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.

Essay

Comment

Politics

War & peace

30 August 2024

7 min read

What it takes to travel from ceasefire to peace

With Bertie Ahern, Kevin Hargaden explores an unlikely journey.

Kevin Hargaden

Kevin is a social theologian studying ethics and economics.

A TV graphic labelled 'ceasefire' lists bullet points

How the news was reported in 1994.

RTE.

August 31st marks the thirtieth anniversary of the historic IRA ceasefire. After decades of effective civil war in Northern Ireland, on this day in 1994, the nationalist paramilitary force announced “the complete cessation of military operations” and declared that they looked forward to a just and lasting settlement with “a spirit of determination and confidence”. While not without interruptions, that ceasefire has led to more than just a cessation of conflict. While still fragile, Northern Ireland has a functioning parliament, closer ties than ever with the Republic of Ireland, and the dissident threat – still present – is marginalised.

One of the remarkable elements of that day at the end of summer 1994 was how unlikely it seemed just a year before. The intensity of “The Troubles”, as the conflict is called, varied over the years but a series of atrocities in 1993 left an already traumatised population in a state of desperation. In March of that year, the IRA exploded bombs in the market town of Warrington. This callous attack clearly sought to strike terror into the hearts of English civilians – people who had no real connection to whatever injustices had been inflicted on the nationalist communities of Northern Ireland. Two children, Jonathan Ball and Tim Parry, were killed and almost sixty people were injured.

Another IRA bombing, in October of that year, caused outrage and disgust across Britain and Ireland. Again, hitting a civilian population, the Shankill Road bombing had been intended to target Loyalist leaders but ended up devastating a fishmongers. Ten people were killed.

Brutal responses followed from the Loyalist side. Five days after the Warrington bomb, the Ulster Defence Association murdered four construction workers and a week after the Shankill Road bombing the same organisation descended upon a Halloween party held in a bar in rural Derry, killing 8 people and leaving 12 with dire injuries.

Along with many other atrocities, the year ended with most people on the island dreading another generation of pointless violence. But below the surface, intense grassroots efforts and official negotiations were beginning to bear fruit.

The viewer is bound to see the peace process that emerged as a kind of miracle. How could forgiveness reign in the face of such savagery? How can a society build a future out of the wreckage of such a past?

This story is told vividly in the BBC documentary Once Upon a Time in Northern Ireland. Spread across five episodes, the show does not intend to offer an encyclopaedic analysis of how the Troubles emerged. Instead, it focusses on the experiences of the ordinary people embroiled – whether intentionally or not – in the conflict. The effect is deeply moving, even overwhelming at times.

So often, our culture engages with war and conflict as abstract concepts to be debated. Even in the context of active, live battle, we are typically presented with “talking heads” offering expert opinion. But in Once Upon a Time in Northern Ireland you get to hear from the people who planned the attack, or who conducted the arrests, or who were just trying to buy some fish for dinner when a bomb exploded in the shop. This direct testimony from those were caught up in the Troubles allows the viewer a visceral understanding of what is at stake, without having to understand the centuries of colonialism, conflict, and oppression that generated the civil war. That human trauma, that is glimpsed in great poetry or felt as an echo in a folk song is captured in this series directed by the award-winning James Bluemel.

There is a stubborn misunderstanding that the Northern Irish conflict was “Catholics against Protestants”. Once Upon a Time in Northern Ireland disposes of this myth, if in part by showing how those two groups were never distinct. It was a complex conflict fuelled by land and ideology, traumatic history and conflicting cultures. Religion was a component of course, but expressed through the lens of sectarianism, the almost racial animosity that grew up between the opposing tribes, the marker that differentiated them. When one man, named Michael, is shown tending gently to the racing pigeons he keeps, the effect is incongruous in the extreme because his story is one of unimaginable despair.

He was raised Catholic; his mother was Protestant. She had ten children. And one day, two women showed up at their home and took his mother away and she never returned. The IRA killed her. It wasn’t because of her views on Papal primacy or biblical authority. Something even more absurd and terrifying was at work here, a hatred that at some point did not even need justification.

The consequences of each callous and brutal attack rippled outwards, affecting not just the victims but their loved ones and then their community. By the end of the five episodes the viewer is bound to see the peace process that emerged as a kind of miracle. How could forgiveness reign in the face of such savagery? How can a society build a future out of the wreckage of such a past?

That was their baseline assumption throughout – no one at the table was “happy with the fact that thousands of people had been killed and maimed.”

This exposes one of the limitations of the format of the series. By placing the perspectives of ordinary people at the centre of the narrative, profound truths are exposed. But the mundane details of how the peace process developed – why it was the IRA agreed to a ceasefire and how things developed from there to the Good Friday Agreement and the years since – are unaddressed. Perhaps a sequel is required where the politicians and diplomats who made that possible are given the chance to tell that story?

One of the undoubted architects of peace in Northern Ireland is Bertie Ahern, who was the Taoiseach (Prime Minister) of the Republic of Ireland from 1997-2008. I sat down with him to do just that – to hear his recollections of the process that brought about peace. Since his youth, he had always taken a keen interest in Northern Ireland – “I took a particular interest in the Civil Rights movement when we were in school; that was before it got into the violence.” Raised in a Republican family just north of Dublin city centre, once the Troubles began, it was hard “not to be subsumed into everything that was happening on the island.” As he became a political leader, he was keenly aware of how the violent conflict exacerbated underlying problems – even his vision for economic regeneration in the Republic was blocked because “part of the reason that it was difficult to get investment and to get people to come here was the Troubles.”

As he remembers the process, it would be misleading to think it popped out of nowhere in the 1990s. There had been attempts through the years, notably with the Sunningdale Agreement in 1973 and the Anglo-Irish Agreement of 1985, but also through less publicised conversations between the peacemakers and paramilitaries, like the conversations led by Fr Gerry Reynolds at Clonard Monastery – which began to generate movement. He attributes the ceasefire to the Downing Street Declaration that was orchestrated by the British Prime-minister John Major and Ahern’s then boss, Taoiseach Albert Reynolds, on December 15, 1993. That showed a serious willingness from London to engage, and the 1994 ceasefire was the result.

But when the ceasefire broke down in 1996, all that work dissipated. “That was a disaster, really.” With the election of Tony Blair, Ahern suggested they “take it up again”. With a concerted focus – “I was nearly doing the Northern stuff full-time” – progress was restored. He remembers that the negotiations involved ten different parties, including the British and Irish governments and the active and influential participation from the American government and “went on practically non-stop from September 1997 to Good Friday 1998.” The strategy sought to be as inclusive as possible – “we would try and get everyone in” – and “to be as comprehensive on the issues” as possible, so that no issue was off the table. Patience and resilience were central. Although there was “a huge amount of conversation and talks up to Christmas, it didn’t really gather momentum until February.”

With the “totality of all the issues out on the table”, the dialogues began to bear fruit. How draconian legislation might be rolled back, how paramilitary prisoners could be released, how demilitarization would proceed and how the police could be reformed. He remembers that negotiations on that question – the reform of the corrupt Royal Ulster Constabulary police force – went on deep into the Good Friday night, April 10th. When an obstacle appeared, the London and Dublin governments reminded people of the goal of stopping the violence. That was their baseline assumption throughout – no one at the table was “happy with the fact that thousands of people had been killed and maimed.” The second guiding principle was that “you have to try to treat everyone with dignity, regardless of what views they have.” And slowly, rapport was built up between people who had been combatants.

When the agreement was finalised, a kind of euphoria followed. “That week we were just at it night and day; we had been at it night and day since March.” But the celebrations, as intense as they were, did not linger. The agreement had to be passed by popular referendum in both the North and the Republic of Ireland. And the work continued even after that. Ahern notes that it took years to achieve an agreement “and then another ten years to implement it”.

But the effort was undeniably worth it. “I think the big success of the Good Friday Agreement was that the Troubles have by and large ended.” And the story of how that happens traces back to a cassette tape released in August 1994 announcing the IRA ceasefire.