An Idol of Autonomy

I changed my mind about euthanasia in June 2015. 

Until then, I had favored making “death with dignity” accessible so that people could avoid the hardest part of dying. I believed (and still do) that medicine often prioritizes length of life over quality of life. I did (and do) hate the framing of a “battle” with a terminal illness that is eventually lost. I don’t like the suggestion that the patient has an obligation to pursue any treatment, no matter how harrowing, before eventually being bested by his or her body. 

But then I read Rachel Aviv’s “The Death Treatment,” her feature on Belgium’s euthanasia regime for The New Yorker. Aviv told the story of a Belgian mother who had struggled on and off with depression for many years. When she switched doctors, her treatment goal became completing suicide, not avoiding it. She died without her family knowing she had chosen a date or having the opportunity to intervene. That story changed my mind.

The rest of the world changed its mind too—but in the opposite direction. The Netherlands, Canada, and 11 American jurisdictions also allow for assisted suicide in some form. Late last year, the United Kingdom followed them and is now on the cusp of legalizing medical aid in dying (MAiD).

I had thought that “death with dignity” might be appropriate for a small range of patients, and that it would be restricted to only those patients for whom pain control was inadequate. I was wrong on both counts. What Aviv’s feature revealed in Belgium has become the pattern of MAiD in most nations that have allowed it. A narrow, sympathetic category of patients forms a beachhead, but then, often on nondiscrimination grounds, more and more patients are allowed or even urged to die. Belgium and the Netherlands have both expanded their euthanasia regimes to include children. One of the first to be killed was an 11-year-old with cystic fibrosis. 

It has been hard for the law to allow only a narrow range of “acceptable” deaths once doctor-assisted suicide is allowed at all. Doctors cannot accurately forecast when a person is within six months of death (one common standard for “terminal” diagnosis). When researchers tracked patients whom doctors felt had six months to live, they lived for an average of six weeks. Doctors’ discomfort with forecasting death means patients enter hospice later than they ought to and receive limited palliative care. And, in practice, it is not actually the nearness of death that many candidates for medical suicide cite as the reason for needing to die now. 

In contrast to Europe and Canada, Oregon has maintained a comparatively narrow medical aid in dying law and, to its credit, has published detailed annual reports about who chooses to die and why. Over the period Oregon has kept records, nearly all (90 percent) respondents cited their loss of autonomy as a factor leading them to choose to die. A similarly high number (89 percent) said they lost the ability to participate in the activities that made life enjoyable. 

Less than a third (29 percent) cited the pain of dying—the leading reason cited in advocacy. Dying is not easy, and it’s harder when a patient struggles to receive care or has no one to care for them. But physical pain is something we know how to ameliorate, if not erase. (It requires prudently using painkillers, shifting patients earlier into palliative care, and avoiding interventions that cause pain without improving quality of life or minimizing hospital time.) Ultimately, euthanasia isn’t just about pain, but about what pain and need make us: more animal, less autonomous.

Nearly half (47 percent) were concerned with sparing others pain. They chose to die to avoid further burdening their loved ones. Dr. Ellen Wiebe, a Canadian doctor who specializes in euthanasia and abortion, said in an interview with the New York Times that of course she would and did sign off on MAiD requests that hinged on the fear of being a burden. She cited the example of a man who told her that he wished to die because “he had been a person who’d taken care of his family and now he could have people take care of him, and it was unbearable to him that he was in that state and wasn’t getting better.” In her judgment, he was “most definitely eligible.”

It is hard to reconcile the man’s pride in caring for others with his self-disgust at requiring care. Had he been degrading his family by supporting them during his many years of strength? Would they too have been eligible for MAiD if they’d interpreted his support as humiliation, not love? Dr. Wiebe was not interested in whether her patient was correct to interpret receiving care as a fate worse than death. It was enough that he hated it.

Once the state officially agrees that some lives are not worth living—that it might be unfair to others to continue to draw breath—there can be a contagious effect. Canada, which has a particularly permissive law, has seen MAiD death rate surge until 1 in 20 Canadian deaths in 2022 came by medically legitimated suicide. The country has not yet hit a suicide ceiling—advocates want to allow “mature minors” (defined as children 12 and up) to be allowed to elect to die. It remains on the cusp of allowing MAiD for purely mental health conditions (depression, autism, schizophrenia) with legalization currently delayed until 2027. And advocates are suing to allow the depressed to die immediately.

The simplest framing of what is wrong with MAiD is that it leads to the government operating two competing suicide hotlines, and being, at best, indifferent about which one you call. On one line, people will tell you that every life is worthwhile and that your loved ones do not despise you for your frailties. On the other, a kind doctor will solicitously schedule you for a lethal cocktail or injection.

The two approaches to the desire to die were on stark display when Dignity in Dying, a U.K. euthanasia advocacy group, placed pro-assisted dying ads in the London Tube. In one poster, a fit woman leaps in the air with the uncanny joy most often on display in period product ads. Next to her in block capitals: “MY DYING WISH IS THAT MY FAMILY WON’T HAVE TO SEE ME SUFFER, AND I WON’T HAVE TO.”

Suicide awareness posters are common in metro systems the world over, but until now they have always been anti-suicide. Walk to the end of a platform and you’re likely to see a small reminder that life is worth living, maybe even a callbox with a button to press to reach someone who will tell you to hold on. Subway platforms, like bridges, are a dangerous place for the suicidally inclined, who may allow a momentary impulse to self-destruction to be acted upon in an instant. 

The few people who have survived a leap off the Golden Gate Bridge report they regretted their suicide attempt in the first moments of their fall. A person who turns to pills might have their stomach pumped, but someone tempted by a train or a bridge can survive only by luck. But for the person who receives medical aid in dying, the medical professional they might otherwise appeal to for help is the agent of their death. 

What kind of resistance can be fruitfully offered to a regime that endorses its citizens’ suicides? In London, anti-suicide advocates papered the pro-suicide Tube ads with the number for the extant suicide hotline—the one that helps you out of the hole. In Canada, advocates for the vulnerable have put up signs specifically promising, “This organization WILL NOT recommend, suggest or refer you to Medical Assistance in Dying (MAiD) as an alternative to assisting in obtaining the necessary supports and services you require. You are safe here.”

Without that promise, it can be hard to know which suicide line your doctor or social worker will suggest. A Canadian Paralympian who contacted Veterans Affairs for help getting a wheelchair ramp for her house received an unsolicited offer to be given MAiD instead. In seminars for MAiD assessors in Canada, they receive training on how to be emotionally prepared to greenlight requests to die from Canadians with non-terminal conditions for whom “poverty [is] the driver of her MAID request.” It’s a grim idea of what the healing profession is for.

The easiest way of pushing back against new euthanasia laws (or advocating for the repeal of existing ones) is to say that it’s a nice idea in theory but one that we have no capacity to pull off in practice. Here, euthanasia is like taking out life insurance policies on strangers, trading in unregistered securities, or international adoption. The ideal use case is quickly crowded out by exploitative cases.  

It’s a perspective that is somewhat compelling even to MAiD advocates. In Canada, the British Columbia Civil Liberties Association (BCCLA), which filed the case that led to the legalization of MAiD, now opposes the way euthanasia has been put into practice. Among the abuses BCCLA cites are “reports of MAID being used in prisons while incarcerated people were shackled to their beds.”

But safeguarding has been difficult to achieve because the logic of euthanasia advocacy corrodes attempts to set limits. If suicide is framed positively for any population, it is very hard to devise a legal regime that denies it to vulnerable populations (the poor, the young, the mentally ill) on the basis of their precarity. If it’s a right—even the guarantor of dignity—then the dispossessed will get their rights good and hard. 

Arguing legal suicide might be good but is impractical is thus a short-term, tactical move. It might be relevant in places like the U.K.—where Parliament voted in favor of a legalization bill in November—but it is unlikely to galvanize a repeal effort. Offering compelling resistance to a MAiD regime requires giving an account of how to die well that is not equivalent to dying painlessly or predictably. 

That’s the task before the Rev. Benjamin Crosby, an Anglican priest serving in a Canadian parish, who sees offering resistance to killing as part of his pastoral work. Crosby has written with disappointment about the concessions mainline Protestant churches have to the nation’s program of euthanasia. Once legal suicide was available, he wrote, many churches withdrew their objections, accompanying parishioners in whatever way they chose to die, even offering liturgies to bless what had been previously forbidden. One church offered a prayer for choosing a time and place of death, suggesting that the person considering suicide pray, “I do not want my family and loved ones to watch me suffer to the bitter end. I do not want them to be haunted by memories of a slow, painful death. Daily my dignity is being eroded. I am ready to go through that final door.”

It is as though the church has adapted the psalms of the suffering servant, keeping the narrations of agony (“My heart is like wax, it has melted within me. My strength is dried up like a potsherd, And my tongue clings to my jaws; You have brought me to the dust of death”) while excising any consolation (“But You are He who took me out of the womb. You made me trust while on My mother’s breasts. I was cast upon You from birth. From my mother’s womb, You have been My God”). Notably, the consolation of the psalm is not the recollection of past strength or the hope of its recovery. No, it is the recollection of the one universal weakness—the naked dependence of infancy—that reminds the psalmist who he is and what God has done and will do for him. The Christian understanding of the human person is as a created being—someone for whom autonomy never was or is a possibility. 

But even a materialist perspective that doesn’t acknowledge a creator can concede that we are never truly “independent.” Moving past the desire for “death with dignity” requires admitting that autonomy is not the ordering principle of a human life. Every person begins their life as a burden to someone else. It isn’t pejorative to say so—a baby simply must be carried, first by just one woman, in utero, and then after birth as a shared burden among more bearers. 

Most of us (though not all of us) grow out of this severe, stark dependence, but our trajectory is an orbit, not an escape. For those with pronounced disabilities, chronic illness, or a severe accident, the orbit is tightly constrained. For others, the loops are a little more sprawling until illness, injury, or (for many women) childbearing, turns us inward to the space where our lives are more obviously defined by our weakness and need. But for almost all of us, dying is a return to our origin—a time of profound need, copious bodily effluvia, and reliance on another’s strength.

We are heavier in our old age, requiring more helpers to carry and clean us, but also freighted with shame. The need of a baby is seen as a natural feature of his or her age, but the needs of an elderly person are not seen by our culture as natural to them in the same way. A baby is not aware they will one day do more; an elderly person feels the lack of what they once could do. But a baby does not abhor her body. A baby would not desire to die rather than be suckled. 

There is already copious evidence that we cannot sustain a modest euthanasia regime. Though advocacy for euthanasia began with the avoidance of pain, it has inevitably slipped into making an idol of autonomy. But no human person has ever fully possessed bodily autonomy, and the legal right to destroy the body cannot make this aspiration achievable. Opposing euthanasia begins with care for the weak, but it ultimately depends on simply telling this truth about the human person.