Tuesday, 14 June 2011

Choosing to Die? A Review:

A Cup Of Hemlock.

The poison is to be drunk
and best sooner
than later

It is ridiculous to cling to life
when it has no more
to offer

Such cowardice suffices
only to delay

Better to drink the poison now
with the swift calm
of a dead man

Having so spoken
Socrates drained the cup
in one breath

And a short while after
was found still
and cold

Watching Terry Pratchett on assisted dying, on the BBC 2 documentary last night, I think it is debate that needs to be aired, as publicly as possible. I have considerable reservations relating to pressure on the elderly and vulnerable, but I can see that there may be exceptions; it is a very difficult area, and I'm not sure it can be presented in simple black and white terms. But against the strident voices who accuse the BBC of bias, and of breaking guidelines, I think we need to tackle the taboo subject of death, and do it in a way that brings the effects home, and not at a distance.

Peter, who took the poison at the Swiss Clinic, died quietly and with dignity, and yet there was a moment when he cried out that he was thirsty and wanted water, and it was refused, and was clearly in discomfort, and it flitted through my mind that he might have, at that eleventh hour, changed his mind; it was an unsettling moment, even if only for a few seconds, and I was not happy watching that.

If I had Alzheimer's,  I'm not 100% sure how I would feel. I've seen people deteriorate until they become shells of the human beings they once were, their memory lost, and unable to live with any kind of dignity. I certainly don't think they should be "given" euthanasia, but what if they made the choice while they good, knowing what was to come? Unlike other illnesses, like cancer, or motor neurone disease, there would be a point where one would be unable to make a conscious choice, and Terry Pratchett could see this problem very well: where would the "tipping point" be, because he would not want to die too soon, but wanted to taste every last morsel of life.

I was struck by how the person had to take the drug themselves; they could not in fact be assisted to do it, and no one could do it for them. Also it was clear that the environment in which this took place was very strongly organised against any coercion being given.

This reminded me of the problem of the trolley, which Michael Sandel introduced in his lectures on Justice:

"Suppose you're the driver of a trolley car, and your trolley car is hurdling down the track at sixty miles an hour and at the end of the track you notice five workers working on the track. You tried to stop but you can't your brakes don't work - you feel desperate because you know that if you crash into these five workers they will all die. Let's assume you know that for sure and so you feel helpless until you notice that there is off to the right a side track at the end of that track there's one worker working on the track. You're steering wheel works so you can turn the trolley car if you want to onto this side track killing the one but sparing the five. Here's our first question, "What's the right thing to do?" Because it can't be right to kill five people when you can only kill one person instead. It wouldn't be right to kill five if you could kill one person instead.

Most people said they would turn the wheel, but then they were presented with another problem:

This time you're not the driver of the trolley car, you're an onlooker standing on a bridge overlooking a trolley car track and down the track comes a trolley car -  at the end of the track are five workers. The brakes don't work - the trolley car is about to careen into the five and kill them - and now you're not the driver you really feel helpless until you notice standing next to you leaning over the bridge is it very fat man. And you could give him a shove he would fall over the bridge onto the track right in the way of the trolley car he would die but he would spare the five. Now, how many would push the fat man over the bridge?

And he makes the point:

Most people wouldn't. Here's the obvious question, what became of the principle better to save five lives even if it means sacrificing one? What became of the principle that almost everyone endorsed in the first case?

What happens is that behind the original principle is another principle, which is in the second case, you are involved in making an active choice of pushing a person - and that person himself would otherwise not have been involved in the situation at all. You are choosing on his behalf, and otherwise he would have escaped.

I can see the same kind of distinction at work here between someone giving another person a lethal injection, and the person taking a cup of poison themselves; there is a difference in volition, even if the end result is the same. It may seem minor, after all, I could request someone to give me an injection, just as I could request the cup, but it is not quite the same, because - as with the trolley thought experiment - there is the element of active personal action. Another person is supplying the poison, but the choice, and the decision to drink it, must be yours - they cannot choose to act on your behalf, however much you may request it. Thomas Szasz makes this same distinction, and he warns against the use of slippery language in which doctors actually kill the patient, but it is termed "physician-assisted suicide":

"Physician-assisted suicide" can be one of two things. The physician can give the patient a drug--let's say a barbiturate--and then the patient takes the drug and dies. But that's simply suicide, a person killing himself. If you buy a rope in a store, you don't talk about "merchant-assisted suicide." On the other hand, what can also happen is that the physician helps a person to die--in effect, speeds his death or kills him. This is how many old people have died in the past and continue to die. They are going to live another few days or weeks; they are in heart failure and can't breathe. The physician gives them a little extra morphine, and they stop breathing. This is how Sigmund Freud died. But this is not suicide.

I don't, as yet, have a life threatening illness (as far as I know), so it is very difficult for me to know how it must feel from the inside, as we could get glimpses from Peter in the programme, and Terry Pratchett. That's I think part of the problem: looking at it from the outside, there seem to be a number of problems, and indeed Terry raised the problem of coercion, and of doctors or relatives deciding, or the state of mind (as with depressives). Granny will be encouraged to die because she is a burden on the family. And that's a real problem.

Thomas Szasz illustrated cases of how elderly relatives in the USA would be sectioned as "mentally ill" simply because it was an easy option for their families to take. If an elderly widow decided to give away most of  her money to charity rather than family, or sell up the family home and enjoy holidays with the proceeds, or the father wanted to marry a much younger woman - he gave cases where psychiatrists would be brought in to section them as "mentally ill", and allow the families to ensure they didn't lose their inheritance. That's not a good omen where "assisted dying" is concerned.

Rather than having a debate about the ethics of taking away an individuals freedom, psychiatrists often colluded with the families, used a medical model to side-step the moral issues, and give the families what they wanted. Szasz called this "bootlegging humanistic values through psychiatry", and noted that the same evasion of debate took place in the domain of abortion. So coercion is a real problem, and if professionals get involved, the situation can be very dangerous for the most vulnerable.

But from the inside, from having a life threatening illness, with no hope of remission, the choices must, I am sure, be much more stark and final. That's why I wouldn't be dogmatic about it, because I don't know what I would perceive the matter if it concerned me. Terry also raised the matter of people who decide to commit suicide in such cases of terminal illness in the UK, which is invariably botched and messy, because DIY just isn't that reliable.

Certainly medication without assistance would seem to be one kind of protection, and I would not be happy with someone giving a lethal injection. But is it enough? It is fine when there is a remote clinic, and not many people are queuing up to pay the £10,000 price tag, but when it becomes more of a mass-market affair, of the kind that Terry Pratchett wants, the safeguards would have to be iron-clad to prevent abuse, and I'm not sure that is possible.

I do understand that most Christian teaching, certainly in Catholicism, is firmly against assisted dying of any kind, but that also raises the question of whether those values should form the basis for the legislative framework for the rest of society; that's difficult. I think insofar as they can be presented as purely ethical arguments, that's ok, but while internally Christian values can be supported by scriptures and tradition, that is a kind of argument that may not hold value in the public domain, what Richard Dawkins terms "playing the God card" as a kind of trump.

Certainly some things should be "common ground". I would never countenance under any form the society that starts judging life by "quality of life", and then proceeds to remove the handicapped. The dangers of abusing such a system to save money is very great, and of course, we all know the lesson of history

The nationwide policy of administering euthanasia to mentally defective people, psychotics, epileptics . . . was in violation of the [National Socialist] penal code. . . . The program was regulated according to the motto: "The needle belongs in the hand of the doctor." (German euthanasia policy, 1938-1945)

But should individuals have the right to make up their own mind? Should Christianity trump matters as the backbone for our decisions, or should they be made on rational grounds that can be universally agreed?

The Modern Pagan writer Emma Restal Orr presents a quite different view of suicide:

If we acknowledge an individual as having responsibility for what he makes of his own life, we must also allow him responsibility for how he might end it. In Paganism, there is no God, nor any other body wielding authority, whose judgment on such a decision has any validity. Indeed, the very idea that someone would prevent another from ending their life would be an act of force that negated the individual's freedom, implying that their life was in fact not their own. Yet in a culture that does not accept slavery, who might justifiably claim ownership of (authority over) another's life is an incomprehensible question. With its emphasis on the importance of self-governance, such an idea is entirely counter to Pagan thinking.

But she is also aware that the pressures of our society are also an important factor, and the cool decision taking that Peter took in the Terry Pratchett film are not possible for many. Peter was clearly a wealthy man, and Terry looked around his house; here was a life with considerable luxury, in which the only factor was his own health. For the great mass of the population, living with considerably less means, and to whom £10,000 would be a huge sum of money, that kind of cool stoic thought may not be possible:

What does compromise our human freedom are the flooding tides of desolation and depression, now at epidemic levels in Western society. Unable to function or think clearly, an individual may stumble into fantasies of suicide, particularly if legal or illegal drugs are further complicating the chemical mix, paralysing parts of the brain. These urges can be temporary, provoked by loss or trauma, and to make critical decisions when emotionally flooded is always dangerous. Blinkered by the experience of suffering, seeing only pain ahead, we risk behaving with clumsy dishonour, lacking courage, dismissing our responsibilities, forgetting loyalties. Yet, even dishonourably done, through the selfish fog of despair, the decision to end the suffering by taking our own life is still ours to make.

Schopenhauer, a man who had journeyed extensively through the dark valleys of despair, supported the right to commit suicide: it is quite obvious that there is nothing in the world to which every man has a more unassailable title than to his own life and person'. However, he also spoke of the risk of being overwhelmed by suffering, acknowledging the difference between submitting to the dreadful torrent, letting despair overcome reason and killing oneself through an act of destruction, or stepping aside from the force of Will and choosing to end the nightmare by taking one's own life, fully awake to the nature of existence. With a clear head, mindful of the threads of connection and relationship, fully present in our authenticity, we can commit suicide with honour.

And in her book "Living with Honour", she makes the distinction between two kinds of people who may be thinking of taking their own lives:

Through my own experience with people who dance the precarious edge of suicide, Pagan and non-Pagan, and having meandered within that place myself, I perceive a very clear distinction: between those who do not want to live and those who want to die. The former are crying out for  help, desperately needing to re-establish the functionality of their life.  Without that help, finding themselves unable to make the suffering  disappear, they want to disappear from the suffering, and death appears to  offer that option- At the crucial moment, however, the soul clings to life.  Overwhelmed by fear, such people wish that they could let go, but they have not yet crossed the river. The latter have. Whether requesting help or acceptance from others, or just to be left in peace to walk their chosen road, their situation is totally different from the person who does not want to live, and needs to be acknowledged as such. Here we find authenticity, and so the possibility of honour.

That is a clear distinction in theory, and very true - I've heard of a young man, desperate for work, whose thoughts have turn in despair to suicide  - but how would that be put in practice to legislate for the latter but protect the former? I'm not convinced it can be easily done.

An analogy would be like distinguishing between messages you want to let through, and spam. As human beings, we can spot spam very easily, but for a computer, it is very difficult to provide formal procedures which are failsafe. And the same may be true of legislation.

I am concerned where this may all lead. And sometimes science fiction can cast a warning note for the present. One such example is in Isaac Asimov's novel "Pebble in the Sky". Set thousands of years in the future, it portrays a society where the pressure of population has led to a legislative policy of euthanasia, where the old have to die at sixty to make way for the young. That, of course, would solve our own demographic time-bomb in an instant. This extract is from when Arvardan, an archeologist from Sirius, is visiting Earth for the first time. Is it a vision of a society in which assisted suicide is at first beneficent, and then becomes cheaper than palliative care? Because whereas the Nazi ideology was driven by race, our own ideologies are driven by cost-effectiveness.

From the dark wine-purple of the extreme stratosphere, Earth presented a fabulous appearance. Beneath him the vast and misted land areas in sight (obscured here and there by the patches of sun-bright clouds) showed a desert orange. Behind them, slowly receding from the fleeing stratoliner, was the soft and fuzzy night line, within whose dark shadow there was the sparking of the radioactive areas.

His attention was drawn from the window by the laughter among the others. It seemed to centre about an elderly couple, comfortably stout and all smiles. Arvardan nudged his neighbour. 'What's going on?' His neighbour paused to say, 'They've been married forty years, and they're  making the Grand Tour.'

'The Grand Tour?'

'You know. All round the Earth.'

The elderly man, flushed with pleasure, was recounting in voluble fashion his experiences and impressions. His wife joined in periodically, with meticulous corrections involving completely unimportant points; these being given and taken in the best of humour. To all this the audience listened with the greatest attention, so that to Arvardan it seemed that Earthmen were as warm and human as any people in the Galaxy. And then someone asked, 'And when is it that you're scheduled for the  Sixty?'

'In about a month,' came the ready, cheerful answer. 'Sixteenth November.'

'Well,' said the questioner, 'I hope you have a nice day for it. My father reached his Sixty in a damned pouring rain. I've never seen one like it since. I was going with him-you know, a fellow likes company on a day like that-and he complained about the rain every step of the way. We had an open biwheel, you see, and we got soaked. "Listen," I said, "what are you complaining about, Dad? I've got to come back."'

There was a general howl of laughter which the anniversary couple were not backward in joining. Arvardan, however, plunged in horror as a distinct and uncomfortable suspicion entered his mind.
He said to the man sharing his seat, `This Sixty, this subject of conversation here-I take it they're referring to euthanasia. I mean, you're put out of the way when you reach your sixtieth birthday, aren't you?'

Arvardan's voice faded somewhat as his neighbour choked off the last of his chuckles to turn in his seat and favour the questioner with a long and suspicious stare. Finally he said, 'Well, what do you think he meant?'
Arvardan made an indefinite gesture with his hand and smiled rather foolishly. He had known of the custom, but only academically. Something in a book. Something discussed in a scientific paper. But it was now borne in upon him that it actually applied to living beings, that the men and women surrounding him could, by custom, live only to sixty.

The elderly man was talking again. 'She's coming with me,' he said, nodding toward his genial wife. 'She's not due for about three months after that, but there's no point in her waiting, she thinks, and we might as well go together. Isn't that it, Chubby?'

'Oh yes,' she said, and giggled rosily. 'Our children are all married and have homes of their own. I'd just be a bother to them. Besides, I couldn't enjoy the time anyway without the old fellow-so we'll just leave off together.'

Justice, Michael Sandel
Fatal Freedom: The Ethics and Politics of Suicide. Contributors: Thomas Szasz , 1999
R. Proctor, "Racial Hygiene", pp. 190, 193; and D. Pappas, "Recent Historical Perspectives Regarding Medical Euthanasia and Physician-Assisted Suicide", British Medical Bulletin 52 ( 1996): 390.
Living with Honour, Emma Restall-Orr
Pebble in the Sky, Isaac Asimov


1 comment:

Fern 24 said...

Excellent article - you could do better than a lot of the reporters currently out there. I do hope there is more discussion of this seminal topic at this level.