This post is written by Wayne Ramwell, Senior Tutor at University of Manchester, Law School, UK. Wayne’s research interest include legal theories, euthanasia among many others.
Introduction – Context
Lawful assisted dying (aka. euthanasia) is a recurring issue in the United Kingdom. It was previously debated in the House of Commons in 2015 and was overwhelmingly rejected by a vote of 330-118. Significantly, another private members’ bill aimed at its partial legalisation, and sponsored by Baroness Meacher, was recently introduced. It will be interesting to see how this legislation proceeds through both the House of Lords and House of Commons, that collectively comprise the UK Parliament, in the coming months and more likely years.
Key Aspects – Relevant Background
Assisted Dying – Overview
At first sight, it might appear that the notion of assisted dying is relatively straightforward. However, there are at least two distinctive categories: (i) euthanasia and (ii) assisted suicide. To complicate matters further, each of these have their own sub-categories. The former includes four different elements: (i) active voluntary euthanasia; (ii) active nonvoluntary euthanasia; (iii) passive voluntary euthanasia; and (iv) passive nonvoluntary euthanasia, while the latter encompasses two alternative components: (i) medical assisted suicide; and (ii) non-medical assisted suicide. Importantly, the latest bill, in consonance with the earlier one from 2015, is centred on voluntary euthanasia in the specific context of medical or physician-assisted suicide.
Current Legal Models – Overview
A reasonable way of organising the possible legal approaches to lawful assisted dying include the following: (i) narrow; (ii) intermediate; and (iii) wide. In essence, the differentiation between them is based upon a spectrum where access to assisted dying services is variable. In terms of examples of these models in practice, the UK could be viewed as falling within the narrow category because it only currently permits passive assisted dying where life-sustaining treatment can either be withdrawn or administered in line with the doctrine of double effect. Interestingly, this also seems to be the position in India, especially following the fairly recent landmark case of Aruna Shanbaug. In stark contrast, an instance of the wide paradigm could be Belgium that allows active assisted dying where physician-assisted suicide is not only readily available, but also accessible in a rather extensive range of circumstances, such as those suffering from disabilities and psychiatric illnesses. For the sake of completeness, an illustration of the intermediate archetype could be the proposed UK bill that aims to limit assisted dying to those with a terminal illness where this is defined as someone who is “…reasonably expected to die within six months.” Admittedly, however, this middle category is much more fluid.
Argument 1 – Principle of Autonomy
As foreshadowed in the title, the central arguments that inform the discussion concerning the legalisation of assisted dying revolve around certain values. One of the foremost values relied upon by advocates is the principle of autonomy. Essentially, this refers to persons being empowered to make decisions in relation to ending their own life. The autonomy argument is also rooted in the foundational Millian harm principle that expresses the idea of state actors only interfering insofar there is harm to others. Indeed, this tends to offer one of the most authoritative philosophical bases for criminalisation. It is therefore often contended that assisted dying should be made available because it does not lead to harming others, but rather enhances the quality of life for those wishing to utilise such services. However, it is notable that one of the constant arguments promulgated against lawful assisted dying is the (potential) irreparable harm it does to vulnerable persons. This can be understood as a reference to safeguarding dignity. It is certainly the case that this was a central concern during the debate in 2015, which will undoubtedly resurface in the current Parliamentary session should the latest bill be selected for further deliberation.
Argument 2 – Activity vs. Passivity
A popular argument promulgated against lawful assisted dying rests upon the distinction between activity and passivity where the former refers to a positive act of killing and the latter denotes a negative act of letting someone die. A good example of a positive act would be a medical professional administering a lethal dose of medications, whereas a negative act could be the removal of a feeding tube that is keeping someone alive. It is said that these acts are qualitatively different, as activity requires an interference with nature, on the one hand, while passivity merely speeds up the natural process of death, on the other. There are some good discussions as to whether these acts are distinguishable. Fundamentally, the core of the argument is that moving away from a passive model towards an active approach represents a morally illegitimate paradigmatic shift. Again, this clearly involves a conflict of values between killing (undermining the sanctity of life) and letting die (preserving the sanctity of life).
Argument 3 – Slippery Slope of euthanasia
Another argument that often features in opposition to the legalisation of assisted dying is the slippery slope. This builds upon the aforementioned harm principle by considering the potential unintended consequences of lawful assisted dying, including the following: (i) an erosion of trust between patients and physicians due to the collapse of the moral centre of medicine where the Hippocratic Oath would no longer be sacrosanct; (ii) a weakening of the level of care provided for dying patients because assisted dying might become a cheaper alternative; (iii) its potential impact upon pre-existing rights in the context of being able to refuse life-sustaining treatment; and (iv) the inevitable expansion of assisted dying outside of morally acceptable standards, particularly evident from the precedents in Switzerland, Netherlands, Canada, and Belgium, amongst others. It is this last point that seems to cause the most concern because once assisted dying is legalised, there will in all likelihood be a gradual expansion of its practice, perhaps, in circumstances never even envisaged. This can be aptly demonstrated by the Belgian experience where children can access assisted dying services if terminally ill or Canada where those suffering solely from mental illness look to be able to utilise such services from March 2023.
Conclusion – Summary
In conclusion, there does appear to be an irreconcilable conflict between certain values, such as individual autonomy and safeguarding the vulnerable, doing no harm and preserving the dignity of the person, and the sanctity of life and quality of life. There are certainly no easy solutions to these conflicts. As with most contentious issues, there can be a reasonable pluralism on whether assisted dying should be legalised where it is ultimately left to proponents and opponents alike to persuade people through the processes of democratic deliberation.