The metaphor of an hourglass succinctly encapsulates the fulcrum on which balance the ideas expressed in the previous three posts when you apply them to the act of assisted dying. As with many aspects of humanity, the general principles of mutual behaviour, however wise and robust in the public arena, can be broken into pieces when dropped onto the hard surface of private family pain.
Those who have experienced the anguish of witnessing someone they love in pain as death approaches will probably have scoffed at the apparent detachment of the ethical arguments I have previously raised. The alleviation of suffering is always a worthy goal, but it depends of the amount of sand remaining in the top of the hourglass. When only a little sand is left, it occupies a narrow space that matches the narrow perspective of the final stage of person’s life. By this I mean the very end, when the medicine given to ease pain can bring death a little sooner, perhaps with the quiet consent of a medical professional who can focus general legalised ethics down to the moral imperative of sparing everyone concerned the final mile of pain. This has been done since before Hippocrates wrote his oath, as it is both practical and compassionate, and it requires the close involvement of the physician with the patient.
The danger lies in allowing death to be prescribed as a medical treatment when there is plenty of sand left in the hourglass but the patient would rather have the matter settled before any more time runs out. The inevitability of death applies to us all, not only those with a terminal diagnosis, so to request death when so much sand remains is to diminish the true value of life. That true value is to experience as much of life as possible for as long as possible and enrich the lives of those around us with our presence and our contribution. Only when we are within our last mile can we say that our debt has been paid to the grand web of humanity that has carried us through to our finale, and only then can our exit justifiably be eased.
If we assist a loved one to die when only a little sand remains in the hourglass, we remain within the parameters of compassion and can see our society as a culture where life matters. If we allow people to request a compassionate death at too early a stage, the compassion involved becomes non-reciprocal, and thus is no longer true compassion. What do I mean by non-reciprocal compassion?
If we look at the matter in stark terms, we can say that we should only wish for compassion if we are willing to extend it in return, otherwise we are not worthy members of a true society. This implies that a person with a terminal condition who has a significant amount of time remaining should remember their debt to the shared life of which they are a single strand. That person should be mindful of the consequences of demanding an assisted death before they reach their last mile, for such an insistence, especially if enshrined in law, takes us beyond the parameters of compassion and towards a culture where death is seen as a medical treatment. Do not think that I say this lightly. It is at the heart of my struggle with the moral and emotional complexities of this subject.
In such a legalised culture of death, those with a few miles remaining will be granted the ability to be assisted in the act of dying when they judge the time to be appropriate. We will draw a line on the hourglass and offer death to those whose sand drops below it. So far, so neat and tidy. However, what about those people with just a bit more sand and just a bit more fear about the prospect of their decline? If they petition a judge and are granted a dispensation, the line of the hourglass is redrawn and more people are offered death as medicine.
It is feared, especially by those who speak for the vulnerable, that there is no stopping this process, no matter how many supposed safeguards are written into the original legislation that permits assisted dying, because the appeal is too great to those whose sand is just above the line. Their determination, especially when it will take only a word from a judge to allow their specific circumstances to be accepted, will raise the line a little more and thus encourage the others to follow suit. In less time than we might imagine, people who were initially far above the line could be the new marginal cases, with their requests for consideration made easier by the precedents already set. This rising of the line on the hourglass is not hypothetical, as the implementation of legislation to allow assisted dying in The Netherlands and Belgium has illustrated. If we fail to keep watch, we could find death being prescribed as medicine to those who are not terminally ill, but instead just ill and deserving of compassion and care, not a hasty exit.
This is how we could move from a culture of life to a culture of death, and we could allow this to happen by incremental steps until we are too far down the wrong road to easily turn back. In a culture of death, our sense of kinship is narrow and we think too much about ourselves. In a culture of life, the opposite is true. So, we have to decide in which of these two versions of society we would prefer to live.