Assisted Dying logic makes perfect sense but imposes a dreadful dilemma

The case for assisted dying appeals to choice and autonomy, yet not all choices are good. It means vast numbers of people will face a terrible choice as their life nears its end.

Graham Tomlin

Graham is the Director of the Centre for Cultural Witness and a former Bishop of Kensington.

A black and white picture shows a woman head and shoulders, she is looking up and to the side in an unsure way.

Anastasiya Badun on Unsplash.

Two broad cultural trends have led us to our current debate over assisted suicide.

One is the way consumer choice has come to be seen as the engine of successful economies. Emerging from Adam Smith’s theories of rational choice based on self-interest, given a boost by Reaganomics and Thatcherite thinking in the 1990s, the provision of a range of choice to the consumer is usually argued, with some logic, as key to the growth of western economies and the expansion of freedom.

The other is the notion of individual autonomy. Articulated especially in the past by figures such as John Locke and John Stuart Mill, the idea that individuals should be free to choose to dispose of their property, their time and their talents as they choose, as long as they don’t harm anyone else, has become standard moral fare in the modern world.

Put these two together, and the logic of assisted dying makes perfect sense. What can be wrong with offering someone a choice? Why should the state restrict individual freedom to end your life in the way you might decide to do so?

Yet expanding choice is not always good. Forcing an employee to choose between betraying a colleague or losing their job is not a fair choice. There are some choices that are unfair to impose upon people.

Assisted dying will lead us to this kind of choice. Imagine a woman in her eighties, living in a home which is her main financial asset, and which she hopes to leave to her children when she dies. She contracts Parkinson’s or dementia, which will not kill her for some time, but will severely limit her ability to live independently (and remember about of third of the UK population will need some kind of longer-term care assistance as we get older). At present, her only options are to be cared for by her children, or to sell her house to pay for professional care.

With the assisted suicide bill, a third option comes into play – to end it all early and save the family the hassle - and the money. If the bill passes, numerous elderly people will be faced with an awful dilemma. Do I stay alive, watch the kids’ inheritance disappear in care costs, or land myself on them for years, restricting their freedom by needing to care for me? Or do I call up the man with the tablets to finish it soon? Do I have a moral duty to end it all? At present, that is not a choice any old person has to make. If the bill passes, it will be one faced by numerous elderly, or disabled people across the country.

Even though the idea may have Christian roots, you don’t have to be religious to believe the vulnerable need to be protected

Of course, supporters of the bill will say that the proposed plan only covers those who will die within six months, suffering from an “inevitably progressive condition which cannot be reversed by treatment.” Yet do we really think it will stay this way? Evidence from most other countries that have taken this route suggests that once the train leaves the station, the journey doesn’t end at the first stop - it usually carries on to the next. And the next. So, in Canada, a bill that initially allowed for something similar was changed within five years to simply requiring the patient to state they lived with an intolerable condition. From this year, there is a proposal on the table that says a doctor’s note saying you have a mental illness is enough. In the same time frame, 1,000 deaths by assisted dying in the first year has become 10,000 within five years, accounting for around 1 in 20 of all deaths in Canada right now. Some MPs in the UK are already arguing for a bill based on ‘unbearable suffering’ as the criterion. Once the train starts, there is no stopping it. The logic of individual choice and personal autonomy leads inexorably in that direction.

Of course, some people face severe pain and distress as they die, and everything within us cries out to relieve their suffering. Yet the question is what kind of society do we want to become? One where we deem some lives worth living and others not? Where we make numerous elderly people feel a burden to their families and feel a responsibility to die? In Oregon, where Assisted Dying is legal, almost half of those who opted for assisted dying cited fear of being a burden as a factor in their decision. Or would we prefer one where the common good is ultimately more important than individual choice, and where to protect the vulnerable, we find other ways to manage end of life pain, putting resources into developing palliative care and supporting families with dependent members – none of which will happen if the option of assisted dying is available.

Even though the idea may have Christian roots, you don’t have to be religious to believe the vulnerable need to be protected. Changing the law might seem a small step. After all, doctors routinely administer higher doses of morphine which alleviate pain and allow a natural death to take its course. Yet that is a humane and compassionate step to take. To confront numerous people, elderly, disabled and sick with a dreadful dilemma is one we should not impose upon them.

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War & peace

25 September 2024

6 min read

How Ukraine reckons with its reality

From Kyiv's coffee shops to the front line.

Mark Meynell

Mark Meynell is the author and minister.

A woman squats and touches a war memorial

War memorial in Bucha.

How on earth it came up I have no idea, but I vividly remember chatting with my grandmother about the ‘Phoney War’ of 1939. I can’t have been much older than 10. It’s not that I was especially inquisitive about history, nor that I had the presence of mind to ask for stories from her extraordinary life. How I wish I’d done that with all four of my grandparents. But my hunch is that it was prompted by sitting in the garden on a glorious summer’s day. We were probably shelling peas or peeling potatoes or something—she always got people staying to do jobs.

She was reminiscing about how weird those months in mid-1939 were, in particular remembering how lovely the summer had been, far brighter and drier than normal. Even after the Nazi invasion of Poland on 1st September (thus triggering Britain and France to declare war two days later), the weather remained good. A sense of war’s inevitability had hovered throughout 1939, so even after Chamberlain’s famous ‘final note’ was rejected, nothing much changed. At least, not for ordinary Britons. Life went on. It would take many months before the conflict came all too close to home.

I couldn’t help but think about this during my visit to Kyiv and Lviv earlier this month. The difference, of course, is that there was nothing phoney about Russia’s 2022 invasion or the horrors inflicted on eastern Ukraine since the 2014 annexation of Crimea. But for the majority, routines continued uninterrupted. As they must.

For example, assuming the worst, I had contacted several Ukrainian friends offering to bring any scarce or unavailable items from Britain. No one took me up on it; it was unnecessary, they all said. After wandering through both cities, it was obvious why. Although trade will undoubtedly have been slower than before the war, shops seemed well stocked with all the necessities and not a few luxuries.

Then on my final morning, I was quietly sipping a cappuccino in Lviv’s historic Rynok Square when the air-raid sirens suddenly cranked up into their now familiar whine. Being kept awake by Kyiv’s sirens had been a new experience for me (a mark of our Western privilege that we have avoided all-out war on our soil for decades). But this was my first daytime alert. It was even accompanied by booming Ukrainian announcements, although the advice was inevitably lost on me. As it was on all around me, who seemed assiduously to ignore it. The few mid-morning pedestrians—few tourists come here— maintained their ambling pace unchanged; the taciturn waiter patiently took orders at the next table; a middle-aged businessman on the square continued his negotiations on the phone while gesticulating with his briefcase. So naturally, I kept sipping.

This was not because the sirens cried wolf. Just 10 days before my visit, Lviv had suffered one of the worst air attacks of the war, with 7 killed, over 60 injured, as well as the destruction of schools and historic buildings. Moreover, I met a friend for lunch an hour later who told me that some man-sized drones had attacked his side of Lviv and he saw one or two shot down. So it was all real enough. What was everyone thinking?

Those who keep going amid a siren’s whine are not perhaps ignoring it but taking calculated risks in their perseverance.

Ignoring reality

T. S. Eliot famously observed that "Humankind cannot bear very much reality." So perhaps that was what was going on here. After two and a half years of war, I can quite imagine exhaustion and resignation to what was going on. So it just gets ignored. Ordinary life must go on. After all, only a small proportion of the population is actively engaged in the war; the rest, if they haven’t already left, must try to keep calm and carry on. In fact, men aged between 18-60 are unable to leave at all without the necessary papers and these are hard to come by. Perhaps the only way, then, is to avoid thinking altogether. On a beautiful day, once autumn has begun to temper Ukraine’s oppressive summer heat, sustaining the illusion is simple. Life carries on.

Of course, it can’t last. Every single person I spoke to had family or friends at the front; some had already been killed. The destruction caused by air raids brought a distant conflict onto people’s doorsteps. However, it was driving through the pleasant Kyiv suburbs of Bucha and Irpin, both of which I had previously visited several times, that reinforced the impossibility of ignoring reality. Bucha is now emblematic of the invasions very worst atrocities, from when Russian forces had Kyiv almost entirely surrounded before being pushed east. Locals were rounded up and slaughtered, with the bodies of several hundred civilians later found to have died from bullet wounds rather than shrapnel. But as we drove through, it was impossible to conceive of those horrors. Apart from anything, the weather was so lovely. Atrocities don’t occur on beautiful days… or in lovely places… surely?

Persevering amid reality

What impressed me most in those areas was the speed of the rebuilding work. Entire shopping malls and neighbourhoods had been razed. But after only twelve months or so, a memorial to Bucha’s 500 dead had already been erected. As we drove through, major construction projects were underway, with multiple cranes towering over rapidly rising apartment blocks and retail parks.

These are not signs of reality ignored but faced. These are signs of gritted hope. So it struck me that those who keep going amid a siren’s whine are not perhaps ignoring it but taking calculated risks in their perseverance. Just as it is unwise, if not impossible, to live on a permanent adrenaline rush, so one cannot always exist in flight or fight mode indefinitely. It is simply that in wartime, risk thresholds change. Human beings are resilient and adaptable. They endure the most extraordinary setbacks and conditions.

So, to be with Ukrainian friends in my limited, deficient expression of solidarity, has been inspiring. No one I met had any illusions about the realities of Ukraine’s current plight (especially with a harsh winter looming as Russia systematically destroys power stations). But still they persevere.

Seeking deeper perspectives of reality

However, Eliot did not primarily refer to bearing the reality of the mundane. As the novelist Jeanette Winterson explained, Eliot was identifying how little twentieth century society (that of his Waste Land in particular) could bear of spiritual reality. He meant the phenomenon of resistance to a journey towards God or of facing themselves as they stand before God.

However, the horrors of invasion and the nightly anxieties of air raids have put paid to all that. One friend I was glad to see again is Andriy, previously a fairly well-known Ukrainian journalist and now a church pastor. He regularly goes to the frontline as an unofficial chaplain, visiting troops in their camps and the injured in hospital. He was unequivocal. Before the war they would undoubtedly have been shrugged off. But now, he has not met a single soldier who is uninterested in the things of God and eternity. War has forced them to face their mortality and Andriy has found that most are desperate to talk about little else. These things matter. Even on a beautiful, bright, early autumnal day.