die with our personality intact, rather than have it swamped by blank misunderstanding; many fear a long process of dying, in which the body outlasts the mind, and indignity, humiliation and panic may ensue.”
Viewed from a philosophical perspective, the contributions to the special issue are marked by an emphasis on the importance of respect for individual decisions and worries about medical paternalism still prevailing in the doctor-patient relationship. This approach mirrors the way Western bioethics address the assisted dying debate, focusing on individual choices and control around the way one’s life will end. The collection’s title, ‘The Ultimate Choice,’ is also very much in line with a bioethical canon whose fundamental value is individual autonomy. Having dignity, or avoiding indignity, at the end of life also looms large.
In the popular consciousness, the idea of a “dignified death” or “dying with dignity” seems inextricably linked with advocating for assisted death. The terminology immediately invokes institutes such as the Death with Dignity Acts in various US states, the Dignitas Right to Die Association in Switzerland, or the British campaigning group Dignity in Dying. Those who call for the development and better integration of palliative care services are sometimes seen as taking the opposite side in this debate, arguing for broader provision of interventions aimed at symptom control and maintaining quality of life until the end rather than expanding access to assistance in dying.
However, dignity is a powerful concept often utilized in palliative care research and practice. The Dignity Therapy and Dignity Conserving Care approaches pioneered by Harvey Chochinov and colleagues during the 2000s emphasize psychotherapeutic interventions aimed at alleviating emotional and existential distress at the end of life and ensuring that patients feel valued and see their lives as meaningful. Such interventions are applied to beneficial effects and adapted to different cultures with varying conceptions of personal dignity, although they seem less explored in the philosophical literature.
How is it possible that the concept of dignity is so central to what appear to be opposing views? In a recent paper in the Journal of Medicine and Philosophy, Morten Dige notes that the sometimes paradoxical use of dignity in the assisted dying debate may stem from a conceptual confusion between dignity in the status-ascribing sense versus as a feature of particular situations. The first sense is present in accounts of dignity as an inalienable feature of human beings, which we possess by virtue of species membership or being God’s creations. However, when we understand dignity as a contingent characteristic, which can be impacted by our circumstances or the way others treat us, then it is plausible that it could be preserved through retaining control over the circumstances of the end of one’s life—or damaged, even lost, by not being allowed to make choices in this context. Dige suggests these two senses of dignity are compatible. If human beings have a basic dignity that circumstance cannot take away, then this is grounds for demanding that they be treated dignifiedly.
Furthermore, it is possible that the supposed dichotomy between assisted dying and palliative care also conceals two approaches to death that may be more compatible than it seems at first sight. Advocates of both care about dignity, but also pain relief, comfort, and maintaining quality of life until its end. Experiences from countries like Belgium show that both can exist and function well side by side. And practices like palliative sedation, especially continuous deep sedation until death, suggest that the line between assisted dying and palliative care may be blurrier than it appears.
Despite the enthusiasm for assisted dying laws expressed by contributors to the Guardian special issue, letters from readers in response to it contain some dissenting voices, warning about the nuances and practical pitfalls of such legislation. Some individual stories also challenge the views presented in the original contributions. A reader whose wife died of cancer recounts her experience: “Not once during those five years of palliative treatment, brutal and unremitting as it was, did she feel that her life should be ended, or ask for it to be… Despite everything, she did die with dignity and as herself.”
The narrative of dignity in death is a powerful one that resonates with many, especially in the Western world. However, it also might ultimately turn out to be vague and unhelpful as a political and philosophical guideline when it comes to assessing the acceptability of assisted dying. Perhaps we need to look more closely at the factors that can make dying a good or bad experience for patients and their families and consider the different available routes to reaching better outcomes.
The Current Events in Public Philosophy series of the APA Blog aims to share philosophical insights about unfolding events and topics. If you would like to contribute to this series, email RichardBGibson@hotmail.com.
Dunja Begović
Dunja Begović is a Lecturer in Medical Law and Ethics at Keele University in the United Kingdom. Previously, she worked as a Research Associate at the International Observatory on End of Life Care, Lancaster University, and completed a PhD in Bioethics and Medical Jurisprudence from the University of Manchester.
