'Enduring Intolerable Suffering' Isn't Contradictory

I’d like a word

Photo by Meghan Rodgers

A funny thing about English is that words often have multiple meanings, and one of the benefits of being an English speaker is that I’m competent to comment on such matters. When the words apply to medical assistance in dying (MAID), I’m practically over-qualified.

There are some requirements to have MAID in Canada. One of them is that you must have a ‘grievous and irremediable medical condition’, which the criminal code says requires meeting three criteria, the last of which is the following:

(c) that illness, disease or disability or that state of decline causes them enduring physical or psychological suffering that is intolerable to them and that cannot be relieved under conditions that they consider acceptable.

In a new paper called “Words Matter: ‘Enduring Intolerable Suffering’ and the Provider-Side Peril of Medical Assistance in Dying in Canada”, Christopher Lyon argues that this criterion contains two contradictions, one between ‘enduring’ and ‘intolerable’ and another internally with intolerability. 

As Lyon describes, according to the Oxford English Dictionary, ‘to endure’ means “to last, continue in existence”, “to undergo, bear, sustain (continuous pain, opposition, hardship, or annoyance)”, or “to suffer without resistance, submit to, tolerate; to contemplate with toleration”. In contrast, according to the OED, ‘intolerable’ means “that cannot be tolerated, borne, or put up with; unendurable”, or “that cannot be withstood”. “The Canadian Oxford Dictionary similarly defines intolerable as ‘that cannot be endured’”, says Lyon.

Words matter, as Lyon’s title reminds us, so an obvious contradiction won’t do. To resolve the issue, Lyon recommends removing the subjective intolerability standard and replacing it with objective medical criteria such as physical and mental decompensation.

Enduring as Continuing

Here’s where I get to use my powers as an English speaker. The verb ‘to endure’ does indeed mean ‘to undergo or suffer’, as in 2 Timothy 2:3: “Thou therefore endure hardness, as a good soldier of Jesus Christ.” But the adjective ‘enduring’ means ‘lasting’. When we speak of an ‘enduring power of attorney’, we don’t mean someone who is bearable when dealing with property and financial affairs. No, we mean someone who remains the power of attorney. They continue to be the power of attorney over time.

‘Enduring’ is used in Carter, the Supreme Court of Canada’s 2015 decision that struck down the general prohibition on assisted dying. The decision speaks of someone having a grievous and irremediable medical condition that “causes enduring suffering that is intolerable to the individual in the circumstances of his or her condition.” ‘Enduring’ here obviously means ‘lasting’, which we can tell not just from the context, but because the word is ‘enduring’, the adjective for ‘lasting’, instead of ‘endurable’, the adjective for ‘able to be endured’.

Now, Lyon is aware of the difference between the verb and the two adjectives, noting that “enduring is synonymous with terms like ‘continuous’ or ‘lasting’”. However, he equivocates between the two, since doing so is necessary to get his argument off the ground. Here’s the main move, with my italics on the slippery bits:

If suffering is lasting or continuous, it conforms to the other definition of ‘endure’, which is to bear, sustain, or tolerate. Someone bearing lasting or continuous suffering can be easily understood as tolerating it. It is much harder to claim that someone with lasting or continuous suffering is somehow not tolerating it. Thus, the criterion statement in the legislation regarding health conditions that cause “them enduring physical or psychological suffering that is intolerable to them and that cannot be relieved under conditions that they consider acceptable” is a contradiction in that a person who endures physical or psychological suffering must, therefore, be tolerating their suffering or condition—even if it is severe. Conversely, a person suffering intolerably must be unable to endure it.

This last sentence is particularly noteworthy. The verb ‘to endure’ has a different meaning to the adjective ‘enduring’, so swapping one for the other is unbecoming of someone who claims that words matter. Given this, what Lyon claims is a contradiction isn’t really one. When he says that ‘endure’ is antonymic with ‘intolerable’, that’s true only of the verb ‘to endure’, but not the adjective ‘enduring’.

Intolerable as Unacceptable

Still, although there’s no contradiction between ‘enduring’ and ‘intolerable’, in the quotation above, Lyon makes a claim based on the definition of ‘intolerable’ that’s worth considering. His argument is that there’s a problem with intolerability. Some people who qualify for MAID choose not to have an assisted death, waiting instead to die by natural causes. In such cases, says Lyon, this means their suffering wasn’t actually intolerable. After all, they tolerated their suffering by continuing to live, and if this is true, they didn’t really meet the criteria for MAID.

Now, again, I know some English, so let’s consider this point. People use ‘intolerable’ to mean ‘unendurable’—that’s a perfectly fine use—but they also use it to mean ‘unacceptable’, which is a synonym, or in the sense the Cambridge Dictionary gives: “too bad or unpleasant to deal with or accept”.

Consider how Miss Bingley describes Eliza Bennet in Pride and Prejudice: “in her air altogether there is a self-sufficiency without fashion, which is intolerable.” Does Miss Bingley really mean that she can’t be in the same room as Miss Eliza Bennet, that it’s unendurable? Of course not. She means it’s unacceptable. Lyon mentions this usage, calling it ‘symbolic’, but intolerability as unacceptability is a legitimate use of the word.

In this way, Lyon sets the bar for intolerability extremely high. The only way to tell if someone’s suffering is intolerable in the Lyonian sense is if the person takes her own life, making it intolerable—that is, unacceptable—as a definition. But that’s not how the law is using the word. ‘Intolerable suffering’ means that a person no longer judges her life to be worth living. The amount of suffering she experiences is unacceptable. The bad outweighs the good, so she is unwilling to tolerate it. English speakers use the word in this way. So, again, there’s no contradiction.

All Suffering is Subjective

Lyon then makes a different point, which is that ‘intolerable suffering’ is too subjective to be useful. “While they may and should consider a patient’s perspective, competent licenced clinicians in good standing do not and must not defer to patients when diagnosing medical conditions,” he says.

This move is also mistaken. Criterion (c), which I quoted earlier, is a condition for something being a ‘grievous and irremediable medical condition’. The first two criteria are that “(a) they have a serious and incurable illness, disease or disability” and “(b) they are in an advanced state of irreversible decline in capability”. By arguing that (c) is part of the definition of ‘medical condition’, Lyon is committing the fallacy of division, claiming that something true of the whole must apply to each part. 

Not so. ‘Grievous’ is captured by the third criterion, ‘irremediable’ by the second, and ‘medical condition’ by the first. Therefore, diagnosing a medical condition isn’t the same as finding the medical condition intolerable. This is why there are three separate criteria, but it’s also clear by the wording of the third criterion:

(c) that illness, disease or disability or that state of decline causes them enduring physical or psychological suffering that is intolerable to them and that cannot be relieved under conditions that they consider acceptable.

The medical condition is the illness, disease, or disability. The grievous part is the medical condition causing intolerable suffering.

So, when Lyon says that “competent licenced clinicians in good standing do not and must not defer to patients when diagnosing medical conditions,” he’s accusing them of doing something the legislation doesn’t ask of them. Having a medical condition is the sort of thing a physician can diagnose. But, as we like to say around here, having intolerable suffering is a value judgment. The only acceptable form leaves it up to the patient to decide when her suffering has become intolerable. Also, healthcare providers defer to patients about their subjective experience all the time. “How bad is the pain from one to ten?” is such an example.

The Subjective Criterion Should Be Abandoned

I’ve considered three of Lyon’s main arguments. None of them work. For all that, I’m on board with his point that the subjective suffering criterion should be abandoned, though I believe it leads in the opposite direction. In “The Case for an Autonomy-Centred View of Physician-Assisted Death,” Jeremy Davis and I argue that a suffering condition for permissible assisted dying is unnecessary because it’s redundant. Autonomy does all the work. As we say,

if the subjective assessment that one’s suffering is intolerable justifies [physician-assisted death], then this must include the full range of ways people might face conditions that are intolerable to them, not only the physical kinds of suffering on which many writers have focused. But once the condition is understood this way, as we have argued it must be, then the [suffering] condition does not require anything beyond what the autonomy condition already stipulates. Suffering is just one instance of the broader category of judging one’s life as no longer worth living, which the autonomy condition already captures.

Lyon mentions this type of approach but dismisses it as “ethically, clinically, and legally perilous.” Naturally, I beg to differ. Ethically speaking, Lyon’s approach would leave it up to physicians to tell patients when their suffering has become too much, which is exactly the type of medical paternalism we should, and already do, reject. Clinically, since suffering can’t be measured objectively, any attempt to objectify it is bound to fail.

Lastly, since words matter, we might wonder why the judges in Carter specify that MAID requires “enduring suffering that is intolerable to the individual”. The criminal code similarly specifies that the suffering be “intolerable to them”. What, you might wonder, is the point of these additional words? The answer, clearly, is that the law means intolerable as judged by the individual, or the very subjectivity Lyon thinks is legally perilous. If the judges and lawmakers wanted an objective standard, they wouldn’t have added the qualifications. This means Lyon is mistaken about all three points: the ethical, clinical, and the legal.

It Helps to Have Been There

I’m sorry to say that this isn’t the worst of it. Strangely, although Lyon wants to give MAID providers more power, he spends a good portion of the paper casting doubt on their moral character. MAID providers tend to describe their work in positive terms, but Lyon finds this unseemly.

Such sentiments are disquieting because death is usually a deeply painful or difficult moment for the patients and their loved ones, which may be compounded by questionable provider behaviours. Pleasure, on the other hand, is a categorically inappropriate affective response to causing or observing harm, suffering, or death in others.

I’ve witnessed multiple assisted deaths and have done many more debriefs with MAID providers, and I can report that Lyon is mistaken about how patients and families typically react. Of course, it’s hard to have a loved one die, but most of the deaths I’ve witnessed haven’t been deeply painful in the way Lyon believes. Contrary to the way most standard hospital deaths go, assisted deaths tend to be closer to joyful. People sing songs. They give speeches. They give thanks for being in each other’s lives. 

They go the way Katie Engelhart describes the first assisted death she witnessed in The Inevitable. Bradshaw, a Californian patient, has a smile on his face moments before he takes the drugs that kill him. As soon as he dies, Stephanie, his daughter-in-law, turns to the doctor and says, “it’s a great thing you do.” “This is peaceful,” adds his daughter. This is the MAID I’ve experienced, and likening it to causing harm or suffering is to fail to understand in the most basic way—in the way that patients and their families understand so clearly—that death in these cases can be a good thing.

A heuristic I’ve recently adopted is that, if you think all nine Supreme Court judges don’t know what a word means, you’re probably mistaken. Anti-MAID arguments are quickly approaching “It depends on what the meaning of the word ‘is’ is” territory, although Clinton was at least correct about the meaning of ‘is’. It’s too bad, because words matter.

Correction: A previous version of this post contained the following sentence: “In reading his paper, one gets the feeling that Lyon has never seen an assisted death, which is too bad.” In fact, Lyon has witnessed an assisted death, so I’ve removed the sentence.

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