The 'choice' to die - Dr Rachel Perkins - 
(From Openmind 117 Sept/Oct 2002)

In July I participated in a debate about doctors' rights to prevent suicide.' As it turned out, the debate rapidly moved away from the rights and wrongs of preventing suicide to a consideration of the ethics of assisting people to kill themselves. And I came away feeling very disturbed, by what I had heard.

The vast majority seemed to agree that if someone is acutely distressed or disturbed then it is right to stop them killing themselves, at least until they are in a better position to make such decisions. But the major issue discussed was the right of people who make a 'rational' decision to die, and in particular their right to the assistance of doctors in killing themselves

It started with the well-rehearsed arguments about the rights of people close to death to choose the manner of that death. While compelling arguments were made, I could not help asking questions like how near to death a person has to be, or in how much distress and pain, to make the decision to die 'rational'? Have they really been offered everything that could make their remaining life as pleasant and pain free as possible? Death occurs in a social context, and the 'choice' to die cannot be divorced from that context: the opportunities and attitudes that people face and the value and possibilities of their remaining life.

As the debate continued, my disquiet grew. I found myself questioning the whole idea of 'rationality' and 'choice'.

Over coffee someone described the situation of an elderly relative in a residential home. Apparently, she had expressed a wish to die in order to leave her money to her children rather than squander it on the cost of her own care - and it was clear that the speaker respected her choice. What better illustration of the social context of supposedly individual decisions? Her choice was made in a society that values youth over age and in which older people must pay for the support they need. How different would her decision have been in a society which venerated the wisdom of age and where support was a collective responsibility funded through taxation?

As the debate moved on to the Netherlands, where assisted suicide is legal beyond the setting of terminal illness, my concerns increased. We were told of a woman with recurrent depression who 'met all the legal criteria' for assisted suicide and whose doctor helped her to die. Now there is one part of me that says people with mental health problems should enjoy the same rights as anyone else. But a much larger part of me was appalled.

We live in a society that seems to value 'freedom' and 'choice' above all else. But the whole idea of 'rational' and 'individual' choice bothers me greatly. None of us is free to make unconstrained choices, and , the choices open to devalued groups are even more restricted. Our choices are determined by our vision of possibility, which is limited by the values of our communities and our social and material circumstances.

Prejudice and discrimination ensure that people with mental health problems are denied access to social and economic life, deemed at worst a nuisance and a danger, and at best unable to contribute fully to their communities and dependent on others. I have heard so many people talk about being a burden on those around them. And professionals collude with such ideas via, for example, the huge research literature on the 'burden of care' and systems to measure the 'value' or 'quality' of life.

'Rationality', like 'choice', is socially determined. The 'rationality' of a person's desire to die is determined by the extent to which their reasons are understandable to and acceptable within their society. In a society where people with mental health problems - and others who are deemed 'imperfect' are systematically devalued and excluded, it is 'rational' that many might choose. to die.

Perhaps if there really were a level playing field for all citizens, irrespective of their physical, cognitive and emotional impairments, age, race and so on, then I could entertain the idea of the 'rational choice' to die. But we are not in this place. There seems to me something obscene about those in position of status and privilege washing their hands of responsibility for the lives of others under the guise of 'choice'. Should we not focus our energies on reducing discrimination and enabling people to live satisfying and valued lives, however long those lives might be, rather than agonising about acquiescing to their supposedly 'rational choice' to die?

1. 'Whose life is it anyway? This house believes that doctors have no right to prevent suicide, Maudsley Debate, London, 10 July, 2002.