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 powerful. But will 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”.
(1) 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, 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, notably indigenous peoples and Latinos, especially for end-of-life decisions.
(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 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.”
5 thoughts on “Can ‘assisted dying’ ever be fully autonomous?”
Hi, Mr. Cook–You and your readers might be interested in this recent study, showing how assisted suicide can interfere with palliative care:
A study conducted by a group of physicians in Canada reveals the detrimental impact that the legalisation of assisted suicide has on palliative care.
In their 2020 qualitative study, Matthews and Colleagues interviewed palliative care physicians and nurses who practiced in healthcare settings where patients could access Medical Assistance in Dying in Southern Ontario. Their findings conclude the negative impact that MAID has on palliative care in Canada:
All clinicians spoke about a conflict between maintaining Medical Assistance in Dying eligibility and effective symptom control. Clinicians felt they must withhold symptom control medications that could cause sedation or confusion and therefor jeopardise MAID eligibility, even if the medication could significantly alleviate their patient’s pain. This difficulty in providing optimal symptoms management created by the Medical Assistance in Dying legislation resulted in increased providers and patients’ distress.
Many clinicians described the prevalence of ethical and moral dilemmas regarding the appropriateness of certain discussions regarding MAID with their patients, such as introducing MAID to patients who did not initiate these requests. Clinicians were concerned that introducing the topic of Medical Assistance in Dying might be misinterpreted as an invitation to request for it, and may add to the burden of vulnerable patients and erode families’ trust. Participants also described challenging conversations around supporting patients and resolving tension with families around Medical Assistance in Dying.
Medical Assistance in Dying has a significant emotional and personal impact on palliative care providers. Many of the clinicians described a large emotional toll created by exposure to Medical Assistance in Dying.
Medical Assistance in Dying changes the patient palliative care provider relationship. The clinicians described how patients thought that palliative care included assisted death, which complicated their relationships with these patients. Further, clinicians with moral or religious objections to Medical Assistance in Dying described substantial challenges with building trust with patients pursuing assisted death.
The clinicians felt that the providing of assisted suicide led to more palliative care resources being dedicated to assisted deaths that would have otherwise been allocated to palliative care.
This study should serve as a warning to the UK as Parliament debates the legalisation of assisted suicide. If Canada serves as any example, the implementation of assisted suicide will have a profound negative impact on palliative care.
Ronald W. Pies, MD
“Rational autonomy has both a cognitive dimension and an emotional dimension.”
Yes, I agree with this statement and I support PAS.
None of the decisions we make in our daily lives are done in a vacuum. Not a single one. Humans aren’t machines who make decisions independent of any internal constraint(s) because it’s simply impossible. Hence we judge requests for such permanent decisions (not just PAS mind you) on the basis of mental capacity and competence.
My uncle who received MAID in Canada for early-onset dementia had a reasoning that did involve an emotional dimension. He was terrified of the disease as he saw his father (my grandfather) deteriorate slowly and steadily from Alzheimer’s over a span of a couple of years. Slowly losing all his mental and physical faculties, forgetting virtually all of his memories. In late-stages of the disease when his brain was severely atrophied he was confined to his bed needing constant 24/7 care. He would urinate and defecate himself and would wake up at night screaming and being absolutely bewildered not knowing where he’d be or who he was. My uncle never forgot the screams with his horrified wide-eyed face. So yes, there was an emotional dimension to his decision and there’s absolutely nothing wrong with that.
I don’t believe in god (and neither did my uncle). All evidence suggests that once we die it’s nothing but eternal oblivion; essentially the state you were in before you were born. I don’t believe in an afterlife where all this suffering from such a severe progressive disease will be one day rewarded by God by allowing you access to heaven. Even if I did however, and was a religious person I wouldn’t force my decision and beliefs on people who possess capacity to make such a choice.
Ultimately I value quality of life more than the quantity itself, and simply do not consider death to be the worst of fates. I truly am glad and comforted to know that should I ever suffer from such a condition I have the option of a death of my own choosing in my country. And virtually all of the surveys done here regarding PAS shows that the majority of my fellow citizens agree with me.
Much appreciated. We reported earlier on similar insights by Ole Hartling in the BMJ
Thank you for the reference to Dr. Hartling’s work, Mr. Cook. I don’t believe I had seen it before.
Ronald W. Pies MD
Many thanks, Mr. Cook, for your succinct summary and call-out to our work. On behalf of my colleague, Dr. Geppert, I thank you.
Ronald W. Pies MD
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