Article
Assisted dying
Care
Comment
Death & life
Suffering
5 min read

Why end of life agony is not a good reason to allow death on demand

Assisted dying and the unintended consequences of compassion.

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

A open hand hold a pill.
Towfiqu Barbhuiya on Unsplash.

Those advocating Assisted Dying really have only one strong argument on their side – the argument from compassion. People who have seen relatives dying in extreme pain and discomfort understandably want to avoid that scenario. Surely the best way is to allow assisted dying as an early way out for such people to avoid the agony that such a death involves?  

Now it’s a powerful argument. To be honest I can’t say what I would feel if I faced such a death, or if I had to watch a loved one go through such an ordeal. All the same, there are good reasons to hold back from legalising assisted dying even in the face of distress at the prospect of enduring or having to watch a painful and agonising death.  

In any legislation, you have to bear in mind unintended consequences. A law may benefit one particular group, but have knock-on effects for another group, or wider social implications that are profoundly harmful. Few laws benefit everyone, so lawmakers have to make difficult decisions balancing the rights and benefits of different groups of people. 

It feels odd to be citing percentages and numbers faced with something so elemental and personal and death and suffering, but it is estimated that around two per cent of us will die in extreme pain and discomfort. Add in the 'safeguards' this bill proposes (a person must be suffering from a terminal disease with fewer than six months to live, capable of making such a decision, with two doctors and a judge to approve it) and the number of people this directly affects becomes really quite small. Much as we all sympathise and feel the force of stories of agonising suffering - and of course, every individual matters - to put it bluntly, is it right to entertain the knock-on effects on other groups in society and to make such a fundamental shift in our moral landscape, for the sake of the small number of us who will face this dreadful prospect? Reading the personal stories of those who have endured extreme pain as they approached death, or those who have to watch over ones do so is heart-rending - yet are they enough on their own to sanction a change to the law? 

Much has been made of the subtle pressure put upon elderly or disabled people to end it all, to stop being a burden on others. I have argued elsewhere on Seen and Unseen that that numerous elderly people will feel a moral obligation to safeguard the family inheritance by choosing an early death rather than spend the family fortune on end of life care, or turning their kids into carers for their elderly parents. Individual choice for those who face end of life pain unintentionally  lands an unenviable and unfair choice on many more vulnerable people in our society. Giles Fraser describes the indirect pressure well: 

“You can say “think of the children” with the tiniest inflection of the voice, make the subtlest of reference to money worries. We communicate with each other, often most powerfully, through almost imperceptible gestures of body language and facial expression. No legal safeguard on earth can detect such subliminal messaging.” 

There is also plenty of testimony that suggests that even with constant pain, life is still worth living. Michelle Anna-Moffatt writes movingly  of her brush with assisted suicide and why she pulled back from it, despite living life in constant pain.  

Once we have blurred the line between a carer offering a drink to relieve thirst and effectively killing them, a moral line has been crossed that should make us shudder. 

Despite the safeguards mentioned above, the move towards death on the NHS is bound to lead to a slippery slope – extending the right to die to wider groups with lesser obvious needs. As I wrote in The Times recently, given the grounds on which the case for change is being made – the priority of individual choice – there are no logical grounds for denying the right to die of anyone who chooses that option, regardless of their reasons. If a teenager going through a bout of depression, or a homeless person who cannot see a way out of their situation chooses to end it all, and their choice is absolute, on what grounds could we stop them? Once we have based our ethics on this territory, the slippery slope is not just likely, it is inevitable.  

Then there is the radical shift to our moral landscape. A disabled campaigner argues that asking for someone to help her to die “is no different for me than asking my caregiver to help me on the toilet, or to give me a shower, or a drink, or to help me to eat.” Sorry - but it is different, and we know it. Once we have blurred the line between a carer offering a drink to relieve thirst and effectively killing them, a moral line has been crossed that should make us shudder.  

In Canada, many doctors refuse, or don’t have time to administer the fatal dose so companies have sprung up, offering ‘medical professionals’ to come round with the syringe to finish you off. In other words, companies make money out of killing people. It is the commodification of death. When we have got to that point, you know we have wandered from the path somewhere.  

You would have to be stony-hearted indeed not to feel the force of the argument to avoid pain-filled deaths. Yet is a change to benefit such people worth the radical shift of moral value, the knock-on effects on vulnerable people who will come under pressure to die before their time, the move towards death on demand?  

Surely there are better ways to approach this? Doctors can decide to cease treatment to enable a natural death to take its course, or increase painkillers that will may hasten death - that is humane and falls on the right side of the line of treatment as it is done primarily to relieve pain, not to kill. Christian faith does not argue that life is to be preserved at any cost – our belief in martyrdom gives the lie to that. More importantly, a renewed effort to invest in palliative care and improved anaesthetics will surely reduce such deaths in the longer term. These approaches are surely much wiser and less impactful on the large numbers of vulnerable people in our society than the drastic step of legalising killing on the NHS. 

Article
Comment
Leading
Psychology
Theatre
6 min read

Are you a narcissist?

We all have a little bit of narcissism in us – the question is whether we’re a Moses or an Iago
An Elizabethan man holds a dagger up while grinning.
Kenneth Brannagh's Iago in the 1995 film of Othello.
Sony Pictures.

Is everyone a narcissist these days? It sometimes feels so. Google Trends data shows an eleven-fold increase in searches for “narcissism” between 2010 and 2023, and the term has become a social media buzzword. Online quizzes asking, “Am I a narcissist?” are everywhere, offering dubious self-diagnosis at the click of a button. Genuine Narcissistic Personality Disorder, however, is complex and painful – especially for those in close relationships with someone who cannot acknowledge the harm that they are able to cause or feel any sense of remorse. Narcissus, in Greek mythology, was a handsome young man who was cursed to fall in love with his own reflection, but it was not until the early 20th century that the term “narcissism” was then picked up by the emerging field of psychoanalysis. Initially, Sigmund Freud adopted it in a non-pejorative way to describe the stage in child development when an infant is aware only of their own need for love and attention. Eventually, as that infant grows into a child it begins to experiment with showing others love and attention, and if surrounded by the right relationships, the child learns that love can be reciprocal – a back-and-forth pattern of give and take. Freud wrote:  

“Loving, then, contributes to the lowering of self‑regard. Having one’s love returned, however, restores one’s self‑regard and replenishes one’s narcissism.”  

In its healthiest form, narcissism reflects a positive sense of self – a recognition of one’s own needs and a reasonable desire for them to be met, whilst also knowing that we must give of ourselves, again within reason, to meet the needs of others. In this sense, yes, we are all a little bit of a narcissist. It is only occasionally, most commonly when the early bond between a child and their caregivers is inconsistent or unstable, that this self-focus can become problematically distorted, sometimes leading to a personality disorder. For such a person, a constant hunger for attention and affirmation, often combined with a lack of empathy or a tendency to use empathy as a means to manipulate others, leads to a life of take-take-take; one which can cause significant harm to others and ultimately to themselves.  

Estimates for Narcissistic Personality Disorder are that it affects about one to two per cent of the population, a number which is intriguingly high. The unfortunate news is that true Narcissistic Personality Disorder is notoriously difficult to treat, precisely because key tenets of the condition include a lack of self-awareness and an overinflated sense of self belief. The classic response of the one with Narcissistic Personality Disorder is, of course, “How dare my therapist say that I am a narcissist? They must be the problem!” 

However, much more prevalent are what might be called “sub-clinical narcissists” – people who act selfishly, arrogantly, or manipulatively, influencing others to conform to their desires. We all know one or more of those – sometimes we meet one when we look in the mirror. Whilst this may make us feel pretty rotten, whether we are the giver or the receiver of such treatment, it does not always warrant a clinical intervention. Even so, it can still be extremely difficult to process how and why human narcissistic tendencies are able to cause others so much pain. If, as Freud proposes, a certain degree of narcissism is hardwired into human nature, what can we do about its tendency to evil?  

In Shakespeare’s tragedy Othello, the character of Iago is a master manipulator who displays all the cold-hearted indifference of a true narcissist. Early in Act 1 he expresses his indignation that he has been passed over for promotion. Firmly convinced of his own superiority, he slyly boasts that he will play a false self to Othello, feigning loyalty for his own ends and stating: “I am not what I am.”  

These words are a clever and rather chilling inversion of a famous phrase from the Bible. In the story of the Exodus, God meets with Moses in the form of a burning bush, and when Moses asks for the name of God a voice replies: “I am what I am.” As Moses stands before God, barefoot and awestruck, he hears that enigmatic statement and is forced to confront the question of who he truly is – an ashamed murderer, a fugitive, a short-tempered man of slow speech but hasty acts. Moses acknowledges all these awkward truths about himself and declares himself wholly unfit to be called by God as a leader. Yet God uses Moses anyway, and at the end of his life, Moses dies a celebrated hero – a deliverer who is mourned by all his people.  

Not so Iago. As the tale of Othello draws to its tragic close, Iago is wounded, arrested and escorted from the stage. The audience knows that he has been condemned to execution, but unlike pretty much every other character in that fateful final scene, Iago’s death does not take place onstage. He is simply removed, dismissed from everybody’s notice – a narcissist’s worst nightmare.  

One can see the crucial difference between Moses and Iago – whilst Moses is concerned that his own flawed nature makes him unfit to be become a great leader, Iago is driven to grasp at leadership by a belief in his own grandiosity and acts vengefully when passed over. Right to the end, Iago expresses not one word of self-doubt or regret for his actions. Indeed, he refuses to account for himself at all. “Demand me nothing,” he says at the close; “What you know, you know.” 

Seemingly, the problem of narcissism’s tendency towards evil lies not in actions, but in methods of self-evaluation. While we all make regrettable mistakes, and sometimes it can be hard to judge the difference between unreasonable selfishness and reasonable self-preservation, the true narcissist is afraid to explain themselves, unwilling to bear the judgement of outside scrutiny. The narcissist will look only in the mirror.  

But whereas a mirror only reflects light, a burning bush produces it. In the end, the resources of the Christian tradition do not simply diagnose our narcissism, they offer us a way through it. They offer an outside perspective from which we can truly evaluate our own actions – a light that shines through the mirror.  

If you have ever clicked the link for the online quiz, or been tempted to, then that is an encouraging sign of willingness to be open to outside scrutiny. But of all things, would we really want to trust only human voices, especially the unknown and unknowable voices of the internet, as an authoritative arbiter? If narcissism is so inherent to human nature, it logically takes something higher and brighter than our fellow human beings to really bring it into the light. But in any case, you can save yourself the time of completing that dubious online diagnostic quiz since the whole enterprise can be summed up in just one question:  

Have you ever wondered if you have Narcissistic Personality Disorder? If the answer is yes, you probably do not. So demand yourself nothing, what you know you know.  

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