I first became interested in the debates surrounding assisted suicide through watching my father battle cancer. His story is, sadly, unremarkable in the sense that like so many before him, he was diagnosed with a disease that killed him a short time later. However, to me, his last months were emblematic of an ethical debate that reverberates throughout the domains of law, medicine, and philosophy.
The 3 months he spent fighting the disease were a sobering window into what dying actually looks like. In his last weeks in the hospital, he slipped from cognizant to delirious—the result of multiple infections he contracted in his drab white room—and eventually into a coma. As his organs failed one by one, their functions were externalized, relegated to machines that filled the room with a mechanical cacophony. When he died, it was as much a relief as a tragedy.
Witnessing the process of his dying made me pursue a study of bioethics, and particularly a study physician-assisted suicide. Watching his suffering made me understand with more gravity than ever before why someone would want to avoid that at all costs, even if that meant ending her life.
In both the philosophical arguments and public debates regarding physician-assisted suicide, a single question seems to haunt the discourse: Do we own our lives, or are we stewards of our lives?
Ownership, Stewardship, and Autonomy
Assisted suicide calls these ideas of ownership and stewardship to the surface. The issue isn’t only life or death, but also what our relationship to our own lives is, and whether or not we have an inherent right of determination over them? If we truly own our lives, what holds us accountable to others? If we are stewards of our lives, why is it that we hold self-determination in such high esteem? Do we owe others our presence in their lives, if they have determined that our lives impart great value to theirs? And if we do, to what extent, and at what cost?
The idea that we possess ownership over our lives owes much to the Enlightenment philosophers, and to the subsequent secular moral philosophers that gathered the strands of the individual and attempted to craft her into an autonomous self. Affirmations of individual rights to self-determination are inherent in medical ethics, where we defer to the wishes of the individual regarding treatment through living wills, the right to refuse care, and even through medical proxies who use substituted judgment to determine what a patient would choose for herself.
If ownership was completely uncontested, I suspect the assisted-suicide debate would never have reached the fervent pitch it has today. But something happens to the idea of ownership when that power can be used to end one’s life. Many are uneasy with the prospect of creating legal allowances for assisted-suicide. This uneasiness is expressed not only as concern for a devaluation of an individual life, but as a precursor to a devaluation of all life. Why, then, if I alone am the sole owner of my life, does what I do with that life have any external effect on the value of the lives of others?
One explanation is that while we might be owners of our own lives, perhaps we owe it to each other to act as stewards, either as supporters of their lives, or as supporters of our own lives to the benefit of theirs. But if we have an obligation to act as stewards, what prevents others from overriding our decisions about our own lives for their benefit? The idea that an individual’s will can be rightfully and morally superseded by the will of another only because of this obligation is not only disconcerting, but antithetical to our autonomy.
If ownership is too focused on only the needs of the individual, then stewardship seems to be an appealing alternative. A stewardship model should theoretically preclude anyone from shortening her life in the face of a terminal illness because her life is, effectively, entrusted to others. Does that, then, mean that others can make that decision for her? Can those others determine her suffering and consent to treatment for her?
What is troubling in the stewardship model is not the idea of mutual obligation, but what might be allowable by extension. Does stewardship necessarily entail enduring life as is? Would it preclude other medical procedures—for instance, a medically induced coma in order to be unconscious during a particularly painful and protracted recovery process—because those procedures would interfere with a moral duty to others? Would painkillers, then, or experimental surgeries also be disallowable, or could they be prohibited if others felt they devalued a patient’s life?
Perhaps most importantly, if an individual is a steward of her life, then who holds the decision-making power over her? Does it rest in the hands of others she has endeared or engendered herself to? Does it rest on the determinations of society as a whole, or at least a community in which she is a part? We would protest such a model. An individual indeed has a right to make these determinations for herself.
Reciprocity and Mutual Obligation to Life
Since elements supporting and refuting both the concept of ownership and of stewardship are at play, then perhaps the physician-assisted suicide debate is situated within a structure where we hold both seemingly opposing options to be simultaneously true. What if we do have ownership of our lives, but we own those lives within a context of reciprocity, serving as stewards for one another’s lives, and thereby offering our own lives in services of others’ wills in a pact of mutual obligation? If the individual’s estimation of the quality of her life can be thus embedded in a complex of mutual obligation to one another which stems from the recognition of each individual’s ultimate determination of self, perhaps such a framework would offer a more humane home for such a challenging issue.
Which brings me back to my father. He would have wanted to stay alive as long as possible, to append as many extra days together to his biography as he could. I wanted that, too. But neither of us wanted him to suffer, to endure the pain of his body slowly crumpling under the weight of a terminal disease. Somewhere in the dying process, we encounter the entanglement of ownership and stewardship, where self-determination and mutual obligation might not be a zero-sum game.
While I do not have the ultimate answer regarding assisted suicide, the existing oppositional framework of ownership and stewardship overlooks the very real possibility that the moral framework in which we must situate the debate is not either or, but a hybrid of both, something that is ours to shape for others and for ourselves.
Meghan Guidry (Harvard University)Meghan is a Masters of Divinity candidate at Harvard Divinity School, where she studies bioethics, humanist philosophy, end-of-life care, and health policy. Her research focuses on the disconnection between ethics and technologies, assisted suicide, and other cheery subjects. Her interests include creative writing, swimming, language philosophy, medical sociology, and coffee. You can check out her books at Empty City Press, find her on Facebook, and follow her on Twitter @monocrescent.
Applied Sentience 
A nicely-reasoned argument for more discussion of this topic and an approach that considers all aspects and all who will be affected. I recently taught a class about the need for discussion of “dangerous ideas”–ideas that make people uncomfortable for various reasons. Given the fact that the Baby Boomers are coming up on their 70s, this dangerous idea seems both important and timely.
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Thanks so much for your comment. I agree that this is a dangerous idea in the sense you described, but that it is crucial to engage a wider audience in dialogue. In addition to the human demographics you mentioned, there are also questions of how prepared some medical institutions are to handle these, and how our insurance system tends to favor certain treatments over other because of payment structure incentives. It’s a challenging issue with a lot of moving targets, but it’s one we can’t ignore.
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Lets get this straight. I own my body and as long as I am mentally capable I will decide what happens. If I am beyond deciding, then thats when the stewards have responsibility. That also means that if I decided before to give ‘end of life instructions’ then that should be followed. It is not for stewards to make discissions re ending life, that is my right.
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Thanks so much for your comment. You’ve provided a succinct, and articulate summary of the philosophy that undergirds most pro-PAS arguments. It’s an argument that I, personally, find very compelling. But the ownership/autonomy model is rooted in a completely different ontology than the opposing views, and I don’t think any significant progress can be made on this issue so long as there are two different conversations happening.
Many anti-PAS arguments draw both directly and indirectly from the notion that we are stewards of lives imparted to us by divine beneficiaries. Because of this, I think that those of us who support the legalization of the practice need to be attuned to that element of the opposing arguments, so that we can address those questions directly and engage in the construction of an ethics that acknowledges those concerns even if we don’t share religious viewpoints. My hope is that an ontological model that incorporates a secular idea of stewardship of well-being into its framework will move us closer to a consensus on this issue.
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At 15 I witnessed a similar end to my father. A struggle with an incurable illness that took him from a proud and loving human being to becoming a barely conscious shell.
I believe we have a right to determine when our life should end and I have expressed to my family and closest friends this sentiment.
I have found religious dogma plays a role in the euthanasia debate (at least in Australia.) A famous or infamous Australian doctor has been assisting in consensual suicide for many years and is lucky to not be in prison.
The right to both live and die with dignity is foremost in my thinking and no one has the right to deny me that.
Thanks for the article, I will forward it on.
Peter Kelly.
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Thank you for your comment, Peter, and I am so sorry for the loss of your father. I share your core belief that we should promote dignity for ourselves and others at all stages of life.
You mentioned religious dogma playing a role in the euthanasia debate in Australia. My research has mostly focused on the debate in the United States, but I would be curious to read more about the dialogues happening in Australia. The Pew Research Center for People and the Press published a report on end-of-life care views amongst Americans, and one unexpected finding was that people who have been witnesses to loved ones’ end-of-life treatments and decision-making are much more likely to support physician-assisted suicide. You should check out the report (http://www.people-press.org/2006/01/05/strong-public-support-for-right-to-die/). I’d be curious to know if you see any parallels with public opinion in Australia.
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I am a cancer survivor….at least for now. Yes, infections. I was in the hospital for 3 days when I got my first. Yes I was in a coma. I survived that infection. I was released to rehab with an infection unbeknownst to me. I went in and out of the hospital for another month having that infection and never being diagnosed. I had symptoms that should have triggered tests. I complained of those symptoms over and over and over. I was given lomotil and given more and more and more lomotil . Two months later I was diagnosed. Too late! Had to have my entire colon removed. Was in a coma, organs failed. The doctors would have let me die at the hospital where I was except that my daughter insisted that they move me to where I could be care for. I was moved. I was given lasix which revived my kidneys. The hospital where I was at had not even considered lasix even though it very common treatment to bring kidneys back. The hospital where I was taken to had a difficult time reviving me because the hospital where I had previously been had sedated me far too heavily. Hospital are dangerous places. Infections are all over them. Nurses, doctors, family members, housekeepers, technicians and others are responsible for improper hand washing or no hand washing. Doctors do not run test that they should and both doctors and nurses do not ask patients questions and patients fail to tell doctors and nurses important things. It sounds like this father died not of the cancer but of the infections. That was me! I am alive today but for the the grace of God. I am happy to be alive. I am glad that my daughter refused to pull the plug. I am pissed about the care that I received. It was a multitude of inept errors that accumulated. I do not think that assisted suicide is answer. I think we should be revamping health insurance so that doctors are not so constrained by insurance plans. Insurance companies drive the care that is received. I think we should work on improving infection control throughout the hospital systems in the US.
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Thank you for your thoughtful comment, Jane, and I am so sorry for the pain and suffering you had to endure (and I’m glad that you are recovering and getting stronger). I agree with your points about hospitals and infections; my father contracted pneumonia while he was on an inpatient unit, which led to numerous complications. I think what’s important to keep in mind here is that improving hospital quality (and particularly the quality of palliative care) is not diametrically opposed to implementing death with dignity measures. Aside from the question of physician-assisted suicide, we need to really examine our current health care system and assess how well inpatient and long-term care units are serving the needs of their patients. While I don’t believe that improved palliative care and inpatient systems will completely eliminate the demand for death with dignity measures, I do think that improving those systems will help ensure that people in critical and terminal conditions have access to the quality of care that they deserve, and that we should actively and conscientiously push for reforms that will improve those systems as soon as possible.
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If some people want to consider their lives as gifts from a deity, they are entitled to such a belief. I do not believe this. If the law allows me to excercise the consequence of my belief and to request assisted suicide (with suitable protection within the law to ensure that I am not being coerced) this does not affect the person who thinks their body is a gift from refusing such services from a physician. If, on the other hand, as is the case in many jurisdictions, the law is framed so as to not permit physician assisted suicide it is only I (and people like me) who are the losers. Surely this is not fair!
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Thank you for your comment, Josh. I think you bring up a very interesting point, and one that continues to fascinate me: Is the prohibition of access to death with dignity measures ethically impermissible? It’s a bit of different question from the legalization-of-PAS question, philosophically speaking (because you don’t have to prove that such measures are “good” or allowable, only that preventing them as available options is ethically impermissible). I think Brittany Maynard’s story has pushed the national debate more into this territory than it was before, so it will be interesting to see how this question is engaged in a wider cultural dialogue.
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As i sit not having a significant experiential investment in this topic, but a contemplative one. I can only hope that your voice is a loud one amongst the rabble.
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Thank you for your comment, Joshua. I hope that there is more substantial dialogue around this issue in general. I don’t think this question is going to go away, so I hope that we, as a society, are able to find productive and humane ways to discuss it more publicly.
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I am at a risk to develop Alzheimer’s disease. Three of my grandparents and one of my parents have or have had this disease. I feel that Alzheimer’s disease “protects” the diseased through a large span of having the ailment through physiological ignorance; however, I would want my family to not experience the inevitable pain in the form of a slow ‘mind-death’ of their father/brother/husband. In the spirit of mixed stewardship and ownership philosophies, could one *logically* plan a personal death once a quantitative brain image confirms a predetermined gray matter threshold has been reached? This assumes that the gray matter threshold ensures a certain level of lost autonomy.
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Thank you for your comment, Toby, and I am deeply sorry for the pain you and your family have experienced because of Alzheimer’s. You bring up an interesting issue when you talk about a planned assisted-suicide. I think the bioethical challenge lies in both the idea of consent (can you consent to do something in a future time when your future self might not want the original thing?) and in the question of who would be responsible for administering the medication at the time of self-termination. These are not impossible questions to answer, but the dialogue in the bioethics community is still in its nascent stages. This an article discusses these very questions. I don’t know if it will offer you with anything new, but it does affirm that these questions are being discussed actively: http://www.ncbi.nlm.nih.gov/pubmed/23850340.
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I am currently considering suicide & truly wish I had the benefit of physician assistance. As a practical matter, I feel I must rely on violent methods, since an unsuccessful attempt might leave me worse off than I am now. I have been in respiratory failure a dozen times – only invasive, intensive measures kept me alive. Respiratory failure is not, per se, painful since lungs do not register pain. But slow death by suffocation while mostly conscious is every bit as cruel. I chose medical intervention for my illness, I can choose to stop intervention & yet I can’t choose to stop my illness because medicine can’t?
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I am not personally a believer in the option of suicide (we don’t know what we don’t know, and if there is a purpose for us continuing through suffering, which I think there is, I think our lack of knowledge is a good reason for holding back our own hand at taking our lives. Rarely do we know what can come from suffering and tragedy during that suffering and tragedy, but it is often great, great things) but whatever you decide I will be praying for you and your situation. I wish you all the best.
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Dear Lisa, I am deeply sorry for your current pain and suffering. I can’t imagine what you’re going through, and your story cuts to the heart of this issue. You are suffering, and you have more at stake here than most of us.
I do not know the specifics of your illness or your current support network. However, given what you have said here, I would urge you to talk about your experiences with people you trust. Please reach out to someone, and share with them what you have shared here. Please reach out to a close friend, a family member, a doctor, a counselor, or even a service hotline (http://www.suicidepreventionlifeline.org/gethelp/yourself.aspx) or an online chat line (http://www.suicidepreventionlifeline.org/gethelp/lifelinechat.aspx). You have shown such courage in sharing your story here. Please let others show you the same courage in exploring what options you have, and in exploring how your situation can be improved.
And if you don’t feel that you have anyone with whom you can have this conversation, please let me know. I would be happy to get in touch with you privately so we can continue talking.
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Thank you for your concern, but please understand this is not a mental health issue, it’s a physical one. Frankly, I find it bizarre that others are usually fine with the idea of my personal decision to turn off my ventilator, but taking a fatal dose of morphine, for example, is another matter. Strictly speaking, either action would be suicide – a taking of my own life by my own choice.
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Very nicely written article, thanks for sharing it.
It’s hard for me to comment when we’ve all been given that gift of “free will” and it’s not my place to tell anyone they don’t get to have it. I would say, in my own life, suicide was never on the table when I was young because I was taught (falsely) that it was spiritually forbidden and meant damnation. So fear kept me from (many times) taking actions to end the depression or pain I was in. (As an aside, I’m thankful for that false teaching at that time, because it literally saved my life on more than one occasion. It had its use.) Once I learned that was not actually accurate, though, I was thankfully at an age where I had learned just how much benefit comes from suffering. Now, I’d never willingly walk into a situation to purposefully increase my suffering (that would be foolish in my view) but when it does come- and it will throughout life- I take strength in knowing I’ve gone through things before and come out a much better person. Also since I am generally aware of the succinctness of life every day, to me the “final weeks of life” some experience are of a similar mindset to all weeks of life. Because it could always be the final weeks, we have no idea. And when one crosses that line into “it’s okay to kill yourself if you’re going to die in X number of days anyway” to me that’s a green light for ANY time frame. Because years fly by, and everyone reading this will die at some point that we probably don’t know for certain. It’s part of that journey we’re on, and I think an important part. So, again for ME, that’s never an option. Not with 1 day left, not with 10 days left, not with X days left. I’m here until I’m not here, and then I’ll be where I am next, and I’m not smart enough (can’t see the future) to determine when that time should be. I leave that in the hands of one who knows the future.
Anyway, I’m always glad to see really well thought out conversations on the topic, since a lot of places online (and off) end in name calling and screaming matches. 😛
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Thank you so much for your thoughtful comment, JK, and I agree that the discussion here has been insightful, respectful, and very open. I want to thank you for sharing your thoughts, especially regarding what you said regarding how you have come to understand suffering. Trying to make sense of the suffering we and others have endured is one of the most difficult parts of our human experience. It will be a difficult conversation moving forward, but I am glad that there are places where a plurality of opinions can be expressed and engaged with.
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Thanks for this article. According to international human rights laws set up by the UN ten years before I was born, no human is ever incompetent nor does any human lack insight into his/her own condition. To declare a person incompetent is a crime against that person and a crime against all humanity. We should own our bodies, but sadly, they are really owned by corporations. I would never want a “doctor” to kill me in assisted suicide. They nearly killed me enough times. I’d save myself time and money and do it myself if I ever wanted to. While doctors who do mercy killing may be hunted down and threatened, it’s even worse for those of us who decide to do it for ourselves and fail. We’re locked up, called incompetent, abused, and if we ever get out of “treatment hell,” we’re blacklisted in our communities. After you realize they destroyed your life, you wonder if you should have died after all. So much for stewardship. I got damn tired of being lied to by that one demeaning statement, “This is for your own good.” Because it never was, and I know better now.
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Thanks so much for your reply, Julie. You’ve gathered a lot of really intriguing threads here, from human rights to institutional infrastructures that erase personhood to how illnesses of all kinds isolate people. Regarding the specifics of physician-assisted suicide, the question I keep coming back to is how a system, any system, can codify suffering. If suffering is an experience defined not just by its presence, but by its specific manifestation in a person’s lifeworld, then I find it troubling that we have these implicit thresholds of suffering that we hold all people to. My hope is that, as wider dialogues about physician-assisted suicide continue to gain wider audiences, we will also have to talk about human suffering more openly, and to discuss the fact that suffering isn’t a static and stratified system (like a 1-10 pain scale), but is a protean force that continually shapes and reshapes our individual and communal lifeworlds in ways we must be attentive to and conscientious of.
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