The Right to Die

Photo by Kateryna Hliznitsova on Unsplash Abstract This paper examines whether the autonomous self can give rise to a right to die in the form of a right to physician-assisted death (PAD) with a geographic focus on Europe. The paper questions whether a patient’s request for PAD can be justified as an expression of true autonomy or whether autonomy itself must be understood as inherently relational. The paper further explores case-law concerning human rights and the incompatibility of a right to die with the right to life, which serves as the foundation for human rights protections. The paper argues that neither patient autonomy nor the right to life provides a sufficient basis for establishing a right to die. Rather, autonomy should be viewed within an interdependent ethical framework that recognizes human vulnerability and mutual responsibility. The paper concludes that legitimizing PAD risks altering the meaning of care and eroding societal and medical commitments to preserving life. Introduction This paper examines whether autonomy justifies a right to die in the form of physician-assisted death (PAD) and explores the possible implications of this right in the European countries where PAD is legal. The paper begins by analysing autonomy in the context of end-of-life care, through the lens of the patient-doctor relationship and the decision-making process. The issue is whether a patient’s request for PAD can be seen not only as justifiable but also as necessarily grounded in the patient’s autonomous decision-making capacity. The paper then delves into the legal implications of a putative right to die, exploring its incompatibility with the right to life, which is a cornerstone of protecting all human rights. The paper also investigates the conditions under which PAD might nevertheless be legally permissible, e.g., under European Law. Finally, the paper concludes that neither patient autonomy nor the right to life provides a solid foundation for a right to die. It argues that patient autonomy should be understood as inherently relational, emphasizing that individual decisions impact society at large, and that autonomy as a purely individualistic concept is ultimately illusory. Moreover, the theoretical foundation of the self is shown to depend on its relation to others, which implies that the act of killing is not only an act against the other but also against the self. Background In Europe, six countries – Switzerland, the Netherlands, Belgium, Luxembourg, Spain, and Austria – have legalized some form of assisted dying, while others, including England and Wales, are in the process of doing so. In addition, Colombia, Canada, New Zealand, ten states in the US and six states in Australia allow assisted dying. In some countries, patients can access assisted dying only in case of terminal illness, while in others the requirement can be ‘severe suffering’ from a ‘chronic disease,’ which may encompass mental health conditions. Generally speaking, the legislative safeguards which place conditions on access to PAD raise concerns over equal access.[1] Yet the safeguards are meant to protect against uses of PAD that legislatures have not approved and to make sure that citizens requesting PAD are doing so freely and without any form of coercion and external pressure. The Concept of the Autonomous Self in End-of-Life Care and Its Implications Autonomy is a central concept in Beauchamp and Childress’s four principles of biomedical ethics, often seen as the cornerstone of medical ethics. To these authors, respecting autonomy means recognising a person’s right to make choices based on their values and beliefs, not just by avoiding interference but by actively supporting their ability to decide freely.[2] Beauchamp and Childress’s conceptualization of autonomy explains the paradigm shift of the past half century from the ‘doctor knows best’ tendency towards a more balanced doctor-patient approach where patients are seen as active protagonists with their own opinions, desires, and, above all, a right to know about and consent to medical treatment. Patients’ autonomous choices may not always align with what doctors consider to be in their best interests, as seen in refusals of life-saving treatments that their medical practitioners deem essential. And, patients cannot force doctors to administer medical treatments that they do not consider optimal. These two assumptions create tension when it comes to life-and-death decisions and whether the patient’s autonomous choice can stretch to the point of choosing when and how to die. The questions, therefore, are whether a legitimate request for PAD can stem from autonomy. According to Beauchamp and Childress, public policies on PAD should prevent abuse but should not undermine its moral justification: “A favourable response by a physician to a request for assistance in facilitating death by hastening it through prescribing lethal medication is not relevantly different from a favourable response to requests for assistance in facilitating death by easing it through removal of life-prolonging technology or use of coma-inducing medication.”[3] On this view, the principle of autonomy (the ‘patient’s perspective’) and the principle of beneficence (the ‘clinicians’ perspective’, i.e., a positive obligation to contribute to the welfare of others) do not necessarily conflict ethically, although competing principles should be balanced on a case-by-case basis. Countries where some forms of PAD are legal offer an example of how these principles need some kind of ‘support’ to avoid exploitation. An Autonomy-Based Argument for PAD The expressivist objection to assisted dying claims that allowing PAD for a specific group of persons expresses a negative judgment on whether their life is worth living. Some argue that an autonomy-based approach is the only way to address this objection. For example, Esther Braun claims that policies permitting assisted dying to all autonomously choosing it avoid the expressivist objection.[4] To Braun, the autonomy-based approach is the way forward since “assisted suicide should not be understood as a medical procedure that can be ‘indicated’ but rather as an autonomous action that can be carried out for all sort of reasons that should not be judged by others.”[5] Consequently, PAD should not be considered a medical practice because, as such, it would fall under the umbrella of indicated treatments under certain circumstances (such as irremediable suffering) where the patient would benefit.[6] Second, intentionally terminating the life of a patient can lead to a harmful division within the clinician’s medical and social role. Instead, “the judgment of whether her [the patient]’s life is worth living is strictly the patient’s.”[7] According to Braun, assisted suicide should be removed from the realm of beneficence relevant to all medical procedures and confined to the autonomous self who has full power over his or her fate. Braun’s autonomy-based position is that it would be legal to provide PAD to anyone who makes an autonomous request regardless of their medical condition, thus circumventing the principle of beneficence. To her, restrictions would be needed only to ensure that the patients’ decision to end their own life is taken autonomously (so the patient has decision-making capacity, the decision is informed and voluntary). This avoids depicting any group as less worthy of living. However, Braun refrains from delving into the practical implications of this kind of autonomy-based approach to PAD. Given the fact that people are situated in social contexts, the question is whether this decisional power stemming from the autonomous self, in particular in circumstances of vulnerability, can be seen as entirely beginning and ending in the individual – as Braun maintains – or can be the subject of external influences. “Desperation and a feeling of being superfluous”[8] form the context in which individuals exercise self-determination.[9] This creates a fragile foundation for both autonomy and decision making. Therefore, Ole Hartling defines autonomy when it comes to deciding about one’s own death as a “prison of freedom.”[10] The idea of deciding autonomously – understood as acting independently not only of other people’s influence but also of any duress (physical or psychological) may seem like an illusion. End-of-life decisions are undoubtedly grounded in the concept of autonomy, but not in the individualistic sense that views human beings as isolated entities. Rather, these decisions reflect that people are deeply embedded in the fabric of society, which shapes their identities in both positive and negative ways. Autonomy needs to be considered in the context of the wider ethical framework of medicine and society.[11] It is not just a matter of individual will, but it is relational: when patients express their desire to die due to suffering, clinicians should look beyond autonomy and focus on relieving the suffering, not ending the life of the sufferer. Patient choices are not an isolated exercise of will and can also affect others both directly and indirectly – to such an extent, for instance, that in countries where PAD is legal, it has increased at a steady pace in the years immediately following its legalization, likely due to rising public acceptance.[12] Unassisted suicide has also increased in jurisdictions where PAD is legal.[13] PAD and A Duty of Care PAD is not a "neutral" act but has profound implications not only for the patient but for the clinicians’ duty of care embedded in their professional ethos, since this becomes the umbrella under which PAD falls. In this regard, the American Medical Association Code of Medical Ethics is clear: “Physician-assisted suicide is fundamentally incompatible with the physician’s role as healer, would be difficult or impossible to control, and would pose serious societal risks.”[14] Some assert that doc

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