Spending Down Solidarity 

Do Not Go Gentle:
The Case Against Assisted Death
by kathleen stock
the bridge street, 304 pages, $30

Imagine that you work as a janitor in the office building of a large corporation. One evening you encounter the distraught CEO standing on a window ledge.

“Don’t jump!” you cry.

“I’m free to do as I wish,” he replies.

“Very well,” you say, “I respect your freedom, and I won’t physically restrain you.”

“Help me!” he cries.

“I know life can seem dark,” you begin, “but—”

“Not that kind of help! Just give me a little push!”

You refuse.

“But I thought you respected my freedom!”

“That doesn’t mean I’m willing to push you,” you explain.

“Well then, have mercy on me! I’m really better off dead!”

“What’s wrong?” you ask.

“I’ve been fired,” he explains. “After what’s happened, nobody will hire me! The only job I could get is as a janitor.”

This rather awkward moment is cut short when the CFO emerges from a nearby office to reveal that she has overheard the whole conversation.

“Don’t worry,” she tells the CEO. “I respect your freedom (except, of course, in matters of business), and if you think your life is not worth living, then that’s your call. I will have mercy on you!”

With that, she runs to the window and gives him a push.

This story gives us a clue about why so many disability rights groups oppose assisted suicide and euthanasia. Most people who request these services do so because they would rather be killed than be disabled. When society regards this preference as reasonable (“Of course you wouldn’t want to live like that!”) and facilitates the choice (“I will have mercy on you!”), people living with disabilities rightly feel targeted.

It’s tempting to imagine that assisted suicide is designed to spare people a painful exit, but the reality is that it is used primarily to spare people the “indignity” of being disabled at the end of their lives. We observe the belief that disability is undignified in the names of groups such as “Death with Dignity,” “Dignity in Dying,” and “Dignitas,” which advocate or provide what philosopher Kathleen Stock calls “assisted death,” that is, assisted suicide or euthanasia.

We again see that assisted death is motivated by disability rather than pain when we consider the great strides made in pain relief over the past century, along with the fact that doctors can provide much more serious pain relief in end-of-life contexts than at any other time.

When a patient is terminally ill, doctors worry less about long-term harms such as opioid addiction and overdose. If I am suffering extreme pain and anxiety in an end-of-life context, doctors can legitimately provide me with a lotof morphine, even put me into an artificial coma for as long as is necessary to keep the suffering at bay—which may well be for the remainder of my life. To be clear, many people do not get the pain relief they should—including people who are terminally ill and people who aren’t—and this is a serious problem. But the desire to avoid pain isn’t the main reason that people want assisted death.

We can see that assisted death is mostly about the “indignity” of disability if we consider the reasons people actually cite when requesting it. People who request assisted death almost always cite a desire to avoid disability, and they typically don’t even mention pain. In Oregon, the top five reasons for requesting assisted suicide exclusively concern disability avoidance. (I’m using the term “disability” in the most straightforward sense of “loss of ability.”) These reasons are: “losing autonomy” (cited by 89 percent of recipients), decreased ability to “engage in activities making life enjoyable” (also by 89 percent), “loss of dignity” (65 percent), “losing control of bodily functions” (53 percent), and becoming a “burden on family, friends/caregivers” (40 percent). Each of these reasons is entirely about disability—some combination of not being able to do things, needing more help from other people, and the sense that the whole situation is “undignified.”

In other words, most of these “mercy killings” are not last-ditch efforts to spare a person pain that can’t be controlled by other means. Instead, they are designed to spare a person the “indignity” of losing various abilities and becoming more reliant on—and perhaps more “inconvenient” to—other people.

Most of the people who favor assisted death view this insult to those with disabilities as a price worth paying, in large part because they think the value of offering assisted death is very great. There are, after all, some people with terminal illnesses who are suffering, and who want help in prematurely ending their lives. And in the face of the actual wishes of a specific suffering person, it can seem callous to withhold assisted death, particularly if our reason for doing so involves an abstract and perhaps indirect harm (such as the devaluing of disabled lives), or a long-term social harm (such as the erosion of social services for the terminally ill), or an abstract moral or religious principle (such as blanket opposition to suicide). It can seem that the opponents of assisted death are asking terminally ill people to sacrifice themselves for the good of the collective—or worse, for the good of an unshared principle—and that this demand is unjust and unmerciful.

In Do Not Go Gentle: The Case Against Assisted Death, Kathleen Stock flips this narrative on its head. Stock is not interested in the question of whether suicide is always wrong. (She’s inclined to think that suicide and mercy killing can be legitimate moral choices in some limited circumstances.) Instead, she’s interested in two things. First, do we have a right to assisted death? And second, if we don’t, is it genuinely merciful for the medical establishment to offer people assisted death? Her answer to both questions is a resounding no.

Stock begins by showing that we don’t have a right to assisted death. To do this, she considers two archetypal proponents of assisted death: “the Freedom Lover” and “the Merciful Helper.” The Freedom Lover says, “We must respect people’s freedom!” The Merciful Helper says, “And spare them from terrible pain!” But as Stock points out, neither of these archetypes has a strong argument for the claim that people in general—or terminally ill people in particular—have a right to assisted death. The Freedom Lover may have a freedom-based argument for the (controversial) claim that I have the right to end my life without interference, whether or not I am terminally ill. However, this freedom-based argument doesn’t show why other people have an obligation to help me end my life. This is where the Merciful Helper comes in, arguing that if I am suffering greatly, it is merciful for others to provide me with access to the assisted death I long for. But as Stock points out, this understanding of mercy does not establish a general right to assisted death for the terminally ill; at best, it establishes a right to assisted death in those vanishingly rare situations in which pain cannot be controlled in another way (for instance, by palliative sedation).

Stock shows how the Freedom Lover and Merciful Helper conspire to promote a program that is neither particularly merciful nor conducive to freedom. In actual and proposed assisted death programs, a “right” possessed by those dying in agony (a Merciful Helper concern) expands (for Freedom Lover reasons) into eligibility for anyone who is suffering from a terminal illness, regardless of their motives—even when other options are available. As we’ve seen in Colorado, Canada, and the Benelux countries, the ratcheting of these alternating archetypes can extend eligibility further: to babies, young adults suffering from anorexia or depression, and those who say they would prefer to stay alive if they had access to adequate housing.

Some proponents of assisted death may think it a straightforwardly good thing to have access to assisted death for any kind of suffering that one finds intolerable, but Stock cautions against this. Since assisted death is not an absolute right, we should offer it only if the value of offering it is justified in view of the harms it brings. And it brings many harms, including harms that encroach on personal freedom.

Stock points out that wherever assisted death is offered, some people will be coerced into premature deaths. This expectation doesn’t require any special level of paranoia. We already know that people in general—and vulnerable people in particular—get pressured into stuff they don’t want all the time (sex, to give an obvious example). Sometimes the pressure involves direct threats and coercion, other times manipulation or social pressure, and sometimes it arises from conflict avoidance or power asymmetries. When assisted death is offered to vulnerable people, people who may regard themselves as “inconvenient” for those on whom they rely, we can safely assume that many will experience some degree of pressure to sign up for assisted death, and also that many will end their lives prematurely in response to this pressure. 

Nor is there any easy and sufficient solution to this consent problem, because people who have been coerced into requesting death can also be coerced into assuring their doctors that it is what they really want. Indeed, it may be “what they really want,” in the very limited sense that they would rather be killed than deal with the consequences of upsetting their caretakers. Stock cites horrifying examples of demonstrated coercion, and adds that most coercion cases presumably go undetected, because the victim does not survive to tell the tale.

Unfortunately, coercion into unwanted assisted death is only one of the ways in which terminally ill people are harmed by assisted death. The moment assisted death is offered, terminally ill people are exposed to two additional forms of harm.

First, they are made morally responsiblefor what they are “doing”to their loved ones by staying alive. If assisted death is a legitimate moral choice, suffering people can be morally guilty (even if not legally culpable) for refusing to end things when it is “reasonable” to do so. 

Imagine a mother who is terminally ill. When assisted death is off the table, she and her loved ones are in the same boat, undergoing a difficult situation together. But when assisted death is offered, she gains the ability to dock the boat and let everyone off. She becomesresponsible for everything her family is undergoing related to her illness. She ceases to be the victim of a tragedy and becomes the perpetrator of every aspect of it other than her death. Thus, one of the harms of legalizing assisted death is the moral burden it imposes on each terminally ill person, the burden of responsibility for what she is “doing” to her loved ones when she decides not to end her life.

The next harm is downstream of this moral responsibility: Other people simply will not feel the same sense of obligation toward a person who is dying slowly when he has the option to die quickly. As a result, many terminally ill people will be neglected in ways they wouldn’t be otherwise.

We should be clear: If assisted death really is a legitimate choice, then this neglect is also legitimate. In general, when a person capriciously refuses a legitimate means of alleviating his own suffering, this refusal reduces the duties other people have toward him. Other people owe us more help when we’re unemployed as a result of illness or economic conditions than when we simply prefer not to work. Likewise, you will rightly give more sympathy and help to the friend whose headache isn’t palliated by ibuprofen—or who can’t take ibuprofen for a real reason—than to the friend who refuses to take ibuprofen because he wants to seem tough. When there is a socially sanctioned way to end your own life, other people will place more limits on what they’re willing to do for you. Come out for one last weekend to say goodbye? Of course! Come by regularly over an indefinite period to cheer you up and listen to you complain about your hardships? No way. You can solve this yourself. I’m not an enabler.

So the availability of assisted death immediately exposes people who are suffering from terminal illness to new forms of neglect: neglect by loved ones, neglect by the medical establishment and other institutions, and neglect by the government. Faced with this neglect, many people will want assisted death who wouldn’t otherwise.

Of course, the thoughtful proponent of assisted death will have various replies to these problems. One is that many good policies have negative side effects, which are acceptable when the benefits outweigh the harms. Yes, when a society offers assisted death, many people with disabilities will feel devalued, many terminally ill people will be comparatively neglected—some even coerced into premature death—and social services for the terminally ill are likely to worsen over time. But these bad effects must be weighed against the benefits: both the benefits involved in receiving assisted death (skipping unwanted suffering without breaking the law) and the benefit of reduced anxiety, which comes of knowing the option is available. Proponents of assisted death typically regard these benefits as very great indeed. They may also point out that our medical system is imperfect and that a significant minority of patients don’t receive adequate palliative care—and that for these patients, assisted death eliminates pain that would otherwise be severe. Further, many proponents of assisted death may dearly value the ability to spare loved ones the uncertainty, labor, expense, and inconvenience of a prolonged natural death.

Some proponents of assisted death also caution against exaggerating the level of harm involved when a terminally ill person is pressured into assisted death. After all, people in this situation “were going to die anyway.” If a few difficult months are wrongly shaved off their lives, this may be less of a problem than when—for instance—a healthy young person is bullied into taking her life. Stock quotes Henry Marsh, a prominent British advocate of assisted death: “Even if a few grannies are bullied into committing suicide, isn’t that a price worth paying so that all these other people can die with dignity?”

Stock has replies to these considerations. However—for reasons I’ll discuss in a moment—I suspect her arguments won’t be persuasive to a certain sort of assisted death advocate.

With respect to the advantage of relieving anxiety and other forms of psychological suffering, Stock points out that psychological suffering can be a moving target and that our efforts to eliminate it by shielding people from the things that provoke it can backfire terribly, cultivating hypersensitivity and—paradoxically—an increase in suffering.

With respect to bad palliative care, Stock argues that a more merciful solution is to provide better palliative care, and that offering assisted death is very likely to result in the worsening of palliative care, given the realities of limited resources. I would add that if it is too difficult—or too expensive—to provide comprehensively better pain relief, simply offering a track for more pain relief than is provided by traditional hospice would be a more merciful option than assisted death. Setting the dose a bit higher on the PCA pump, or allowing more frequent administrations, would be somewhat dangerous—and there would be a higher chance of accidental death—but it would be much less dangerous than intentionally killing the person.

Concerning the advantage of sparing your loved ones the suffering involved in watching your decline, Stock writes: “A terminally ill person’s empathy is used against them, as it were. They are encouraged to think of their own early death as a mercy.” And, of course, Stock insists that it is a big deal to kill a person against his will, regardless of his age and regardless of how many days he has remaining.

Despite the strength of Stock’s arguments, I have a number of friends who I suspect will be largely unconvinced, and for two reasons. Both reasons have to do with social solidarity. One is that people simply don’t trust that society will take proper care of them (or of others), so they want the option of a convenient and early exit.

The other reason is that—at some level—people identify with the CEO. Simply put, there are people in their communities—for example, people with certain disabilities—whom they would rather die than resemble. This sort of assisted death advocate views himself as a “real person” who belongs to the community of “real people.” To live as a different sort of person—a person from outside this community—would threaten his sense of belonging in a way that death does not. When the CFO pushes the CEO out the window, it is a real act of solidarity with the CEO, even as it also expresses a real lack of solidarity with the janitor. By pushing the CEO, the CFO “spares” him the fate of leaving the C-suite community. Apparently his membership in this community is important to him, and his desire to preserve it seems legitimate to his colleague.

And it turns out that many people—whether CEOs or janitors or stay-at-home moms, whether healthy or sick or unemployed—have some personal status that they would rather commit suicide than lose. For this reason they’re invested in having the ability not only to end their lives, but to end them with the blessing of society. Solitary suicide would endanger membership in their preferred community, but sanctioned suicide allows them to remain members in good standing until the very last moment.

A society in which suicide affirms the social status of the suicidal person—at the expense of the social status of the people left behind—is not long for this world. We simply cannot afford to spend down the solidarity that exists among the living in order to give the dying the illusion that they will never lose membership in their preferred social class.

Stock’s book is excellent, and it would be very hard to read it and say blithely, “If you don’t like assisted death, don’t get one.” I have some quibbles, above all with the idea that killing a person to spare him physical pain might be a legitimate choice in extreme circumstances, an idea that I think runs into the same problems Stock identifies for disability in general. (People in chronic pain should be alarmed by this line of thinking.) But the book is well researched, thoughtful, and very well written. I know what I’ll be getting everyone for Christmas 2026.

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Jeremy Poland via iStock