• disabilities
• end-of-life
• ethics
• reproductive medicine

In his thought-provoking piece, ‘Expressivism at the Beginning and End of Life’, Philip Reed contrasts the application of the expressivist objection to the use of reproductive technologies (such as prenatal testing and preimplantation diagnosis) with its application to interventions that bring about death (such as physician aid in dying and euthanasia). In the process of supporting his comparative conclusion, that ‘expressivism at the end of life is a much greater concern than at the beginning’, he makes some interesting observations and offers some convincing arguments. Further examination, however, shows that his arguments actually support conclusions far beyond the modest one he intends to draw. The absurdity of these conclusions can be used to identify the flaws in Reed’s argument.

Reed summarises the expressivist objection in the context of physician-assisted suicide (PAS) as follows:

When we allow PAS for individuals who are terminally ill or facing some severe disease or disability, we send a message of disrespect to all individuals who face such adversities in that we imply that they are inferior or their lives are not worth living.

Analogous arguments have been made about decisions to use reproductive technology to prevent the birth of people with disabilities. Reed describes a common rebuttal to the expressivist objection when applied to these beginning-of-life scenarios: that decisions in those contexts are about people who do not yet exist and, therefore, that those decisions say nothing about the value of people who do already exist. He correctly notes that the same cannot be said about decisions regarding people at the end of their lives. As a result, permitting access to PAS sends a clear message that the lives of some existing people may not be worth living, undermining this rebuttal to the expressivist objection in the end-of-life context.

While convincing at first pass, closer consideration of this argument reveals that it takes us a bridge too far. In his discussion, Reed notes that allowing PAS makes it permissible to end the existence of persons with a particular disadvantageous condition by ‘voluntarily or involuntarily killing or letting die’ which, in his words, ‘raises serious problems’. While ‘non-existential methods’ of preventing disability—those that prevent or eliminate disability without preventing or eliminating the existence of people with disability —are generally uncontroversial, ‘existential methods’ send a clear message about the value (or lack thereof) of some lives. If sound, however, this argument proves more than that PAS and euthanasia send negative messages to people with disabilities. It proves that any decision to limit the length of a person’s life does so, including decisions to withhold or withdraw life-sustaining treatment that are generally agreed to be permissible.

In a time of increasing medical capability, where it is technically possible to keep a person alive almost indefinitely, decisions about whether to forgo or remove interventions such as mechanical ventilation and extracorporeal membrane oxygenation are becoming a routine part of care planning at the end of life. The ethical and legal permissibility of making such decisions has been a matter of consensus for over 40 years. Because Reed’s argument is grounded in concerns about all existential methods of preventing disability, including those in which patients voluntarily decline life-sustaining treatments, its adherents would be forced to hold that despite this ethical consensus, these decisions express disvalue for people with disabilities. The extreme nature of this conclusion raises questions about the soundness of Reed’s argument regarding the expressivist objection when applied in end-of-life contexts. There are at least two places where the argument falls short.

First, there is a conceptual problem that can be found Reed’s description of the expressivist objection quoted above. He claims that allowing PAS for patients who are ‘terminally ill or facing some severe disease or disability’ has implications for ‘all individuals who face such adversities’, dramatically broadening the set of individuals receiving any message purportedly sent. This approach assumes some sort of equivalence between terminal illness and any type of disability, an assumption that is highly questionable. There are morally relevant differences between the lives of most people living with disability and the lives of people who are facing a disease at the end of life. While there may not be a clear, bright line to distinguish the two groups, equating them is a conceptual mistake. If a distinction can be made between the set of all people with disabilities and the subset of that group who would be eligible for PAS, any message sent by the acceptance of PAS would apply only to those similarly situated—that is, those eligible for PAS.

Second, because Reed grounds his argument in the use of existential, as opposed to non-existential, methods of preventing disability, it produces the unintuitive conclusion that any decision to withhold or withdraw life-sustaining treatment would send a message of disvalue. Even if the recipients of that message are only those similarly situated—those facing choices about whether to accept or continue such treatment—this conclusion seems to be out of line with commonly accepted norms. As a result, the claim that it is the existential nature of these decisions that generates the moral concern is brought into question. While it may be one factor, there are likely additional factors that must be considered.

It is worth noting that there are additional reasons to question whether the legalisation of PAS expresses any message to anyone at all that cannot be addressed in this commentary. Nonetheless, this critique is not intended to deny that people living with disability may have feelings about how acceptance of physician aid in dying reflects on the value of their own lives. It does raise doubts, however, about Reed’s comparative analysis and therefore about his conclusion that the expressivist objection raises worries that are more clearly justified in the context of end of life than at its beginning.