Should Suffering Be Necessary to Qualify for Assisted Death?
A response to Davis and Mathison.
Jeremy Davis and Eric Mathison argue that autonomy should be the only criterion to access assisted death. Here are some key excerpts:
“Most people who defend physician-assisted death (PAD) endorse the Joint View, which holds that two conditions — autonomy and welfare — must be satisfied for PAD to be justified. In this paper, we defend an Autonomy Only view. We argue that the welfare condition is either otiose on the most plausible account of the autonomy condition or else is implausibly restrictive, particularly once we account for the broad range of reasons patients cite for desiring PAD, such as ‘tired of life’ cases” (p. 345).
“At its core, autonomy involves self-governance or self-determination in accordance with one’s self-conception and values” (p. 346).
“Our view is that the best interpretation of the suffering condition collapses into the autonomy condition. First, notice that while physical pain is sometimes the reason for requesting PAD, due to many advancements in palliative care…other forms of suffering of the sort Sumner mentions above are more common... These are typically due to losing what one once valued — e.g., dignity, life projects, independence... Many people also suffer from what some have called ‘life fatigue’... Others cite ongoing and incurable psychological distress... In some cases, these values might not be entirely agent-centred. For example, a woman might care deeply about being able to support her family, and the loss of that ability — or worse, becoming a burden — will cause her great suffering” (p. 348).
“what is morally relevant about suffering is that one judges continued life to be intolerable to oneself. But the foregoing examples show that there are many other ways that life might be intolerable that do not involve pain in the ordinary sense, such as living a life that is inconsistent with one’s values or is otherwise judged to be no longer worth living. Importantly, judging that one’s life is not worth living is not restricted to a prudential judgement. People care about living in accordance with their values, and the inability to do so is a significant source of distress. This is so even if one lacks physical suffering. On our view, it is possible to be prudentially well off while judging that something one values that requires death outweighs the prudential value of continued life” (p. 348).
“In short, if the subjective assessment that one’s suffering is intolerable justifies PAD, then this must include the full range of ways people might face conditions that are intolerable to them, not only the physical kinds of suffering on which many writers have focused. But once the condition is understood this way, as we have argued it must be, then the welfare condition does not require anything beyond what the autonomy condition already stipulates. Suffering is just one instance of the broader category of judging one’s life as no longer worth living, which the autonomy condition already captures” (p. 349).
“Autonomy Only does not require (as the Joint View does) that physicians and policymakers make judgements about which lives are worth living — that is, by judging that certain illnesses or disabilities can satisfy the welfare condition while others cannot” (p. 351).
“If we accept the Autonomy Only view for PAD, does consistency demand that we accept it for all other decisions in healthcare? Not necessarily. Indeed, there seem to us good reasons for rejecting this principle in certain other cases. Imagine a patient who requests a prescription for a non-lethal but still very dangerous drug (e.g., one of the very addictive opioids). Even if this decision is made fully autonomously, we suspect most would judge that the physician is not permitted to accede to this request. It is not clear whether this intuition rests on reasons of welfare or if there is something particular about prescribing potentially harmful drugs that is unique” (p. 353–354).
Response
I think the authors are onto something here, but I don’t know if their Autonomy Only view is fundamentally “autonomy only.”
First, it’s hard to make the distinction between autonomy and well-being because they can and often do overlap. For instance, you may think that well-being just is living a life characterized by “self-determination in accordance with one’s self-conception and values.” So, to the extent one isn’t living autonomously, one has low or even negative well-being.
To elaborate, desire-satisfactionists believe that well-being is constituted by getting your desires fulfilled. So a species of desire-satisfactionism (let us call it value-fullfillmentism) could say that living a life according to your values constitutes your well-being. Valerie Tiberius argues for something like this.
And even if you don’t find desire-satisfactionism or value-fulfillmentism convincing, other theories of well-being could easily incorporate an autonomy component. For instance, hedonists could say that not living autonomously is painful in some sense. Objective list theorists could consider autonomy as an objective good.
What this suggests is that it’s difficult to disentangle the two concepts because well-being can be flexible enough to incorporate autonomy. In a sense, the exact opposite position of the authors can be argued. Instead of well-being collapsing into autonomy, autonomy collapses into well-being.
Consider an example the authors use to defend their position —nontherapeutic abortion. They state, “[T]here is no welfare condition. Doctors do not assess whether an abortion is in the woman’s best interest, and the woman is not required to defend her decision by showing that it is good for her” (p. 354).
This is true only if we reject the notion that well-being is constituted (at least partly) by living according to one’s values. I, for one, find it entirely plausible that there’s an implicit well-being assumption involved in justifying nontherapeutic abortions.
So, am I arguing that autonomy collapses into well-being or should be considered subsumed under well-being? Not exactly. While I do think that autonomy is part of well-being, I’m open to it being a separate intrinsic value as well. I just don’t think it’s easy to separate the two.
Second, the authors state that one benefit of the Autonomy Only view is that under that framework, doctors would not need to judge certain lives as not worth living. This is true, but I question how much of a benefit that really is.
Assuming that death can be good for someone, and assuming the patient thinks death is good for them, why would it be problematic for others to agree? Consider the case of becoming paralyzed. Assuming that it can be prudentially bad, and assuming the patient thinks becoming paralyzed is bad for them, why is it problematic for a doctor to agree?
I suspect the source of the concern of judging other lives as being not worth living is multi-fold. First, there’s an implicit assumption that death cannot be good for someone. Second, there’s an implicit assumption that life is sacred, meaning that life has intrinsic value and that it’s always wrong to destroy it intentionally. And third, there’s a conflation of the value of life to the person and the value of the person themself. I, of course, think all of these are mistaken. To save space, I will only elaborate on the third point.
Some think that if a doctor judges my life not to be worth living anymore, it necessarily means he devalues me as a person. This is the impression I get, at least from some folks who argue from a disability perspective. This is mistaken. What is necessary is for a doctor to determine that they agree that the patient is suffering intolerably. It’s about the prudential value of continued life for the patient.
In other words, there’s an important distinction between judging me as Jason Chen to be of less value and agreeing with my own assessment that death would be better for me. The former is characterized by thinking that since I contribute less to society or that since I am a financial/emotional burden, it’s okay to destroy my life. That’s not what (partly) justifies assisted death. Rather, it’s about the prudential value of my continued living for me and the doctor agreeing with my own judgment.
And third, I find it interesting that the authors don’t believe that their view permits the dispensing of nonlethal but still very dangerous drugs to a patient for whom it would not be beneficial. If we’re only focused on autonomy, then I see no reason why we shouldn’t fulfill those requests. It seems to me that the only justification for not doing so would be considerations of their well-being. Or perhaps there could be some political philosophical argument about harm to society.
In any case, I suspect what this shows is that well-being is indispensable. And in the cases where the Autonomy Only view seems to get it right, perhaps it’s only because there’s an implicit well-being judgment.
To test this, we need a scenario in which a patient autonomously requests something that could not be in any way prudentially good for them and, in fact, must be prudentially bad for them. I cannot think of a case like this, unfortunately, because I think a reasonable account of well-being should include something like value fulfillment.
In the end, I’m not sure how to disentangle autonomy from well-being or vice versa. They seem so closely connected that fundamentally, I don’t think the Autonomy Only view is truly “autonomy only.”