Wednesday, July 20, 2016

Is assisted dying the baby boomers’ last frontier?

It is truly remarkable how radically Western societies were remade by the baby boomer generation. They campaigned for the decriminalisation of abortion and succeeded in most liberal democracies. As Carole Levine rightly notes, ‘the women’s movement of the 1960s and 1970s was a frontline attack on (the) patriarchal and authoritarian model’ of decision-making in the medical profession.[1] Baby boomers also campaigned for the decriminalisation of same sex acts and eventually brought us marriage equality, even in a country as conservative as the United States. They campaigned for the decriminalisation of (soft) drugs and we are beginning to see increasing numbers of jurisdictions dabbling in the decriminalisation of at least cannabis. This, of course, is also partly due to the failure of the war against drugs. Restrictive drug legislation is reportedly responsible for about 5 billion people’s lack of end-of-life access to opioids across the globe.[2]

With baby boomers being anywhere between 52 and 70 years of age, invariably the end of life is coming into focus for an increasing number of people belonging to this generation. They would have seen parents and relatives suffering often terribly at the hands of a medical system that ignored their end-of-life choices in favour of life support at nearly all cost. Even today about 35% of patients who are at the end of the life receive non-beneficial medical care, including care that will result in a deterioration of their quality of life, such as, for instance, radiotherapy and dialysis.[3] Bioethicists have long proposed a patient focused approach to these kinds of challenges. Robert Veatch, for instance, noted that ‘the arrogance of the medical professional claiming that he or she (mostly ‘he’) had the authority to decide, even against a patient’s wishes, what was best for the patient was morally indefensible. Physicians were deciding not only that continued torturous life-support was in a dying person’s best interest, but that the physician’s ‘order’ justified continued infliction of that torture.  That ethic seemed so wrong, so contrary to any moral decency, that it was only natural to challenge it in the name of patient rights.’[4]

It is not terribly surprising, with baby boomer finding themselves – perhaps to their greatest surprise - at the levers of power of the system that they rebelled against in the 1960s and 1970s, that the number of jurisdictions that have decriminalised assisted dying is steadily increasing. Many legislators and judges are baby boomers. Just like baby boomers fought hard for the right to live their life by their own lights, they were bound not to hand control over to others when it came to their own dying. Their own foreseeable demise has clearly focused minds in many a jurisdiction and highest court room. The debates about supposedly significant moral distinctions between active forms of assisted dying and letting die – never an ethically plausible distinction to begin with - seem to have quietly faded away in favour of respect for considered patient choice. Today’s debates focus on the potential for abuse affecting disabled people and vague others labelled ‘vulnerable’ by those campaigning against medical aid in dying. Where you stand on these questions is not that significant as they will be settled by empirical evidence that is accumulating rapidly in the increasing number of jurisdictions that are decriminalising medical aid in dying in different forms and shapes. As I write this the Canadian parliament voted in favor of legislation that would make euthanasia and assisted suicide available to competent terminally ill patients. The availability of legal access to euthanasia is a first in North America. The state of California passed assisted suicide legislation a few months ago. It came into effect in June 2016. Access to assisted suicide in California is limited to terminally ill patients. Similar efforts are underway in a number of other states in the USA. France decided, also in 2016, to introduce a terminal sedation regime for eligible patients. Step by step baby boomers successfully wrestle(d) away control over our dying from the medical profession and restrictive legislation.

The next frontier for our baby boomer legislators and judges, undoubtedly, will be the issue of scope, when it comes to assisted dying. Should it be patient choice, irreversibility of the disease condition and unbearable quality of life as decision-making criteria, or should impending death be added as another necessary condition. The former arguably gels with the ‘my life, my body, my choice’ attitude that drove most of the political campaigns that led to the societal changes mentioned earlier. Historians of bioethics will hopefully keep a watchful eye on these developments.

[1] C. Levine. Analyzing Pandora’s Box: The History of Bioethics. In: L.A. Eckenwiler, F.G. Cohn. 2007. The Ethics of Bioethics: Mapping the Moral Landscape. Johns Hopkins University Press: Baltimore, p. 7.
[2] Economist Intelligence Unit. 2010. The quality of death: Ranking end-of-life care across the globe. London. [Accessed 27 June 2016]
[3] M. Cardona-Morrell, J.C.H. Kim, R.M. Turner, M. Anstey, I.A. Mitchell, K. Hillman. Non-beneficial treatments in hospital at the end of life: a systematic review on extent of the problem. International Journal for Quality in Health Care 2016, 1–14 doi: 10.1093/intqhc/mzw060.
[4] R. Veatch. The Birth of Bioethics: Autobiographical Reflections of a Patient Person. Cambridge Quarterly of Healthcare Ethics 2002; 11: 344-352.

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