Sivakumar Sathasivam, Consultant Neurologist, Te Walton Centre NHS Foundation Trust, Lower Lane Liverpool
In the debate over whether assisted suicide should be legalised or not, dignity is a key battleground area.1 Recently, Sir Terry Pratchett, a world renowned English novelist and known sufferer of the progressive neurodegenerative syndrome posterior cortical atrophy increased the profle of support for and courted controversy in assisted suicide. He appeared in a documentary that followed a patient with motor neurone disease travelling to Switzerland for assisted suicide.2 A strong supporter of dignity in dying, he stated “lack of dignity would be enough for some people to kill themselves.”3 For many patients the right to die with dignity equates to dying without having to suffer from severe physical pain, without being dependent on others for bodily hygiene, hydration and nutrition, and without family and friends having to witness the deterioration and sufering of loved ones.4 Proponents of assisted suicide demand dignity as a way of promoting the autonomous right to die in a respectful way. However, opponents of assisted suicide also use dignity, but in this case to forbid assisted suicide because, according to them, assisted suicide is intrinsically immoral and dignity is intrinsic in human beings,5 is against religious beliefs,6 or may potentially lead to a duty to die because vulnerable patients may feel pressurised to do so.7 Terefore dignity in death ofen acts as a divisive wedge between the two ideologies, for and against assisted suicide.8 Tere are four concepts of dignity put forward by Schroeder.4 Te frst is Kantian, which is the intrinsic dignity in every individual rational being with life plans that is an end in itself, and that cannot be bought for a price.9 Te second concept of dignity is aristocratic dignity which can be defned as “the outwardly displayed quality of a human being who acts in accordance with her [or his] superior rank and position.”4 The third concept of dignity is comportment dignity. It is related to aristocratic dignity in that it concerns outward displays of appropriate behaviour, but differs in that the determining factor in the appropriateness of the behaviour adheres to social expectations and norms, rather than the rank of the person.10 Comportment dignity is most easily grasped in the negative. For example, a failure to show comportment dignity occurs when a person throws food at another in a restaurant. The final concept of dignity is meritorious dignity, which is an extension of Aristotle’s thinking that dignity is something that is deserved rather than inherent and that one deserves it through being honourable.10 According to Aristotle, to be honourable is to have a morally praiseworthy, principled and admirable character disposition towards the virtues of prudence, justice, fortitude and temperance.4 Supporters of assisted suicide align dignity with the standards and values one has had to live by in the past.4 Therefore, they appeal most closely to the meritorious and comportment concepts of dignity. Consequently, what standards and principles one has tried to adhere to during life, one may not be able to achieve in death if assisted suicide is not allowed. In addition, one has to have this witnessed by others, leading to the loss of comportment dignity. Furthermore, if one is in unbearable pain or psychological trauma, the cardinal virtues of prudence, justice, fortitude and temperance may be undermined, leading to the lost of meritorious dignity. On the other hand, opponents of assisted suicide say that unbearable pain, embarrassment and psychological trauma have no relevance for Kantian-inspired inviolable dignity because such dignity cannot be lost.4 Those sufering from extremes of pain, embarrassment and psychological trauma have the same amount of dignity as those who are more fortunate. By legalising assisted suicide, people will have the choice to choose in what they believe in. Some at the end of life do not require assistance in dying, but others do. At present, the law only prolongs the sufering of some, and may in fact cause others to die before they need to as they have to travel abroad to avoid the prosecution of their helper and thus cannot leave things to a point when they are incapable of travelling.
References and full text of this article are available on online version at www.gmjournal.co.uk