Daryl Pullman examines a recent article that defends expanded eligibility for medical assistance in dying on questionable grounds of autonomy and harm reduction.

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Imagine you are a parent and a ruthless criminal has taken you and your child hostage. The criminal offers you a tragic choice. She will let either you or your child go free, but only on the following condition; you must kill either yourself or your child. If you kill your child, you will go free; if you kill yourself, your child will go free. If you choose to do neither your deranged tormentor will kill both you and your child. You decide to kill yourself.

According to the line of reasoning developed in a recent article in the Journal of Medical Ethics (JME), although it is unfortunate you found yourself in such an unjust circumstance in which your options were so severely restricted, your choice was nevertheless “autonomous”.  You did not have to take your own life, but you chose to do so in order to reduce the harm that would result from both you and your child dying. Your choice was certainly tragic, but it was nevertheless “meaningfully autonomous”.

Photo Credit: Pickpik. Image Description: Health care professional holding a patient’s hands.

Weibe and Mullin, the authors of the JME piece, are of course not talking about maniacal kidnappers. Their focus instead is the current situation regarding medical assistance in dying (MAiD) in Canada. The passing of Bill C-7 expanded the eligibility criteria for MAiD. No longer does one’s death need to be reasonably foreseeable. Any person, who deems his or her life situation is causing intolerable suffering, for virtually any reason, can now apply for MAiD.  Cases are now emerging of individuals opting for MAiD when they are unable to find adequate social supports to relieve the burden of their day-to-day existence. When a society devolves to the point where it redefines every kind of social injustice as a “medical problem” such that MAiD is a legitimate or even preferred option, society in general and bioethicists in particular must consider the moral options. Either we challenge the legal and moral processes that now sanction such desperate actions, or we perform the moral and intellectual gymnastics necessary to justify those tragic “choices”. These authors chose the latter.

Weibe and Mullin focus on the recent case of a 51 year-old Ontario woman who suffered from multiple chemical sensitivities. Unable to find adequate housing she opted for and received an assisted death. It is “worst case scenarios” such as these, state these authors, that receive attention in the mainstream media and thus have the potential to sway public attitudes against MAiD. Hence, they aim to explore the quality of the decisions that people in such desperate circumstances are making. They conclude that such decisions are in fact “meaningfully autonomous” and our moral obligation is to respect them. Doing otherwise risks unjustifiable paternalism.

Weibe and Mullin argue that the fact someone’s options are restricted due to oppression is insufficient to reduce autonomy. Oppressed persons retain the ability to understand and appreciate the consequences of their choices, just as you, the fictitious parent in our opening paragraph, would and did. Furthermore, these authors maintain that oppressed persons often retain capacities and self-regarding attitudes necessary for autonomy, such as the ability to understand and appreciate the consequences of their choices, the capacity to value, and the ability to reflect upon the values guiding their decisions, even as they display attitudes of “engaged hope”. Again, you in your role as fictitious parent would no doubt meet all the putative conditions for “meaningful autonomy” as outlined by these authors, including the “engaged hope” that your tormentor would be true to her word and would release your child. Interestingly (or perhaps, disturbingly), Weibe and Mullin maintain there is no evidence to suggest that individuals who find themselves in such unfortunate circumstances do not trust themselves, or that they despair completely. However, given that the oppressed individuals in both the fictitious and actual scenarios described here have decided to choose death over continued existence, it is difficult to imagine what would count as “evidence of despair” for these authors.

Bill C-7 drove a wedge between the end of life and suffering, thus co-opting the medical profession into providing a solution for individuals facing all manner of social injustice. These authors are complicit in this process by driving another wedge between persons and the tragic choices they feel compelled to make. By then describing these forced decisions as “meaningfully autonomous” they make it more important to respect the putative “choice” than to respect the persons driven to make them. Elsewhere I’ve described such sophistical reasoning as “moral nonsense”.

Toward the end of their paper Wiebe and Mullin change gears and offer a consequentialist consideration, ostensibly in support of their rationale for honoring such tragically “autonomous” choices. Honoring them, they contend, will result in harm reduction. That is, rather than forcing people to suffer through their circumstances by refusing them MAiD, thus furthering the harms their unjust social circumstances have already inflicted upon them, we should end their suffering by killing them (MAiD). All things considered, they argue, this would be a lesser harm. We cannot discuss all the potential chilling sequelae of such creeping consequentialism in the context of an expansive and ever expanding MAiD regime such as we have in Canada. A closer reading might conclude that such consequentialist reasoning is really the core argument here: the attempt to salvage some notion of “autonomy” is intended to make it more palatable. It is just such reasoning that keeps the disability community awake at night.

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Daryl Pullman is a Professor of Bioethics in the Centre for Bioethics at Memorial University.