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Expressivism at the beginning and end of life
  1. John Keown
  1. Kennedy Institute of Ethics, Georgetown University, Washington, DC 20057, USA
  1. Correspondence to Dr John Keown, Kennedy Institute of Ethics, Georgetown University, Washington, DC 20057, USA; ijk2{at}

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Philip Reed’s interesting and welcome comparison of the expressivist case against, on the one hand, prenatal testing and abortion and, on the other, physician-assisted suicide (PAS) and voluntary active euthanasia (VAE), indicates the relevance of the expressivist case against the latter and its resilience to criticisms of the expressivist case against the former.

Advocates of PAS/VAE commonly argue that they should be lawful out of respect for autonomy: everyone has the right to choose a physician-hastened death if they meet specified conditions such as ‘terminal illness’ or ‘unbearable suffering’. The focus on autonomy is distracting, for the real work of justifying PAS/VAE is done by the argument that life with the conditions specified is not ‘worth living’. Legalisation endorses, and expresses, the judgement that it is reasonable for people with those conditions to think their lives no longer worth living and obtain medical help to end them. Were the justification to respect autonomy, why limit the choice?

It is small wonder, in light of the discriminatory nature of such a judgement, that disability groups have been outspoken opponents of legalisation. As society’s ‘canaries in the coalmine’ they have warned of the dangers, especially of pressure on the disabled to end their lives to relieve the burden on the state.1

Reed pertinently asks why the ‘expressivist’ argument has not as such featured in the debate. An answer could be that it has, although not under that label, and that it is implicit in, and secondary to, the key moral argument against legalisation. As the House of Lords Select Committee neatly captured that argument, the prohibition on intentional killing is the ‘cornerstone of law and of social relationships’ which ‘protects each one of us impartially, embodying the belief that all are equal’.2 That argument from equality rules out discrimination based on disability.

Reed might profitably have explored whether judgements about whose lives are thought not ‘worth living’ can sensibly be limited to those who are ‘terminally ill’ or experience ‘unbearable suffering’. If death can benefit them, why not others, such as the lonely or frail elderly? In 2016, the Dutch government proposed extending its law permitting a hastened death to include old folk with a ‘completed life’. Dutch researchers who interviewed people over 70 found that their wish to die was strongly influenced by their feeling worthless. The government said it was important to increase older people’s sense of their own worth and to ensure they felt appreciated.3 Quite how facilitating their hastened demise was supposed to promote this laudable goal was unclear. The pushback in the Netherlands against the proposal has been welcome, precisely because the proposal would reinforce negative stereotypes of the elderly by crafting an exit door with their name on it.

Reed mounts a thoughtful and modest case that, whatever force the three objections to the expressivist argument against prenatal testing and eugenic abortion may have, they are weaker in relation to the expressivist argument against PAS/VAE. By showing the weakness of the objections in relation to the latter, his paper also indirectly raises issues about their cogency in relation to the former.

The following questions, that track the three objections he considers, merit consideration. First, do PAS/VAE laws, that do not mention disability as such, express that much more determinate a meaning than a law that, like the English abortion law, explicitly permits abortion for disability and, unlike most other grounds, until birth? Does not a specific eugenic ground reinforce, as the Disability Rights Commission observed, negative stereotypes about disability?4 Does not the limited but documented practice of late abortion even for harelip and cleft palate demonstrate the remarkable degree of negativity towards early disability? So too the pressure (the risk of which Reed understates) sometimes exerted on parents to test and abort?5

Second, could not Reed’s response to the second objection have been more robust? Why should contentious ‘rights to autonomy’ so easily trump the expression of negative attitudes? Is not the right to free speech sometimes limited even to prevent others being offended? Why does a ‘right to control the circumstances’ of reproduction include access to expert means if those means would be used to implement and express (by the experts and the parents) negative attitudes to the disabled (or to girls or gays)? And, if there is such a right of access, and if there is a ‘right to die’, why deny expert assistance to control one’s end?

Third, could the paper not have at least flagged the controversial nature of the dualism that underlies the third objection, and its disturbing implications? Would it not regard human beings who lack a stipulated level of intellectual ability—whether disabled newborns or adults with profound intellectual disabilities, including millions of demented patients—as ‘non-persons’, who lack a right not to be killed or exploited? Mary Warnock (in)famously said: ‘If you’re demented, you’re wasting people’s lives—your families lives—and you’re wasting the resources of the National Health Service’.6 Would killing or exploiting these many ‘non-persons’ not express a negative attitude (to put it mildly) to disability?

Reed could also have mentioned the cultural context in which we live, which prizes youth, beauty, physical and mental perfection, and productivity and disvalues the non-productive, the disabled, the dying and the elderly. The neglect of those in care homes during the pandemic is but the latest example. Our practices, norms and laws express our attitudes to the disabled. They also say something about us.



  • Contributors JK is the sole author of the comment.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Patient consent for publication Not required.

  • Provenance and peer review Commissioned; internally peer reviewed.

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