Nobody can tell me what to do with my life, right?

No one argues that the good of autonomy should allow running red lights.

The strongest argument for euthanasia and assisted suicide may be “autonomy”. In its crudest form, this means: “who are you to tell me what to do with my life?” Bioethicist Xavier Symons argues that autonomy is completely inadequate as a key to assessing the “right to die”.

MercatorNet: In a nutshell, what’s wrong with the argument “nobody can tell me what to do with my life”?

Xavier Symons: Liberal democratic societies already place quite significant limits on the exercise of autonomy (limits that any reasonable person ought to be able to accept). No one argues that the good of autonomy should allow child abuse, for example. Nor do people protest public decency standards or traffic regulations, save for exceptional circumstances.

Current social circumstances demonstrate, therefore, that the argument “my body my choice” is crude and not accepted in many spheres outside of healthcare. Indeed, it is not at all clear that it holds in healthcare either, if we consider the strict public health measures that have been introduced across the globe in response to the COVID-19 pandemic.

The notion that the logical conclusion of upholding the good of autonomy necessarily means legalising practices like euthanasia is inherently flawed. Autonomy is a value that is important but also is the subject of appropriate limits that protect the common good.

Indeed, an adequate conception of autonomy ought to be set against the backdrop of an objective moral order and situated in the context of the common good. Autonomy ought to be conceived of as part of a matrix of social conditions that taken together are conducive to the realisation of basic human goods. Autonomy is one condition, but not the only condition, for human flourishing.

Or, as Daniel Sulmasy has written, “free choice is the context of morality, not the content of morality”. Autonomous choices should be aimed at basic goods – or, at least, not be in violation of basic goods – for such choices to be considered authentic exercises of autonomy.

The exercise of authentic autonomy is enabled by virtue of the human communities to which one belongs. Indeed, there is a very real sense in which “your life is not your own”, at least with respect to your identity as a practical reasoner. Human beings become mature practical reasoners through education and life experience, and both these come from the communities of which one is a part – the family, friendships, neighbourhoods, educational institutions, intellectual communities, clubs and societies, religious tradition(s), and so forth.

Ironically, respect for autonomy requires that we seek to preserve and sustain the community norms and relationships that support and sustain the practical reason. I feel like the whole “it’s my life” mentality misses this point completely.

Autonomy is the ideology of political liberalism – which has come under fire in the wake of Black Lives Matter and the rise of critical race theory. Are there philosophical critics of autonomy nowadays?

Philosophers have engaged in extensive debate about the nature of autonomy in recent decades. Communitarian critics of autonomy argue that a liberal conception of autonomy – a view that conceptualizes the individual as self-sufficient and existing in isolation from other members of society – ignores the fact that human beings are situated within communities and ought to focus first of all on the ethical norms that arise from one’s membership of communities.

Similarly, feminist critics of autonomy argue that liberal political theorists overlook the relational dimensions of autonomy, and, in particular, the fact that autonomy can be enhanced or diminished based on the social conditions and network of relationships in which one is embedded.

It seems that recent social criticism of liberalism focuses on the meritocratic dimension of liberal political philosophy. There is a widespread view that it is not sufficient to simply provide equality of opportunity in society. We need to take affirmative steps to redress structural inequalities (e.g. structural racism) that can leave people at a disadvantage even where ostensibly we have created a level playing field.

The effects upon relatives and friends are a major issue when we mention suicide. Why do people privilege “autonomy” and ignore the collateral damage when we debate assisted suicide?

The broader cultural effect of legalised euthanasia is something that has been largely ignored in public debate. We should realise that euthanasia contains within it a philosophical position on the value of life. As Albert Camus once wrote, “judging whether life is or is not worth living amounts to answering the fundamental question of philosophy”.

Euthanasia represents the view that human existence only has conditional value or worth; the value or worth of life can be lost if one’s quality of life is sufficiently poor. This conditional approach to the fundamental question of human existence creates a world in which there are two categories of life – lives that are worth living and lives that are not.

Make no mistake: this is a departure from the view that human life has value by default precisely because it is human life. Indeed, we are entering an era where practices like rational suicide are becoming much more difficult to resist and suicide prevention is becoming harder to rationally defend. This is because we have debased the ethical foundation for our opposition to suicide. Human life is no longer viewed as having intrinsic and inalienable moral status. The ethics of suicide is reducible to a question of consent and autonomy if one can alienate or waive their own right to life.

Does a radical position on autonomy threaten our society’s commitment to human equality?

Yes. A crude ethic of autonomy threatens our society’s commitment to protect and promote human dignity. We outlaw all sorts of things – like dwarf tossing, for example – on the grounds that they are an affront to human dignity. Consent is not sufficient to override our fundamental commitment to respect in this case. In 1995, France’s highest court rejected a lawsuit by a man with achondroplasia to overturn the country’s ban on dwarf tossing. The court concluded that dwarf tossing was an “affront to human dignity”.

A crude ethic of autonomy rejects this reasoning and leads to a situation in which choice trumps human dignity. This is a perilous situation and can undermine our commitment to human dignity altogether. A universal prohibition on the taking of human life, for example, ought to function as a limiting principle on individual autonomy – a red line that ought not be crossed. Yet if we say that autonomy overrides the right to life then an individual agent can choose to “‘waive’ their right to life”.

Fundamental human equality presupposes the inalienability of the right to life of the human person and is a necessary ethical foundation of any civilised society. Aside from ensuring the maintenance of social order, fundamental human equality ensures that members of society who might otherwise be subject to discrimination – people living with disabilities, people with chronic health conditions, older members of the community, and so forth – are treated with dignity rather than derision, and respect rather than repugnance.

The treatment of care home residents in the early stages of the COVID-19 pandemic is one example of a worrying erosion of the principle of human equality in Western societies. As Charles Camosy warns, “if we continue on our current path […] the idea of fundamental human equality may simply die out”.

But how can euthanasia and assisted suicide (EAS) possibly harm other people? They are not being forced to get a lethal injection or even to agree.

We routinely ignore the effects that our choices have on other people. This is a regrettable fact of our pathologically individualistic culture. The reality is that one agent’s exercise of autonomy can lead to a diminution of the autonomy of other agents. Indeed, the very existence of options or choices can harm people.

This idea is compellingly explained in the bioethical papers of American philosopher David Velleman. Regardless of the ostensible public support that exists in favour of euthanasia and assisted suicide, there will always be vulnerable members of the community who do not want to have to confront the question of whether they should avail themselves of a legal option to end their own life. Many people may not want to have this choice available, because, in the words of Velleman, “to offer the option of dying may be to give people new reasons for dying”.

In a world where so many dwell in a rational space where the value of continued existence is in constant question, the option of EAS could alter the personal existential calculus of vulnerable individuals in catastrophic ways. This is one clear autonomy-based argument against the legalisation of EAS.

Can people who are at the end of their lives really make autonomous decisions to end it all? Is there something special about those last days?

People nearing the end of life often have diminished autonomy and it thus becomes difficult to justify giving terminally ill patients total autonomy to decide whether they will end their own lives. Crucially, agency – understood as the human capacity to freely choose one’s thoughts, motivations and actions without undue internal or external influences – comes apart from a crude conception of autonomy in morally important ways. One can meet Tom Beauchamp and James Childress’s criteria for autonomy, namely, intentionality, understanding and control, while still experiencing diminished agency.

Factors that diminish agency include a loss of meaning and purpose in life, a bleak and pessimistic outlook on the future and a distorted perception of one’s own prognosis. A desire for death or a loss of the will to live would ordinarily be seen as a factor that impairs one’s capacity for rational judgement.

Yet in the case of EAS, this sentiment becomes the very context for decision-making. EAS thus distorts conventional conceptions of agency and leads to the adoption of a crude conception of autonomy whereby one only requires the ability to understand information and the absence of overt forms of coercion.

This dimension of decision-making about EAS is particularly insidious. EAS challenges the traditional constraints that we put on decision-making in situations of severe depression or demoralisation, leading instead to a scenario in which these factors provide legitimacy and rational justification for one’s decision.

Your recent paper suggested that genuine respect for autonomy is actually a good argument against assisted suicide. Can you explain that?

The excessive emphasis on autonomy in recent decades draws attention to the dangers of conceiving of this value in a moral vacuum. We ought to instead theorise autonomy within the context of other values that are of fundamental social importance. In particular, we ought to acknowledge the symbiotic relationship between autonomy and human dependence, and the role that autonomy plays in the flourishing of human communities.

Autonomy is a portmanteau word  formed from two Greek words, namely, αὐτος (autos; ‘self’) and νομος (nomos; ‘law’). Autonomy, thus, is concerned with self-legislation or self-governance. The autonomous individual is one who is capable of moral self-determination and who is free from external and internal constraints on their motivations, thoughts, decisions and actions. The concept need not be cashed out in terms of an atomistic, liberal conception of the self and society.

Even on that worldview, one can still argue for limitations on autonomy, such as traffic regulations. Otherwise, one could not drive anywhere for fear of other drivers being on the wrong side of the road. Rather, autonomy can be understood within the context of an integral vision of human communities. Two considerations are particularly relevant here: the role that autonomy plays in the realisation of basic goods; and the role that communities play in facilitating authentic exercises of autonomy.

First, autonomy can be conceived of as part of a matrix of social conditions that taken together are conducive to the realisation of basic human goods. In their recent book The Way of Medicine, Curlin and Tollefsen identify two functions that illustrate the importance of autonomy in human flourishing. First, some goods are only realised if people make commitments (e.g., marriage, friendship, religion). That is to say, some goods come into being via certain commitments made by persons. Marriage, for example, is a contract (or covenant) between two individuals (a man and a woman, on the traditional conception). Second, commitments also help human beings in community to realise goods to a greater degree, in themselves and one another. If society were governed in a totalitarian manner whereby people of working age were merely assigned to professional roles rather than voluntarily choosing to occupy such roles, we would probably end up with a workforce that is less dynamic and cohesive than one which is made up by free actors.

Such a workforce would be less efficacious in their pursuit of the basic goods constitutive of the flourishing of society.

Second, the exercise of authentic autonomy is enabled by virtue of the human communities to which one belongs. Indeed, the self that is at the heart of any plausible conception of autonomy is a self that is shaped and formed through communities such as the family, friendships, neighbourhoods, educational institutions, intellectual communities, clubs and societies, religious tradition(s), and so forth. The circumstances of one’s life can vary remarkably with respect to the communities to which one belongs.

Yet one fact is undeniable: from childhood to old age, from times of health to times of illness and disability, human beings are constantly dependent on each other to know themselves and the world and to make decisions that are conducive to their wellbeing. Most relevant for our purposes, an individual’s reliance on the help, support and encouragement of other human beings is typically most acute in one’s final days and hours.

Vaccine mandates around the globe were widely accepted during the Covid pandemic while refuseniks were ridiculed. Is this relevant to the debate over assisted suicide?

I think there are aspects of our response to the COVID-19 pandemic that lend support to the anti-euthanasia case. For example, scholars have argued that the rigid focus on saving lives in the pandemic – which was used as a justification for lockdowns and various other restrictions on social and economic activity during the pandemic – actually makes it harder to justify the legalisation of euthanasia.

If there is a possibility of even one wrongful death from euthanasia legislation (and this is quite a plausible contention) then it seems that there is a good case for restricting people’s end of life liberties to protect that one life that could be wrongfully taken if we legalised euthanasia.

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