‘Be careful what you wish for.’ Euthanasia and Rob Jonquiere’s ‘ideal’ society
An uncle of mine often used to quip: 'Be careful what you wish for!' It's a reminder that things we desire often come with unforeseen and undesirable consequences. If there was ever an instance in which this applies it is in regard to euthanasia and assisted-suicide
Proponents of a law change believe the issue is fundamentally about 'choice'. Allowing those who want it to choose when and how they die would not affect those who think otherwise, it is argued. Euthanasia/assisted-suicide can seem acceptable, fair and safe when the focus is solely on individual 'hard' cases.
As someone opposed to euthanasia and assisted suicide, I am often accused of imposing my choices on others. Actually, I don't have a problem with people exercising choice. In an 'ideal' world, a world of total empathy and inclusion, a world of equitable access to health care in which the elderly were truly valued, I could live with people being given this choice. But we don't live in such a world.
A robust, informed debate about euthanasia and assisted-suicide needs to take into account a number of interacting social factors that define our current New Zealand context: the continuing rise of elder abuse; the increasing social isolation of the elderly; a growth in the overall proportion of elderly; greater pressure on families to provide care; smaller and more fragmented families; an increasing tendency to see persons from a narrow functional perspective; and increasing economic pressures on our health system and families. As one commentator bluntly put it: "I oppose introducing euthanasia in a toxic climate."
The availability of state-sanctioned 'mercy killing' in this environment will, in the first instance, create additional pathways for abuse and neglect. There has never been a more dangerous time to introduce such laws.
There are also the threats that euthanasia/assisted-suicide would pose for quality end-of-life care, our trust in doctors, its potential impact on youth suicide prevention and the inevitable extension to children and to those incapable of giving consent. Further, in the current "toxic climate", a law change will reframe the way the sick, elderly and disabled see themselves and are seen by others. As an experienced nurse recently wrote: "Do assisted-suicide supporters really expect doctors and nurses to assist in the suicide of one patient, then go care for a similar patient who wants to live, without this having an effect on our ethics or empathy? Do they realise this reduces the second patient's will-to-live request to a mere personal whim — perhaps, ultimately, one that society will see as selfish and too costly?" In other words, hey realize that this reduces the second patient's will-to-live request to a mere personal whim—perhaps, ultimately, one that society will see as selfish and too costly? How does this serve optimal health care, let alone the integrity of doctors and nurses who have to face the fact that we helped other human beings kill themselves? expanding personal freedoms to include euthanasia or assisted-suicide undermines the right to remain alive without having to justify one's existence.
As overseas and New Zealand reports show, and contrary to popular opinion, the main reasons people favour euthanasia are not related to extreme physical pain (an experienced palliative-care physician reassures me that these days no-one need die in physical pain) but to such things as loss of autonomy [i], feelings of being a burden and dependency on others [ii], decreasing ability to participate in activities that made life enjoyable, fear of losing control, and social isolation [iii].
This knowledge is not at all contentious. Pro-euthanasia doctors such as Dr Rob Jonquiere openly recognise that many concerned elderly people will choose euthanasia or assisted suicide for such reasons. As Jonquiere noted in a 2013 presentation: "The elderly have feelings of detachment ... The elderly have feelings of isolation and loss of meaning. The elderly are tired of life ... Their days are experienced as useless repetitions. The elderly have become largely dependent on the help of others, they have no control over their personal situation and the direction of their lives. Loss of personal dignity appears in many instances to be the deciding factor for the conclusion that their lives are complete". [iv] In the same presentation, Jonquiere freely and readily admits that "the problem is not so much physical, but social and emotional ..."
What is particularly frightening and distressing, however, is the fact that Jonquiere's response to this is to advocate even more vociferously for these people to have the right to die. "The conclusion that life is completed is reserved exclusively for the concerned persons themselves ... They alone can reach the consideration whether or not the quality and value of their lives are diminished to such an extent that they prefer death over life." All of which leads him to the cold-hearted and brutal conclusion that it is "never for the state, society or any social system" [v] to question or otherwise interfere in such a person's decision.
Looked at through a lens of social justice and inclusion, Jonquiere's analysis and conclusion is deeply disturbing. The intolerable situation that increasing numbers of elderly people find themselves in might be a direct result of neglect, ageism, abuse, ignorance, lack of funding for services, poor public policies or, worst of all, a lack of will to care from family and/or society. But in Jonquiere's ideal society the most moral and caring thing to do is to not interfere with people's choice to kill themselves or be killed by a doctor! In effect, this means that the state, which governs over the society in which these persons live, the very same society that will in very many cases be complicit in their intolerable condition, can assuage its conscience by assisting these people to die.
This is not just. This is not the sort of society I care to live in. Rather than appealing to the best in people, rather than calling forth the sort of commitment and care that is quintessentially human, Jonquiere's 'solution' amounts, metaphorically, to a radical 'lowering of the bar' that sets the standards for inclusion in society.
It raises the spectre of a society in which elderly people's deepest needs, their need to overcome isolation, neglect and the ignominy of feeling a burden, will be ignored in favour of making it easy for them to dispose of themselves; their real needs papered over by appeals to the principles of autonomy and compassion which are morally vacuous because the choice to die would, for such people, be a choice made out of desperation, a choice made because of a lack of real choices, a tissue-thin choice that is ultimately the product of institutionalised familial and/or societal neglect.
This is precisely what Pope Francis was referring to when he recently commented that abandoning the elderly and disabled is itself a form of euthanasia. In fact, Jonquiere's response is just as much about abandoning the foundational principles of an ethical and caring society as it is about abandoning particular individuals.
We can do better than that! We must do better than that for the sake of future generations, our children and grandchildren who, for better or worse, will inherit the legacy of the choices we make. 'What sort of a world are we shaping for them?' is a key question not often asked.
Personal dignity and respect, as well as a commitment to equality and social justice, calls for nothing less than a whole-hearted active dedication to holistic care for those who are suffering, elderly or disabled. It will require a determined and focussed effort to ensure that what makes us distinctively human – our ability to show and receive care – is reflected in our personal and societal attitudes and familial, social, political and cultural structures.
True 'death with dignity' occurs when a person's deepest physical, emotional, social, cultural and spiritual needs are met, when a person feels loved and cared for and feels included and valued no matter what. It is, I accept, not the 'easy way out'. Neither is it for the faint hearted. At this point in our history, the call to care will demand from us great resourcefulness as well as sacrifice. But then, as life teaches us over and again, the easy way out rarely pays dividends.
We must be honest about the unintended, long-term, negative consequences of euthanasia and assisted-suicide for both individuals and society. There would be a huge social price to pay for legalising state-sanctioned killing, counted in lives prematurely ended because of a sad perception by persons that they were 'past their used by date' and had become 'useless eaters'.
Be careful what you wish for!
Dr John Kleinsman is a member of The Care Alliance and director of The Nathaniel Centre
[i] See, for example, Oregon Public Health Division – 2013 DWDA Report at http://public.health.oregon.gov/ProviderPartnerResources/EvaluationResearch/DeathwithDignityAct/Documents/year16.pdf
[ii] See, for example, Malpas, P, K Mitchell, and M Johnson. "'I Wouldn't Want to Become a Nuisance under Any Circumstances' - a Qualitative Study of the Reasons Some Healthy Older Individuals Support Medical Practices That Hasten Death." New Zealand Medical Journal 125, no. 1358 (2012): 9-19.
[iii] See, for example, Nicole Steck, Christoph Junker, Maud Maessen, Thomas Reisch, Marcel Zwahlen, Matthias Egger, and for the Swiss National Cohort "Suicide assisted by right-to-die associations: a population based cohort study". Int. J. Epidemiol. (2014) 43 (2): 614-622 first published online February 18, 2014. doi:10.1093/ije/dyu010
[iv] Jonquiere, R. Fourth Annual Lecture to the Society for Old Age Rational Suicide, London, September 20, 2013 http://www.soars.org.uk/index.php/pages