Tuesday 10 June 2008

By John Ozolins 

At the outset, it should be stated that the care and protection of the terminally and chronically ill is of paramount importance. The alleviation of pain and suffering is part of this care of the human person, especially as he or she is coming to the end of his or her life. We all are, the proponents of the Bill included, concerned with the alleviation of pain and suffering in chronically ill and dying human beings; where we disagree is on the question of how this is to be done. This is not, however, simply a disagreement about treatment, but a much more fundamental disagreement about the nature and dignity of the human person and about how we are best able to provide treatment which is consonant with that dignity.

The human person does not have being  or existence as an isolated individual; “no man is an island”, wrote John Dunne, and this expresses a very simple thought, one elaborated more fully by philosophers and theologians. Although each person is unique, human beings at their most basic level have their being from others. We come into the world not alone, but into the company of others, a web of relationships.

Each person born is a gift to the world that changes forever the web of relationships which exist in that world, creating a new world and altering what had gone before. Those who have experienced the birth of child (and even during a pregnancy, the presence of the child in the womb of the mother) know well how radically life can never be the same ever again. Everything that we are and everything that we will be depends on the myriad relationships that we have with others.  As we grow to maturity, it is others who help us to learn, to form not only our understanding of the world, but also us in our understanding of ourselves. Moreover, it is often others who understand us better than we understand ourselves. For a human being, being in the world necessarily involves other human beings. It is what we are.

Whether we are in the last stages of life or at its beginning, or whether we are chronically ill or disabled, we have our being within a web of human relationships, but at this time, more so than at any other time in our lives, we need the support of others. As illness, infirmity, physical pain and suffering take away our ability to do things for ourselves, the more we come to depend on others for everything.  For those, whose lives have been defined by their ability to act and to be the ones on whom others depended, a redefining of who they are may be forced upon them. This is a time of great crisis. They may begin to see themselves as a burden, as useless and their lives as having little purpose. Great pain and suffering may lead them to feel that there is little point in continuing their lives.

One impulse, which is that of the proponents of the Bill, is to agree with those who feel that there is little point in continuing their lives and to assist them in speeding up the dying process by providing the means to end their lives there and then.  It is an impulse to be rejected for two reasons:  (i) It is an intervention which confirms to the dying or the chronically ill that their view that they are a burden is true, that their suffering and pain, their struggle to remain alive is futile and must not continue. It is a rejection of their being in the world, since we no longer can see how, in the condition that they are in, that we can stand in solidarity with them as they die. (ii) It is a betrayal, since we switch from palliation of pain and suffering to ending life. What we do for the patient is no longer focused on caring, as best we can, for them in their frailty. The reality which we actualise is one of hopelessness and despair, since there is nothing further to hope for in this life. This is not to say that we hold out false hopes for the recovery of the persons who are dying, but rather to always see them as precious in every moment, even as their lives ebb away.  We keep watch with them until the dying of the light.

In contrast, those who oppose the Bill argue that in order to express our solidarity with the dying and chronically ill, we need to stand with them at every step. Human life is a gift and reverence for its uniqueness and for what it contributes to our own being in the world calls us to respect persons even if they can no longer function. The essential nature of human persons is such that they always belong to the human family and have their being in communion with others. Our communion with them is expressed through the care that we give, the comfort that we provide and the hope that we offer in attending to them.  It should not be supposed that this is easy to do. Dying persons may be filled with despair, in their affliction curse those who would help them, be ungrateful for what is done for them and ask for their lives to be ended. Nevertheless, in order to be faithful to our respect and reverence for them as persons, we do not accede to such a request. Deliberately taking a human life, whether he or she asks or not (and it must be noted that the Bill only talks of voluntary assisted dying) runs contrary to our obligations to one another to provide support and care to those in direst need and for whom perhaps all that is left is their communion with us. In the final analysis, it is contrary to what we are as human beings.

As created, finite beings, human beings are dependent on infinite being for their existence. It is God who is the author of all being, who gratuitously brings us into being and who holds us in existence. We are, as the Psalmist says, like flowers that come up and are cut down (Jb 14:2), or like grass which withers and the flowers fall off (1Pe 1:24). Our existence is of short duration and our lives do not belong to us.  We are, however, made in the image and likeness of God (Gen1:26-27) and we are God’s children (1Jn3:2) and this gives us an inherent dignity and worth which is beyond measure. If we take this seriously, then no matter what our condition is, we have inestimable worth and our lives are precious. Any deliberate shortening of human life denies the reality of this. Moreover, since our lives belong ultimately to God and because it is through His infinite Goodness and Mercy that we have our being and continue to exist, by deliberately deciding to shorten a life we abrogate to ourselves the power of life and death, a power that is not ours to exercise.

A second, more pragmatic argument that can be mounted against the Physician Assisted Dying Bill concerns the ability of people who are suffering from a terminal or chronic illness or who are involved in their care to give voluntary informed consent. Although a full analysis of what might be meant by voluntary would require a considerably longer discussion, it is pertinent to point out that whatever else we might  want voluntary to mean,  that we would expect that  there would be some kind of normative understanding of what it meant. That is, when individuals give voluntary consent, they are of average mental ability, are not under any constraints (mental or physical) which might affect their decision-making, have an average education, can understand the implications of the decisions they make with some degree of clarity, have sufficient information on which to base their decisions, are neither too young (under 18 is the norm) nor too old and have normal health. Those who are suffering from a terminal or chronic illness do not fit these criteria. This does not necessarily mean that they cannot make decisions for themselves with clarity about what they want. It does, however, mean that those who are involved in their care are forced to make a judgement about  the sufferer’s competence, especially if they request physician assisted dying. The risk is that they may get it wrong. A patient, for example, when asked how his pain is, may reply, “Excruciating,” and be given an increased dose of morphine. When asked again how the pain is, replies, “Excruciating”, and the dose is increased again, this can continue until eventually a psychotic episode is brought about. Family who know the patient well know that he has a tendency to exaggerate his levels of pain, but this might not be reported to those treating the patient because of a misplaced confidence in the caring team or a belief that they would already know this. Reports of levels of pain are not always easy to judge. By the same token, a patient’s statement that he can no longer endure his pain and suffering and so wants assistance to die may not be taken at face value. There may be factors at work in a request for physician assisted dying that are hidden and  even with the most meticulous process always carefully and properly applied, may not be uncovered. The judgement that the patient knows what he is doing always remains to some extent  problematic.

 A simple example, drawn from Aristotle, who discusses the nature of voluntariness (Nichomachean Ethics, Book III, i) illustrates the difficulties of being able to not only give voluntary consent but to ascertain whether it has been given.  A ship finds itself in a storm and is in danger of sinking.  Having considered their course of action, the sailors jettison their cargo. The question which Aristotle poses is in relation to the degree to which they were acting voluntarily. It is true that they acted voluntarily in the circumstances, but involuntarily in the sense that the circumstances compelled them to act. Aquinas  (Commentary on Aristotle’s Nichomachean Ethics, Book III, Lecture II) comments this action can be seen as voluntary because decision-making making needs to be seen in its context.  Not all examples, however, are straightforward and it is not easy to decide how narrowly or broadly we need to consider circumstances in order to decide whether an action is voluntary or not. An action, both Aristotle and Aquinas agree, is involuntary when it is done through some form of compulsion or through ignorance, in the modern terms in the latter case, without sufficient information to determine a course of action. Information is not enough, however, we also need to have understanding of what the information is about and what the act actually entails. Wanting to choose to end one’s life, which is the end of being in the world, is understandable where a person is obviously and evidently in terrible agony. Undoubtedly, though it is a cry for an end to the distress of one’s dying, it may in fact mask a cry of the spirit for an end to the spiritual and mental torment arising out of unresolved or irresolvable issues. An agreement to provide assisted dying destroys any hope of resolution and though it provides an end to one kind of suffering, another kind is not ended and a person may die in terrible despair and loneliness. Moreover, as we have argued, if our lives are not ours to dispose of, then it is not a choice we can make and by insisting that it is, we begin to tear at the fabric of the community of relationships in which we have our being.  If legislation says that it is a choice that a person can make, then three things are being asserted: (i) that the patient is able to make a voluntary informed decision, and it has been suggested that this might not always be easy to determine; (ii) that no harm will be done to fabric of the web of relationships in which the patient has his or her being and this far from obvious and (iii) places an obligation on someone to carry out the patient’s request.  Some may be willing to carry out the patient’s request, but if they are health care workers, it changes the fundamental purpose of their work 

In the circumstances that the terminally ill or the chronically ill find themselves, a question mark always remains whether the persons allegedly asking for physician assisted death are in a mental state in which a free and unconstrained decision can be made. The matter of their illness and the particular request that they make, namely to be assisted to end their lives, are not routine situations, but ones fraught with emotional, spiritual and existential significance.  Those having to judge that their decisions are voluntary and informed are faced with a difficult task and may well miss deeper issues which may have prompted a particular decision.  The question of who is then to carry out the patients’ wishes leads to the possibility of obligating health care workers to do that to which they may have serious objections and undermines the confidence a patient might have in the health care system. Moreover, in the community of human relationships in which we have our being, ambiguities are created about the voluntariness of the decisions that may be taken.

Associate Professor John Ozolins is the Head of the School of Philosophy at Australian Catholic University National's St Patrick's Campus.