The Better World Argument

Postponing MAiD until the world improves isn't the answer

Photo by Ian Taylor on Unsplash

When you’ve been publicly covering the ethics of assisted dying for as long as I have (since August), you notice that the same arguments keep popping up in different forms. Here’s a popular one, which I call the Better World Argument:

1. The world right now is deficient in some way, which is causing people to choose MAiD who otherwise might not.

2. We can imagine a better world where, due to some societal improvements, people might not choose MAiD in the same situations.

3. Therefore, we should ban MAiD in some forms until we reach that better world.

This argument has been around for a while. Before MAiD was legalized in Canada, people argued that MAiD shouldn’t be allowed until access to palliative care improved. More recently, as I’ve discussed here and here, people argue that MAiD shouldn’t be allowed when financial factors, such as lack of affordable housing or home care, play a role in a person’s decision to seek MAiD.

Another version concerns mental illness. Starting next March, people can qualify for MAiD based solely on a mental illness, so long as they meet the other eligibility requirements. (Currently, having a mental illness doesn’t exclude someone from accessing MAiD, but they must also have a physical illness that meets the other criteria.) People worry that, since access to mental health care in Canada is poor, people will turn to MAiD instead. But if proper treatment were available, they might not choose MAiD.

The Better World Argument takes pride of place in a longform article by Erin Anderssen on mental illness and MAiD that was published in The Globe and Mail last week. Here are a few excerpts:

[T]he Canadian Mental Health Association has raised serious concerns about expanding MAID without first increasing mental health care funding.

And

Rather than worrying about equal opportunities in death, says Sonu Gaind, chief psychiatrist at Humber River Hospital, society should first correct the wrongs his patients face in life.

And

In a telling exchange at the parliamentary committee, Dr. [John] Maher argued that a system that cannot provide care should not offer death as an alternative. For instance, he said some patients will have to wait five years to get the kind of specialty care he offers. “Telling my patients that you will make it easier for them to die has enraged me,” he told the committee. “They will die because psychiatrists will now have legal permission to give up.”

In each case, the argument is that MAiD for mental illness shouldn’t be allowed until access to mental health care in Canada improves. As with other aspects of health care and housing, there’s no doubt that there are serious deficits that need to be addressed. The lack of affordable housing across Canada is a preventable tragedy. So too are the long wait times that patients are experiencing in all aspects of health care, from emergency departments to the five years that Dr. Maher says patients have to wait to get psychiatric treatment.

Given this, the Better World Argument is tempting. But it’s a mistake. There are two reasons why one might find banning MAiD in these cases to be attractive. First, by delaying access, this might provide a means to accelerate systemic improvements. However, it’s unclear why we should expect this. Housing and health care are facing systemic problems, and there’s no clear connection between them and MAiD. And even if there were such a connection, it would be wrong to use patients now as a means to getting better care for those in the future.

The second and more compelling claim is that banning MAiD will be better, all things considered, since it gets rid of one aspect of the tragedy. The Better World Argument relies on the claim, which is surely true, that some people who want to access MAiD now wouldn’t do so if they had better housing, mental health support, etc. It’s a tragedy that MAiD is the most attractive option for people in these situations, so banning MAiD takes away an option and thus, the argument goes, produces a better result.

But this too is mistaken. Consider one of Dr. Maher’s potential patients, who’s experiencing intolerable suffering—a requirement for MAiD—while facing five years without psychiatric treatment. Since banning MAiD isn’t likely to reduce wait times, the result of a ban will be forcing the person to wait five years so that they can begin treatment, which might then take months or years to produce improvements, if it works at all. With both options available, it would be reasonable for someone in such a position to choose MAiD instead. Contrary to the claim the Better World Argument depends on, taking away MAiD doesn’t produce a better outcome. It increases suffering.

Dr. Derryck Smith makes a similar point in the Globe article:

[Smith] argues that if a person is capable of consenting, meets the legal requirements, and wants to die, it would be morally wrong to deny their right to choose. Otherwise, those patients are truly trapped: they can’t get timely treatment to alleviate their suffering, and they can’t choose to end that suffering themselves.

We can appeal to patient autonomy to justify this view, as the article does. Patients with decision-making capacity should be the judges of when their suffering has become intolerable, as is the case with physical illness. But we can also appeal to patient well-being and the corresponding principles of beneficence and non-maleficence. Suffering is bad and we should do what we can to prevent it. MAiD achieves this. To be sure, MAiD isn’t a replacement for fixing the healthcare and housing problems Canada faces, but it’s not meant to be.

The Better World Argument is unlikely to go away. When housing and healthcare access are too low, banning MAiD is a tempting response to a genuine issue. But for all that, it’s a fallacy that distracts from the real changes we need.