Choosing death in unjust conditions: hope, autonomy and harm reduction
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Philosophical arguments about autonomy and Medical Assistance in Dying (MAiD), such as those recently espoused by Wiebe and Mullin  in the BMJ Journal of Medical Ethics are deeply troubling in their implications and flawed in their considerations.
In a nutshell, Wiebe and Mullin argue that MAiD can be a ‘harm-reducing’ embrace of individual autonomy to avoid prolonging suffering in oppressed people who cannot access adequate socioeconomic resources. They speak specifically to the application of Bill C-7 MAiD, also known as not-reasonably-foreseeable-natural-death or Track 2, which is for people with chronic physical conditions causing suffering but not death. They argue that even though a person may be poor or have limited options, they can still hold and express autonomy to request and receive death. Death, in their formulation, is the least bad option for people suffering social inequality in an unjust world.
Theirs appears as the latest in a series of recent papers attempting to use autonomy arguments to justify MAiD access under an expanding range of circumstances. Davis and Mathison , for example, argue that a person's ‘welfare condition’ is irrelevant to the ‘moral permissibility’ of MAiD. Braun similarly argues for the ‘provision of assisted suicide (but not euthanasia) as justified when it is autonomously requested by a person, irrespective of whether this is in her best interests’ .
These are not new arguments.
Thirty year...Show More
Wiebe and Mullin argue that autonomous individuals requesting MAiD because of “unjust social circumstances” or “oppression” should receive MAiD as part of a “harm reduction approach.”
To successfully defend this thesis, one would be required to defend a particular understanding of autonomy and harm. As these authors note, these terms are notoriously difficult to define. The authors assert that “acting autonomously…requires hope,” the implication being that a truly hopeless person cannot be meaningfully autonomous. The authors subsequently argue, in seeming contradiction, that “people whose reduced opportunities have led them to lose all hope” are autonomous decision makers. Their attempt to resolve this tension involves asserting that the act of pursuing MAiD is, itself, evidence of “engaged hope.” This runs directly contrary to the witness of patients in these circumstances, who cite despair and hopelessness as their motivation. It is an idiosyncratic and paternalistic (and therefore ironic) understanding of hope that suggests that patients who report a desire for MAiD because of hopelessness are, contrary to their own feelings, hopeful and therefore autonomous.
It may be helpful to think in particulars. In my work as a physician and ethicist in Canada, I have encountered the type of cases that Wiebe and Mullin allude to. In a representative case, a previously able-bodied individual experienced sudden, inexplicable neurological illness that caused significa...Show More
In a recent article two Canadian ethicist/philosophers argued the appropriateness of granting early medical termination (MAiD) to those requesting it because of poverty or a lack of socioeconomic or institutional resources. These are those who would prefer to live but only with unavailable support services ranging from housing to social or rehabilitative and housing resources.
That the ethical focus should be on the a lack of resources so severe as to make life seem intolerable is not considered by these authors or most other ethicist/philosophers. They assume limited resources are fixed and institutionalized. This ignores the long history of medical and social activism begun in the mid-1800s--Rudolph Virchow being the most famous example--that focused on the failure of social support rather than the inevitable deaths that resulted. If one were to take ethics seriously, the issue would not be permissiveness but activist arguments in that earlier tradition for the care required by the fragile and vulnerable. It is thus that was lost--what Jane Adams called the 'guardianship function' when bioethicists sought successfully to disparage the ethical engagement of physicians involved in patient care.
Alas, an ethics of 'least harm' that accepts the status quo driving individuals to seek an early death is really no ethic at all. It's simply an acceptance of an unacceptable status quo that in ethics, should be the focus.