[Herewith our second post for Applied Ethics April, by Matt King.]

‘Death with Dignity’ statutes, as they’re often called, allow terminally ill patients to bring about their own deaths under a very specific set of conditions. The purpose of such laws, made clear by their text and proponents’ arguments, is to empower terminally ill patients, giving them greater control over their deaths. The justification for such legislation is patient autonomy: the right to control how one’s life goes, including how it ends. Such statutes are also thought to mitigate whatever moral objections may attend forms of euthanasia that involve others in bringing about the death.

But ‘Death with Dignity’ statutes are not free of moral problems of their own. Consider Brittany Maynard, who was the inspiration behind the new law in California. A 29-year old terminal brain cancer patient, she moved to Oregon to gain access to its Death with Dignity provision. On November 1, 2014, she took a lethal dose of medication. Yet, while she certainly exercised more autonomy over the circumstances of her death than many, she still died before she preferred. Indeed, she faced a special kind of rational pressure to bring about her own death before she really wanted to. Moreover, given the absence of legal alternatives, she also faced a coercive pressure. If structuring life-and-death choices such that individuals face coercive pressure to bring about their own deaths is morally problematic, especially as a matter of public policy, then Death with Dignity statutes are morally problematic.

To understand the nature of the pressure Maynard faced, one need only examine what she cared about. As her testimony made plain, just prior to her death, she still valued her life. What she disvalued was being incapacitated, dying slowly and painfully from her cancer. Unfortunately, Maynard couldn’t know just when she could be incapacitated in the very ways she judged to be disvaluable. That is, she couldn’t ascertain just how much time she had remaining. This is a standard sort of uncertainty. We often can’t be sure just what the future holds, and often it will matter greatly how things turn out. But for Maynard and others like her, the problem is more pronounced. For Maynard did know for sure that she was going to die soon. As a result, she settled that she would rather die quickly under her own terms than suffer a prolonged death at the hands of her cancer. The difficulty was, however, that en route to a prolonged death, she was very likely to be rendered incapacitated by her frequent seizures. Since the only legally available death under these statutes requires that the patient self-administer the lethal medication, if Maynard was rendered incapacitated, she wouldn’t be able to bring about her own death. As a result, she would be stuck with the prolonged death she sought to avoid.

Maynard’s moral problem was that the very circumstances she wished to avoid were such that were she sure she was in them, she would no longer be able to avoid them legally. Artificially, we might arrange her case like this. If she knew that upon waking up next Thursday, she would experience a massive seizure that rendered her incapable of self-administering, then she could decide to self-administer next Wednesday night. If she self-administered before that, she would be bringing about her death before she had sufficient reason to, by her own lights.

Of course, she couldn’t be confident that an incapacitating seizure wasn’t imminent. So, she couldn’t be confident in planning her death appropriately. Instead, she had to gamble that she would wait long enough that she could still enjoy the life she valued, without waiting too long such that she was stuck with a disvaluable death. Since her worst-case scenario was a drawn-out death, it was rational for her to opt to die sooner rather than later, since the longer she waited, the more likely it became that she wouldn’t be able to self-administer. Thus, Maynard faced rationalpressure to die before she really wanted to.

What was wrong about the pressure Maynard faced? One plausible answer is that it was unnecessary. Notice that her predicament dissolves if she has access to basic forms of euthanasia. If she could have empowered another to bring about her death, then she could have made clear that once certain circumstances obtained, she wished to have her life ended. Importantly, those circumstances could have included her incapacitation. With the requirement that she self-administer gone, she could have confidence that she wouldn’t die until her life was disvaluable and that she wouldn’t have to suffer through those disvaluable circumstances. (Of course, we could then inquire about the moral problem of relying on others to bring about your own death, so I’m not here claiming that there are no moral problems with euthanasia.)

A second answer is that the pressure was coercive. Death with Dignity statutes actually create an additional incentive for patients to bring about their own deaths before they really want to die. Since these statutes create a narrow class of legally allowed self-killings, they incentivize opting for the legally sanctioned method as opposed to some other one. Since such a problem does not persist were forms of euthanasia available, this is some reason to prefer schemes in which euthanasia is available, at least if we are inclined to try to promote patient autonomy and avoid coercion.

One might insist that it is still surely better for those like Maynard to be able to avoid a slow, disvalued death, even if the mechanism of Death with Dignity laws is imperfect. And perhaps such statutes are most justified all things considered. But since their primary justification is typically given in terms of respecting autonomy, there is an unacknowledged conflict in such appeals. It’s hard to see how a law that creates coercive pressure of this sort is the best way of empowering a person. While Death with Dignity statutes may mitigate certain moral risks that pertain to euthanasia, it doesn’t seem that they do as well respecting patient autonomy.