Can we talk about assisted dying?

Will we be able to talk rationally about assisted dying or will it be overrun by the culture wars?

We were talking about assisted dying.

The person who brought it up said assisted dying is an example of liberal governments out of control. On another Substack, Richard Hanania made the opposite case — forcing people approaching the end of their lives to wear diapers and to spend their remaining days drooling takes away more dignity than letting them choose their own date of departure.

This is why assisted suicide must be legal. If you disagree we have the deepest possible differences about what it means to be human and you should reconsider.
— Hanania

Assisted dying, or Medical Assistance in Dying (MAiD), provides a perfect example of the need to choose a side in the culture war. Most people can imagine a situation where death is inevitable and they will have to endure months of drooling in pain before death arrives. Most people can imagine a law that allows others to choose an early death, even if they wouldn’t make that choice themselves but unfortunately, these aren’t the people with the loudest voices in the culture war.

On the pro-MAiD side, Hanania argues that there should be no limits on assisted suicide at all. Making an analogy with free speech, he claims that as soon as you allow the government to control some aspects of free speech (or assisted dying), the temptation to control more aspects is too much to resist. Hanania says that our culture cares so much about stopping people from dying that the only sensible option is to allow suicide or euthanasia in every situation.

Two prominent groups oppose MAiD. Christians say that only God can decide when and how a person should die but the Bible has very little to say about people in a coma for years on end or suffering in pain with terminal cancer. God moves in mysterious ways.

The tragic story of Terri Schiavo highlights an extreme version of this position. Terri Schiavo was in a vegetative state from 1990 to 2005 and fed artificially, unable to interact with the outside world or with her family. Her husband requested the right to remove her feeding tube, arguing that this is what his wife would have wanted. Terri’s family, citing a Catholic obligation to continue artificial feeding until death, opposed him in court.

In America, where Christian views are more influential, the demands of the culture war turned this family dispute into a partisan battle joined by Congress, the Governor of Florida, the President of the United States and Pope John Paul II. After 13 years of court battles, a Federal Court affirmed Terri Schiavo’s right to die despite the Florida law passed specifically to deny it.

The administration of water and food, even when provided by artificial means, always represents a natural way of preserving life... not a medical procedure.
Pope John Paul II

The other group that opposes assisted suicide makes a slippery slope argument in opposition to Hanania’s. While MAiD might be acceptable in certain cases — like that terminal cancer patient — it is inevitable that the government will run riot with its new-found powers and start ‘killing the inconvenient’, as Mr LSO put it. Liberal governments use ‘genuinely heart-rending edge case examples’ to bring in a law but over time, the laws will creep and result in ‘universal and destructive changes’.

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There is currently strong support in the United Kingdom for a bill to allow assisted dying. TV personality Ether Ranzen has stage four cancer and wants ‘the chance to die in my favourite place’. Ranzen leads the advocacy for a new law and says that if the UK does not pass the law in time for her, she will join the Britons who ‘buzz off’ to Switzerland every eight days where Dignitas helps them to die.

Esther Ranzen — That’s Life!

The service provided by Dignitas is much needed but is far from perfect. It costs around £10,000 and you have to be fit enough to travel to Switzerland. Family members who help you travel are subject to prosecution so you must travel alone. This results in people choosing to die earlier than they would have otherwise because when the appropriate time comes, they won’t be able to travel without assistance.

A sensible solution is on the horizon though and Parliament will almost certainly pass a bill allowing assisted suicide soon. Public support is around 70% and Starmer has promised a free vote. Members of Parliament usually vote along party lines but a free vote allows them to vote their conscience and they will be allowed to discuss the consequences of the bill without fear of censure from their party.

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The early debate over assisted dying suggests that we are losing the ability to make difficult moral decisions based on thoughtful consideration. Such decisions are increasingly tribal in America and England seems to be following their example but perhaps MAiD will be a rare exception.

Consider abortion in America. Abortion was originally considered a matter of conscience in most states, legal until ‘the quickening’, the first sign of movement. However, in the mid-nineteenth century, states began to impose increasing restrictions on abortion and by 1960, abortion was a crime in most states. The Supreme Court reversed this in Roe v. Wade, ruling that laws that restrict abortion before the viability of the foetus were unconstitutional.

After Roe v. Wade, discussions about abortion became increasingly tribal and everyone was obligated to choose a side. As of 2018, 48% of Americans were pro-choice and 48% were pro-life and elections are determined by a politician’s stance on abortion. For many years, Supreme Court justices had to endure the farce of pretending to support Roe v. Wade and the recent decision that reversed Roe v. Wade merely shifted the status quo. It is still necessary in America to have a strong opinion on abortion and a moderate opinion might cause you to be excluded from polite society. Did it have to be this way?

‘The dogma lives loudly in you’

In contrast with America, abortion was essentially banned in Great Britain from the start of the nineteenth century until the 1967 Abortion Act made abortion legal until viability. That was the end of the discussion. A few activists occasionally attempt to make the law more restrictive or more liberal but the rest of us just roll our eyes.

Until recently, Britain has been successful at keeping the culture wars out of everyday moral decisions but, like America, we are increasingly required to choose a side and nuance is considered a betrayal of the ‘correct’ position.

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We used to be able to talk about immigration in the UK but one’s attitude towards immigration is now determined by one’s position in the culture wars. In the current climate, it would take a brave commentator to wonder whether the unimaginable horror in Southport had anything to do with immigration or whether immigration is too high. The only acceptable position in polite society is to condemn the far-right thugs hurling bricks and to emphasise that the murderer was British. Immigration must have nothing to do with it.

Discussion of immigration is almost beyond the pale in recent weeks and there’s no one in mainstream politics for anti-immigration types to rally around. If the only choices are between right-wing thuggery and condemning discussion of immigration as racist, it’s hardly surprising that too many choose to become right-wing thugs.

Can we talk about immigration yet?

The women’s boxing in the Olympics provides another example. None of us knows the gender status of the Algerian boxer at the centre of the controversy but everyone is confident that their evidence will clinch the argument. She was raised as a girl. He has XY chromosomes. She has labia. He has testicles. Her passport says she is a woman. He adjusted his balls before a fight. What chance do we have of finding a solution in this intellectual climate? As with the debate over trans participation in sport, the space for honest discussion is shrinking.

The UK has historically been good at finding a sensible compromise to these culture war issues. We find a practical middle ground and then move on. We did it for gay marriage and inner city pollution and we’ll do it for trans battles and climate change. Sure, there will be a few extremists who throw their bricks at mosques or splash their orange paint on works of art but the rest of us will roll our eyes and get on with making sensible laws that we can all live with.

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Bentham’s Bulldog had a recent post on Substack describing a reality caucus. While most culture warriors echo the narratives on Twitter, people in the reality caucus try to see things as they really are. As a result, they often see the evidence differently from the folks who have pre-chosen a side and they present views that comport with neither side.

For example, for a long time, the only acceptable positions on President Biden were that he was either perfectly healthy or was in the final stages of dementia. Starting earlier this year, folks in the reality caucus were able to suggest that maybe Biden was not the best candidate for president even while mainstream journalists were still claiming that everything was fine. On the other side, there are still Republicans who don’t believe the 2020 election was stolen or that the COVID vaccine was a secret plot by the government to control us. But perhaps the lockdown did go on too long and the masks did not help much.

Hanania calls these people Enlightened Centrists — but they are not necessarily centrists. Not really. Their opinions might be all over the political spectrum but the essential thing is that their views are based on reality even if it means contradicting their own team.

Enlightened Centrists

Perhaps if we had more enlightened centrists, we’d have less plans to ban burgers made from lab meat and less mandatory DEI requirements.

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Many people form an opinion on MAiD before they have really thought it through. For some commentators, MAiD is just another example of government overreach: liberal governments everywhere will help people to die to cut down on healthcare costs and eliminate the burden that disabled people place on society. For others, of course everyone should have the freedom to choose when to die.

Canada was one of the first big countries to legalise MAiD in 2016 and assisted dying has proved very popular there. More than 3% of all deaths now are by MAiD and over 10,000 people were helped to die in 2021 but those deaths are not without controversy. There have been several cases where the patient’s family has challenged the decision to die in court.

In one case, a woman alleged that her brother-in-law, Alan, had been granted the right to end his life because of his hearing loss and resulting depression. Alan’s family contested this right.

Should the family have the right to contest a patient’s decision to die? Do they have the right to contest other medical decisions too? Alan’s sister-in-law:

I was appalled by all of it and I said we want this stopped, this can’t happen. Our family doesn’t agree with this.

In this case, the doctors who granted Alan’s right to die confirmed that Alan knew what he was doing, perhaps suggesting that there might be more to his condition than just hearing loss and depression; and his death certificate listed several more serious conditions. Alan’s family could not have known this — but why should the family have access to a medical record that the patient explicitly wants to keep secret?

Canada has one of the most liberal regimes for MAiD. Most assisted dying laws require that the patient be suffering unbearably and have a terminal disease with the end in sight but Canada does not require a terminal condition and extends the right to many other conditions including disabilities and — soon — mental illness.

One objection to granting disabled people the right to die is that it seems to suggest disabled people are less than full members of society. Perhaps the slippery-slope people are correct to fear a government that might suggest MAiD to a severely disabled patient. But should one disabled person’s self image override another disabled person’s choice to end a life of suffering?

People with a mental illness are especially prone to end their lives by suicide which society overwhelmingly tries to prevent. Might we become a little more reluctant to prevent it if the means to commit suicide are provided by the government? Conversely, might someone tempted by suicide seek help sooner if they know that seeking help does not close the door to a future choice.

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Oregon’s Death with Dignity law is limited to patients with a terminal illness that will kill them within six months. The request must be initiated by the patient and confirmed by two witnesses, one of whom must have no financial gain from the request. The request must be reviewed by a doctor who has no previous relationship with the patient. There must be a fifteen day cooling off period and either the patient or the doctor can cancel the request at any time.

Oregon’s law was held up in courts and political battles for several years until the Supreme Court finally ruled that the Federal government had no business interfering in Oregon’s practice of medicine and Oregon’s law has since been copied by several other states. In 2020, Florida lawmakers attempted to pass a bill similar to Oregon’s but it died in commitee and instead,

"every person deliberately assisting another in the commission of self-murder shall be guilty of manslaughter, a felony of the second degree".

— Florida Statute, 782.08

The experience in Canada is troubling in other ways. Over 35% of those choosing to die in 2021 said that they did not want to be a burden on their family. I can imagine that after two years of full-time care, I might want to give my wife a break and move on — but what’s to prevent over-enthusiastic grandchildren from persuading grandma to move on so they can get earlier access to her assets?

How will patients learn about the option to seek MAiD? Should we just expect that patients will know to ask for this option? If it is anything like other aspects of cancer treatment, most patients will accept whatever their oncologist recommends as the right choice. Will the oncologist be permitted to recommend assisted dying? Perhaps there will be yet another leaflet in amongst the wad of leaflets you are given when you are diagnosed with cancer. Or perhaps there will be posters on the wall of the clinic.

‘Have you considered assisted dying?’

There will be no easy choices when we come to design the laws and procedures for assisted dying in England. Lord Falconer recently introduced a bill into the House of Lords that is based on Oregon’s Death with Dignity law. Kier Starmer has promised to grant it a free vote in the House of Commons but already, commentators are stirring up trouble based on fears. Even those not opposed to assisted-dying per se contend that ‘The middle way never stays that way for long.’

I am confident that we will find a sensible middle ground. If you have a terminal disease with less than six months to go and you are living in pain or indignity, you can say your goodbyes. You‘ll have to fill in a form ahead of time to prevent evil shenanigans by greedy relatives and you’ll need to persuade a second doctor that you are sure. As in Oregon, the worst fears of assisted-dying’s opponents will not come to pass and it will become an option that those diagnosed with terminal cancer will be glad of.

Why force someone to stay alive in agony for months on end when they will soon die anyway?