A prisoner is assessed for “medical assistance in dying” (MAID) while wearing shackles and is given a fatal “medication” to end his life in the presence of guards and police. A disabled man repeatedly requests assisted living but is instead offered assisted dying and reminded of the expense of his hospital stay. A celebrated defender of medically assisted dying declares that it is ridiculous that a society with so much “unaffordable” age-related illness should hesitate to accept the practice. A pro-MAID tract bluntly notes, “If you’re on the fence about killing yourself, the fact that you’re a burden on your family or the wider society should be taken into consideration.”
Does this sound like a context in which “patient autonomy” is paramount? Canada’s decision to legalize MAID in 2016 was held up as a triumph for the freedom of the patient. The promotion of assisted dying is about a lot of things. But it is not about autonomy. It is about subjecting the unpredictability and unruliness of death to bureaucratic control.
Subject to global criticism for its gradual expansion to ever more groups, Canada’s notorious MAID law is due to be extended to those with mental illness, and has even been proposed for children (“mature minors”). Academic papers continue to pour in justifying MAID under an ever-broadening range of circumstances. One such paper argues that even in situations of injustice, MAID represents “harm-reduction” for those living in a world that is unlikely to get better any time soon: “Not allowing people to access MAID because their request is driven by unjust social circumstances, when those circumstances show no short-term chance of improving, succeeds only in causing further harm.”
A good portion of the population seems to agree, with a third of Canadians expressing support for MAID in situations where the recipient’s only affliction is poverty.
“Assisted dying is the quintessential policy of our times.”
Assisted dying is the quintessential policy of our times. It is a policy that reflects the fatalistic mindset of those who rule over us, leaders who can no longer promise a good life so instead offer a “good death.” Opponents of assisted dying in Canada and elsewhere have asked how a society can maintain a commitment to preventing suicide with one hand while enabling it with the other. The answer is that our society doesn’t actually value human life and so doesn’t oppose suicide. What it opposes is the lack of a bureaucratic process that oversees, controls, and administers suicide.
Assisted dying is defined by a powerful sense of pessimism. Every day, we are told about the destructiveness of the “human footprint,” that “we,” the undifferentiated mass of humanity, are responsible for climate change and environmental destruction. Theorists have begun to make the case against human life as such, with one surmising that since “nonexistent” persons have no environmental impact, “not existing is more moral than existing.”
Commentators will often root their arguments in classical liberalism, drawing on John Stuart Mill to claim that the exercise of free will shouldn’t be impeded if it isn’t harming others. However, a closer look at what is actually involved shows that legislation being proposed isn’t about the exercise of a patient’s full and unimpeded free will. To be eligible for MAID in Canada, one must first fill out a form populated by predetermined criteria. The appropriately blandly titled Form 1632 is then passed to a coordination office and, from there, to an external “health authority,” which assesses eligibility.
It isn’t even a physician who ultimately takes responsibility for the process. One startling account details a man with a history of mental illness seemingly fast-tracked for MAID with few questions asked. When a concerned family member begged for a psychiatric assessment, the MAID provider noted that it would be little more than a formality that would “provide cover” for the decision. In effect, both physicians and patients are relinquishing autonomy to a bureaucratic process. In this system, autonomy is a mirage overshadowed by institutional control. All the boxes have been ticked. No one is at fault. No one can judge or be judged.
A society that has produced seemingly endless choices has also produced a desire to endlessly defer responsibility for those choices. We can see this process apparent elsewhere in medical care, for instance in recollections of gender “detransitioners” who express retrospective shock at how little they were assessed by medical professionals. “Patient-centered care” means regarding the patient as an expert in his own suffering. At the same time, the authority of the physician is invoked to ratify the patient’s judgment as medically correct. In the end, no one is accountable for the life-altering, even life-ending treatment administered. Responsibility is dispersed in a bureaucratic process.
Far from being the triumph of the liberal progressive project that began in the 18th and 19th centuries, the rise and expansion of assisted dying marks its defeat. It isn’t about expanding self-determination, but about seeing the ongoing destruction of liberal subjectivity through to the end of life. Today, people are not encouraged to be autonomous. Our society invites people at every turn to doubt their capacity to decide for themselves. We are constantly told that human beings are weak, irrational, and vulnerable. Good citizens learn to see the exercise of their own free will without the careful consultation of expertise as a risk to themselves and others. The guiding ethos of our time assumes that most of the problems that face us are caused by the unruliness of human behavior. If people could just be made to think, feel, and thus behave in the correct ways, we would not have larger problems like economic crises, climate change, or even wars. While assisted dying isn’t about autonomy, it is about control. It is about control of the dangerous and unruly process of dying and thus the smooth and efficient functioning of the great administrative machine.
Death as nature intended comes for anyone at any time. It is difficult to plan for, and it has no apparent purpose. But death in the comfortable and safe confines of bureaucratic process can be subject to rational calculation. In a world where the quality of our lives seems stubbornly resistant to improvement, death emerges as a new market: On a scale from one to 10, how satisfactory was your loved one’s death today?
Masked as progress, assisted dying is intimately linked with our present regress. It is the death of the liberal outlook that places the sovereign, free-willing subject at its center. The zealous extension of institutional control from the cradle to the grave is the politics of the void. It is the politics of a world that has never been able to bridge the chasm between what is and what ought to be, and which has begun to toss human beings down into its abyss. In failing to oppose MAID, we are assisting the death of the ethos that celebrated human agency.