Assisted Euthanasia

Nancy Gibbs has penned a thoughtful piece on the question of assisted suicide (or euthanasia depending on your point of view) in the latest installment of Time.

The story of Sir Edward [Downe]’s “death pact” was at first sight an irresistible love story. His wife Joan, 74, a former ballerina, had a diagnosis of terminal liver and pancreatic cancer; because assisted suicide is illegal in Britain, they traveled to a Zurich clinic, where, for a fee of about $7,000 per patient, the group Dignitas arranges for death by barbiturate. “They drank a small quantity of clear liquid and then lay down on the beds next to each other,” their son Caractacus said. They fell asleep and died within minutes, he reported, calling it a “very civilized” final act.

I have to confess that I find the son’s interpretation of their act as “very civilized” very creepy.  [I also am tempted to crack a “I am Caractacus” joke but pay that no mind].  I could see interpreting that act as loving, sacrificial, or one brought about by deep sadness and the desire to not lead a deteriorating life of loneliness without your soulmate.

But civilized?  Is that the right frame of reference?  Maybe this is just classic British stiff upper lip, jolly good show-ism or something, but civilized I don’t think is the proper frame for which to approach matters of this ambiguous moral (and literally life or death) nature.

I mean we know that anything less than Right Guard is uncivilized.   And it’s not a cookie, it’s fruit and cake.  And so on.  That I get.

But death as civilized?  I mean the opposite of civilized is barbaric right?  If Sir Edward hadn’t partaken of the poisonous draught and lived a few more (undoubtedly very grief-stricken) years without his wife and then died, would that have been barbaric?

Doesn’t strike me that it would have been.  A barbaric death would be one brought about by barbaric actions–e.g torture, murder, sanitized bureaucratic processes that cause people to die because they don’t meet a proper criterion on a line-item.

Otherwise civlized ceases to be about a civilization (where the term comes from), from the civitias, i.e. the city/the commonwealth, and at its worst leads to this kind of thing.

Cue the stereotypical (you could have predicted this was coming) response:

Some euthanasia activists, including Dignitas founder Ludwig Minelli, believe in death on demand. “If you accept the idea of personal autonomy,” he argues, “you can’t make conditions that only terminally ill people should have this right.” Autonomy and dignity are precious values; the phrase sanctity of life can sound sterile and pious in the face of profound pain and suffering. But Minelli is arguing for much more: that autonomy is an overriding right. This view rejects the idea that society might ever value my life more than I do or derive a larger benefit from treating every life as precious, to the point of protecting me from myself.

Now on one level, this is a honest opinion.  I would tweak it slightly to say:  If you accept the exclusive (or primacy of) the idea of personal autonomy”, then Mr. Minelli is in fact correct.  As best as I can surmise, that seems to be Minelli’s real view anyway.  I’m just making it more explicit.  The (il)logical conclusion to such a view is that everyone has a right to kill themselves whenever they wish, and therefore private enterprises should be allowed to flourish which simply assist in that process and those groups should not be interefered with by state entities.

Of course as soon as the profit-margin enters into the game and/or you get people thinking that they know better via the creation of a targeted system you get this:

A study in the Netherlands found that one in four doctors said they had killed patients without an explicit request–including one doctor who believed that a dying Dutch nun was prevented from requesting euthanasia because of her religion, so he felt the just and merciful thing to do was to decide for her.

As un-libertarian an action as that seems, I think it’s important to remember it’s not a great leap to say that individuals must autonomously choose for themselves to the idea that some are prevented from that decision–and once that cat is out of the bag look out–so therefore we must free them by choosing for them.

Gibbs again:

We allow for the removal of feeding tubes, the withdrawal of respirators, the replacement of aggressive treatment with palliative care; these can all be wise and merciful choices. But each step forward gets a little more slippery. Is there some point, visible in the cloudy moral distance, where the right to die becomes a duty to die? We don’t need to set Grandma adrift on her ice floe; the pressures would be subtle, wrapped in the language of reason and romance — the bereaved widower who sees no reason to try to start over, the quadriplegic rugby player whose memories paralyze his hopes, the chronically ill mother who wants to set her children free. Already in Oregon, one-third of those who chose assisted suicide last year cited the burden on their families and caregivers as a reason.

Now I think Gibbs has mixed up two things in that paragraph.  The reference to Grandma adrift on the ice floes of course refers to a common practice among traditional tribal societies across the planet where elders would voluntarily accept a death outside the group so as not to be a burden upon the tribe.  This was a necessity given the low carrying capacity of such groupings.  i.e. There was very limited resource base–particularly among hunter-gatherer societies–and tragically if elders didn’t sacrifice themselves for their kin, then the whole group was in danger.  So it’s not about setting Grandma adrift; Grandma choose it.*

Which is still alive and well in non hunter-gatherer societies today.  The 1/3 number of assisted suicide (again or euthanized or murdered depending on point of view) patients in Oregon did so for fear of over-burdening their families.  It’s simply replicating our hunter-gatherer mind if you like.

So Gibbs’ idea that a right to die becomes a duty to die is undercut by her examples.  The bereaved widower does not have a duty to die because of his grief.  In Gibbs’ language that’s a question of his right/choice to die.  It’s an entirely different prospect that feeling a duty to die so that descendants are not economically hurt.

All I’m trying to do here is tease out the various values/rationales for these reasons.

–We have the hunter-gatherer/tribal mind of the group over the individual.

–Then (though only off handedly referred to in this post) a more traditional religious (often monotheistic) notion of the sanctity of life in all cases.  i.e. No assisted suicide ever morally justifiable.

–The the modern notion of totally autonomous self-contained hermetically sealed individuals with their own maximizing will as the ultimate judge.

–The (post?)modern specter of the technocratic wise one who knows true freedom for all and will choose it for them.  As well as the commodification of the human body and its death processes.  The postmodern could also include the idea that the self is a construct of actions.  So by choosing this route, the self lives on–i.e. Sir Edward is now forever remembered.  While that my seem, at first, a heroic overcoming of social conditioning, if that practice becomes embedded in society, then it will simply be another form of social and cultural conditioning over time.

All of which I think as over-riding, stand alone views, fail in my estimation.  Another way might be to take the permanent deepest truth from each and let them sit in tension together and out of that make judgments based in relative discrimination given the overall complexity.  Life is sacred.  The tribe does matter.  Individuals also must be free and yet we are never completely autonomous beings.

Gibbs’ alternative offer is a somewhat half-hearted plea (or at least an undeveloped/ungrounded one) on the need for more palliative care and a critique of the increasing euthanization.

The growing traffic in “death tourism” is an indictment of a health-care system that seems to incentivize everything except the peaceful death to which we all aspire…Advances in palliative care mean that those last years of life do not have to be a moral, medical and financial nightmare.

That needs some unpacking although I generally favor that point of view. Still I think it overestimates the reality that death is often not painless, whether with drugs or not, palliative care or no.

In this vein line of inquiry, I highly recommend Sherwin Nuland’s book How We Die.  The thesis of which is that pain is inevitable in death.  Death isn’t pretty.  It’s both very depressing (at first) and then later grounded in a much more realistic hope and actual potential to do what good can be done instead of these pie in the sky fairy tales of peaceful death in bed and miracle panaceas.  Of course some people do have the relatively painless death while sleeping scenario.  I’m not really sure I would ever call that a good death (or shudder shudder, a civilized one).

But my sense is if the painless scenario is made out to be a good death, then it increases guilt both on the caregivers and the dying if they don’t live up to that standard.  And then we are always pining or searching for some other scenario whereby death will be (really shudder shudder here) perfected.

Which is of course not to just throw up the hands and say sorry charlie, it’s just to say that death is not the problem.  It doesn’t require a solution.  The problem, such as is there is one (and I”m generally loathe to use that word here), is our fear around the process.  The fear that drives irrational decisions–however sympathetically understood–like not letting a loved one go at the right time, hooking them up to tube, and then having to make a much more horrible decision later about whether to cut the tube and watch them a die a much more horrible death than the would have if they had died when their body was ready to go.

Which is where Nuland’s book, though a very challenging read, can be helpful.  It allows one to face into the fear.

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*I suppose we could have a philosophical argument about how free such a decision was given that it was socially inculcated, but my sense is that it is not right to characterize it as setting her adrift.  Although I’m reading setting Grandma adrift as somehow a kind of enforced decision.  It could I suppose also legitimately be read as Grandma having chosen to place herself on the ice floe and she needs someone simply to shove it out to sea.