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Essay: Euthanasia and assisted suicide – underlying social forces

Campaigners in favour of assisted suicide sometimes seem to live in an alternative reality. It’s a world in which rational people make choices about how they wish to die on the basis of personal preferences, untouched by crude social and economic forces. If elderly and dying people want to choose to end their lives then we should let them.  But in the real world it is very different. As theologian Nigel Biggar has argued, the notion that we are all rational choosers is a flattering lie told to us by people who want to sell us something.

The uncomfortable truth is that much of the time we are influenced and motivated by social and psychological forces that we barely understand. In particular we must consider the impact of the marked increase in the numbers of elderly and frail people in our midst and the social, medical and economic pressures which this inevitably creates.

Increasing life span

In the UK there are currently about eleven million people who are over 65 years old.  This figure is projected to rise to 15.5 million by 2030 and to around 19 million by 2050.  Within this total, the number of very old people is growing even faster. There are currently 3 million people aged more than 80 years in the UK and this number is projected to double by 2030, and reach 8 million by 2050.   Whilst one in six of the UK population is currently aged 65 and over, by 2050 one in four will be. 

And the phenomenon is occurring globally.  People aged 60 years and above account for 11% of the global population.  This proportion is expected to double to 22%, or 2 billion people, by 2050. The global number of older people is expected to out-strip the number of youth under 16 years by 2050. This is not just a phenomenon in rich countries.  The fastest growth in the number of elderly people is occurring in developing countries, with profound implications not only for older people themselves, but also for social and community infrastructure.  This is particularly relevant because resources for caring for dying people and providing palliative care are inadequate in most developing countries.

The startling increase in the number of older people is happening at time when there is a progressive weakening and breakdown of traditional family structures.  A UK survey of people over the age of 75 found that about 1 in 6 felt socially isolated.  42 per cent lived alone and this figure rose to 72 per cent of those aged over 85.  Many lived long distances apart from their children and were visited by their children just once every two to six months.   Some were visited once a year or less.  Those in the oldest age cohort were most likely to report the highest rates of loneliness.  Over 6 out of 10 of those aged 80 said they felt lonely.  Again this is not just a rich country phenomenon.  A recent study in Bulgaria, Ghana, Nicaragua, Vietnam and the state of Andhra Pradesh in India reported that between 15% and 30% of older people lived alone or with no adult of working age.

Some social planners see a nightmarish future, where large numbers of isolated and abandoned elderly people are kept alive to suffer a pointless and degrading existence, and a lonely death, thanks to improvements in medical care.  Wouldn’t a liberal euthanasia and assisted suicide policy provide some kind of solution to this horror? 

Health consequences of an ageing population

Improvements in healthcare and medical technology have contributed directly to the increase in lifespan.  This is surely a good thing, but it has had unforeseen consequences in increasing the number of elderly people who have chronic health needs.  Approximately 20% of people aged 70 years or older, and 50% of people aged 85 and over, report difficulties in such basic activities of daily living as bathing, dressing, toileting, continence, feeding, and transferring from chair to bed.  As life expectancy increases, so does the likelihood of more years spent in ill health, with women at present having on average 11 years and men 6.7 years of “poor health”. 

Loneliness also has health consequences, as it is associated with increased mortality, illness, depression and suicide.  A 2008 study found that chronic loneliness is a health risk factor comparable to smoking, obesity and lack of exercise and contributes to a suppressed immune system, high blood pressure and increased levels of the stress hormone cortisol.

Alzheimer’s disease and dementia

At the time of writing about 850,000 people in the UK suffer from dementia, and the Alzheimer’s Society predicts that this figure will increase to over a million by 2021 and 1.7 million by 2051.  The proportion of affected individuals in the population is predicted to rise from 16% between 75 and 85 years to more than 25% over 85 years.   According to current predictions, someone born now has a one in three chance of developing some form of dementia before they die.   The numbers of people living with dementia worldwide is expected to double every 20 years and by 2050 it is projected there will be 115 million people with dementia worldwide, 71 per cent of whom will live in developing countries.

In July 2015 newspapers reported the tragic story of a devoted elderly couple Michael and Meryl Parry.  Meryl had dementia and Michael had struggled to care for her at home in a way that respected her dignity.  Eventually Meryl had been admitted to a care home but Michael said she was treated “like a farm animal”, and he had taken her back home.  Unable to find appropriate emergency care, in desperation he killed her with a plastic bag and pillow over her face. 

Finding an appropriate way to care for Alzheimer’s sufferers represents a major and still partly unsolved challenge for the medical and caring professions.  In the Netherlands there is increasing public and medical acceptance that voluntary euthanasia may be appropriate for individuals who are in the early stages of dementia and who wish for a way to escape.

Economic consequences of increasing lifespan

Much of the UK Government’s spending on benefits is focussed on elderly people, equivalent to £100 billion in 2010/11 or one seventh of total Government spending.   The proportion of the UK population who are not employed is expected to rise significantly.  In 2008 there were 3.2 people of working age for every person of pensionable age. This ratio is projected to fall to 2.8 by 2033. Continuing to provide state benefits and pensions at today’s average would mean an additional spending of £10 billion a year for every additional one million people over working age.

Not surprisingly growing numbers of elderly people are also having an impact on the NHS, where average spending for retired households is nearly double that for non-retired households.  The UK Department of Health estimates that the average cost of providing hospital and community health services for a person aged 85 years or more is around three times greater than for a person aged 65 to 74 years.  The final year of life is often the time when expenditure on healthcare is greatest. 

How do these factors influence the assisted suicide debate?

Most of those who are arguing for a change in the law, explicitly distance themselves from any argument based on the potential social and economic benefits which might come from the medically assisted suicide of the elderly and infirm.  Their arguments are based on individual rights to choose the timing and nature of their own death, and on compassion towards those who are suffering hopelessly and unbearably. 

However Baroness Mary Warnock is one of the few euthanasia advocates who has been prepared to follow the logic of her position in public.  In her book “Easeful Death” published in 2008, she discusses the benefits of assisted suicide and euthanasia for the elderly and dependent.

“One of the fears most commonly expressed is that, if assisted dying were an option, patients in the last stages of illness might have pressure put on them to ask for it, when it was not what they really wanted.  It is not difficult to imagine feeling that one’s children were getting impatient either for their inheritance or simply for relief from the burden of care, and that one had not so much a right to ask for death as a duty to do so, now that it was lawful to provide it.  There undoubtedly exist predatory or simply exhausted relatives.  But it is insulting to those who ask to be allowed to die to assume that they are incapable of making a genuinely independent choice, free from influence.…”

“….In any case to ask for death for the sake of one’s children or other close relatives can be seen as an admirable thing to do, not in the least indicative of undue pressure, or pressure of any kind.  Other kinds of altruism are generally thought worthy of praise.  Why should one not admire this final altruistic act….Part of what makes a patient’s suffering intolerable may be the sense that he is ruining other people’s lives.  If he feels this keenly and asks to be allowed to die, he is not a vulnerable victim, but a rational moral agent.”

 “Contemplating the wretched lives of patients with dementia… we may feel despair.  They are allowed to die, many of them, by a slow and horrible death, far from the ‘good death’ or the ‘death with dignity’ that euthanasia would afford them.  Many of their relatives, if there are any, must long for them to die.…What is to be done?  This is a question which, as far as we can see, society can at present supply no answer.  But it must be faced as we become an increasingly aged population.”

In a widely-quoted interview in 2008 Mary Warnock stated “If you’re demented, you’re wasting people’s lives – your family’s lives – and you’re wasting the resources of the National Health Service. I’m absolutely, fully, in agreement with the argument that if pain is insufferable, then someone should be given help to die, but I feel there’s a wider argument that if somebody absolutely, desperately, wants to die because they’re a burden to their family, or the state, then I think they too should be allowed to die.”

Her remarks created a furore, and were strongly opposed by the majority of those who care for Alzheimer’s sufferers, but in reality they reflect the unspoken thoughts of many.  Faced with the demographic time bomb of an aging population with its profound social, economic and health risks to the future survival of civilisation, maybe legally controlled and medically supervised suicide can provide a solution.  Perhaps choosing to kill yourself in old age will come to be seen as the responsible, compassionate and altruistic option.   

Euthanasia can provide organs for transplantation

The possibility of making a link between euthanasia and the shortage of organs for transplant seemed entirely theoretical until recently.  But several cases of organ donation coupled with euthanasia have now been reported from Belgium.  In 2005 and 2007, four patients expressed their will for organ donation after their request for euthanasia was granted.  The patients were aged 43 to 50 years and had a debilitating neurologic disease.  According to the published report, “the euthanasia procedures were carried out on the date requested by the patient, by three physicians independent from procurement or transplant teams, in the operating room.  After clinical diagnosis of cardiac death, organ procurement was performed….” 

In 2012 it was stated that nine cases of organ donation following euthanasia had occurred.  A total of 1100 cases of euthanasia occurred in Belgium in 2011 and it was reported that since the majority of cases were in terminally ill people with cancer, only a small proportion were suitable to be donors. Most people, including most doctors, have an intuitive reaction against the association of euthanasia with organ transplantation, but on strictly utilitarian grounds the argument is clearly persuasive.   

Too many people already

Even world over-population can be seen as a factor in the trend towards the increasing acceptability of euthanasia and assisted suicide.  The current population of the world is over seven billion and it is continuing to rise at nearly 2% per annum.  Several recent environmental studies have argued that the entire resources of the planet are only sufficient to sustain a significantly smaller population at a European standard of living.  This is described as the “carrying capacity” of the planet – the maximum population size of the species that the environment can sustain indefinitely.  If global living standards are to be maintained, and catastrophic climate change is to be avoided future generations will have to face the challenge of ensuring a drastic reduction in world population to sustainable levels whilst avoiding destabilising violence and social breakdown.  Perhaps the promotion of old-age suicide, maybe with a range of incentives to encourage wide scale adoption, will provide a solution.

These sinister and dystopic fantasies may seem far-fetched.  Those who wish to promote the legalisation of medically assisted suicide strongly disassociate themselves from such goals, preferring to concentrate on individual choice and liberties.  But it is surely naïve to imagine that the enormous challenges raised by a growing and ageing population can be entirely separated from the legalisation of medically assisted suicide.

This material is adapted from my book Right to Die? Euthanasia, assisted suicide and end of life care, published by IVP. For all other material on euthanasia and palliative care, including my other introductory essays, click here.

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