What Does It Mean to Have a Right to Die?

Non-medical assisted dying, part two

This is the second instalment in my series on non-medical assisted dying. Part I is here.

In my last post, I discussed some of the reasons in favour of a non-medical approach to assisted dying. These reasons don’t mean that abandoning the medical model is best all things considered, but they’re worth taking seriously. One reason I described is practical: healthcare providers are busy, the assisted dying process is time-intensive, and, while there have been hard-working providers from the beginning, medicine as a field has been reluctant to get on board.

The second set of reasons is philosophical: some people object that the criteria for assisted death are too stringent, meaning that people who should be able to receive assistance are unable to. The relatively moderate solution to this problem is to expand the criteria, but, as Canada shows, doing so leads to opposition, including from healthcare providers.

A deeper objection is that the medical model requires receiving someone’s permission to access the resources necessary for a peaceful death, which, the argument goes, is wrong.

In The Inevitable, Katie Engelhart’s excellent book on non-medical assisted death, she describes case after case of someone believing that life is no longer worth living, then encountering barriers to accessing assistance. In some cases, the police show up at the door to confiscate the means the person acquired to end her own life. In others, they are detained under mental health legislation. In all of them, they are forced to suffer longer than they would have to if the law recognized a right to die.

Another argument, which I haven’t mentioned, is that the non-medical approach resolves some of the core objections made by disability rights advocates who oppose medically assisted death. (Despite the attention these arguments receive, polls show that there’s no difference in support for assisted dying between those with disabilities and those without them.) One objection is that people with disabilities are vulnerable to pressure or coercion in interactions with healthcare providers. Right now, since assisted death is treated as a medical intervention, providers will mention it as part of the suite of options potentially available to patients. Since it’s their job to inform patients of their options, it’s fine that they do this in most cases, but de-medicalizing assisted death would mean they don’t have to.

Some disability advocates also argue that the current criteria devalue the lives of people with disabilities. As I wrote in an article for Impact Ethics,

To access [medical assistance in dying], a person must have a “grievous and irremediable medical condition”. The Criminal Code says that a person must “have a serious and incurable illness, disease or disability” for their condition to be grievous and irremediable. The [Special Joint Committee on Medical Assistance in Dying] is concerned that the use of “disability” in the law implies that having a disability is alone sufficient to qualify for MAID, and thus stigmatizes people with disabilities who are not negatively affected by their disability.

Again, the non-medical approach would address this. Although there would still be criteria, they would no longer specify which medical conditions are required to qualify. Disability would no longer be a stated qualifying condition, so the non-medical approach would eliminate the concern that assisted dying stigmatizes people with disabilities while still allowing people with disabilities to choose to die.     

What’s a Right to Die?

By ‘right to die’, people mean that you could make a decision to end your life and acquire the means to do so without requiring the permission of a healthcare provider. People advocate for a non-medical model because it removes the physician’s authority, thereby empowering people to live and die on their own terms. For advocates of this view, getting a physician’s approval violates their right to make decisions about their own lives.

Patient-centred care is, essentially, letting people make their own healthcare decisions instead of their doctors doing it for them. Physicians still have an important role as medical experts, but patient-centred care puts the decision in the patient’s hands. The FDA’s decision to allow an oral contraceptive to be sold without a prescription is patient-centred because it does away with the traditional gatekeeping role of healthcare providers.

In this way, the right to die isn’t a radical new claim. Instead, it follows from the general claim to self-governance or self-determination. In the 1914 decision Schloendorff, the first American legal decision to recognize the right to informed consent, Justice Cardozo wrote that “Every human being of adult years and sound mind has a right to determine what shall be done with his own body.” Of course, the justice wasn’t proposing a right to die, but a right to determine what shall be done with your body could extend to choosing death.  

Much more recently, the trial judge in Carter, which led to the Supreme Court of Canada striking down the general prohibition on assisted death, discussed the various Charter rights involved in the decision. Section 7 of the Charter says that everyone has the right to life, liberty, and security of the person, which the trial judge said that, when applied to healthcare, means “the right to non-interference by the state with fundamentally important and personal medical decision-making.” Ending one’s own life is compatible with this.

Most rights have limits, however, and, as Section 1 of the Charter says, even affirmed rights can be subject to reasonable limits. The right to free speech doesn’t extend to inciting a riot. Even people who think the Second Amendment creates a strong right to own guns usually don’t think that this also applies to anti-aircraft guns or nuclear weapons. The rights to self-determination and liberty are the same. There are limits, such as when a person who might have ebola is forced to quarantine for the safety of others. The main question of Carter was whether allowing assisted death is compatible with the state’s interest in protecting vulnerable people. The Supreme Court unanimously agreed that it is possible, but that doesn’t mean that all versions would balance those interests.

My aim in this series is to sort out the ethics of non-medical assisted dying, not the law. To make progress on this question, we need to determine what we would be giving up by switching to a non-medical model. In the next post, I’ll discuss decision-making capacity and whether dying should require informed consent.

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Quick Hits

• I’m a sucker for any story about implementing a technology that seems likes a no-brainer. In this article, Dylan Matthews describes the effectiveness of ultraviolet light at killing viruses. When hung in rooms, these lights kill basically everything that could infect you. As he says, there are some trade-offs, but the possibilities are interesting.

• Opioid-related harm reduction has been having a bad couple years, but harm reduction is a goal, not a specific method. I’ve previously defended safe supply, and a new study by researchers in British Columbia found that people prescribed a safe supply of opioids significantly lower levels of all-cause mortality (not just from overdoses). The full study is here and a news article is here.