Without sentimentalising or romanticizing illness, the reality of the onset of severe disability is not only of loss but also of personal growth, as evidenced by studies of personal growth in spinal cord injury (1), or narratives of severe stroke such as Kirk Douglas' My Stroke of Luck or Jean-Dominique Bauby's The Diving-Bell and the Butterfly. In addition, our efforts to use this growth are enormously influenced by a negativity about both advanced age and disability that position of 'better dead than that form of disability' will do little to advance.  This was particularly marked in Clint Eastwood's film Million Dollar Baby whereby euthanasia took place in the face of palpable depression, inadequate facilities and support and a dismally untherapeutic environment. This mindset is strikingly mirrored by how much advance directives are phrased almost exclusively in terms of that which I should not have, rather than in terms of what I should have that my might enhance the quality of my life and my care (2).

A further troubling aspect of the debate is the tendency to disconnect the debate from the pain caused by suicide in other settings, and a failure to ask why suicide might now become right in the context of some diseases and ages but not others: is it a deep manifestation of prejudice against significant disability and age-related disease that suicide should be somehow acceptable in these settings but not at younger ages?

It is also unhelpful to portray professional resistance to assisted suicide as either paternalistic – clergymen and doctors telling us how to die – or as another correspondent writes 'doctors playing god'. An understanding of human vulnerability, a historical sense that doctors have been here before (widespread support for eugenics in the 1930s), an awareness that we change our priorities and insights with the dying process (3), insights into prejudice against disability and the professional imperatives of assisting the troubled and vulnerable are more prominent themes in the literature.

Finally, unlike Mr Lansley, while it would be nice to think that I have been responsible for all aspects of my life, the reality of my autonomy is that it has always been exercised in the embrace of others. It is exceptionally rare, if not impossible, for most of us to state that we have been 100% autonomous and had 0% co-dependency of some form or another during the course of our lives.  We diminish the reality of our human existence if we allow the hugely important principle of autonomy to have a vice-like and inflexible hegemony over the wide range of other important aspects of our individual and shared lives.

Desmond O'Neill MD FRCPI
Centre for Ageing, Neuroscience and the Humanities,
Trinity College Dublin

1. Pollard C, Kennedy P. A longitudinal analysis of emotional impact, coping
strategies and post-traumatic psychological growth following spinal cord injury:
a 10-year review. Br J Health Psychol. 2007;12:347-62.
2. O'Neill D. Present, rather than, advance directives. Lancet. 2001;358:1921-2..3. Micco G, Villars P, Smith AK. The death of Ivan Ilyich and pain relief at the
end of life. Lancet. 2009;374:872-3.