By Kayla Wiebe and Amy Mullin.

In February, 2022, a Canadian citizen with a severe case of multiple chemical sensitivities (MCS) requested and subsequently received medical assistance in dying (MAiD). The decision to request MAiD was made after a two-year fight to access housing that would have made living with their condition tolerable. This kind of case, involving persons with chronic conditions who cannot access social supports to make living with their condition tolerable, is certainly not the most common reason for accessing MAiD. Neither is it rare – several similar cases have followed. All involve people suffering from a chronic condition, but whose deaths are not reasonably foreseeable, requesting MAiD. Furthermore, each person indicates that MAiD is not their preferred choice, and that a large part of the reason they are choosing MAiD is due to insufficient social supports (such as housing, disability supports and finances). They were not eligible for MAiD under the previous regime but are now eligible under Canada’s Bill C-7.

Public responses to these cases express understandable uneasiness that it is permissible for people in such circumstances to access MAiD. They condemn the fact that it seems easier for persons with chronic but non-terminal conditions to access MAiD than to continue living in a manner that is acceptable to them, argue that they reveal serious gaps in Canada’s ‘universal’ healthcare system and social supports more generally, and raise larger questions about what restrictions on MAiD are reasonable.

In our paper, “Choosing Death in Unjust Conditions: Hope, Autonomy, and Harm Reduction“, we agree with the diagnosis of a crisis in Canada’s healthcare system. However, we disagree that MAiD should be restricted in response. In addition, we respond to a different kind of argument, one that we have seen employed regarding these MAiD cases but also in relational autonomy theory more generally. This is the argument that people who make decisions in the context of unjustly restricted options are lacking in autonomy and therefore cannot give voluntary, informed consent.

The argument goes as follows: having sufficient autonomy is dependent upon an absence of oppressive circumstances. An absence of oppressive circumstances is precisely what is not available to oppressed persons and thus oppressed persons lack autonomy (or possess it to a lesser degree). Given the role that attributions of ‘autonomy’ have in clinical spaces, this theoretical conclusion naturally leads to a practical one: if a person is not autonomous because they are oppressed, it is reasonable and justified to restrict their choices to protect them and preserve their autonomy or potential for future autonomy. In the MAiD cases considered above, signalling that such persons are not appropriate candidates for state sanctioned assisted death furthermore sends an expressive message that the lives of such persons are valuable.

One central point of our paper is to identify how this type of argument is problematic. There is every evidence that many people subjected to oppressive socioeconomic circumstances demonstrate full autonomy in the relevant ways: they understand their options, appreciate the consequences of their actions, and persist in a course of action they view as better than the alternative of continuing to live in their current circumstances. Further, treating them as though they lack autonomy replicates the kinds of harmful biases that relational theorists aim to avoid.

We think that arguments about the autonomy of people choosing MAiD in these circumstances reflect and perpetuate ineffective individualism about systemic problems. When we target the agent’s decision-making as the primary problem (problem: the person is non-autonomous), we locate potential solutions in individual interventions aimed at altering those individual decisions (solution: supporting them to restore autonomy or refusing their request altogether). However, they will still be left in the circumstances in which they started: egregiously unjust ones. And, if anything sends an expressive message that certain types of lives are not valuable, it is not the alteration of MAiD law to include persons who suffer from chronic but non-terminal conditions. Forcing people to exist in structurally ableist conditions and providing chronically insufficient social and financial supports send this message long before.

It is tragic and unjust when people with chronic conditions lack adequate social supports to make living with their conditions tolerable and elect to receive MAiD. However, targeting and problematizing the autonomy of persons making these decisions, even if intended to protect people presumed to be collectively vulnerable, is a mistake. When social conditions combine with chronic health problems to lead people who sought other alternatives, without relief, to request MAiD, the least harmful approach is to evaluate their requests as we do any other. This means ensuring that the choice is informed and the person requesting it is competent to do so. The injustice of those social conditions should lead to social reform rather than a restriction of the options of the suffering individuals involved.

Paper: Choosing death in unjust conditions: hope, autonomy and harm reduction

Authors: Kayla Wiebe,¹ Amy Mullin²

Affiliations:

¹Graduate Department of Philosophy and Joint Centre for Bioethics, University of Toronto, Canada

²Professsor and Associate Chair and Director of Graduate Studies, Graduate Department of Philosophy, University of Toronto, Canada

Competing Interests: None declared.

Social Media Accounts: @KaylaJWiebe