Can ‘assisted dying’ ever be fully autonomous?

Respect for autonomy, even more than fear of pain, is the fundamental reason why the argument for “assisted dying” has been so successful in capturing the imagination of voters and politicians. But can a decision to deliberately choose death ever be fully autonomous?

In an impressive article in Psychiatric Times, two psychiatrists, Ronald Pies and Cynthia Geppert, make a persuasive case that it is not. (Hat tip to Alex Schadenberg.)

They advance several reasons for criticising what they call “the autonomy myth” about assisted dying.

(1) The first is administrative. Patients are still caught up in a web of procedural requirements – diagnosing their illness, confirming the diagnosis, deciding whether they are truly terminally ill, writing the prescription, etc. It is more an exercise of the physician’s autonomy. “The entire process of PAS is critically dependent on the authority of powerful others who must approve (or veto) every decision along the way,” they write.

(2) Autonomy is only one of the four universal and basic ethical principles in contemporary bioethics. The others in the widely used approach of principlism, promoted by Tom Beauchamp and James Childress in their 1979 text Principles of Biomedical Ethics, are beneficence, non-maleficence, and justice.

Autonomy dominates in a consumer society. However, autonomy, as a principle of medical ethics, has a markedly Anglo-American cast. It makes an uneasy fit with other cultures. In the United States indigenous peoples and Latinos are not fond of autonomy discourse, especially for end-of-life decisions.

In Africa, too, things are notably different. Writing in Developing World Bioethics, South African bioethicist Kevin Behrens says No. He claims that sub-Saharan cultures have a communitarian approach which finds the radical individualism of principalism almost incomprehensible:

“In essence, it is concerned only with individual decision-making, with the purported right of individuals to make choices about their health and life entirely on their own. On many African accounts this notion of autonomy is problematic. A pervasive notion is that it is central to the worldview of most Africans that community is prized and that individuals are bound up with their communities. Decisions about one’s body and life are, therefore, not to be taken by individuals acting alone, but in engagement with their families and communities.”

(3) The laws framed to legalise assisted suicide in the US do not take family dynamics into account when assessing whether the patient is making a truly autonomous decision. Nor do they assess autonomy at the moment of taking the lethal medication – which is the moment which matters.

(4) Rational autonomy has both a cognitive dimension and an emotional dimension. Patients who are fully aware of what they are doing may still have a distorted view of reality.

Cancer patients, for instance, might make erroneous assumptions like, “No one can help me,” or “No one understands what I am going through.” Absence of clinical depression does not exclude demoralisation and hopelessness. “Genuine rational autonomy and authentic voluntarism are frequently undermined by subtle cognitive and emotional factors that are likely to be missed with standard, cognitively based evaluation tools,” they write.

In short, Pies and Geppert are reminding us of the traditional wisdom expressed in the words of the 17th Century poet John Donne. We are not Robinson Crusoes living alone but happy on a desert island; the life of each of us is woven into a web of human relationships:

No man is an island, entire of itself; every man is a piece of the continent, a part of the main; if a clod be washed away by the sea, Europe is the less, as well as if a promontory were, as well as if a manor of thy friends or of thine own were; any man's death diminishes me, because I am involved in mankind


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