Euthanasia and assisted suicide: the illusion of autonomy.

Alex Schadenberg
Executive Director, Euthanasia Prevention Coalition

Dr Ole Harling

The British Medical Journal (BMJ) published an excellent essay - Euthanasia and assisted dying: the illusion of autonomy written by Dr Ole Hartling, a Danish physician for more than 30 years and a past Chair of the Danish Council of Ethics. Hartling examines the arguements in favour of euthanasia and assisted suicide with the intent of creating "a little doubt" in the minds of those who absolutely favour legalization. Hartling primarily examines the concept of autonomy.

Hartling begins with his premise:

I question whether self-determination is genuinely possible when choosing your own death. In my book, I explain that the choice will always be made in the context of a non-autonomous assessment of your quality of life—that is, an assessment outside your control.

Hartling differentiates autonomous decisions in relation to dying as compared to other autonomous decisions. He writes:

Decisions about your own death are not made in normal day-to-day contexts. The wish to die arises against a backdrop: of desperation, a feeling of hopelessness, possibly a feeling of being superfluous. Otherwise, the wish would not be there. Thus, it is under these circumstances that the right to self-determination is exercised and the decision is made. Such a situation is a fragile basis for autonomy and an even more fragile basis for decision making. The choice regarding your own death is therefore completely different from most other choices usually associated with the concept of autonomy.

Hartling comments on why a "choice" to die can translate into a "duty to die." He states:

But if a law on assisted dying gives the patient a right to die, that right may turn into a duty to die. How autonomously can the weakest people act when the world around them deems their ill, dependent, and pained quality of life as beyond recovery?

He refers to this situation as the "prison of freedom." He continues by commenting on internalised external pressure. He states:

French bioethicist Emmanuel Hirsch states that individual autonomy can be an illusion. The theologian Nigel Biggar quotes Hirsch saying that a patient “may truly want to die, but this desire is not the fruit of his freedom alone, it may be—and most often is—the translation of the attitude of those around him, if not of society as a whole which no longer believes in the value of his life and signals this to him in all sorts of ways.

Hartling then writes about the concept that assisted death is actually about the end of autonomy. The "choice" of an assisted death is an act that ends autonomy. He then comments on the limit of autonomy by stating:

However, a patient’s autonomy means that he or she has the right to decline any treatment. It does not entail a right to have any treatment the patient might wish for. Patients do not have the right to demand treatment that signifies another’s duty to fulfil that right. If that were so, autonomy would be the same as “autocracy”—rule of the self over others.

Hartling argues that assisted death requires a binding agreement between two people, one who wants to be killed or assisted in death and another who will do the act. Hartling states that society only condones exemptions to the killing ban based on war and self-defense.

Hartling then comments on the valuation of a life that occurs when assisted dying is legalized. The decision is not only about autonomy but it includes a decision by a medical professional that as to whether a person's life is worth preserving.

Hartling ends his essay by commenting on the concept that assisted dying relieves suffering. He states:

If a competent and legally capable person must have the option of voluntarily choosing assisted dying in the event of unbearable suffering, why does suffering have to be a requirement? The answer is straightforward: our concepts of assisted dying imply that compassion must form a crucial aspect of the decision—mercy killing and compassionate killing are synonyms. But this leads instantly to the question of why we should not also perform assisted dying on people who are not in a position to ask for it themselves but are also suffering.

This is exactly the debate that is happening in Canada and other nations that have legalized euthanasia. The arguement is that someone who is incapable of asking for death should also be allowed to die to avoid suffering, especially if they had previously stated that they would not want to live in this way. The problem being, the person cannot ask for it themselves so they lose the right to change their mind. Hartling continues:

Some people find the reasoning unproblematic. It stands to reason that relieving suffering is a duty after all. But in this context it is not unproblematic, because it effectively shifts the focus from the autonomy claimed. According to prevailing ideas about autonomy, patients initially evaluate their quality of life themselves, but ultimately it is those around them who end up gauging that quality and the value of their life. That is to say, the justification for assisted dying is borne on the premise that certain lives are not worth living rather than the presence of a request. The whole point is that in the process, respect for the right to self-determination becomes relative.

Hartling completes his article by focusing on compassion and care and not killing.

Autonomy is largely an illusion in the case of assisted dying. A patient overwhelmed by suffering may be more in need of compassion, care, and love than of a kind offer to help end his or her life. It is not a question of whether people have a right to say that they are unworthy. It is a question of whether they have a right to be believed when saying it.

Hopefully many people will read share Dr Ole Harling's essay.