Assisted dying
A crisis of the liberal-utilitarian state
Supporters of assisted suicide seem to prefer the term “assisted dying.” This is an unusual piece of linguistic gerrymandering, in that it might actually reveal as much as it conceals. The problem with “suicide,” presumably, is that it carries traces of religious stigma. In its potted history of the subject, the Humanist Heritage website refers to earlier campaigns for “what was then called ‘suicide’”, as though we no longer even recognise the word. Secular humanists, by contrast, favour “individual self-determination… and the exercise of reason and compassion in arriving at moral decisions.”
Maybe a degree of emotional detachment is helpful for “the exercise of reason and compassion.” But to my ears, the term “assisted dying” has the distinctive – or rather, the suspiciously indistinct – ring of a bureaucratic euphemism. It does not suggest an act or decision at all, but an impersonal process. Far from emphasising self-determination, it evokes the legalistic neutrality of the utilitarian state, managing its population from a distance where the names, faces and circumstances of actual individuals are bleached out.
This brings us, I think, to the substance of the issue. The U.K. parliament recently took a significant step towards legalising assisted dying in certain circumstances. Debates surrounding the vote have exposed a longstanding tension in the governing ideology of Britain, and of many western countries. The tension is between liberal ideas of autonomy – giving individuals more rights to determine their own lives, or indeed their own deaths – and some of the institutions that manage liberal societies, which are basically utilitarian. These institutions make rules and allocate resources in ways that, at least in theory, try to maximise wellbeing and justice across society as a whole.
I want to look at an early but still resonant critique of this liberal-utilitarian paradigm. It comes from the architect Augustus Pugin, best known, as it happens, for his work on the very building where British MPs cast their votes on assisted dying, the Palace of Westminster, or Houses of Parliament. You only have to look at this structure to get a sense of where he was coming from, ideologically speaking. This was not a man who Humanist Heritage would necessarily celebrate. He idealised medieval Catholic society, and was hugely influential in popularising its Gothic architecture among the Victorians. In 1836, he published a polemic called Contrasts, or, a parallel between the noble edifices of the Middle Ages, and corresponding buildings of the present day, shewing the present decay of taste. Pugin’s tactic in Contrasts was essentially the same one that propagandists for traditional architecture use on social media today, juxtaposing images of medieval and modern buildings to emphasise the ugliness and depravity of the latter.
One of these contrasts focused on “Residences for the Poor.” The modern example will be familiar to readers of Dickens, or readers of Foucault for that matter. It is a workhouse of the kind that was commissioned by the British state after the New Poor Law of 1834. In this prison-like structure, the poor were expected to labour and endure punitive conditions in exchange for their subsistence. The octagonal layout allows a small number of overseers, positioned in a central observation tower, to keep watch over the inmates. Pugin based his drawing on a plan by Sampson Kempthorne, who in turn was inspired by the famous Panopticon design of the utilitarian philosopher Jeremy Bentham. The policy of using workhouses for poverty relief was justified in utilitarian terms too. It was reasoned to be in the interests of the population as a whole because it disincentivised the poor from claiming charity, thereby saving public funds and encouraging greater self-reliance.
This is the same dehumanising logic of efficiency that critics of assisted dying rightly fear. Such a program will be implemented by bureaucracies that are tasked with dividing increasingly scarce resources between a range of services and patient demands. In principle, the National Health Service aims to help everyone and anyone, but since this is an impossible task, decisions have to be weighed according to metrics such as Quality Adjusted Life Years, as well as political and publicity considerations. For instance, it was recently announced that the weight-loss drug tirzepatide will be made available to fewer than 10% of eligible obese patients, “in order to protect other vital NHS services.” This may change, however, if the drug proves effective at getting the unemployed get back to work, since that would cut the benefits bill.
In this context, the danger that assisted dying will become a de facto cost-saving measure, by allowing vulnerable people with expensive needs to be culled from the population, appears obvious. Pugin’s bleak vision of the workhouse looks all too relevant when we consider that, in Canada, there are numerous cases of “medical assistance in dying” being offered, or encouraged, for those who can’t afford a decent standard of life, even as state officials tally the “net cost reduction” in healthcare spending.
What then should we make of Pugin’s model for the ideal poorhouse, a bucolic almonry with religious buildings, dutiful monks, generous lodgings and well-fed paupers? I don’t think we need to endorse Catholic theocracy to appreciate the point of this contrast. The “ancient poor house” represents a society whose spiritual orientation engenders a sense of collective responsibility towards the poor. As such, it implies that Kempthorne’s brutal workhouses are the result not just of utilitarian logic, but of a more general lack of responsibility, which stems from the liberal principle that individuals should pursue their own happiness and self-interest.
This too remains relevant today. In certain historical conditions, giving a broad scope to individual autonomy probably does produce the greatest happiness for the greatest number; but it inevitably erodes social bonds, undermining support for the vulnerable. Since Pugin’s time, the solution has increasingly been to outsource that support to the state. This too can work well. An effective welfare system, using the impersonal tools of money and bureaucracy, can extend a measure of independence even to the destitute. No monks needed.
The problem arises when that system does not work effectively. Then we could be left in a situation where, prioritising personal autonomy on the one hand and impersonal efficiency on the other, we are no longer capable of handling our interpersonal responsibilities in a decent, civilised way. Hence the all-too-plausible prospect of a state that not only nudges the vulnerable towards an “assisted death,” but celebrates the process as an expression of the victim’s freedom.