Why I support active euthanasia

A woman killed her grandfather in 1992. She did this in a neighbouring country, having watched him suffer excruciatingly and after he had pleaded with her to help him end his life. She told this story on my radio show recently, talking publicly for the first time about what had happened.

She had never spoken about this event because she was scared that she may be jailed for murder. To avoid possible requests to have herself extradited from South Africa, she chose not to reveal the country where this happened.

She simply wanted to convey the conflict she had felt between how she thought ethically about her grand-father’s desperate request and the law forbidding assisted suicide or active euthanasia in the country in which this had happened.

The woman is clear that, for herself and her grandfather, she did the right thing ethically. But she has private anguish, one could sense, about the law and varying attitudes of people towards what happened.

There is a legal prohibition against active euthanasia in South Africa. This is why an older woman, who clearly had her mental faculties intact, called in on the same show and cogently explained a decision she has taken. She is weeks away from going to Europe where she will be able to die a dignified death through assisted suicide.

She told me that she was under no pressure from anyone to end her life but that the quality of life she now has meant that she wished to suffer no longer.

Sadly, her last bit of suffering involves the isolation of travelling all the way to Europe to die there, instead of dying at home. She would have wanted to be surrounded by friends and family in her final days.

When I asked her how she feels about some people who may think it shameful to consider assisted suicide, she said she doesn’t care about others’ feelings. She cares most deeply about her own life and her values and wishes for herself. She cannot be bothered to spend the end of her life being absorbed by the moralising narratives of people who are not her.

There are two sets of issues here — policy and morality.

I do not want to discuss the nuts and bolts of a policy that allows active euthanasia — that is a debate I can return to, if there is interest among readers — because policy debates can be a smokescreen for the elephant in the room. I want to talk about the elephant. So, let me simply say the following about policy. Obviously we need to think carefully about a range of practical policy fears. How would you design an assisted suicide policy, in a deeply unequal society such as ours with concomitantly high levels of poverty and unemployment, that reduces the risk of someone choosing to die because they think they are a burden on a family? How, too, do you deal with a momentary bout of hopelessness during which someone might feel they want to die when they are first diagnosed with a terminal illness? What safeguards do you build into the policy to both respect patient autonomy but not let unreflective or impulsive expressions of wishes be a hasty basis for choosing death?

What about the medical ethics and role of doctors? Given increasingly rapid advances in treatments for many medical conditions and illnesses that are painful or terminal, who decides what prospects there are of survival? How many doctors or specialists must jointly give input into a decision of this kind? How much time must the medical experts say someone probably has to live before a desire to hasten death can be expressed and actioned?

What, too, about mental health? Very often the debate on active euthanasia focuses on the physical body, but many people with mental health illnesses may argue that they are qualitatively in similar states as someone suffering, say, the very final stages of an incurable, aggressive and merciless cancer. What should public policy say about this?

I take policy debates very seriously. We could craft sensible policy on all of these legitimate, practical questions and issues if we thought that active euthanasia should be allowed. The policy language to be chosen and framework to be settled on aren’t insurmountable challenges for lawmakers, in collaboration with experts and activists, and also through an iterative process of meaningful public consultation.

There is no use pretending you think we cannot design a good policy when secretly your biggest objection is a moral one, and your practical objections are secondary — even when they are sincere practical worries. That is the elephant in this discussion.

Some people think active euthanasia is a case of “playing God” and that it is ethically unacceptable. Let’s debate this moral elephant honestly.

I think we should legalise active euthanasia because the moral case for doing so is persuasive.

First, we keep claiming to take the value of autonomy seriously. It is central to our Constitution and has been the basis of many social policies we have adopted or chosen to reject. Besides the law, we also rightly make reference to the value of autonomy in some of our ethical reasoning.

To take one of countless examples, we think that it is wrong for a doctor to not get the consent of a patient before performing a certain operation. We recognise, say, that it is unethical to bypass the autonomy of a patient in a discussion about their welfare.

This is also why the more egalitarian societies become regarding gender equality, the more we recognise that women’s rights to bodily integrity and reproductive autonomy matter — because women, as persons, deserve to have their autonomy respected and affirmed. If your autonomy is to be limited, then the pressure will be on the one doing the limiting of that right to justify why the limitation is fair. But the presumption, in the first instance, is in favour of respecting autonomy.

So why then do we not respect the autonomy of people, under defined circumstances, who express a wish to die?

Yes, we can debate what the policy should be, but that is detail, frankly. Those who are morally squeamish need to recognise that they have the higher burden in this debate to make argument for limiting the autonomy of a person who is lucidly expressing a wish about wanting to die when medical experts, pending the meeting of criteria stated in an adopted policy, have agreed that there is no hope of living much longer.

We must examine our inconsistency here. We respect autonomy more during the earlier stages of someone’s life than we do near the end of their life. Why is that?

Second, we need to think ethically about our attitude towards suffering. Suffering isn’t cool. I was almost in tears listening to family members talking about the incredible levels of suffering some of their loved ones experienced during the last stages of terminal illnesses.

You might think suffering is necessary for you. But is it your place to compel other people to adopt your values?

Here we must be honest, too, about the sociology of religion.

Sometimes we do not think straight about received “wisdom” handed down through religion and culture. We have received ideas about how we must die that become the de facto basis of public policy. But we need to allow for value pluralism — the idea that there are many plausible values, even if they are in conflict with each other — in public policy.

Your god or deity may forbid you from hastening death. If others do not share your moral framework, why should they be governed by a law of general application that is founded on the moral rules of your religious or cultural community?

Finally, dignity is a central moral value of our liberal constitutional foundation. The connection between dignity, roughly understood as intrinsic self-worth, and autonomy, roughly understood as self-governing, is important and brings us full circle.

If we truly want all people to live dignified lives, then we must extend that idea to allowing for people to self-govern their dying with dignity.

Let’s choose rationality and compassion over moral squeamishness and overreaching conservatism.