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When It Comes to Medical Aid-in-Dying, We Must Protect the Vulnerable

(Heidi de Marco/Kaiser Health New)

Many such persons will have internalized the idea that they constitute an inconvenient and expensive burden on loved ones, as well as the healthcare system. Legalizing MAID risks reinforcing that message.”

Medical aid-in-dying (MAID) laws are increasingly being enacted across Europe, North America, and Australia. It is easy to see the appeal of these laws. They comport with our Western emphasis on autonomy and self-determination. “Death with dignity” is a compelling catchphrase. The rhetorical questions one encounters in Facebook threads and letters to the editor (“Who are we to control someone else’s death,” “If we put our pets to sleep, why won’t we do the same for  human beings,” and so on) carry considerable weight. One could be forgiven for assuming that anyone not in thrall to rigid religious fundamentalism or an abstract and arid vitalism must be a supporter of MAID. 

Let us gently challenge that assumption. There are no “knockdown” arguments against MAID—just reasonable people on both sides of the debate. This issue, however, is more complex than it might initially appear, especially for those who stress social justice, societal progress, and support for the marginalized. 

First, one need not share the view that all acts of suicide, assisting a suicide, and mercy killing are morally wrong to have concerns about MAID. The debate does not turn on whether such acts are invariably wrong but whether legalizing them under certain conditions would be prudent public policy. There is wisdom in the old maxim that “Hard cases make bad law.”

Second, while individual autonomy is undoubtedly a cardinal value, it should not be wielded like a trump card in discussions of MAID. The ongoing Coronavirus (COVID-19) pandemic usefully illustrates the limits of autonomy. Throughout the pandemic, governments have restricted autonomy to safeguard life and health. Legalizing MAID would surely advance autonomy, but if it conflicts with other crucial values–such as protecting the vulnerable and preserving human life–it is not necessarily obvious that claims of autonomy should carry the day. 

Many disability rights activists are skeptical of MAID. This is too often elided by supporters who prefer to emphasize the opposition of traditionalist religious institutions. Disabled perspectives can help correct for the biases and blindspots of the able-bodied. The fact that prominent voices in the disabled community have spoken out against MAID should give us pause. 

The physician-assisted suicide laws adopted by nine states and the District of Columbia limit eligibility for MAID to terminally ill individuals with a prognosis of six or fewer months to live. But these prognoses can be mistaken. It is easy to imagine someone told that he has less than six months to live opting for MAID as an alternative to incurring medical bills and enduring an illness he believes is on the verge of killing him, when he would have ended up living many more months or years with a decent quality of life.

Most importantly, MAID entails a significant risk that vulnerable people will experience pressure to end their lives. This might take the form of coercion from family members unwilling to shoulder the costs of their continued care or harboring even more sinister motives, like getting their hands on the deceased’s estate. It requires only a passing familiarity with the crooked timber of humanity to realize that this kind of scenario cannot be ruled out. 

Explicit coercion would probably be less prevalent than more subtle and indirect forms of influence. Ideologies of ageism, ableism, and atomism suffuse our society, unavoidably affecting the self-perception of the elderly, disabled, and chronically ill. Many such persons will have internalized the idea that they constitute an inconvenient and expensive burden on loved ones, as well as the healthcare system. Legalizing MAID risks reinforcing that message.

As bioethicist Charles C. Camosy puts it in relation to the elderly, “It is something close to diabolical that, after creating a culture of which older persons do not feel a part and in which they do not feel welcome, a society would then create a method by which older persons could kill themselves more easily.” Some of those eligible for MAID will welcome the expansion of their end-of-life autonomy and make fully voluntary, uncoerced decisions to die. However, others who have ostensibly chosen MAID will, in reality, have been coerced by insidious cultural forces.

There is a parallel here to the argument that even if capital punishment furthers the value of retributive justice by giving the worst offenders their “just deserts,” the risk of mistakenly executing the innocent should nevertheless lead us to abolish it. Advocates of this argument admit that if we had a perfect criminal justice system that could be trusted to convict and execute only the guilty, then capital punishment would be acceptable. They reason, though, that because our criminal justice system is imperfect, avoiding the risk of executing innocent people should take precedence over inflicting maximal retribution on the guilty. 

Likewise, while MAID would advance autonomy by expanding the range of end-of-life options available, it carries with it the risk that some will be pressured into an untimely, assisted death. If we lived in a society where disability and dependence were not disparaged and the odds of illicit pressure were minimal, then legalizing MAID might make sense. Given that we do not yet live in that kind of society, we should instead prioritize protecting the vulnerable.

Tanner Matthews is a third-year law student at the University of Utah’s S.J. Quinney College of Law.

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