Yesterday’s post promised a few thoughts on death with dignity. Having taught medical ethics for more than a decade, I have spent some time reading, thinking and writing about the subject. In 1994 I published a piece called, “Worse Off Alive: Reply to Garcia” in the American Philosophical Association’s Newsletter On Philosophy and Medicine. The newsletter is still published, but a twenty-year-old hard copy is hard to find and no soft copy exists, as far as I know. Here is the original version based on my hard copy.
“Worse Off Alive: Reply to Garcia” (from the American Philosophical Association’s Newsletter On Philosophy and Medicine, 1994.)
The goal of J.L.A Garcia’s article, “Better Off Dead,”(Volume 92, No. 1, pp. 82-85) “is to cast doubt on the doctrines that someone’s dying can be a good thing for that person, that some lives are not worth living, and that there can be a right to die.” Thus, he argues, we are never “better off dead” and that nearly all human lives are worth living. He also implies—but never specifically argues—that there is no right to die. I argue that, though we are not “better off dead,” in the sense that death is an experienceless state, we may be “worse off alive” in situations when enduring extraordinary suffering. I also argue that lives deprived of certain goods are not worth living. Let us examine Garcia’s arguments in turn.
According to Garcia, euthanasia proponents deem death an instrumental good because it relieves a patient’s suffering. But instrumental goods, he argues, are good only when they “make our lives go better,” and being free from anxiety or physical pain “is good inasmuch as it yields a less troubled life.” Since causing or allowing someone to die does not make their lives go better, it is not an instrumental good. In short, dying brings about no good for a person—since dead persons don’t exist—and thus, one cannot be “better off dead.”
Garcia is partly correct. It is never better to be dead in the sense that one’s life improves by dying, and therefore, if to be dead is to not exist, then being dead is itself neither good nor bad. The problem with this argument is twofold: 1) it reduces to the self-evident and trivial assertion that non-existent persons cannot experience good; and 2) it misconstrues the issue. Few persons who desire to be relieved from excruciating suffering believe they will gain from their death by experiencing some benefit, except possibly in an afterlife. What they obviously do believe is that, in their present condition, they are “worse off alive,” and this justifies euthanasia for them. In their condition, they prefer death to life because life offers so little, not because death offers some gain or benefit.
Now in certain cases, Garcia seems to agree: “When we permissibly withhold or terminate treatment in such cases, it is because we judge that the kind of life that aggressive treatment could secure the patient is not so great a good as to require us to secure it at staggering cost to the patient herself or to others.” Presumably, the cases to which he refers are those that employ extraordinary means, though he does not explain why this rationale applies only to these cases. Nonetheless, if the kinds of life secured by certain treatments are not good enough to be preferred to death, then we are sometimes “worse off alive.”
Next Garcia turns to the claim that some lives are not “worthwhile.” This claim, he argues, results from the disparity between healthy, highly educated, and economically advantaged bioethicists, and the dying. These professionals judge the quality of life of the dying to be quite minimal, overlooking many similarities between themselves and the dying, particularly their shared existential despair. Such considerations [should] caution us against hasty generalizations about the value of human lives. Who is to say that our lives, projects, and goals are valuable? And if we cannot be certain about the value of our own lives, how can we be so sure about the value of the lives of others?
This argument is problematic for at least two reasons: 1) it applies only to those advocating non-voluntary active euthanasia; and 2) what follows from it is that we should reject proxy judgments of the value of individual lives, not that it is never better to die or that all lives are worth living. What he has shown is that by resisting generalizations and proxy judgments we respect human autonomy, a fundamental value according to Garcia, “even if the choices we make are often disastrous.”
Garcia concludes by “rejecting the suggestions that it might be better for someone to die and that her life might be improved by her death.” He correctly assumes that our lives do not improve when we die because then, obviously, we no longer have experiences. And if life is a good so great that no possible agony, suffering, pain, or torment negate its value, then life is always preferable to death.
However, most ordinary individuals disagree. They applaud the advanced directives for health care, sign their living wills, and ask loved ones to act as their surrogates. They choose to forgo the remainder of lives deprived of those things that make life valuable—the ability to love, think, touch, reflect, and remember—for the uncertainty of death. They prefer not to debase human life or glorify suffering but to exercise human autonomy.
So for those who believe there is meaning in the most excruciating forms of physical pain and dementia—let them be free to suffer if they so choose. But for those of us who believe that, at least sometimes, we are “worse off alive”—let others respect our autonomy as well.
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Addendum – I still agree with the sentiment of this paper from more than twenty years ago—there are fates worse than death. If I am in even the earliest stages of dementia, knowing the toll this disease will take on my family, I will hopefully find a way to end my life. When one’s consciousness has been severely compromised and will become increasingly so, that life has lost its meaning. I would happily die rather than subject my family to such a fate.
Ideally, science and technology will overcome death and suffering. But in the meantime, I hope others respect my autonomy and help me die (assuming it doesn’t put them in legal jeopardy) when I deem life no longer worth living. And if I can’t voice these preferences—say because of being comatose or demented—I would hope my family will respect my previously stated wishes. Perhaps they can at least take me to the Netherlands or some other country with liberal euthanasia laws. (For more please consult advanced directives for healthcare.)
JGM – February 2020
I pretty much agree with this too. I have found that many (if not most) people *know* what their wishes are regarding their own death. Obviously it is impossible to generally define “a life worth living” or a “valuable life”, so to me it is simple– those definitions are highly personal and subjective, hence decisions about how to manage ones medical choices (including whether or not to procreate or when to decide to wave goodbye to all medical interventions whatsoever) should also be left to each individuals discretion. Unfortunately, our mainstream society doesn’t much support autonomy, neither medically speaking nor on a broader level.
Maybe its that matters of life and death intimidate and scare a lot of people. I am not afraid of death, but I also dont attach a magical or superstitious value on life or death; to me it just is what it is–dying is an inevitable part of life. [At least right now it is inevitable—I am throwing this in for you, Dr M., because I am nice like that. ]Many people who do subscribe to supernatural beliefs about these matters feel compelled to force their views on everyone else; hence we have gotten to the point where we are now, where the mainstream US belief system is spawning legislation and regulatory nonsense that is seeping into the practice of medicine and by extension, obliterating any whispers of patient autonomy that may have previously existed.
If we cannot prevent death from catching up to us at some point, I see nothing wrong with defining and limiting our own suffering. To me, that is empowering in the face of being stripped of power.
This is an interesting argument with Garcia. While reading this, it made me think of Brittany Maynard, who had terminal brain cancer and decided to end her own life because she was better off dead, than alive. This made me think of the statement “It is never better to be dead in the sense that one’s life benefits or improves by dying, and therefore, if death is non-existence as he seems to suppose, no good or bad comes from being dead.” You bring up the idea of that this can be interpreted wrong. “Few persons who desire to be relieved from excruciating suffering believe they will gain from their death by experiencing some benefit, except possibly in an afterlife.”
The idea of better off dead vs worse off alive is an interesting idea and I think it depends how you look at it and your point of view. For Maynard, she thought that it was better being dead that living in suffering and hurt, when her chances of death were high. But from someone’s point of view where they believe that treatment can help them live and that they could say become cancer free than they would want to live and their life would be better off alive than dead.
In this idea of “Better Off Dead,”(Volume 92, No. 1, pp. 82-85) “is to cast doubt on the doctrines that someone’s dying can be a good thing for that person, that some lives are not worth living, and that there can be a right to die,” can be agreed with and disagreed with. I believe in my state right now that I would be better off alive than dead, but that doesn’t mean that in the future I may change my mind.
I believe that some people are better off dead than alive, but I do not think I am one of those people who are better off dead than alive.