The good death

Featured image: <verdiende rust.jpg> image: Martine/Flickr CC BY-NC 2.0)

Decisions are a matter of trade-offs, and end-of-life decision-making is literally a matter of trading off life and death. But our society exhibits a status quo bias that raises big ethical questions*

Earlier this week I had a conversation with my father about his death. He is 94 years old, and he has recently been diagnosed with Alzheimer’s. He is presently in good physical and psychological health, with symptoms of the condition sporadic and minor. But that may change soon, and suddenly, so we spoke about the choices he might want to make in this regard.

A decision denied

For others, though, things are rather different. They have reached the final episode of their life and suffer excruciating pain, no longer recognize their nearest and dearest, or have sustained irreversible brain damage. Some of them would, if given the choice, opt to not wake up tomorrow morning and die peacefully.

Bearing in mind that not making a decision is also making a decision, we literally decide whether we live or die every day. For the vast majority of us, this is not a conscious choice. We simply get up, and go about our daily business. We then go to bed, firmly expecting to get up again the next morning to repeat the process. Deciding to live is, for most people, the unconsciously chosen default.

Thankfully, for my father, that option is real. He lives in a country where euthanasia (from the Greek eu – good – and Thanatos – death), sometimes also referred to as assisted dying (which technically applies only to people in a terminal condition) is legally possible under certain circumstances. Anyone experiencing persistent, irredeemable psychological or physical suffering caused by a serious and incurable condition as a result of illness or accident can apply. As long as the application has been made voluntarily and is well-considered, the applicant can legally be administered a lethal substance, and effectively choose the time of their death.

Should it be an obligation? (image: fair use via Wikimedia)

This right, however, does not exist in most countries – including the UK, which has been my home for many years now. Not for the first time, parliament is debating a private member’s bill that would legalize assisted dying, for people who have less than six months to live. As before, the debate has become heated once again. Proponents wheel out individuals who, were they to live in my father’s country, would have no problem applying for euthanasia relating their plight. Opponents, alongside moral imperatives that are beyond reasoning, invoke the potential for pressuring the old and disabled to sign on the dotted line so inheritances can be collected early, or so they stop being a financial and practical burden on their relatives. Some even suggest it might protect rogue doctors like Harold Shipman, who was convicted of the murder of 15 people, but who probably killed around 250 people over 27 years, from prosecution.

These concerns are for a large part quite valid. But they are not insurmountable.

So the resistance almost seems to be a pernicious case of status quo bias: if you are alive, you must stay alive. Of course, most people do want to keep on living, at least for most of their lives. But the unquestioned assumption that everyone does, unconditionally and unchangingly, no matter their condition or age, is, well, questionable. Opponents of assisted dying point out that good palliative care can alleviate many of the discomforts and indeed the suffering that being old, ill and decrepit brings about. This is quite likely true – but one wonders who should make the judgement it does so sufficiently to make the final few months of life worth living. Should we not recognize that nobody is better placed to make the trade-off whether the benefit of another day of being alive outweighs the cost of the indignities and pain they experience, than the person herself or himself?

The trade-off of life

25 years ago, my mother was dying of cancer. She was in great pain, and when I saw her for the last time, 10 days before her death, she confided in me that she no longer wanted to fight on. I had a hard time understanding that at the time – for me life just had to be worth living, with several small grandchildren to see grow up, a husband of nearly 40 years to spend time with, and so on. But it made me think, and gradually I came to understand what she had meant: she made the trade-off.

Trade-offs should be about establishing whether benefits outweigh costs, or whether additional cost produce sufficient additional benefit. Denying people the right to die when they want is tantamount to rigging the scales so that there is effectively no amount of suffering and pain so great that it would be reasonable to decide life is no longer worth living. No question: you shall live.

But should it be only about pain and suffering? If we consider it reasonable for people to be able to determine when the amount of suffering they experience is no longer outweighed by the joys of being alive, and to act in accordance, then there may be another trade-off that we should consider.

When I’ve had enough of this party, I want to go (image: Edoardo Tommasini/Pexels)

Imagine you are at a fantastic party. Among the thousands of guests are your nearest and dearest – your partner and your children, your siblings – and your best friends, and even some more distant acquaintances. There is a wonderful buffet, and you have a great time talking to everyone, joking, reminiscing. But as the day goes on, you start noticing that some of the people you know have gone. Gradually, fewer and fewer of your friends, people your age, are left. At some point, your partner has disappeared too. Only some of your children remain, and they are chatting with people their age. You’re now thinking of leaving as well, as there really is nothing left to do there for you. You have tasted all the food and you are not hungry any more. You don’t want any more to drink, and the entertainment is really not your kind of thing. It’s getting late, and your tired and you just want to go. But every time you get up to leave, someone comes over to you and says you are not allowed to go. The party is still in full swing, and you have to stay.

Now imagine this is actually your life. You are old, your spouse, the people you grew up with, your friends and your old colleagues – they’re all long dead. You are not in pain, and your brain works fine. But you’re just tired. There is nothing left for you to do. You’ve lived enough, and the benefit of going on living does not outweigh even the minor inconveniences of life.

Nobody should be obliged to stay at the fantastic party once they’ve had enough. Should people be obliged to keep on living? That is exactly the situation for people who are denied the right to die. In the Netherlands the concept of a ‘completed life’ (“voltooid leven”) has entered the public discourse, but even in this pioneering nation as far as euthanasia is concerned, it is nowhere near being accepted as a valid reason. There, and in other countries where people who suffer psychological or physical pain can get euthanasia, those who are simply tired of life must keep on living until they drop. That is an ethically questionable state of affairs.

Moral philosophers and economists alike talk of the ‘good life’ (an idea that goes back at least as far as Aristotle’s concept of eudaimonia), something every human should have a right to pursue according to their own needs and preferences. This good life cannot imply the obligation to keep on living indefinitely and unconditionally.

People should also have a right to a good death.

*: for the sake of clarity, this article is not about suicide or suicidal tendencies.

About koenfucius

Wisdom or koenfusion? Maybe the difference is not that big.
This entry was posted in Behavioural economics, Economics, Ethics, Philosophy, Psychology, Society and tagged , , . Bookmark the permalink.

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