Autonomy and End of Life Decisions: A Paradox

Autonomy, voluntariness and assisted dying

“…So, many of these decisions to die are non-voluntary, and thereby undermine the individual's autonomy. [27] Given the widespread view reported above that respect for autonomy counts in favour of permitting assisted dying, this is a startling conclusion. However, we can't avoid it except at substantial theoretical cost, given the practical convergence noted above: we would have to abandon all the (plausible and useful) theories of autonomy which imply that autonomy is undermined by non-voluntariness.…”

“…In an article of 2013, I presented a challenge which faces someone who wants to advocate legalizing assisted dying on these grounds. [27] If the motivating reason for someone's seeking an assisted death is to avoid unacceptable alternatives, then their choice is not voluntary, andcontrary to the optimistic picture painted in Sections 1 and 2their decision to die undermines their autonomy. Empirical data suggests that this often is the reason people seek an assisted death, or wish they had that legal option: they want to die because they fear the prospect of physical pain without relief, or chronic dependency, or psychological trauma (for themselves, or their loved ones).…”

“…It also looks like resisting it pushes us towards the view that there is 'nothing troubling about most contemporary decisions to die.' [27] The defender of legalization needn't adopt that view, and probably shouldn't, given that (as this paradox shows) there is some philosophical support behind the idea that the legal option of assisted dying could end up being an instrument of force (either intentionally or unintentionally) for vulnerable people facing difficult end of life choices, pushing people into dying who would otherwise prefer to live. [33][34][35] I suggested two number of ways to respond to this argument, which I develop further here.…”

“…The first is to observe thatcontrary to the views of the opponents just mentioned -it doesn't give support to proposals that assisted dying should be illegal. [27] After all, non-voluntariness in this sense does not necessarily invalidate consent. And even if many end of life decisions are made for reasons which mean a loss of autonomy, this would be a reason to prevent assisted dying only if that policy didn't come at an even greater cost in terms of autonomy.…”

“…In practical terms, that means combining legalization with reform to the institutional framework which forms the background of people's decisions to die, by trying to ensure that (at least some of) the alternatives to assisted dying are also acceptable, to minimize the danger of someone choosing to die to avoid unacceptable alternatives. [27] That is, in the same way that the option of assisted dying makes it more possible to choose voluntarily to live, it is likewise more possible to choose voluntarily to die if one has access to e.g. adequate pain management, support for independent life and decision-making, and adequate support for carers.…”