Bioethics (Tom Angier)


tom-in-trenoBy Dr Tom Angier (Two PhDs Philosophy from Universities of Toronto & Cambridge)

Based on a presentation given at the University of Cape Town Bioethics Symposium at Groote Schuur Hospital on 18 August 2015


The issue before us is momentous.

Under a euthanasia regime, States not only allow, but also endorse/affirm the intentional killing of their own citizens (innocents, that is).

– This licenses killing as a medical therapy, teaches doctors how best to kill as part of their training;
– It thereby overturns norms which stretch back to Hippocratic Oath (predates Christian era by centuries): deliver no deadly medicine.

All of this in the name of the RIGHT TO DIE.

As we all know, this is a euphemism for the right to kill and be killed (we all have right to die – people do it every day). Is there such a right?

I will argue there is not, and that the opposition have given us no reason to believe there is. No reason that reaches a threshold of plausibility.

But before I make my argument, I want to acknowledge what in the opposition’s case is plausible, even good, perhaps noble. This amounts to three values they hold dear: COMPASSION, DIGNITY and AUTONOMY. These indeed noble values; but I will contend they are not upheld or promoted by an e regime, but each is systematically undermined, radically compromised, even overturned.


We are told, passionately, & with use of emotive examples, that compassion demands that assisted suicide & euthanasia be legalised.

Without these as part of medical practice, we are supposedly abandoning individuals to intolerable, often protracted suffering.
To refuse to allow killing is thus presented as callous, uncaring, unconscionably imposing an outdated rule for its own sake. But what is the reality here?

The reality is a lot less straightforward, & certainly a lot less gratifying to the euthanasia advocate.

For properly speaking, compassion is simply a form of moral feeling. It is ‘sympathetic pity and concern for the sufferings or misfortunes of others’. This feeling then usually motivates us to do certain things. The hard question is, however – what things? What actions does compassion justifiably authorise?

Here the euthanasia advocate almost always begins by being very conservative. We must restrict compassionate killing, he says, to those experiencing clearly unbearable physical suffering, which stems from a terminal illness. And because we are dealing with competent adult humans, we must not allow them to be killed unless they give their autonomous and perhaps repeated consent. Only this is truly compassionate, & moreover respectful treatment. Thus far & no further.

But the demands of compassion will not be so easily contained.

For of course, what constitutes a ‘terminal’ illness is hard to decide. Some illnesses are long-term and progressive, leading inexorably to a terminus. Should they be included? Well, arguably it is uncompassionate to exclude them altogether. But clearly if we include them, then we are on the road to admitting physical suffering does not have to be current, but only future.

Moreover, for the truly compassionate, it comes to seem unduly harsh to insist on physical suffering as the be-all & end-all of their concerns. Why not include mental suffering as well, even anticipated mental suffering? And given that mental suffering can severely impair mental competence, we may have to renege on our well-meaning words about consent. After all, who can, in all conscience, call himself compassionate & bear to see the depredations of the 90 year-old with advanced Alzheimer’s disease?

Now however this erosion of standards & betrayal of promises occurs, it is no idle, philosophical fantasy. For we’ve seen it occur in e regimes over the last 13 years. And the upshot is that ‘compassion’, in the mouths of euthanasia advocates, has effectively become worthless as a substantive guide to action – it is, literally, limitless. And to appeal to the law to fix such limits (cf. Warnock) is, moreover, hopeless. For it is precisely the law that has come to embody such limitless & degenerate compassion in the first place. Legal ‘safeguards’ have simply been eroded or repealed.


This is the second great value driving the case for legalisation. Its salience is seen in how euthanasia lobby groups label themselves: e.g. ‘Dignity SA’, ‘Dying with Dignity (Canada)’. In brief, their view is that certain forms of suffering or misfortune are so acute that they rob individuals of their dignity, or at least bring their lives below a threshold of dignity, so that they are no longer worth living. Such lives are ‘undignified’; given this, the act of killing is represented as upholding whatever dignity a sufferer has left (which may be all of it, if the killing is pre-emptive).

But what is dignity, exactly?

Here we need to make a crucial distinction. We should distinguish between ‘intrinsic’ and ‘attributed’ dignity. Intrinsic dignity is that which every human being has in virtue of being human – he or she therefore cannot be robbed of it, or find it depleted, even under the most difficult conditions, so long as he or she remains alive. By contrast, attributed dignity comes in degrees, and does vary depending on the condition of the self. When, for instance, an adult is unable to breathe on his own, or needs help eating, what could be called the dignified presentation of the self suffers. We attribute less dignity to him, owing to his loss of certain core capacities.

What can we learn from this distinction?

First, that it is attributed dignity that has come to dominate the debate over euthanasia. And secondly, that this is a very dangerous development. For we all tend to suffer a less dignified presentation of the self as we enter old age. More pointedly, some of us – viz. those classed ‘disabled’ – suffer this for most, if not all our lives. It’s for this reason that almost all disabled rights groups are against any liberalisation of the laws on assisted suicide & euthanasia. They are acutely aware of the way in which disabled people’s lives are often judged to lack dignity, & thus to be candidates for ‘mercy killing’ (‘If I end up in a wheelchair, please shoot me’ – this is merely a crude expression of a common sentiment).

Such fears are not unfounded, let alone paranoid. They are borne out by Dutch doctors’ killing of infants with (e.g.) spina bifida under the Groningen Protocol (2005), & by Gerbert van Loenen’s documentation of changing attitudes to adult disabled lives in the Netherlands. [One e.g. – his partner, who became brain-damaged, & needed care. Comments: ‘why does he choose to live? He doesn’t have to. I wouldn’t’.]

So the rhetoric of attributed dignity has led us seriously astray. Not that intrinsic dignity entails the indefinite prolongation of life, when treatment has become highly burdensome or futile (i.e. of no benefit to the patient). It is perfectly consistent with intrinsic human dignity to let death takes its natural course in such circumstances, in the context of palliative care (which also mitigates the undignified presentation of the self). What goes against intrinsic dignity, however, is to claim that upholding dignity requires killing: this is manifestly untrue, & moreover threatens all our well-being, esp. that of the most vulnerable amongst us.


This is the third value in the euthanasia advocates’ sacred trilogy. And indeed, personal autonomy is a genuine value. We naturally baulk at the idea of being deprived of control over our lives, & associate this (at its worst) with slavery. No wonder, then, that autonomy was initially central to Dutch e law, which tempered compassion with respect, & insisted that even extreme suffering did not warrant e without a patient’s consent.

Nonetheless, it remains the case that autonomy is not an absolute value, & furthermore, that it is very doubtful whether even its relative value can be sustained in a e regime. How so? Let me take autonomy’s non-absolute value first.

If I were driving down the N2, and suddenly decided to assert my autonomy or control by stopping in mid-lane to take a tea-break, no one would be tempted to justify my action. Its consequences, for me and for other motorists, would be too dire. Likewise, if an violinist in an orchestra decided to demonstrate his autonomy by playing fives bars behind everyone else, this too would elicit no sympathy. It would ruin the efforts of all the other musicians.

Now some are indignant at the idea that there is any analogy between these cases & the case of assisted suicide or euthanasia. How is my decision to kill myself, or have myself killed, to the severe detriment of anyone, least of all myself? For it saves me (by hypothesis) from severe suffering, & no one has the right to view their projects, needs, etc., as trumping this alleviation. But such moral indignation is misguided and misleading.

I say this for two reasons. First, because there is no evidence that even severe suffering cannot be sufficiently alleviated by palliative care (as we have heard from Liz Gwyther). And secondly, because there are manifold consequences of allowing assisted suicide & euthanasia that are highly detrimental to the common good. Killing of individuals can have very injurious effects on the mental health of family members; assisted suicide & euthanasia undermine the trust between doctors and patients, vide Dutch elderly going to Germany to die; assisted suicide & euthanasia create serious divisions between doctors; assisted suicide & euthanasia are fast becoming ‘rights’, to which citizens are ‘entitled’, thereby undermining doctors’ ability to refuse so-called ‘treatment’. Etc.

Let me turn, finally, to the way in which, despite autonomy’s genuine (if qualified) value, its survival in euthanasia regimes is under real threat. We have already seen how the Benelux countries have jettisoned autonomous decisional capacity as a necessary condition of euthanasia: infants are being killed, along with ‘mature minors’ (if that’s not a contradiction in terms), the demented and the mentally ill. But more insidiously, & less quantifiably, there have been real cultural shifts that cannot but undermine people’s ability to arrive at a properly autonomous decision in this area:

– Health care is increasingly expensive and tightly rationed. It costs around $35-40 for a lethal injection, but often ten times that to pay for palliative care. It is naïve to think financial pressures won’t be felt by patients (indeed, Warnock thinks monetary cost is a good reason to choose euthanasia);
– Being a burden on one’s family, or fear of this, rates far higher as a reason for assisted suicide & euthanasia than suffering (physical or mental). This fear will loom large, even if it is unexpressed or downplayed;
– The middle class & educated are not paradigms of autonomy. They are more likely to lack familial & communal bonds & spiritual resources. In this way they are more prone to depression than many groups, though this may go unnoticed (NB Oregon: 1 in 6 pass assisted suicide tests, with undiagnosed depression);
– People like Katie Hopkins make light of killing the old; there are mobile e units in Belgium & the Netherlands, which visit old age homes despite the lack of prior relationship between doctor & patient. In this cultural atmosphere, the elderly feel devalued. Indeed, the very presentation of e as an option can be extremely undermining to someone towards the end of life;
– In South Africa, life is, as they say, comparatively ‘cheap’. There is in many quarters a lack of respect for life, largely owing to widespread poverty. There are also manifold financial constraints on health care. Instituting a e regime would therefore carry extra & severe risks not found in other jurisdictions.

Given these facts, the idea that voluntary, autonomous decision-making about being killed is straightforward and needs only some ‘official oversight’ is deeply naïve. The above pressures are real and, if anything, growing; even a minority of people succumbing to them is too high a price to pay.


For all these reasons and more, we must err on the side of caution when it comes to legalisation of assisted suicide & euthanasia.

Genuine compassion, dignity and autonomy are all under threat in a e regime. The latter promotes, despite its claims, attitudes close to callousness, conditions close to indignity, and decisions close to heteronomy.

Let’s choose, instead, to foster a culture in which genuine compassion is encouraged, a culture which devotes time, effort, and resources to genuine, sustaining, holistic care. Only in such a culture will dignity be honoured, & autonomy not come into conflict with the common good.

Notwithstanding the wishful thinking so prevalent among euthanasia advocates, we now know – unfortunately – what direction cultures take when they embrace both assisted suicide & euthanasia. We must, therefore, in justice and all conscience resist moves to legalise either of these in South Africa, & thereby save our nation from a similar (if not worse) fate.