During a public hearing by the German ethics committee on euthanasia, Prof. Gethmann presented two ethical questions outlining the topic:[1] First, ‘Is suicide morally permissible?’ Second, ‘Is coercion to continue to live morally permissible?’ In the exploration that followed, Prof. Gethmann provided two conceivable paths that the ethics committee, and more importantly each individual, can take in answering these difficult questions. One is straightforward: If my answer to the first question is yes, then the answer to the second must be no. If, however, my answer to the first question is no, then how do I respond to the second? Is it one’s duty to live?
Any reflection on these guiding questions must begin at the end, so to speak, for it is death we are talking about — the uncomfortable and painful elephant in the room. Being-towards-death[2] as a finite being is a radical reminder that we are necessarily embodied, constituted of and dependent on the matter that biologically grounds each as an individual. We do not know what succeeds death and will probably never decipher this mystery. The same cannot be said for the path thereto, for our Being-towards-death: medical and technological advances in recent decades have altered certain facts of life. The average life expectancy has substantially increased across the face of the Earth;[3] humanity’s quest for a-mortality[4] has encountered fruitful ground in a mechanical future easy to envision. A consideration that therefore cannot be ignored in answering the question at hand is this: ‘What if we are heading towards a future in which we must all choose the time and place for our own death? […] A future in which suicide is the only path to the “natural” end of life, that has remained as the limiting constant for all of humanity’s biological past thus far, and is only now, in the potential wake of a technological civilisation, conceivably blocked.’[5]
Further, why is death even a relevant consideration during life? Ronald Dworkin offers the following explanation: In distinguishing experiential interests (things we enjoy doing) from critical interests (‘hopes and aims that lend genuine meaning and coherence to our lives’[6]), Dworkin concludes that ‘[n]one of us wants to end our lives out of character […] There is no doubt that most people treat the manner of their deaths as of special, symbolic importance: they want their deaths, if possible, to express and in that way vividly to confirm the values they believe most important to their lives.’[7] People therefore have a wish for their death to be in character and reflective of their critical interests, rather than focus merely on the experiential interest of continued life.
It is an illusion to assume, in the context of the ongoing public debate, that simply ‘deciding’ on the moment for our own death as a consequence of the above considerations is at all feasible. Too many points of contention remain for a suicide in dignity, hence physician-assisted suicide known as euthanasia, to be possible. These can be broadly divided into three main categories: structural, legal and moral.
The structural point of contention can be quickly dismissed. An emphasis on the emotionally charged and historically relevant medical ethos is irreconcilable with euthanasia, or any form of suicide assistance: Primum non nocere — first, do no harm — prohibits medical professionals from engaging in such activity, for fear of eroding a holy pillar for building trust: they will quickly lose their credibility in the eyes of those consulting them, so the argument goes. Regardless whether this argument appears plausible or not, it can be easily circumvented so as not to deflect from the underlying and pressing question at hand. This does not render structural concerns irrelevant, but rather accepts uncertainties as to the symbolic nature of assisted suicide and enables room for further debate. As a solution until then: It need not be medical professionals who offer suicide assistance. Specifically trained suicide assistants would suffice just as well.
Progressing to the legal and moral points of contention raises difficult questions, and the argument becomes messier — not least because the boundaries between the two are less clear. An individual’s competency is at the forefront of the legal debate. This calls the mental capacity of the decision-maker into question: To which extent is someone capable of making a rational decision based on understanding the nature and, importantly, the repercussions of any given act? Problematic circumstances are abundant: certain psychiatric illnesses, progressive dementia, other neurological conditions that cause irreversible deterioration, terminal somatic illnesses, chronic pain syndromes, atypical attitudes towards life, such as a suicidal wish in absence of an ‘illness’, and many more. To respect the manifold intricacies rendering each person unique, the question must invariably be answered anew: Should society consider this person legally incompetent? This, in turn, necessitates a reflection on autonomy and its stance in society. As the paternalistic role of superordinate institutions and concomitant religious submission is carefully scrutinised, personal autonomy is woven into the fabric of society. The debate’s remnants hinge on two opposing arguments that can be simplified as a support of precedent autonomy on the one side, and relational autonomy on the other.
Relational autonomy builds its walls of reason in good time. The aforementioned basic premise of a biologically grounded existence is extended at both ends of life: Unlike many coexistent beings on Earth, humans are completely dependant on others for substantial periods, at the least in infancy, and if health allows, likewise at an advanced age. What follows for the argument of relational autonomy is a delicate balance between two poles: autonomy and care. Individuals have a right to autonomy, but there are moments in which fellow humans, and in their collection society, must intervene out of a duty of care — just as each newborn is fed and swaddled without prior consent. This holds for difficult scenarios as introduced above: Those who are no longer decidedly competent and therefore incapable of maintaining their personal autonomy must be cared for, and the weight of decisions consequently ‘taken off their shoulders’. The ambivalence voiced by many who experience such phenomena, or else interpreted by observers, especially as to the simultaneity of a desire to continue and end life; the individual’s presumed will based on an empathetic view of their experiential interests; and uncertainty of the person’s sufficient knowledge regarding the condition, illness or scenario’s ramifications, further solidifies the idea of an external duty of care to protect, and above all maintain, life.
In stark contrast, precedent autonomy is characterised by an immediacy in its demands: an unassailable right to autonomy from the age of competency. This is not just in spite of a conceivable future in which competency can no longer be ascertained; it is precisely in anticipation of these situations that autonomy may be determined as a precedent. Advance treatment directives allow the specification of precedent autonomy. Such advance directives are common tools for terminal somatic illnesses, where they are generally sanctioned and followed. Yet they are customarily disregarded in the circumstances discussed above. Precedent autonomy is charged with shortcomings in light of the aforementioned ambivalence: For example, if competency can no longer be presumed, at which stage should an advance directive to end life come into effect? What to make of the ‘safety nets’ implemented into some advance directives, whereby family members or friends are given the power to ‘override’ the treatment directive? Do these or otherwise perceptible doubts constitute a psychological alteration, a change of mind? A concrete example:[8] Should a patient suffering from progressive dementia who is no longer deemed competent, but to some accounts still enjoys life (based on the individual-in-question’s apparent experiential interests), be given a lethal dose of a medication in accordance with the advance directive they issued prior to illness onset? Or should this advance directive be ignored in favour of the externally perceived contemporaneous autonomy, in which case the question must be asked: What does disregarding precedent autonomy engender?
Suicide is legal in Western nations. The universal view that suicide must be an individual possibility is thereby supported in principle. Dissonance arises only when it comes to the means by which this possibility is explored, or else resulting from a moral double standard leaving the prior universal view in tatters. A final key concept that must therefore be considered is dignity, and importantly dignity in death. Does the legality of suicide likewise encompass the legality of a dignified suicide, in which case euthanasia must be allowed? For the possibility to jump from the roof of a skyscraper or in front of an oncoming train is indeed legal. Equating this to a dignified end does not seem right, however. What about the children who, while skipping home from school, are suddenly confronted with internal organs they have not yet learned the names of splattered across the pavement? Or worse: if one of their friends is crushed by the falling body, thereby suiciding the one and killing another? What about the conductor who cannot forget the sight of the body disappearing under her train; the sound of bones crunching in conjunction with the emergency brakes screeching? The loss of dignity is at least twofold: a negative narrative henceforth overshadowing one’s legacy, with all hope of maintaining one’s physical integrity beyond death quite literally blown to pieces. To equate such examples to a dignified end is therefore to remain in denial of reality and must result in the disqualification from the ongoing debate. But in the absence of euthanasia this is the current reality, shocking as it may sound: A century ago the Psychiatrist Alfred Hoche coined the term rational suicide, describing a clear sobriety with which all arguments for and against suicide are weighed up against each other. In the early 2020s the only legal means to a rational suicide are of the sort just vividly described.
By now the relevant legal ground has been covered without providing a satisfactory framework for answering the guiding question at hand: Is coercion to continue to live morally permissible — is it one’s duty to live? The moral points of contention must thus be considered.
Legalising euthanasia will likely lead to the ‘normalisation’ of suicide in society. Critics perceive a dangerous erosion of a universal moral code herein; proponents, on the contrary, believe this to be an important step towards greater personal autonomy. It’s a given that the rates of suicide may increase in light of such a change, as has been reported in the Netherlands.[9] But such facts do not add constructively to the debate. From a moral perspective this is not a relevant indicator, hence it’s not a question of whether suicide rates will increase or not. Rather, we must consider why we are concerned with increasing rates of suicide; can we morally accept such a trend when weighed against the simultaneous increase in autonomy?
The moral reproach is thus reframed: The ‘normalisation’ of suicide is not the issue, but rather its embodiment as ‘the easy way out’. Suicide, so the argument goes, will be the emergency exit when life confronts us with hardships. Families will push their elders into an early suicide so as not to bear the brunt or financial strain of their growing dependence; individuals will seek refuge in suicide so as not to place an emotional burden on others; the ill, fragile, violent and insane will be given the green light (and perhaps a little more), freeing up vital resources. This polemic paints a bleak and pessimistic outlook, and it necessitates the following clarification. The moral case for enabling an autonomous path to a dignified suicide from an originally competent standpoint does not strive to increase suicide rates, although this will be a probable aftereffect. It remains crucial for society to invest abundant energy into suicide prevention by reducing isolation, improving mental healthcare, expanding palliative care, educating the public, and much more. However, the guiding question at hand is whether one can be morally coerced into living, whether it is one’s duty to live.
To answer this question, it is instructive to first consider the inverse extreme through the words of John Donne, written almost 400 years ago: ‘No man is an island, entire of itself; every man is a piece of the continent, a part of the main […] Any man’s death diminishes me, because I am involved in mankind; and therefore never send to know for whom the bell tolls; it tolls for thee.’[10] These words may be opposed in an existentialist tenor. Although a desire for suicide is often renounced as an egocentric perversion of individualism in the conviction of seeing each as an island, as a fetish of those consumed by post-war peace, the inverse appears to be the case: The egocentric perversion, or as Dworkin put it, an ‘odious form of tyranny’,[11] can rather be found in the attempted and, although unsolicited, continuous involvement in the Being-towards-death of another individual. Conceiving a situation in which somebody else prohibits an individual’s final act of autonomy in life is morally deplorable. Further, hereby returning to the unanswered question from the legal considerations, disregarding a competent person’s precedent autonomy equates to moral paternalism.
When all is said and done and a general agreement to disagreement is maintained, as should be possible in a functioning, pluralistic and mutually respectful society, evaluating the opposition to euthanasia is simply a matter of answering the guiding question: Is coercion to continue to live morally permissible? The answer must surely be no. In other words: One may not be coerced into living, for it is not one’s structural, legal or moral duty to live.
Footnotes
[1] These questions were posed by Prof. Dr. Dr. Carl Friedrich Gethmann (University of Siegen) in his lecture ‘Ethical Questions on Suicide’ during theGerman ethics committee’s (Deutscher Ethikrat) public hearing on 22.10.2020, available along with a transcript of the complete hearing at ethikrat.org
[2] A concept developed by Martin Heidegger in Being and Time (1927), see Milan Röhricht— Being-towards-suicide (Sein-zum-Suizid), isolatarum.org (2/2019)
[3] World Health Organisation, The Global Health Observatory, Indicators: Life expectancy at birth, https://www.who.int/data/gho/data/indicators/indicator-details/GHO/life-expectancy-at-birth-(years)
[4] Harari uses the word a-mortality instead of immortality to emphasise the fact that humans in the future may still die from a fatal trauma. Yuval Noah Harari — Sapiens (Vintage, London, 2015, p. 301)
[5] Milan Röhricht — Being-towards-suicide (Sein-zum-Suizid), isolatarum.org (2/2019), p. 6
[6] Rebecca Dresser — Dworkin on Dementia: Elegant Theory, Questionable Policy (Hastings Center Report 25, no. 6, 1995, p. 33)
[7] Ronald Dworkin — Life’s Dominion. An Argument About Abortion and Euthanasia (HarperCollinsPublishers, 1993, pp. 199-213, direct quotes pp. 211, 213)
[8] There are many case studies in the literature discussing this. For example Andrew D. Firlik — Margo’s Logo (JAMA 265 (2), 1991, p. 201), or Martina Keller — Tod wider Willen (Die Zeit, 25/2020, p. 16)
[9] For example: World Health Organisation — Preventing Suicide. A Global Imperative (2013, p. 85)
[10] John Donne — Devotions Upon Emergent Occasions (1624)
[11] Ronald Dworkin — Life’s Dominion. An Argument About Abortion and Euthanasia (HarperCollinsPublishers, 1993, p. 217)
Isolatarium 