Dying Generously
Philosophy essay on death and assisted dying, tackling some arguments and counterarguments for medically assisted dying.
Abstract
Philosophy essay on death and assisted dying, tackling some arguments and counterarguments for medically assisted dying.
Dying Generously
Having investigated philosophical questions about death for around a quarter century, I am often struck by the seeming inconsistencies in widely held attitudes toward death. One such inconsistency concerns dying generously, that is, using one’s death as an opportunity to promote the interests or well-being of others.
Here’s the inconsistency I have in mind: We tend to venerate healthy people who lose their lives in service to others. Soldiers killed in combat, ‘first responders’ to natural disasters or crime scenes, teachers slain protecting their pupils from a school shooter, martyrs to religious or political causes: These are usually viewed as ‘heroic’ deaths, deserving of tribute.
But this veneration does not extend to those who, as their lives come to a close, try to make their deaths an opportunity for altruism. Consider debates around medically assisted dying. For those strongly opposed to the practice, it does not much matter what a person’s reasons for seeking assisted dying might be. But among those who support the legalisation of medically assisted dying, their support largely extends only to choices to hasten death that rest on what we might classify as egoistic reasons. The different jurisdictions where assisted dying has been legalized have different standards for who is eligible for such assistance. In nations such as Belgium, only those with a medical condition responsible for ‘persistent and unbearable’ suffering can receive assistance in dying. In other nations (Netherlands), the patient must suffer from a condition with no prospect of improvement. Throughout the English-speaking world, the eligibility standards have often focused not on the nature of a person’s suffering but on how proximate death is. In the United States and Australia, for example, only those with terminal illnesses are eligible for assistance in dying.
But in the background of all of these laws is a tacit denial that assisted dying should be available to those who wish to hasten their deaths in order to benefit others. Nowhere in the world, for instance, can a seriously ill person who is otherwise legally ineligible for assisted dying opt to receive such assistance in order to ensure that as many of their organs as possible are suitable for post-mortem donation. The notion that opting for an earlier death could be justified in order to spare your loved ones from having to witness the ravages of your decline is likewise frowned upon, as is the proposition that an earlier death might relieve emotional or financial burdens faced by family or caregivers. So too, a desire to conserve scarce medical resources so that they can be used to improve the lives of others is also not treated as a legitimate reason for a seriously ill person to seek assistance in dying. My burdens, pain, indignity, and the like can justify choosing to die earlier than I otherwise would; your burdens, pain, indignity, and the like cannot.
From a moral perspective, this is puzzling. Typically, we hold altruism in high regard, treating beneficence as among the highest moral virtues. But our attitudes toward the choices of the seriously ill invert this. If a person is dying, selflessness is castigated, and selfishness is mandatory. The firefighter ‘cut down in the prime of life’ while attempting to save the occupants of a burning apartment complex is a hero. The person in the last weeks of life who seeks assistance to die so that their kidneys will not be so deteriorated that they cannot be viably transplanted is a criminal. Dying heroically is celebrated but dying generously — that is, using one’s own death as an opportunity to help others — is proscribed.
The one social practice that appears to be a counterexample to this is the right to bequeath one’s wealth or property. No doubt many bequests are altruistic, aimed at providing financial security to the deceased’s family or loved ones or at supporting worthwhile philanthropic causes. Strictly speaking though, the right to bequest is not a counterexample to the social prohibition on dying generously. Outside of nations such as France, which mandate that children are entitled to some portion of their parent’s estate, the right to bequest allows one to distribute one’s wealth in most any way one sees fit, including destroying that wealth or putting it to frivolous or even evil purposes. Bequest is therefore only conditionally an act of generosity. Indeed, the right to bequest only serves to underscore how odd our opposition to dying generously truly is. If I am permitted to direct that my wealth be distributed in order to benefit my loved ones once I die, why can I not decide to hasten my death in order to ensure that they will have more of that wealth once I die because less was spent on my end of life care? If am permitted to distribute my financial assets to benefit others, why cannot I not distribute my bodily assets (my transplantable organs) to benefit others, especially when their usefulness to me is coming to a rapid end?
The social prohibition on dying generously is not a coherent attitude, in my estimation. We might think we should applaud heroic deaths but oppose generous deaths because there is something especially laudable about the former. The firefighter dies in a show of bravery, putting their life at risk to assist others. Yet there is also bravery in merely facing death square in the eye and choosing it nevertheless. Arguably, the seriously ill patient who chooses to hasten death to help others shows more bravery than the firefighter. The firefighter recognises that they are risking their lives to help others but hopes nevertheless to survive. The seriously ill patient who hastens their death to help others is far more certain to die though. If anything, choosing to die is a greater show of bravery than merely risking one’s life.
Denying people the right to die generously is troubling because it precludes the dying from utilizing their deaths to benefit others. The beneficiaries of dying generously are therefore worse off than they might be. But there is an additional moral reason to object to disallow dying generously: Everyone, including dying people, has a moral right to such generosity. We can legitimately debate whether morality requires that we make significant sacrifices for others – whether affluent individuals should be compelled to pay taxes to support the health or education of others, or whether the world’s fortunate are morally obligated to give away large portions of their income to save the lives of strangers in faraway lands. But even those who deny that morality issues such strong requirements will agree that morality does not forbid such sacrifices. Disallowing people to die generously thus represents an unjustified restriction on their freedom, in this case, their freedom to use their bodies to promote the interests of others.
The freedom at issue is compatible with acknowledging the importance of human interdependence. Some opponents of assisted dying argue that wanting to hasten one’s death in order to relieve the burdens of care we impose on others in the final stages of life treats dependency or vulnerability as shameful. Not so. A person who seeks to hasten death to relieve others of burdens (or in order to conserve scarce medical resources) need not be ashamed of their dependency on others. They simply opt not to impose those burdens. So too for the individual who wishes to hasten death in order to maximise the chances that their organs can be successfully transplanted. Indeed, wanting others to take advantage of bodily tissues that have come to have little value to us is a powerful acknowledgement of human interdependence. So long as the choices to hasten death are made with the ill person’s rational consent, that they are opting to die in order to benefit others is little reason to restrict those choices.
In fact, letting people die generously can provide the seriously with something that is too often elusive as death closes in: meaningfulness. Nowadays, dying is often a highly medicalized process, involving repeated bodily interventions and continual medical attention. Many people find this process undignified or degrading, in no small part because it too often reduces them from active agents with the power to shape their day-to-day lives to passive vessels with a severely limited ability to act in accordance with their values or preferences. Sadly, dying often disempowers us, practically and morally. Yet by standing in the way of dying generously, we bar the seriously ill from wresting back a sense of moral efficacy that the dying process too often robs them of. Benefitting others is one of the most important ways to lend one’s life a sense of meaningfulness. There is cruelty then in depriving those who are approaching death from using the final chapter of their lives to enhance their lives’ meaning through helping others.
Some may argue that barring ‘generosity’ at the end of life aims to protect individuals from abuse or exploitation, particularly members of groups that are coded as especially altruistic. We might worry, for example, that a seriously ill woman who is also a mother may be particularly susceptible to messages that she owes it to her family to protect them from onerous burdens, thereby leading her to opt for assisted dying in order to relieve those burdens when she would not opt for it otherwise. Notice, however, that the mere expression of such messages is not morally problematic. The worry is rather that such messages might manipulate or pressure someone into choosing assisted dying. This is obviously possible, but evidence from jurisdictions where assisted dying has been legalized for some time does not suggest that such manipulation or pressure is likely to occur. In addition, our stance on assisted dying should take into account that manipulation or pressure is equally likely to work in the opposite direction — that is, that seriously ill people can also be subject to messages that lead them to opt for further medical treatments or interventions rather than hastening their own deaths. These messages are especially likely to originate with family members who struggle emotionally with the prospect of a loved one’s death or from medical professionals for whom a patient dying is thought of as a clinical failure.
I am hardly the first to observe that the human lifespan has a cyclical quality inasmuch as in the final stages of life we return to a physical condition akin to childhood: in old age, we are often highly dependent and less capable than we were in midlife, just as we are highly dependent and (not yet) fully capable in childhood. Yet this fact does not justify treating the seriously ill as having reverted to childhood in a moral sense, as having relinquished their say over how they relate morally to others. Denying the right to die generously wrongfully infantilizes the dying, and an enlightened society should instead aim to afford the seriously ill the chance to decide to die nobly in service to others
Professor Michael Chobli holds a chair in philosophy at the University of Edinburgh. His research addresses a variety of areas within ethics, including the philosophy of death and dying, work and labor, punishment, Kantian ethics, paternalism, and moral psychology.
