Addiction, brainwashing, trauma or fatigue, obviously. Any others?

The argument for assisted suicide and euthanasia rests squarely on the doctrine of autonomy. As The Economist has pointed out: “Some activists for the rights of the disabled regard the idea that death could be better than a chronic condition as tantamount to declaring disabled people to be of lesser worth. We regard it as an expression of their autonomy.”

But even if this is granted, how do we know that people are really making an autonomous decision to end their lives? Addiction, brainwashing, trauma or fatigue obviously diminish personal autonomy. Are there other factors?

Two Australian bioethicists tackle this problem in the Journal of Law, Medicine & Ethics. They contend that depression, demoralisation, existential distress and family dysfunction can undermine agency, an essential component of autonomy. Physician-assisted dying:

without appropriate assessment of the agency of individuals would be a failure to respect their personal autonomy. Moreover, the legal frameworks designed to protect this autonomy should establish not only adequate decisional capacity but also prove positively the person’s ability to act with unaffected and undamaged agency. Without true agency, there can be no genuine autonomy.

The authors, George Mendz and David Kissane, point out that “loss of meaning or purpose in life,” “a bleak pessimistic outlook on the future,” “perception of a limited prognosis,” “desire for death or loss of will to live” – familiar factors in discussions of “assisted dying” – subvert agency. Family dysfunction can also contribute to limited insight which undermines agency.

Although the request for death may be expressed freely, their circumstances disempower them from determining their own motives. The motivation to act can be forced upon them by their impaired perception of their own situation. Not being able to appreciate their own motives, they are not self-governing agents.

In an accompanying commentary, the well-known bioethicist Tom L. Beauchamp, of Georgetown University, who has often deployed autonomy to defend the right to die, takes issue with Mendz and Kissane.

There are many good reasons to request assistance in dying, and there is no reason to presume that anyone who wishes to die does not have good reasons or does not have the necessary capacities to make an autonomous choice. Good reasons are found in many last-resort situations.

Michael Cook is editor of BioEdge

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Michael Cook

Michael Cook edits BioEdge, a bioethics newsletter, and MercatorNet, an on-line magazine whose focus is human dignity. He writes from Sydney, Australia.

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