‘Assisted dying’ as a comforting heteronomy: the rejection of self-administration in the purported act of self-determination

Abstract

‘Assisted dying’ (an umbrella term for euthanasia and/or assisted suicide) is frequently defended as an act of autonomous self-determination in death but, given a choice, between 93.3% and 100% of patients are reluctant to self-administer (median 99.5%). If required to self-administer, fewer patients request assisted death and, of these, a sizable proportion do not self-administer but die of natural causes. This manifest avoidance runs counter to the concept of autonomous self-determination, even on the supposition that suicide could truly be autonomous. The avoidance of self-administration does not show that self-administration, when it occurs, is necessarily autonomous. It suggests, rather, that there are other frames by which assisted dying is being understood. One such is desire for medical control, a desire shared by patients and doctors. Such a frame is not directed towards an exacting autonomy (self-directed action by the patient) but towards a comforting heteronomy (letting the doctor take control).

KEYWORDS:

• Assisted dying
• assisted suicide
• euthanasia
• self-administration
• autonomy
• heteronomy

Disclosure statement

No potential conflict of interest was reported by the author(s).

Notes

1 The invoking of dignity here, while commonplace, is problematic. For a more comprehensive discussion of dignity in healthcare ethics see Sulmasy (2009, 2013) and Jones (2015).

2 The language of ‘encourages or assists suicide’ was incorporated into English law by the Coroners and Justice Act 2009, c. 9. Prior to this the Suicide Act 1961 (section 2.1) had referred to the person who ‘aids, abets, counsels or procures the suicide of another’.

3 This figure may be an underestimate as a previous report stated that while in most cases there was no further intervention after taking the barbiturate orally, in some cases this was followed by a further injection with a neuromuscular paralytic drug (CFCEE 2022, p. 27).

4 The Report for January–June 2020 is used for comparability. Later Reports revised the figures for 2019–2020, but the same may well occur in Western Australia, so it is better to compare the initial report after the first year of operations.

5 Data for population is taken from the Australian Bureau of Statistics (2023) and gives 6,590,050 for the population of Victoria in December 2019, midway through the first year of implementation of VAD, and 2,762,511 for the population of Western Australia in December 2021. Figures for assisted suicide versus euthanasia are 104 versus 20 in Victoria (VADRB 2020, p. 3) and 43 versus 147 in Western Australia (VADBWA 2022, p. 24).

6 This figure is lower than the figure cited earlier in this paper for deaths from MAiD in 2022 (13,241) as it refers to deaths where Health Canada have the detailed reports, whereas the earlier cited figure includes 139 MAiD deaths where Health Canada has been notified of the death but has not yet received the detailed report (Health Canada 2023, section 4.0).

7 It should be noticed that no drugs administered in order to end life were developed for this purpose and their use in assisted dying or capital punishment, whether taken orally or by lethal injection, is always ‘off licence’, often experimental, and with limited data on efficacy and safety (Worthington et al. 2022, Regnard et al. 2023, Harmon et al. 2020).

8 The quotation, which is used in the title of Sulmasy’s book chapter, (2020) is from Viktor Brack who organized the infamous T4 Nazi euthanasia programme. It is noteworthy that Brack was not himself a physician but nevertheless thought that euthanasia was and should be an expression of medical power wielded by physicians.

9 Kant’s very clear opposition to suicide is something of an embarrassment for those who wish to promote assisted suicide on the basis of a Kantian understanding of autonomy. Hence there have been a number of attempts seeking to show that Kant should have been in favour of suicide in some circumstances (Brassington 2006, Cholbi 2010, Cooley 2007, 2013).

10 One of the end-of-life concerns that are cited as reasons for seeking assisted death in Oregon is the perception of being a ‘burden on family, friends/ caregivers’. In 2021 this concern was attributed to 54.2% of those who died (ODA 2022).

Additional information

Funding

The author(s) reported there is no funding associated with the work featured in this article.

Notes on contributors

David Albert Jones

David Albert Jones is Director of the Anscombe Bioethics Centre which is based in Oxford. He is a Research Fellow at Blackfriars Hall, Oxford, Professor of Bioethics at St Mary's University, Twickenham and Vice-chair of the Ministry of Defence Research Ethics Committee. He has published widely on ethical issues at the end of life and co-edited Assisted Suicide and Euthanasia: Lessons from Belgium (Cambridge University Press, 2017) together with Chris Gastmans and Calum MacKellar. He was on a working party of the General Medical Council which helped draft its 2010 guidance on Treatment and Care towards the End of Life.