Why Assisted Suicide is Wrong

normally we discourage suicide, because we believe that suicidal people have lost touch with their deepest desires. why assume that the deepest desires of the sick are somehow different?

I originally posted this on Radiopaper, where I’m doing most of my writing these days. The site allows you to (privately) commission to (publicly) respond to a prompt/question of your choice. If you’d like to commission me to write something, you can do so on my homepage. I’m also happy to discuss this post—and quite a lot of other things—for free, so please hop over if you’d like to chat.

*As a trigger warning, I will talk about depression, suicidality, suicide-attempts and suicide in some detail.

When, if ever, should assisted suicide be legal? Always, never, or only in “special circumstances”? Specifically, I’m interested in physician assisted suicide, “Medical Aid in Dying” (MAiD) and voluntary euthanasia.

Normally we think suicide is a bad idea and we try to discourage people from killing themselves. One of the reasons for this is that we distrust that suicidal people are in touch with their “truest” desires. Lots of people have experienced periods of extreme depression, have come out of those periods, and have been very grateful that they did not kill themselves.

To be clear, we cannot figure out a person’s “truest desires” simply by asking them. The reason is that people often have different desires at different times. Depressed-self thinks that non-depressed-self was crazy for perceiving life as desirable, and likewise non-depressed-self thinks that depressed-self was confused in wanting to die.

Instead we preferentially trust non-depressed people about their desires to live-or-die, and we assume that depression causes us to lose touch with our deepest desires. (Even if it feels like the deepest desire is death, there’s an even deeper one underneath it which our depression is hiding from us.) In addition to this, we normally take the desire for suicide as a sign of depression.

At one level this seems kind of unfair, because we are taking as a prior the idea that a person’s real desire is never for suicide; we are ruling out suicide in advance.

But there are two levels at which this approach to suicide prevention is entirely fair.

One is that depressed-self is an existential threat to non-depressed-self, whereas non-depressed-self wants to preserve the conditions that make depressed-self’s (admittedly difficult) life possible. Plus, neither self will live forever so depressed-self will eventually get the longed-for death, even if it’s after a longer wait than depressed-self would prefer. In other words, if we are skeptical of the suicidal desire, we allow the possibility of both sets of desires persisting; whereas if we are skeptical of the desire to live we are siding with one outcome over the other.

The other level at which this is fair is that we are a community of living people, so I think it’s entirely fine for us to rely on a sort of pro-being-alive prejudice. Importantly, this prejudice is not particularly coercive. The argument about assisted suicide isn’t really about whether we should, for example, punish people who attempt suicide (we generally don’t do this), but rather about whether we should honor and celebrate their desire to commit suicide and also whether we have an obligation to help them carry out the suicide.

Here we get into more specific, dark matters. I remember reading a NYT article about MAiD which included a description of a widow who wished that MAiD had been available for her husband while he was dying of glioblastoma. Per her telling, he was so miserable that he wanted to kill himself:

Twice, Mr. Thomas asked his wife to bring him his gun and help him kill himself, Ms. Thomas said. She never did it, but it pained her to see how miserable he was and to know there was nothing she could do to alleviate his suffering….

To her, allowing people like her husband to choose when and how they die is “the compassionate, loving thing to do.”

But what I don’t understand is this: if allowing people like her husband to choose when and how they die would have been the compassionate, loving thing to do… why didn’t Ms Thomas let him have the gun? I don’t think the answer is a fear of criminal prosecution (she could have made sure to be somewhere with an alibi while he did it), but rather that she believes (quite correctly) that it is wrong to help people kill themselves. She also may have believed that only part of him wanted to shoot himself, and that another part wanted to hear his wife say “I would never let you do that.”

Perhaps because MAiD is euphemistically called “medical aid in dying” rather than “medical aid in killing,” it’s easy for people to imagine that it’s importantly different from giving someone a gun, a sort of organic hastening of a natural process, rather than something violent. But it really is not: you are giving them something which they use with the goal of ending their life.

There are lots of things we can do to make death less painful and terrifying. When someone is dying, it can be entirely reasonable to offer them extreme palliative options which we accept will likely also have the unintended, but entirely expected, effect of hastening the person’s death. If I am dying of cancer I want access to lots of morphine, the ability to push the pain down even if it also speeds up my exit.

But accepting death as a side effect is very, very different from killing.

In case this killing vs dying distinction seems arbitrary: We do things all the time which we accept are likely to have consequences which we are opposed to, but which we are willing to accept. If you have a sexually developed thirteen year old daughter and you allow her to walk around in public—which, to be clear, you should allow—you are probably aware that some creepy old men are going to check her out at least some of the time. If you are a good parent this fact by itself is something you will be unexcited about; in fact, parents who parade around their teenaged daughters with the goal of attracting the sexual attention of adults are doing something wrong. But we don’t say “never let your daughter leave the house otherwise you are helping creepy men to look at her,” nor do we say “well obviously since you let your daughter leave the house despite knowing that creepy men sometimes check her out, there’s nothing wrong with trying to get adults to oggle her.” There’s a big difference, and the difference involves what your goal is.

By analogy, it can be fine to give a dying person a lot of morphine, even though you accept that this may hasten their death. But this does not mean it’s fine to give them something with the goal of killing them.

Anyhow, I want to return to my initial claim that one reason we discourage suicide, and refuse to help people kill themselves ordinarily, is that we don’t believe this is their real desire.

Some advocates of MAiD/PAS want to offer assisted suicide in a very “restricted” context: for example, during a terminal illness when the patient has less than 6 months to live.

There are a lot of problems with this approach, but the most fundamental is this: it creates a category for which we say “if these are your circumstances, we accept that your desire for suicide is reasonable, that it probably really is your deepest desire.”

In other words, if we legalize MAiD we must either embrace suicide in all contexts, or we restrict it to lives that we collectively deem to be “legitimately not worth living.”

But what does it do for people when we give their lives that designation? If they are already depressed and suicidal, this designation may push them towards suicide. And if they don’t want to kill themselves, it amounts to a kind of abandonment by society. I suspect Mr Thomas perceived that his wife loved him when she refused to give him a gun; we could also show some love to the dying by refusing to give them MAiD.

And importantly, we simply don’t have any good reason for thinking that a terminally ill person’s desire for suicide is more real or more deeply connected to their authentic desires than a young and healthy person who is suffering from depression. It’s tempting to suppose “well, this person is suffering a lot and they’re going to die anyways,” but we are all going to die eventually, and most of us will suffer all manner of things before that happens. If we distrust the suicidal desire of a depressed teenager who is suffering from Mono, it’s not clear why we should trust the suicidal desire of a depressed adult who is suffering from cancer — even if their days are numbered. Because all of ours are.

(Of course there are important differences: the terminal patient may not have any pain-free days ahead, and it may be that we can be pretty confident about this. With nothing to look forward to, wouldn’t the merciful thing be to just end it? But again, this is not the logic we apply to other people who want suicide. If life were just about some combination of achieving stuff, enjoying things, getting what we want and minimizing suffering, it would be “merciful” to allow depressed teenagers to kill themselves, at least if their depression was coupled with a reasonable expectation that their life would have quite a lot of hardship in it. Perhaps they grew up in a rough neighborhood with a strong school to prison pipeline, and they’d rather just skip all of that. But this is not what we do; instead, we insist that their life is worth living and that this worth is not just a function of what they can expect from their remaining days, which, after all may contain surprises, even for the terminally ill.)

Normally we take suicide prevention seriously because we simply don’t believe that a person’s deepest desire is for death. When we offer MAiD to people who meet a certain criteria, we are telling them one of two things: 1. unlike people leading “good lives”, you probably do desire death, deep down, or 2. when it comes to people like you, we just don’t care about whether your desire for death is authentic; we are happy to help you kill yourself either way. Option 1 is groundless and offensive, and option 2 is an incredibly evil form of abandonment.

I have a lot more to say about this — about the ways in which offering MAiD is contrary to the dignity of disabled people, about problems with coercion, about the badness of viewing our lives in a MAiD-friendly framework, about the ways that legalizing MAiD invites us to neglect the people who need us most… not to mention the horrors that have gone on in Canada and Europe and even in US states like Oregon which have legalized it. But for now, if you want more on this subject: here are some excellent interviews by Amanda Achtman, here is something I wrote recently, this is a physician perspective that I think is very worth engaging with, and here’s the perspective of someone with disabilities.

And if you have questions/comments for me or want to talk further, you can reach me on Radiopaper.