One of the first concepts new students of philosophy are introduced to is Isaiah Berlin’s famous distinction between “freedom to” and “freedom from”: an illustration of the fact that giving more rights to one individual can result in taking away another person’s freedoms, thereby detracting from the sum total of liberty in the world. Looking at just one side of the “liberty ledger” risks a very misleading picture, particularly when the arguments in favour of a new “right” are very powerful, as they are in the case of legalising medically-assisted suicide, often referred to as assisted dying.
Assisted dying has been pushed to the top of the agenda since Kim Leadbeater announced she would be introducing a private members’ bill to legalise it. And the arguments in favour are very strong: if someone has a debilitating illness that is causing them significant pain and indignity, and they have the capacity to decide, surely it is inhumane to deny them medical assistance to put an end to their suffering through the administration of lethal drugs?
A decade ago, my answer would have been a firm yes. But the more I’ve thought about legalising medically-assisted suicide in the past couple of years, the more existential doubts have crept in, as I’ve given more consideration to the impacts it could have on other people’s freedoms.
Once medically-assisted suicide is legalised, how do you prevent people who might not otherwise choose it from being coerced, or just feeling pressurised? Coercive, controlling relationships are sadly common, not just between intimate partners, but also within families, and they affect women more. People with a terminal diagnosis might feel pressured into ending their lives sooner than they want to, perhaps as a result of quite subtle signals from their extended families, who might not have the capacity to care for them. Perhaps their dependents worry about inheritances getting eroded as a result of end-of-life care costs, or perhaps the diagnosed themselves worry about being a burden to their loved ones – physically, emotionally and financially.
Then there’s the question of how to establish whether someone has the capacity to choose a medically-assisted suicide. Depression is a common response to a terminal diagnosis, but it often alleviates over time. If someone is depressed, do they have the capacity to consent, and if so, how do we measure it? If mental health symptoms don’t disqualify someone from assisted dying, what’s the line between that and suicide prevention?
There are also risks inherent in the patient-doctor relationship, which is one reason the Association for Palliative Medicine is opposed to it. When social care and palliative care are so rationed in society, some individuals might feel this leaves them with little choice. What is to stop some medical professionals letting slip their own views about whether an individual in their care should go on living? In Canada, where assisted dying has been legalised, there are cases in which individuals have testified to the Canadian parliament that nurses tried to coerce them into an assisted death. Even if rare, the fear that medics might try and persuade people into a medically-assisted death could seriously undermine trust in the healthcare system.
There’s no taking back a state-sanctioned wrongful death
The response from proponents of reform is to point to two safeguards. The first is that someone’s capacity to choose would need sign-off from medical professionals and/or judges. But neither medical professionals nor judges are at all well-equipped to certify people’s capacity to freely choose a medically-assisted death, or to be certain their decision has in no way been influenced by coercive control. We know judges can get issues of coercive control very wrong in the family courts. And there’s no taking back a state-sanctioned wrongful death.
The second safeguard is the proposed tight parameters for assisted dying in the UK: limited to people with a terminal diagnosis of six or twelve months to live. The issue is that there is no strict definition of a “terminal diagnosis” – in Oregon in the US this has included people with arthritis and anorexia – and palliative care doctors say it is impossible to accurately predict how long someone has left to live (unless it’s clear they will only survive a matter of days). What looks like a tight definition on paper would in practice be open to wide interpretation by doctors.
Beyond that, there’s the risk of a slippery slope even if Parliament does not expand the eligibility parameters. Some expert lawyers believe that limited eligibility could be challenged in the courts as discriminatory under the European Convention of Human Rights; if successful, the courts could end up extending medically-assisted suicide to non-terminal conditions, or to voluntary euthanasia for those who lack the capacity to self-administer lethal drugs.
Some disability activists also argue that establishing the principle that people can choose to end their lives with state assistance is to lead to a shift in popular attitudes that some people ought to do so. It is, frankly, hard not to acknowledge the real risks of this in what is still a profoundly disablist society.
This is why, despite being sympathetic to the argument that it is inhumane to deny someone with a degenerative condition like motor neurone disease the right to end their life before it reaches a stage they feel is intolerable, I can’t support the legalisation of medically-assisted suicide. I just don’t see how it is possible to change the law in a way that doesn’t put others seriously at risk.
Sonia Sodha is chief leader writer at the Observer and a Guardian/Observer columnist
