The House of Lords was split recently on whether to back assisted dying, as supporters argued it would end the excruciating suffering of the terminally ill and opponents warned it was "a whisker away" from euthanasia. Sivakumar Sathasivam, Consultant Neurologist, The Walton Centre NHS Foundation Trust, Lower Lane, Liverpool talks about some of the moral theories around the subject.
The debate on assisted suicide was recently thrust into the limelight again when an 83-year-old man was reported to be the first British person to end his own life through assisted suicide at the Dignitas clinic in Switzerland because he was in the early stages of dementia.1 In the midst of complex legal arguments for and against assisted suicide, one must not ignore the person with his or her emotions, feelings and thoughts, who is involved. Thus, personhood, which is the status of being a person, is an important ethical consideration in assisted suicide.2 To prevent being overburdened by the possible breadth of moral obligations, many commentators have attempted to distinguish between "persons" and "non-persons" so that we only owe strong moral obligations to persons.3 Most moral theories (at least in the Western world) hold that persons possess exclusive or superior moral status, while non-persons have no or inferior moral status.4
Concepts of personhood
Let me now consider two influential branches of personhood, one Kantian and the other Lockean/Parfitian. From a Kantian point of view, only beings who have the capacity for autonomy or "moral agency" (defined by Wikipedia as 'a person's responsibility for making moral judgments and taking actions that comport with morality'5) are persons. These beings have moral obligations to one another, must not be manipulated towards the achievements of ends which are not their own and must always be treated as ends in themselves.6 Kant's model has only one criterion and is categorical - all and only persons are important, and personhood is an all-or-nothing phenomenon.
In contrast, Locke defines personhood in a purely psychological sense. According to him, a person is '[a] thinking intelligent being, that has reason and reflection, and can consider itself as itself, the same thinking thing in different times and places; which it does only by that consciousness, which is inseparable from thinking, and as it seems to me essential to it'.7 Locke's definition of personhood is based upon the concept of memory in that a person 'is the same person who performed a past action only if he can remember performing that action'.3 It is noteworthy that Locke does not consider human physiology as a necessary component of personhood since he says that it is 'not the same body, but the same continuing consciousness, which constitutes the criterion for the identity of persons'.7 The Lockean conception of personhood has largely been superseded by the Parfitian account which, while accepting psychological connectivity, would also consider embodiment in the human brain as a 'background criterion' for personal identity - this would give the effect of incorporating the physical component (the brain) into personhood, rather than the brain existing separately from it.8 It is doubtful that any contemporary advocate of personhood could advance the view that biological life is unnecessary for the survival of the person.
Personhood in assisted suicide
The majority of proponents of personhood as a determinant of full moral status would consider anyone in possession of the qualities of autonomy, rationality and self-awareness as being unequivocally a person.3 Rationality and autonomy are more closely associated to the Kantian approach to personhood, while self-awareness is more closely related to the Lockean/Parfitian viewpoint of personhood. Proponents of assisted suicide would need to consider whether the right to die is morally defensible: it is reasonable for an autonomous, rational and self-aware being to want to end life? Ford asserts that it is morally difficult to justify the wish to destroy something of ultimate value, i.e. life itself.3 Ford also profoundly argues that some personhood theorists would separate the person from his or her life when defining personhood because this conceptual dichotomy would justify the ending of life that significantly lacks value - she regards this as the personhood paradox in the right to die.3
Harris challenges Ford's assertion that ultimate value or moral status equates to inviolability or the need to preserve life at all costs.9 He first points out that by making autonomy central to personhood in the Kantian sense, it is more important to protect autonomy rather than physical life itself. In addition, Harris goes on to argue that personhood should incorporate a set of capacities for one to value one's own existence - thus when one no longer values one's own existence, then it would not be wrong to deprive one of it.9 This would apply nicely to the argument supporting the ending of life in assisted suicide in this case of the man with dementia. Harris also disagrees with Ford's viewpoint of the dichotomy between a person and his or her life when deciding to end life, remarking that it is not life that is being valued, but rather the existence of a particular sort of life that is being valued.9 Thus, one should be allowed to end one's life when one wants to do so, again supporting the argument in favour of assisted suicide in this case.
It is classically argued that the Kantian position on assisted suicide is that it is impermissible because carrying out assisted suicide would amount to treating a person wholly as a means to an end; by aiming to minimise suffering, one chooses to end life as a means to that. However, according to Brassington, in cases 'when a person wants us to kill him, when that desire is necessary and sufficient to motivate us to kill him, and in which we have no other motivationally overt desire to kill him, it would be difficult to sustain the charge that we are acting in such a way so to make a person a means to our end.'10 Therefore, assisted suicide may even be compatible with the Kantian doctrine, if for example, we have no desire to ameliorate the amount of suffering in the world.
Personhood is a complex but crucial ethical dimension in assisted suicide. An understanding and consideration of personhood in the debate on assisted suicide would show an element of humanity and compassion to the individual involved in an often emotive and sometimes distressing situation. More often that not the person is ignored or forgotten in the ethical arguments that ensue in the debate on assisted suicide. This should and must not happen.
Conflict of interest
1. BBC News Health. 'First' UK assisted suicide for dementia. http://www.bbc.co.uk/news/health-22715363.
2. Sathasivam S. Ethical considerations in physician-assisted suicide. Advances in Clinical Neuroscience and Rehabilitation 2011; 11: 25-7.
3. Ford M. The personhood paradox and the "right to die". Medical Law Review 2005; 13: 80-101.
4. DeGrazia D. Great apes, dolphins, and the concept of personhood. The Southern Journal of Philosophy 2007; 35: 301-20.
6. Kant I, Paton HJ. The Moral Law. London: Hutchinson; 1948.
7. Locke J. An Essay Concerning Human Understanding. Woolhouse R, editor. London: Penguin; 1997.
8. Parfit D. Lewis, Perry and What Matters. In: Rorty AO, editor. The Identities of Persons. California: University of California Press; 1976. p. 91-108.
9. Harris J. The right to die lives! There is no personhood paradox. Medical Law Review 2005; 13: 386-92.
10. Brassington I. Killing people: what Kant could have said about suicide and euthanasia but did not. Journal of Medical Ethics 2006; 32: 571-4.