Article
Assisted dying
Death & life
4 min read

Behind the data: the social messages physician assisted suicide sends to the autistic

If intense suffering caused by society drives autistic people to seek assisted death, then society has failed.
A hand rest gently on another outstretched hand.
Alexander Grey on Unsplash.

Statistically speaking, autistic people are far more likely to die by suicide than non-autistic people. They are also, statistically speaking, far more likely to die by physician assisted suicide than non-autistic people, in countries where this is allowed.  

For example, in a study of 927 people who sought physician assisted suicide in the Netherlands (where this is legal) 39 of them were autistic. That’s about four per cent, but the prevalence of diagnosed autism in the Netherlands is only one to two per cent. The researchers go on to note that 21 per cent of these 39 people cite autism or intellectual disability as the “sole cause of suffering” that had prompted them to request assistance to die.  

I don’t like speaking statistically. For a start, 21 per cent of 39 people is 8.19 people, which raises obvious questions. A little digging reveals that what the researchers mean really is eight people. Eight people with eight unique stories that include an account of autistic suffering so intense that they asked for help to end their lives.  

But we do not have those stories, not really. Included in the report are carefully anonymised excerpts from the physicians’ notes, and this is the nearest that we can get.  

‘The patient suffered from his inability to participate in society [ … ] [He] was not able to live among people, because he was easily overstimulated. This made him isolated’ (2019 (22), male, 70s, ASD) 

‘The patient had felt unhappy since childhood and was persistently bullied because he was just a bit different from others [ … ] [He] longed for social contacts but was unable to connect with others. This reinforced his sense of loneliness. The consequences of his autism were unbearable for him [ … ] The prospect of having to live on in this way for years was an abomination to him and he could not bear it’ (2021 (26), male, 20s, ASD) 

The debate about legalising physician assisted suicide in the UK is ongoing, and the British Medical Association have provided a helpful guidance document which sets out the main arguments, both for and against, without making a recommendation either way. In the document, they observe that the reasons people ask for assisted suicide are predominantly personal and social, not clinical, and also that “laws send social messages.” I agree that laws do that, and I also think that those seeking assisted suicide send social messages too.  

For example, even just from these two tiny excerpts, I hear that a life worth living is one where people can participate in society and have social contacts, even if they are a “just a bit different from others.” It would be good to hear more. It would be good to sit down over a cup of coffee with each of these two men and ask them all my questions about their lived wisdom when it comes to autism.  

I could ask “2019 (22), male, 70s, ASD”: 

What causes the overstimulation - are there places where you don’t feel that?  

Can we create more such places for autistic people to socialise?  

And I could ask “2021 (26), male, 20s, ASD”:  

What makes you feel different?  

What kind of social contacts and connections do you think that you are looking for?  

But of course, I can’t do that, because these two men have been assisted to die.   

The word ‘welcome’ is striking to me here. What does it mean to welcome someone, not to merely include or tolerate, but to really welcome someone. 

When approached for comment, autistic theologian Claire Williams said:  

‘There is something of a personal and social tragedy reflected in these cases. If we understand that much of the difficulty that autistic people suffer is caused by society – as per the neurodiversity paradigm – then it is the case that these two nameless men were failed by society. They felt that their lives could not find a place in an unwelcoming world. It is, of course, their choice to end their lives but I do also think that God chose to start their lives and finds them to be infinitely valuable. They were both made in God’s image and reflect something of it. That they felt there isn’t a place for them that is suitable is a tragedy because society should do better to welcome them.’ 

The word ‘welcome’ is striking to me here. What does it mean to welcome someone, not to merely include or tolerate, but to really welcome someone, even if they seem ‘a little bit different from others’? Dr Léon van Ommen, another theologian who writes about autism, suggests that it is a matter of making oneself and one’s resources fully available to that person, to the point where they feel that you belong to them. This is not to promote relationships with unhealthy power dynamics, but to highlight that when a person feels truly welcomed by another, they feel the opposite of owing a debt or being a burden – they feel they are of value, that you would be lacking something without them.  

I feel we are lacking something without you, “2019 (22), male, 70s, ASD”. And I feel we are lacking something without you, “2021 (26), male, 20s, ASD”. Not to forget the 37 others who are a little like you. We can pause to reflect on the social messages that you have sent, what you are teaching all of us about what it means to live a “good” life. But I am sorry that you have all died now and we cannot hear more.   

Whether people in the UK should be able to choose physician assisted suicide, I, personally, am not yet sure. Like the BMA, I see and respect the very good arguments both for and against. But eight people have chosen physician assisted suicide due to autism or intellectual disability, and when it comes to the social messages that sends, I feel compelled to sit down and listen.  

Article
Change
Politics
Psychology
5 min read

How to be a wise diplomat about the election result

It’s not just American citizens weighing-up and trading-off.

Emerson writes on geopolitics. He is also a business executive and holds a doctorate in theology.

An ambassador presents credential to President Trump
President Trump accepts credentials from Indonesian ambassador M. Lutfi.
White House via Wikimedia Commons.

The American election result, whatever the case, is a landmark event in geopolitics. And here, it is unclear which result is better for the world in the long-term, given the ambiguous motives, interests and intentions of its main characters.  

Whereas the Biden Administration led by the Democrats has been fraught with war, the Trump Administration was comparatively peaceful, with breakthroughs such as the historic Abraham Accords. Yet, the rhetoric of President Trump is aggressive and divisive.  

Despite mainstream media assertions focused on the clear best choice in the election, a balanced perspective is necessary involving consideration of trade-offs between what the parties and their leaders each offer. This balance, however, is difficult to achieve as polarisation encourages retrenchment into simple views.  

As the American election approaches, it is worth considering what a diplomatic approach to an election transition might entail. Here we can look to the example of Henry Kissinger, whose diplomatic mindset is illustrated in Barry Gewen’s The Inevitability of Tragedy. Gewen eloquently illustrates the Kissingerian – even if often cold-hearted – approach to the consideration of trade-offs in diplomacy.  

Gewen traces the early-life experience of Kissinger, a German Jew forced to flee Nazi persecution, both serving in the US Army and attending Harvard. Unlike his American peers, Kissinger understood through personal experience that authoritarianism could rise through democratic means, Adolph Hitler the primary example.  

It is partly for this reason that Kissinger was willing as US Secretary of State to intervene in the affairs of foreign states to halt dictators emerging through democratic processes. The trade-off was here between respect of democratic process and the possibility of dictatorship, a trade-off which Americans without German-Nazi experience would never understand and which they saw as deeply unsettling.   

Kissinger is the archetypal diplomat. His example is worth reflecting on in the wake of the American elections. Kissinger approached geopolitics with little emotion, instead considering what course of action in a particular situation served as the least worst evil available.  

He engaged across a wide variety of networks, talking with individuals who would not speak with each other. And he maintained a considerable sense of calm throughout his career as both an actor and commentator, responding to events as they developed. 

An initial consideration in emerging from the American elections is that too much emotionality – amplified by political polarization – will expose politicians, diplomats and the public to risk. Emotion colours careful, strategic calculation of various scenarios and actions across potential scenarios.  

‘People constantly show you who they are; we are just too busy to notice,’ 

An effective diplomatic (or strategist) will carefully consider what might happen and think through potential steps in case these realities actually transpire, while recognising that too much anticipation risks cascading into fantasy. Too much emotion impedes this careful process of reflection and deliberation as part of the development of strategy.  

A second element of effective diplomacy and strategy is to consider people as they are, rather than rely on superficial descriptions in the media, biased second-hand accounts or who or what one hopes another person is. People’s motives, intentions and interests are not easily discernible at first glance, instead requiring careful probing and questioning.

At the same time, there are few more accurate sayings than ‘People constantly show you who they are; we are just too busy to notice,’ conveying that counterparts are always providing information as to who they are, few careful or disciplined enough to mask their real thinking.  

An effective diplomat might consider the early upbringing – much like that of Kissinger – that shapes a person’s character and behaviour, if not their worldview informing action.  

Consider Donald J. Trump, learning right from wrong on the streets of New York City via the mentorship of lawyer Roy Cohn, who served as Chief Counsel to Joseph McCarthy while McCarthy prosecuted potential American communist sympathisers.  

Cohn’s rules of life, work and play were as follows (these summarized by a friend well-acquainted with Cohn and his colleagues): ‘One, attack, attack, attack! Two, deny everything! Three, always claim victory!’ The logic of these three rules of life are readily understandable when considering the harsh New York realities within which Cohn and later Trump operated.  

These considerations are overlooked, however, amid the onslaught of media which fails to consider what really shapes the character of a man or woman.  

Curiosity, a critical mindset and self-restraint in the face of the human temptation to reach rapid and satisfying answers are here necessary, as part of figuring out what exactly is driving action.

A wise diplomat would pay particular attention to these pivotal factors – such as the influence of a long-standing mentor or advisor – as they might manifest in the present. This requires an intellectually honest and serious consideration of the worldview that shapes a counterpart, rather than considering superficial media commentary.  

Third, a wise diplomat will maintain relations across a wide variety of networks, understanding that it is fine to talk with two or multiple individuals whose own relations are fractured (in fact, these strains in relations can be beneficial within diplomacy, the diplomat in this case able to play broker as he or she needs or wishes).  

The maintenance of broad networks is vital, because this enables action under a wide array of potential circumstances, understanding that anything can happen (we are here reminded of Harold MacMillan’s saying “Events, dear boy, events!”) And a key lesson in diplomacy and in the cultivation of strategy is that, once crises unfold, it is the preparatory work in developing networks and alliances that counts; little new network-formation is possible afterwards.  

The previous two points suggest that a wise diplomat will not pay too much attention to what is in the media, but will instead consider their own learning gleaned through in-person interactions with others, as well as the perspective of their most trusted contacts. Curiosity, a critical mindset and self-restraint in the face of the human temptation to reach rapid and satisfying answers are here necessary, as part of figuring out what exactly is driving action, and what can in turn be done to shape action in accordance with interests.  

Finally, an effective diplomat will not try to play God, serving as the arbiter of right or wrong, adopting instead a more considered approach anticipating and responding to circumstances as they gradually or quickly evolve. Effective strategy requires an aloof approach (caring – but not caring too much), removing the self from a given situation so as not to allow natural human vices such as presumptiveness, arrogance or short-term self-interest to affect judgment.  

And the American election bring with them a number of trade-offs, these to be weighed carefully by American citizens, as well as by diplomats and strategists in other countries. These trade-offs will be considered most effectively if approached with calmness – the aloof, even if cold-hearted, approach personified by Henry Kissinger. 

In an age of catastrophising, emphasing emotion, it is easy to descend rapidly into despair, rather than consider action from a long-term perspective. Diplomacy and strategy require the latter, which will be a key to success for those who emerge effective in advancing their interests in the wake of the American elections.