Kathleen Stock is a contributing writer at UnHerd, a frequent columnist at The Sunday Times and The Times, and a co-director of The Lesbian Project, which she runs with journalist and activist Julie Bindel.
In this week’s conversation, Yascha Mounk and Kathleen Stock discuss why liberal arguments for assisted dying are less coherent than they appear, whether palliative care offers a more merciful alternative to medically assisted death, and how different legal regimes around the world reveal the practical challenges of institutionalizing end-of-life choices.
This transcript has been condensed and lightly edited for clarity.
Yascha Mounk: I’ve really looked forward to this conversation, though the topic is obviously somewhat somber. You’ve written a book about medically assisted suicide. You end up arguing against it, but I wonder whether, before we can get into those arguments, you can lay out the basic liberal argument for the practice. Because I think from a philosophical liberal perspective, there are some obvious arguments for empowering people to make their own decisions about the body, their own decisions about how to live and possibly how to die, that are quite powerful. What would you put sort of on that end of the ledger?
Kathleen Stock: Well, it’s part of the argument of my book that what look like powerful arguments from a liberal perspective actually are pretty incoherent. So it’s going to be difficult for me to convincingly lay out the case, since I spend so much of the book attacking these so-called liberal arguments.
Basically, there are two different argumentative strains, which are not often distinguished and are often sort of ventriloquized together, so people get confused. One of them is freedom and one of them is mercy. The freedom one, I guess, is the one that you would associate with liberalism—in my view, pretty illegitimately. That would just say something like, look, it’s my right as an autonomous human being to do what I want with my body. So it tries to tap into a long tradition within liberalism of having rights over one’s body and doing what one wants with it, and tries to justify an argument for state-assisted suicide or state-assisted euthanasia from that basic liberal right. For reasons we can go into, I don’t think that works at all as a justification for state-assisted suicide. It’s really about non-interference, and that’s not what most people who want assisted dying are asking for. Actually, I call it “assisted death” to make it clearer what we’re talking about.
The other argument is mercy. I don’t know if you’d call that a particularly liberal argument. I think it comes from a Christian tradition of relieving heavy burdens from people—of pain and suffering in this case. Everyone can understand that motivation. I do too. Those on my side of the fence have no desire to see people in pain or suffering. We just disagree about the best means of organising the relief of suffering in that way.
Mounk: So let’s go into each of those a little bit to steelman those cases. I really look forward to hearing and engaging with the arguments for why those are less coherent than might meet the eye.
On the first one, at the moment, in most jurisdictions, there are two kinds of obstacles. The first obstacle is that we can go to often state-provided, or at least partially publicly funded, medical services in various countries in order to get all kinds of health services, but we can’t get those services for assisted death. The second one is that in most jurisdictions, a doctor, or even a friend or family member who helps carry out your clearly documented desire to die at the end of a long disease, is going to be put in jail, is going to be prosecuted by the state. That’s where the kind of core liberal argument lies.
Now, you might say that liberal argument shouldn’t go so far as to say that taxpayer money should be used in order to facilitate this. I think that is an interesting argument to make, and we can get into what the particular moral considerations should be to use collectively funded pools of money in order to do something that some people have very strong moral objections to. I’m quite receptive to that, though it has interesting knock-on effects on other debates, like abortion potentially.
But at the very least, there seems to be a strong liberal case, prima facie, to say, well, we should stop criminalizing this. When somebody has a clearly documented desire to stop their suffering, the state shouldn’t be allowed to interfere and say, no, you’re not allowed to render them that act of mercy.
Stock: So that’s the best version of the liberal argument, which basically treats a contract with one other person as if it’s an extension of the individual’s right to do what he wants with his body. It says, look, this person has agreed and they know what they’re doing and I know what I’m doing. So the right of non-interference should come around us both and see off the state from our joint enterprise. So that’s an argument for lack of criminalization. It’s not an argument for state-organized, state-supplied medically or doctor-supplied death through the health system, and particularly the public health system. That’s a massive structure for what is being presented as a much smaller problem.
Now in the UK, and as I conceded at the end of my book, in 2008, the then Director of Public Prosecutions, Keir Starmer, who is now our prime minister, basically decriminalized assisted dying, assisted death. It’s now very, very difficult to prosecute it, and I think there have been five prosecutions since 2008. So effectively, that’s where we are in the UK. I actually say that’s probably okay. I still think that there should be a criminal deterrent. I think that the state should be able to investigate, because obviously, if it’s completely decriminalized, then that opens up opportunities for coercion, particularly of elderly and vulnerably ill people.
Mounk: At the very least you would want an investigation to make sure that it in fact does assist the death and is not just murder, right?
Stock: I have a whole chapter on those sorts of cases, or at least a part of a chapter on the cases where it looks like it’s supposed to be benevolent, but actually the husband cut his wife’s throat or something. There’s something savage going on. But I would not have written an entire book against the decriminalization of private acts of assistance.
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What is happening is bureaucratized, organized, institutionalized assisted suicide and euthanasia, often within the context of public health, free at the point of use, and then filtered into the medical system, the legal system, changing social norms across the country, being advertised as a good thing, feeding into equality law. If this group has it, why can’t this group have it? There are all sorts of ramifications there ethically that just do not get covered when you treat it as a private individual act.
Mounk: So let’s dwell for a moment on the second argument for the practice—the argument for mercy. It doesn’t come in any particular way from the liberal tradition, but it is certainly something that the liberal tradition can also speak to. It is simply the recognition that a lot of people have horrible diseases. In many cases, it is extremely likely that the disease will lead to death within a clear time frame, and a lot of the time, some of the worst hours on earth that we spend are in those last days and weeks and months. So it does seem merciful in some cases to allow people to pass away two weeks, perhaps two months, before they otherwise would, having been spared some of the worst hours, having been spared some of the most extreme suffering and pain that they’re likely to undergo during that time period. What do you make of that argument? Do you see the force of it, or do you think that it’s confused in some way?
Stock: Well, what I’ve tried to do, and what I think we all should do, is talk about the systems we have rather than the ones in our heads. There’s no system I know of that says two months. They all say something like six months at a minimum, if not twelve months. Quite often they say, reasonably, “death is reasonably foreseeable,” which could mean anything up to three years. That’s one of the major problems with that formulation.
So we’re not necessarily talking about people in pain. They need not be in any pain at all. Nearly all the systems I can think of—in fact, all of them—talk about psychological suffering, or allow that psychological suffering, effectively allowing that no pain, just a kind of torment about the prospect of mortality or incapacity or whatever it is, may also be a reason. When you say death is definitely going to happen, well, if you’re trying to give a prognosis of six months, that’s actually really quite difficult to do. There’s not necessarily a definite in these systems. There’s a prediction which may or may not be correct.
But having made those qualifiers, yes—once you pursue this kind of argumentative line, you are saying that assisted suicide is a means to the end of relieving pain and suffering, and also some other stuff that we can get into about so-called “dignity.” But let’s just take pain and suffering as the general descriptor. My point is that we should not be zooming in and trying to think about the individual person who’s in pain and asking, well, is it right that this person here who is suffering has a quick death? We need to zoom out and constantly remember that we’re talking about a massive system. The question is not whether this person should have it. The question is whether the government, the state, should try and provide this en masse for people.
At that point, I say, well, there’s an alternative and it’s called palliative care. It’s a technology that few people really know about, and it’s certainly very imperfectly delivered, because it’s more expensive than providing death. But technologies in pain control and the secondary effects of pain control like nausea have really come on. Britain started the hospice movement and it should be a jewel in our crown—the idea that you provide places where the goal is not to get better, but to have a good death.
If your aim is to relieve pain and suffering, you’ve got two choices: palliative care or killing people, basically. I think the merciful system is the one that pursues the former, not the latter, for reasons that I go into—the effects on the whole. So it’s not that I’m unmerciful. I think I’m particularly merciful. I’m just trying to take a wider view on the effects of bureaucratizing death rather than the one that’s traditionally taken by my opponents.
Mounk: I have one more thing I’d love for you to do to situate us in this debate before we really get into the meat of our thoughts on this. What is actually the legal regime around the world?
Obviously you’re writing this because there’s a change of legal regime that is underway at the moment in the United Kingdom, but a lot of our listeners are outside the UK. What is the law of the land in most places in the United States, in Canada, in Britain, in continental Europe? What kind of range are we talking about? How is it that some of the actual developments in countries like Canada and the Netherlands motivate a lot of the concern around this topic?
Stock: Well, my initial impetus for writing was Britain, because it looked like, very suddenly, over the last year and a half, we were about to get assisted suicide delivered through our National Health Service. It now actually looks like that threat has been seen off for the moment, because the legislation is basically being held up in the House of Lords and the Scottish legislation has just failed. I’m relieved, because precisely the things that I’m worried about were the things that objectors talked about. Across the world, the picture is very diverse, and I really do try to summarize all the different trends. Jurisdictions are coming up pretty much with their own versions. Broadly speaking, you get three kinds of eligibility conditions.
The first is that you just need a terminal prognosis of some length—in some places it’s six months, in some it’s twelve, and in some it’s “reasonably foreseeable.” In those sorts of regimes, there’s no further qualification. This applies to Oregon, and I think most of the United States states where they have it—there’s no further requirement of pain or suffering. You just need the terminal prognosis. You need to establish that you’re not being coerced in some totally perfunctory way, and then you can get it. That of course means that you could be chronically depressed, you could have tried to kill yourself several times throughout your life, you could be homeless—you can be doing it for any reason whatsoever. The prognosis is what gets you through the door. After that, no one really cares about why you’re doing it or whether it’s actually related to your illness at all. The background rationale there is autonomy, and I have some doubts about that. In other regimes you need both. In Australia, in some states, you need both a prognosis of the right length and a diagnosis of intolerable suffering that cannot be remedied otherwise, or something like that.
In Canada, Belgium, and the Netherlands—this wasn’t always the case in Canada, but gradually, as is well known there, the law has extended and become wider in its remit through various legal challenges—all you need to access assisted suicide or euthanasia is a diagnosis of irremediable suffering. You do not need a terminal illness. That’s where you see, particularly in Belgium and the Netherlands at the moment—and actually indeed in Spain today, there’s been a case that’s just hit my newsfeed—young people with no underlying physical illness that would make them die anytime soon, or at all, but with chronic depression, personality disorder, and so on, being euthanized by the state. There are obviously a lot of differences in all of this, but I try to pick out some common themes.
It has basically become the case that assisted death is being used for any disease that might have a natural death as its outcome, because it will include cases, for instance, where the person is not taking their medication. So a person can get diagnosed with something like diabetes, or chemical sensitivity to cigarette smoke, or in one case I can think of, deafness—in these Canadian cases. Maybe they’ll have had a stroke at some point, so they have partial mobility. There’s this massive gray area where people are not fully well, but not dying by any means, and yet the state has and still will consider that their death is reasonably predictable, or that they are suffering enough to pass the test.
There are also people with learning disorders in Belgium and the Netherlands being euthanized. There’s a whole spate of anorexics who basically become so ill through self-starvation that they then get the requisite terminal prognosis, or someone says, well, your suffering is clearly intolerable—and either way, they then get euthanized.
These cases strike most people as horrific, and not what you imagine in the paradigm of the person in terrible pain in the last few days of a fatal illness. That’s not what’s happening.
Mounk: Just to cite one example that crossed my radar over the last few years—a woman called Zoraya ter Beek, who was 29 years old in the Netherlands. She’d been diagnosed with chronic depression, borderline personality disorder, and autism, had tried numerous treatments which clearly weren’t effective, and she was euthanized at her home in May 2024. This is somebody who clearly was in severe psychological distress, but it was a case in which death was not reasonably foreseeable any more than it is for you and me and for every human. Clearly, what was a much more restrictive regime earlier on got expanded and expanded in a way that then made assisted dying available to somebody who clearly wasn’t in physical pain in the last stretches of a fatal illness.
Stock: That’s an interesting case—I talk about it in the book. There’s also a case that came up today, as I say, in Spain: a young woman who seems to have been gang raped, who then became depressed—I’m not sure at what point, whether she was depressed before that, but she certainly was depressed afterwards. She tried to kill herself, then became paraplegic, and she’s being euthanized today.
I did actually, unexpectedly, have a related experience. I was giving a talk in Berlin last year, talking about the Zoraya ter Beek case, and as it happened a Belgian minister was in the audience—it was a gender conference and he was there to see what Belgium could do about youth gender medicine. He said, “I’m a doctor, I have euthanized people and I am partly responsible for the Belgian law.” I said something about 30-year-olds being euthanized for mental illness, and he said, “Listen, we don’t want our young people jumping in front of trains.” The implication being that the state will do it more cleanly. The trains will run on time, as far as I can see. You can get into that mentality quite quickly once you’ve got this mechanism in your system to deal with suicidal ideation, basically.
Mounk: So we have the arguments for some of these practices on the table. You don’t find them fully convincing. I have to say that they have a certain amount of moral pull on me. You’ve started to make some of the case against it. How do we balance between those different considerations? Why is it that rather than trying to restrict the practice, or trying to come up with more restrictive terms for it, you by and large conclude that the arguments are just muddled—that they ultimately don’t carry the weight of a burden of proof here?
Stock: Well, let me focus on the freedom arguments, because they are probably the ones that for some reason seem most attractive to people. I think they are fundamentally confused, because we’re not talking about a liberal right of non-interference—we’re talking about assistance, and we’re talking about assistance from the state, not just from your friend who’s agreed. The demand from the pro-assisted death lobby is that the state, in the form of doctors, should help. That’s not non-interference, and that’s not I want to be left to get on with my own suicide in my own way. Unfortunately, most of us still have that opportunity—not everybody, but most. It’s a grim fact, and one that I do not celebrate.
Generally, we don’t act as though there’s a right of non-interference in suicide. Generally, we have suicide prevention, we have suicide watches. But we’re not talking about someone’s individual right to do what they want with their body—and particularly not before we’ve brought the legislation in. So in Britain, we don’t have it. Now we’re in a public conversation about whether to get it, and before we bring it in, it’s somewhat incoherent to say, just leave me alone to have what I want. That’s not freedom—that’s just a demand that the state do something that I want. It gives us an extra choice, but so does extra breakfast cereals. It just sounds to me, from the perspective of a country which has yet to get it, that people going on about their freedom and their demands that their autonomy be respected are just not making sense.
Now, if they were genuinely interested in freedom to die for everyone, why are they focusing only on the ill? In a way, the Belgian government might have the best idea if it’s really about freedom—anyone who wants to kill themselves should be facilitated by the state. But that’s never the argument. The argument is always about suffering, the ill. That suggests to me it’s not really about freedom for that cohort at all. It is about compassion—or at least that’s certainly a useful defense that opens the door to this sort of legislation. The freedom argument on its own really doesn’t get anyone anywhere. Because of course, once the institutions are in place, someone might be stopped from using them—maybe that’s going to be an inhibition on their freedom. But before the institutions are in place, their freedom has not been curtailed by the lack of them.
Mounk: Those are really interesting arguments, and I want to deal with the connection between the freedom and the compassion argument in a moment. But to stick with the freedom argument—within the very specific context of the United Kingdom and the law that was being discussed there, I think you have a point. But there is a way for liberals to restate the argument in slightly broader terms, which is to say that at the moment there’s, for good reason, a prohibition on murder. We often use the prohibition on murder in order to restrict every form of assisted dying as well. Obviously this is a very complicated issue, because in many cases there are going to be gray zones where we don’t know whether somebody really was in a state where they could request to die, or whether somebody is using this as a cover to commit murder. We obviously want to be very careful so that this doesn’t just become an end-run around the most vile crime there is, which is murder.
But as long as we fulfill those conditions, there could be lots of circumstances where we do want various forms of assisted dying to be permissible on freedom grounds. This could just be being allowed to access the kind of medication that you can take yourself. In general, the state needs a reason to prohibit me from buying all kinds of things, and the state’s reason to prohibit me from buying some kind of cyanide capsule—or whatever it might be that will have the intended effect of killing me if I take it—shouldn’t necessarily be there. One may also say, why shouldn’t I be able to entrust my friend or my relative with helping me die, if that’s what I wish? They need to be free from criminal prosecution if it’s obvious that there really was an agreement between us to do that. And in places where medical services aren’t necessarily state-funded, private insurance should be free to offer plans which include, as part of their provisions, financing for those forms of assisted death.
None of that would fall under your concerns about why it should be a responsibility of the state to provide this—which I take seriously. They would all do an end-run around that and fall more cleanly into the zone of non-interference.
Stock: I don’t think we need to get into the arguments about whether it’s freedom or not freedom. It’s not freedom to die anyway—you already had it. It’s freedom to make contracts with people who are going to help you to die, and it’s freedom to help others without going to jail. If you’re successful, you’re not going to jail. So let’s just say we’re now talking about a different kind of freedom to the one commonly used by the pro-assisted death lobby, which is freedom from pain, or freedom from the burden of your life, or freedom to choose. I think that’s just misleading rhetoric.
Mounk: I’m not part of the pro-assisted death lobby. I’m just a political theorist rooted in liberal values who’s trying to puzzle this through. The way that I would puzzle it through is from this perspective of non-interference.
Stock: I understand, but ultimately, in my experience, people really, really want this and they’ll find any argument that works for them to get it. Maybe we need to, instead of thinking about the arguments, also be thinking about the deep fears and unconscious motivations that are making this seem such an attractive option. That’s part of the book too.
But generally speaking, as I say, I wouldn’t have written a book against mere decriminalization. Some of the arrangements that you’ve just described would still need to be extremely carefully handled, and they start to shade into some of the worrying areas that I go through—for instance, coercion. There is a huge worry about coercion as soon as you have suicide pills floating around elderly, vulnerable, disempowered, ill people, with carers who have financial interests in freeing up their own time or getting their hands on a house or whatever. The courts are extremely familiar with the kinds of motives that lead to murder or manslaughter in this area. Whatever arrangements were put in place, it would have to involve the right kind of investigation, which would be expensive.
In Switzerland, I believe every death through assisted suicide has to have an associated investigation, and that’s enormously expensive for the Swiss state—in fact, it’s becoming so expensive that they can’t really deal with it anymore. Whatever arrangements were put in place, they never just affect the person who wants it and the person who’s helping them. This is the big message: they have knock-on effects for other people who want to carry on living.
Mounk: But something similar is true in lots of cases of non-interference where we still think that there is a compelling case for erring on the side of liberty. Alcohol consumption has all kinds of downstream costs for society. But I think we rightly reject the prohibitionist argument that because somebody who’s drunk is then more likely to lead to other kinds of social costs—from diseases they might suffer, to behaviors that might impose other kinds of costs on society—we should just ban alcohol altogether. So if you allow any kind of claim to non-interference, any claim to “this is something that I’m choosing for myself, for my own life, for my own body,” the fact that it might have certain kinds of downstream harmful social consequences shouldn’t be allowed to trump that liberty interest. Otherwise, we should be able to coerce people to go to university, and we should be able to coerce people to not get a divorce, and all kinds of other things.
Stock: My argument doesn’t depend on the general shape of some things that we allow people to do that have some bad consequences. My argument completely depends on the specific bad consequences of this thing. They are far greater, I can tell you, than allowing people to drink alcohol. We also do not let under-18-year-olds drink alcohol in most countries. I’d rather we just honed in on the actual implications for society rather than say, well, in these other cases we let you do things that are bad for you.
Now, we’re not just letting people die—we’re helping them. We’re deliberately bringing death into a health system. We’re making the very same doctor who in the morning gives you pain control, in the afternoon gives you poison. We are potentially changing the attitude of a population to their healthcare providers, particularly people who are already frightened of going to the doctor. Some of them will be terrified—no matter how often you tell them it’s all fine, they are still going to be frightened. We are placing a burden on every single person with a terminal diagnosis, because now they have to make a choice that was socially unacceptable to think about before, but now it’s there—it’s in the waiting rooms, it’s on the posters, it’s in the news—and they have to explain to themselves or others why they’re not taking that choice. None of this applies to alcohol. Let’s just focus on the problems that this would bring, and is bringing, in countries where they have it.
Mounk: The shape of the argument I’m making is not that these specific bad consequences are there, but that there are lots of other circumstances where individuals making choices—some of which might be bad choices—have harmful downstream social consequences. I’m just nervous about saying that in any case in which there are harmful downstream social consequences, that justifies us interfering with the liberty of the individual.
Stock: I’m not saying that though. So we agree.
Mounk: Well, I’m not sure we do, because there’s a question about... I just worry that when we’re talking about a case in which an individual makes a decision that’s primarily about their own life, but there are secondary and tertiary consequences for society that are complicated—you’re saying that, because of those secondary and tertiary consequences, that liberty interest should be superseded. I’m saying that if we acknowledge that principle in general, I worry that we’re going to be able to limit all kinds of other freedoms that we take for granted in a liberal society.
Stock: My principle is not the general one—it’s the specific one in this case. It’s perfectly acceptable for some attempts to instigate legislation to say, no, we’re not going to bring this in, not necessarily just because of the bad effects on the people it would directly affect, but also because of secondary effects. It’s perfectly fine to take those decisions on a case by case basis, and we do already.
I guess I’m just not getting it, because my argument is entirely directed to this particular case. I think assisted death is a Rubicon. It introduces state-sanctioned killing into societies which don’t even have the death penalty, and that in itself should give us pause. We need to look properly at all the implications—not just at what happens at the deathbed, but what happens across the system. The book is an attempt to get people to think about those things and to ask, is it worth it? Is it going to be worth it, particularly when you have palliative care that could be funded, that would achieve many of the same ends, perhaps even better?
There’s a range of problems—from the potential for coercion, to changing attitudes towards medicine, to slippery slope problems, to what we do with people who will probably be judged to have mental capacity but where we might not feel comfortable about that, like learning disabled people. Are they going to get it? Pregnant women—are they going to get it? There are just so many issues here to be thought through carefully, and they’re not going to be solved by a quick people should be free to do what they want.
Mounk: I feel very torn about this issue and I don’t know what I actually think about it. There’s a reason why a lot of people feel so torn. On the one hand, it does feel like if you suffer from a terrible disease, being able to decide what happens to you—being able to decide whether you want to go through that suffering or be able to cut it short—is an important form of choice we should have available to us. At the moment, in many jurisdictions, there are all kinds of things that are actively keeping us from being able to make that choice, such as being able to contact somebody to buy a pill that I myself can take that would put me out of my misery.
On the other hand, there are all of those very real concerns that I take seriously when I read about some of those cases of assisted death for people who don’t have a mortal disease, or older people who might feel pressured by their families. I read an interesting account recently by a priest who said he was in favor of assisted dying until, in his service, he spoke to a family that said, “Can’t we try and do this by Sunday, because we’re flying off on a skiing holiday on Monday?” That changed his mind. A lot of people have the interests of their loved ones at heart, and some people don’t—and that’s obviously a problem here.
I feel very torn about this, but I guess the way to get to the bottom of it is to try and size up those competing circumstances. One way that I think about this—and I wonder how you respond to it—is that the main way in which I’ve changed my mind about the world over the last ten years is that I’m much less confident about institutions. Ten or so years ago, I had a relatively high level of confidence that in countries like the United Kingdom, the United States, and Germany, where I grew up, our social institutions are relatively functional, work relatively well, have the interests of people at heart, don’t get captured by extreme ideologies, and don’t have deep forms of internal dysfunction. In that kind of world, I think I would have been much more open to legislation introducing something like assisted death, because I would have assumed that the doctors and others who make those decisions would act in a reasonable way.
One of the reasons why I’m much more sympathetic to your argument than I would have been ten years ago is that both from seeing some of those actual examples in the Netherlands, Canada, and elsewhere, and in my general assessment of these institutions, I’m now much more worried that there might be extreme ideologues in charge of some of those decisions who don’t take seriously the case for the other side, or that straightforward financial incentives may drive some of those decisions—with doctors realizing they could be helpful by freeing up a hospital bed. So perhaps we have a conversation with the patient again, and so on and so forth.
For you, is part of what’s driving this a fundamental distrust of our institutions? Do you think that in a place that had much more functional institutions, you would be more open to this case? Or is that not a big part of what’s driving you?
Stock: It’s definitely a big part of what’s driving me. In fact, it’s part of the point I keep making in this book—let’s stop thinking of utopias and let’s look at the systems we actually have, because that’s where we’re going to get assisted death.
In the UK, for numerous reasons, I’ve become more distrustful of institutions. In my previous book I talked about a total, catastrophic failure of the medical and psychiatric professions towards the bodies of teenagers and young people. I’m very aware of how institutions can be captured by glamorous moral precepts that are totally shallow, and as soon as they become bureaucratized, they just become not fit for purpose.
I’m also highly aware of the collapsing health system we have in the UK. People on trolleys in corridors for hours and hours, unable to get an appointment with their GP, care homes not being inspected for years, hospices closing because they haven’t got enough funding. Hospices are only 30% publicly funded—the rest is charity donations. The birth rate is declining, people are living longer, and that pension system is going to collapse soon. Put deliberate assisted death into a system like this and you will effectively have a cheap, quick outlet for many social problems—and the people involved will not be complaining about it afterwards, because they won’t be here. You will inadvertently funnel people towards taking this option, because as soon as assisted death is in a system, there is less momentum towards palliative care. That will actually speed things up.
Can I just go back for a second to the first part of your question, about fear? I think it’s really important and we haven’t covered it yet. The fear that able-bodied people have about terminal illness is often about pain, incapacity, loss of bodily function, inability to move around—things that disabled people live with now, and which are not necessarily terminal. As soon as you say those things are fundamentally undignified—so undignified that if the person wants it, we’ll kill them to get them out of that position—it is impossible to take that attitude and inject it into society in a way that’s sequestered from the rest of it, without having knock-on effects for disabled people. Effectively you are saying, you are in a fundamentally undignified position, and great that you want to carry on, but lots of people don’t, so we’re going to kill them or help kill them. That’s just a terrible message to send to disabled people.
I understand the fear, I’m human, and I also have experiences that are relevant to this. But I just don’t think personally the cost is going to be worth it. We’ll end up with a society that many of us will simply not recognize in about 50 years’ time. That’s my biggest fear.
Mounk: Speaking of some of these institutional failures, to what extent are there safeguards in place to make sure that when patients say they agree to die in this manner, that is actually the case? That doctors don’t try to pressure them because they could really use that hospital bed, that families don’t pressure the medical staff because perhaps they would like to go on that holiday—and one horrible case I read about where the inheritance tax was going to go up on January 1st, and therefore it would be useful if a relative died by December 31st. Those are the things that activate the fear on the other side—that these systems can get so out of control that you get these horrible cases.
There’s an argument I’ve heard from people who defend assisted death, that as long as the laws are drafted in a smart way and as long as they’re sufficiently robust to introduce genuine safeguards, those kinds of cases can be avoided. How would you respond to somebody making that case?
Stock: I’d like to see what they think these laws would look like, because as far as I can see, having looked extensively, they’re not like that at all. There’s very little attention paid to the background circumstances of the applicant. Ideally, in order to eliminate the possibility of coercion, you would want to know the financial status of this person, the family situation, whether there’s been any domestic abuse in their background, any convictions—and you’d want to know their history of chronic depression. None of that you’re allowed to know.
This is the influence of the specter of freedom and autonomy coming in to hollow out the safeguarding process. Every time someone tries to make an appropriate safeguard—saying, for instance, we should have a reasonable time of reflection before we administer the poison, or maybe we should look into whether there’s any domestic abuse charges against her husband—someone will come in and say, no, it’s none of our business, it would be an infringement of their autonomy. What you get is reflection times reduced systematically through various challenges. It starts off being administered by doctors, ends up being by nurses or pharmacists. Access gets wider, safeguards get smaller, because they are presented as obstacles to freedom. That’s the case in all the systems I’ve looked at.
Add into that the basic lack of money floating around most systems, and the fact that doctors really don’t know whether to say yes or no. Somebody comes in and says they’re homeless, or they’re alcoholic, but they’ve got cancer. They’re also dyslexic and can’t fill out the forms to get social housing. They say, I want to die. The doctor is not going to try and argue them out of it. They’ve got several months of life ahead, but the doctor is just not going to look for a reason to say no.
What you do get in Canada, perversely, is doctors feeling pressure to say yes—because if they don’t immediately get the MAID team in when somebody starts saying, I can’t live like this anymore, relatives may start accusing them of holding the process up. In Britain at the moment, I think doctors sign off something like ten million sick notes a year. Doctors don’t seem to be able to say no to people who want things, and I suspect there’ll be no incentive for doctors to say no to people who say they want death. They will just think, well, I’m just part of a bigger system, I’ll just sign it off.
We will not know whether that person was being coerced financially, physically, or whether they just want to get out of a horrible life—and I don’t mean horrible because of illness, I mean horrible because someone’s beating them up at home or whatever. None of that is going to come to light. I just don’t think there are systems that are financially well-resourced enough to establish it.
In the rest of this conversation, Yascha and Kathleen discuss the decline of gatekeeping, why there are parallels between the arguments for assisted death and youth gender medicine, and the gender wars in the United States and UK. This part of the conversation is reserved for paying subscribers…
