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Essay: Euthanasia and assisted suicide – the argument from compassion

The fashion designer Jasper Conran, quoted on the Dignity in Dying website said: “It seems extraordinary to me that as a nation we operate on a moral double standard. If our pets are hopelessly ill we have them put down to save them from pain and call that humane. If however our nearest and dearest are terminally ill and writhing in an agony that drugs cannot help any more, we allow the law to insist that we do nothing.” 

Here are the words of Joel Joffe, the distinguished lawyer who introduced an assisted suicide bill to the House of Lords in 2006: “I care about suffering and want the law changed so that those who presently suffer terrible deaths will in future have the option to end their suffering through ending their lives at a time and in the manner of their choice.” 

In this article we shall look at what is historically the oldest argument for euthanasia, the argument from compassion.  In another article in this series we shall look at the argument from autonomy.  As we shall see these two arguments are persuasive and effective for campaigners, because they are based on genuine concerns for the well-being of dying people, concerns that most people share, including those who are Christian believers.

The argument from compassion seems simple and compelling.  Common humanity demands that we try to reduce the suffering of others and therefore as a humane society we must provide legal means for individuals to end their suffering by ending their lives.

Christian voices arguing for assisting suicide out of compassion 

For the Reverend Professor Paul Badham, compassion for those who suffer at the end of life is a central argument in favour of voluntary euthanasia.  Paul Badham quotes from the famous hymn to love in I Corinthians 13:

“If I have a faith that can move mountains but have not love I have nothing.  If I give all I possess to the poor and surrender my body to the flames, but have not love I gain nothing.”  

Paul Badham argues, “It is hard to see how anyone who takes St Paul’s praise of loving compassion seriously could fail to respond to the desperate cries for help of terminally ill patients who wish to die.”   He emphasises the importance of Christ’s teaching about the Golden Rule and refers to anecdotal evidence that some doctors make private arrangements to ensure that in the event of terminal illness, they receive covert assistance from colleagues to hasten their own deaths.  “If they were to extend assistance to die to their patients they would literally be fulfilling Jesus’ golden rule of treating others as they wish to be treated themselves”.

Lord Carey, the distinguished past archbishop of the Church of England, has added his voice in favour of a change in the law on assisted suicide.  Speaking in the House of Lords debate in 2014, he said that he had changed his previous opposition to assisted suicide:

“When suffering is so great that some patients, already knowing that they are at the end of life, make repeated pleas to die, it seems a denial of that loving compassion which is the hallmark of Christianity to refuse to allow them to fulfil their own clearly stated request—after, of course, a proper process of safeguards has been observed. If we truly love our neighbours as ourselves, how can we deny them the death that we would wish for ourselves in such a condition? That is what I would want…”

So what’s wrong with the argument from compassion?

The argument from compassion sounds compelling, and according to some, entirely consistent with Christian thinking.  But it is important to recognise the highly questionable assumptions which lie behind it.  The emotional power of the argument is that, of course, we do have a duty to respond to those who are suffering.  Both Christian teaching and common humanity demand that we respond with compassion to “the desperate cries for help of terminally ill patients”.  But is killing the best practical and compassionate response that is available?  Can’t practical compassion drive us instead to the provision of expert pain relief, psychological support, and human companionship through the terminal phases of illness?  One of the wonderful discoveries of modern palliative care was that with skilled and dedicated care it is possible to control not only physical pain, but also address the psychological pain, relational pain and spiritual pain so often experienced by dying people.  Further discussion and information about palliative care is available in another article in this series, available from the website johnwyatt.com.

The pro-euthanasia activists use highly emotive and frankly manipulative language which implies that every moment thousands of people are dying in terrible agony – “suffering terrible deaths, writhing in agony”, but these descriptions do not reflect the experience of experts in palliative medicine.  Sadly at the moment, in the UK and elsewhere across the world, the provision of high quality palliative care is patchy and inadequate.  Because of this, even in modern hospitals and healthcare facilities it is true that some people do die in severe pain.  In 2015 an independent report from the UK Royal College of Physicians found that thousands of patients were “dying badly” in NHS hospitals every year.   Some NHS hospitals were failing to adhere to agreed guidelines on palliative care.  But this is a compelling argument for improving palliative care services, not for introducing legalised killing. 

Is there a difference between “unbearable” and “bearable” suffering?

The argument from compassion provides the bedrock for euthanasia legislation in the Netherlands and Belgium.  It is the moral and compassionate response of the treating doctor which is the critical factor in these countries.  The doctor has an absolute medical duty to bring to an end suffering which is “unbearable and hopeless” by ensuring the death of the patient. 

It is not unusual in the Netherlands for the patient’s request for euthanasia to be turned down by their doctor because the degree of suffering was regarded as insufficient.  So there clearly is an implicit threshold of personal suffering which the doctor must consider prior to agreeing to provide euthanasia.  It seems that this represents the threshold between “unbearable” suffering, which deserves euthanasia, versus “bearable” suffering, which does not.

The implication is that the even if a patient pleads to be killed, medical destruction of that life is not morally justified unless this threshold of suffering is reached.  But how is the value of an individual life to be weighed against a subjective assessment of suffering by a physician?

It is interesting that whereas in earlier versions of proposed assisted suicide legislation in the UK, “unbearable suffering” was regarded as a prerequisite before medical suicide could be procured, this requirement was removed completely in the recommendations made by the Falconer Commission: 

“The Commission does not consider that any criterion based on ‘unbearable’ or ‘unrelievable’ suffering should be included in potential assisted dying legislation as we are concerned that a criterion based on suffering would be too unclear and subjective for doctors to assess; we believe it is only for the individual concerned to judge the extent of the suffering caused by their illness.”

So to put it rather bluntly, medical killing is only justified in the Netherlands if the doctor determines there is ‘unbearable suffering’ but there is no requirement to be terminally ill.  In the UK it is proposed that medically assisted suicide would be justified if there was terminal illness, and there is no legal requirement to prove to an outsider that you are suffering. The incompatibility of the different legal frameworks points out the arbitrariness of the legal grounds. 

The assessment of ‘hopeless and unbearable suffering’ becomes even more problematic in the case of individuals with psychiatric disorders.  Those who regard their lives as unbearable due to anorexia nervosa or untreatable psychotic delusions, may legally receive euthanasia in the Netherlands, although this would not be acceptable as grounds for assisted suicide in the UK, (unless, unusually, their life expectancy was deemed to be less than 6 months). 

A highly subjective judgement on behalf of the treating clinician and the ‘special advisor’ seems unavoidable in these cases.  And if the two doctors have concluded that the suffering was indeed ‘hopeless and unbearable’, how might that judgement be challenged?  Indeed it seems that the only successful legal challenges to euthanasia acts in the Netherlands have been on the basis of failure to carry out the correct administrative procedure, rather than on the basis of the assessment of suffering.

And how can one assess the tragic case of Nathan, born Nancy, Verhelst, who was killed by lethal injection in Belgium in 2013 after requesting euthanasia on the grounds of ‘unbearable psychological suffering’?  After a life of being rejected by his parents as a daughter, Mr Verhelst had hormone therapy, followed by mastectomy and unsuccessful surgery to construct a penis in 2012.  Verhelst stated that surgery to turn him into a man had resulted in “a monster”.

The shaky logic of euthanasia legislation

At present euthanasia legislation in the Netherlands and Belgium restricts medical killing to those who have a certain degree of intellectual function.  But if a physician has a moral duty out of compassion to end the unbearable suffering of a legally competent adult, it is hard to see why there is not an equivalent duty to end the suffering of a patient who lacks intellectual and legal capacity, such as a person with brain injury or severe psychotic delusions, or a suffering child or baby.  If there is a moral duty from compassion to end unbearable suffering, then why should this be restricted to competent adults?

In the UK there is also a startling illogicality in restricting assisted suicide to those who have a terminal illness and are likely to die from natural causes within 6 months.  At least in these cases those who are suffering know that death is imminent; their suffering is going to come to an end.  Surely we should have greater compassion towards those who are suffering unbearably but who have no prospect of dying from natural causes.  In these cases the suffering is likely to go on year after year.  Don’t these tragic people demand our compassion too?  On what logical grounds can we exclude these people from assisted suicide whilst offering it to those who are about to die?   Arguments for compassionate killing have also been used in two other circumstances.  First, there are those who are not physically suffering, but who passionately wish to die because they feel their lives are “not worth living”.  Second, there are those who are not suffering in any recognisable way but an external observer concludes that their lives are purposeless and futile – those in coma from severe brain injury, people with advanced dementia, the severely malformed newborn infant.  Should not compassion lead us to end these futile lives?  This of course was the argument used in Nazi Germany that led to euthanasia programme.

Karl Brandt (centre wearing headphones) during his trial

“Compassion” has been used to justify horrific crimes

Dr Karl Brandt, Hitler’s personal physician who led the euthanasia programme explained his motivation at the Nuremberg War Trial:

“The underlying motive was the desire to help individuals who could not help themselves and were thus prolonging their lives in torment.  To quote Hippocrates today is to proclaim that invalids and persons in great pain should never be given poison. But any modern doctor who makes so rhetorical a declaration without qualification is a liar or hypocrite … I never intended anything more or believed I was doing anything but abbreviating the tortured existence of such unhappy creatures.”

It is all too apparent that “compassion” is a slippery concept and that it has been used in living memory to justify the most horrific crimes.  Still the argument from compassion seems to have considerable persuasive power for modern people.  And yet it is ironic that we live in an era of unparalleled advances in techniques for treating and controlling pain and other distressing symptoms.  The treatment available for dying people has advanced remarkably in the last 30-40 years. 

Are we more compassionate than we used to be?

The argument from compassion has special resonance for Christians, as well as others of good will, because it seems to chime with a deep instinct about responding to those in desperate need.  For 2000 years Christian believers and communities have been responding with compassion to those suffering severe and uncontrollable pain at the end of life.  And yet Christian compassion did not drive those believers to help patients to kill themselves.  So why is it now, at this particular time when pain relief and palliative care have become so effective, that Archbishop Carey feels compelled to change his mind?  Are we so more compassionate than our Christian sisters and brothers over the last 2000 years?  Why does the argument from compassion seem so conclusive at this point in history? 

Can suffering have any positive value?

It seems that one of the novel features of our modern technological and liberal society is that we have lost the belief that suffering can have any positive value at all.  Pain, whether physical, mental, relational or spiritual, is seen as useless, futile, destructive, incomprehensible, terrifying.  It is not surprising that utilitarianism, perhaps the most influential form of moral thinking underpinning modern secularism, defines pain as the greatest moral evil in the universe.  Conversely, anything that reduces and minimises the sum total of human suffering represents the greatest possible good.

This utilitarian thinking has penetrated deeply into modern culture.  The ultimate purpose of existence is to maximise personal happiness, and if we can’t be happy then at least we can try to anaesthetize the pain.  So all forms of anaesthesia become potent, desirable and morally acceptable.  Alcohol, recreational drugs, entertainment, retail therapy – they all help to numb the pain.  And when we face our own mortality we respond in the same way.  When asked how we would wish to die, the commonest answer is, “I want to die in my sleep, with no awareness, no discomfort, no anticipation, no warning”.  But if in reality we don’t die in this desirable way, then, “Just put me out of it, doc.  Put me to sleep.  I don’t want to come round.  I don’t want to know what’s happening.” So suicide and euthanasia become highly desirable because they seem to guarantee freedom from pain.  They are the ultimate form of anaesthesia, and hence, in a strange way, the ultimate moral good.

Your “compassion” may threaten my life

“Compassion” is an ambiguous concept, and one that can easily become confused and incoherent.  If I am in the depths of suffering and despair, then it is surely right that I should be treated with compassion by others.  My safety and security as a vulnerable and dependent human being rests on your compassion.  But if your “compassion” may motivate you to end my life, then something seems to have changed. Just when I am most vulnerable and dependent, am I at risk from the “compassion” of others? 

The core meaning of compassion – “It’s good that you are alive”

So what is the core meaning of compassion?  In Christian understanding it is closely linked to love for the other – practical concern for the very best for the other person.   And at its most fundamental, Christian love says to the person “It’s good that you exist, it’s good that you are in the world”, to use the words of the philosopher Josef Pieper.   The problem with euthanasia and assisted suicide is that in effect they say precisely the opposite, “It’s bad that you exist.  It would be much better if you were not in the world”.

Does this mean that when faced with unbearable and hopeless suffering in another that we must just harden our heart?  Is our natural instinct towards compassionate action misguided and dangerous?  No, on the contrary we must always act with genuine compassion towards the suffering one.  But true compassion, when directed by wisdom and judgement, points away from killing and in another direction. Cicely Saunders and the other pioneers of palliative care were extremely concerned to find ways of controlling both physical and other forms of pain, and they discovered that with skilled modern medical care it is not necessary to kill the patient in order to kill the pain.  Compassion for the agonies of suffering people with terminal illness was the primary driving force behind the development of modern palliative care, but it led not to medical killing but to caring – skilled, costly and life-affirming.

This article is adapted from material in my book Right to die? Euthanasia, assisted suicide and end of life care. You can find the rest of my material on euthanasia and the end of life here, including my other introductory essays.

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