Traditional arguments in favour of physician assisted suicide are based in autonomy, and argue that competent individuals should be able to decide to end their lives when continued life would be worse than death. The problem, according to critics of the right to die movement, is that the situations that make a life “worse than death” for some are often part of the day to day reality of others. There is also a worry that the vulnerable will be encouraged to end their lives rather than live as a burden on society or others; further, the “right to die” movement assumes that physical conditions are the source of all suffering, and ignores social factors that could make the lives of disabled individuals better or worse.

1. Arguments in favour of physician assisted suicide
The traditional argument in favour of physician assisted suicide (PAS) is simple. It starts with the widely held premise that autonomous individuals should have control over their medical decision making, and that this includes a right to refuse life-sustaining medical treatment. An appeal is then made to the consequences of this decision: since refusal of life-sustaining treatment results in death, is there a substantive difference between death caused in this manner and death caused by the administration of medication? Proponents will argue that there is not (Sumner 2011), and that PAS should therefore be permitted. This means that individuals with the capacity to consent should be able to request medical assistance to end their lives when they feel as though continued life would be worse than death.

Currently, physician assisted suicide is legal in the Netherlands, Luxembourg, and Switzerland, as well as in the states of Oregon, Montana, Washington, and Vermont. It was also legalized in the province of Quebec in 2014. In 2012 the Canadian prohibition against assisted suicide was struck down by the British Columbia Supreme Court, a decision that was upheld in 2015 by the Supreme Court of Canada.

2. PAS, vulnerability, and ableism
One concern that has been expressed by critics of PAS has to do with how accurately we can measure the motivations of individuals who choose to die. In other words, it may be the case that patients “say the right things” in order to gain access to PAS, but their actual motivations differ from the reasons that they give for choosing death. For instance, an elderly individual might tell their doctor that they want to die because of suffering that they are experiencing, but the actual motivating factor could be a desire to avoid burdening their grown children. Or, an individual without much money might choose PAS because it is a less expensive option than continued treatment. These individuals are vulnerable, according to critics, and it is difficult--if not impossible--to write legislation in a way that allows us to determine when an individual is genuinely motivated by suffering, or if they are being coerced into choosing PAS by family, finances, or some other factor.

A further issue is related to the social circumstances surrounding the PAS debate. Let us be clear: the cases of PAS that seem (at least) intuitively morally permissible are those in which the individual is affected with some kind of progressive and degenerative (though not always terminal) illness. In other words, there’s a popular intuition that becoming dependent or disabled makes death better than continued life (Radke 2005, Golden and Zoanni 2010).

The personal testimony of disability advocates, however, has demonstrated that the “actual” (physical) dependence or disability itself has little to do with one’s quality of life. What is more relevant, on their account, are the social structures that can make life easier, or more difficult, for the dependent or disabled. Paul Longmore, writing about a 1989 case where a quadraplegic man petitioned the court for permission for his ventilator disconnected so he could be allowed to die, has the following to say:

It was not David Rivlin’s respirator that “imprisoned” him in that bleak nursing home for three horrible years. It was not his disability that reduced him to “a cruel semblance of life.” Rivlin’s freedom, and finally his life, were taken by a system that segregated him, refused him the right of self-determination (except to die), and allowed him to be exploited for the profit of the nursing home industry. Nonetheless, the dominant viewpoint consistently made his disability the cause of his confinement in that bleak nursing home. That perspective misread much of what Rivlin himself said about the grueling experience that finally made his life unendurable. (Longmore 2005).

In other words, individuals who are dependent or disabled can have a good quality of life, but this depends on their living in a society that is open to helping them achieve that (Longmore 2005). The problem, therefore, is that the current social situation is one of pervasive ableism, the unhappiness of the disabled is quickly blamed entirely on their physical impairments, and the lack of social support is blatantly ignored (Amundson and Taira 2005). Given this, critics caution against the legalization of PAS until the amelioration of social conditions that can influence the quality of life judgements made by the impaired.

3. Are we being overprotective?
Other disability advocates, however, argue that an all out ban against PAS unfairly treats all disabled individuals as lacking capacity to make judgments about the quality of their own lives. According to Anita Silvers, control over their death may represent the lone remaining way that disabled people are able to exercise control over their lives (1997). On this account, opposition to physician-assisted dying inappropriately characterizes all people with disabilities as “so coercible that they need to be guarded from the liberty to choose their own deaths.” (Silvers 1997). In other words, it is not the case that all disabled people are vulnerable and in need of protection. Rather, we should say that only some disabled people are vulnerable and in need of protection, and that this vulnerability is not due to their physical impairment but rather to some other feature: their socioeconomic status, lack of power, or failure to fit into the mold of a “good citizen,” for instance.

This reconceptualization defines vulnerability not as something inherent to the individual, but as something imposed upon an individual by social structures: a poor individual is made vulnerable, for instance, because they do not have full access to the services provided by society, or a disabled individual is made vulnerable by a society that defines individuals as valuable based on their ability to contribute. Re-defining vulnerability in this way can be helpful when it comes to writing good PAS legislation because it forces us to ask different questions and explore the social factors surrounding an individual’s request for death.

-Caroline Lyster

• Amundson, R. & Taira, G. (2005). Our lives and ideologies: The Effect of Life Experience on the Perceived Morality of the Policy of Physician-Assisted Suicide. Journal of Disability Policy Studies, 16(1), 53-57.

• Assisted Suicide. (n.d.) Wikipedia. Retrieved from https://en.wikipedia.org/wiki/Assisted_suicide

• Golden, M. & Zoanni, T. (2010). Killing us softly: the dangers of legalizing assisted suicide. Disability and Health Journal, 3(1), 16-30.

• Longmore, P.K. (2005). Policy, Prejudice, and Reality: Two Case Studies of Physician-Assisted Suicide. Journal of Disability Policy Studies, 16(1), 38-45.

• Radke, R. (2005). A Case Against Physician-Assisted Suicide. Journal of Disability Policy Studies, 16(1), 58-60.

• Silvers, A. (1997). Protecting the Innocents: People with Disabilities and Physician-Assisted Dying. The Western Journal of Medicine, 166(6), 407-409.

• Sumner, L.W. (2011). Assisted Death: A study in ethics and law. Oxford Scholarship Online. DOI: 10.1093/acprof:oso/9780199607983.001.0001