Twice a month, The duty challenges enthusiasts of philosophy and the history of ideas to decipher a topical issue based on the theses of a prominent thinker.
On February 16, Minister Sonia Bélanger tabled Bill 11 in the National Assembly. If the law is passed as planned, it will allow people who are living with the diagnosis of a disease leading to incapacity, such as Alzheimer’s disease, to make an advance request for medical assistance in dying (MAID). While major figures in the Quebec fight in favor of advance demand welcome this bill with relief, other voices are raised to express their concern at the idea that people who have become incapacitated can receive such irreversible care. and without appeal than that of medical assistance in dying.
Beyond ethical and legal issues, thinking about advance consent involves different understandings of the nature of personal identity and raises some of the most fundamental philosophical and metaphysical questions. What establishes our personal identity? Is it just our biological body? Is it rather the memorial relationship we have with the person we have been through the various periods of our lives? Is it the narrative story that we can weave backwards from the fabric of our lives? Is it legitimate to allow the autonomous people that we are today to decide the fate of the incapacitated people that we will have become tomorrow?
If we aspire to a finer understanding of the issues relating to advance requests, we would be wrong to neglect these difficult and abstract, but crucial questions. These questions are precisely taken head-on in the book. Life’s Dominion. An Argument about Abortion, Euthanasia, and Individual Freedompublished in 1993 by one of the most influential moral, political and legal philosophers of the past 50 years, Ronald Dworkin (1931-2013).
Critical interests
According to Dworkin, despite the hesitations, wanderings and changes of course that punctuate a life, most people will seek to give it meaning and general direction. We do not live by randomly selecting, according to our changing desires, the experiences, achievements, and meaningful relationships in which we will invest ourselves. When at a crossroads, we face a set of possible options, we most often prefer the one that seems to us the most in tune with our deepest values.
To account for these interests which draw a guiding thread in our lives, which confer an overall coherence to our choices and make of our life what philosophers, since Antiquity, call “a good life”, Dworkin forged the concept of critical interest. These critical interests are distinguished from purely “experiential” interests, intimately linked to the experience of sensations and to well-being. The experiential interests we pursue motivate us to seek out positive experiences that enhance our daily lives. They are certainly important, in the sense that a life entirely deprived of them would be much less happy and satisfying. But they don’t structure our lives as decisively as our critical interests do. Experiential interests are those that bring well-being to our lives, while our critical interests are those that give it meaning.
Dworkin’s notion of critical interest fits into the narrative conception of personal identity that he developed. According to this conception, a person remains the same over time, even if the disease has altered his personality, memory and self-awareness. Even if the person affected by such a disease has lost the ability to tell stories, it is not entirely gone. Only, his identity somehow stopped updating. For Dworkin, although a disease that affects memory and aptitude causes a person to forget the critical interests that were theirs and the deep values that guided their choices, it does not make them obsolete.
Objections
Not everyone agrees with this view. For example, for the partisans of the psychological conception of personal identity, which appeared for the first time under the pen of the philosopher John Locke, in the XVIIe century, and that we find today in Rebecca Dresser and Derek Parfit, it is essentially memory that founds personal identity, by linking perceptions of my present self to memories of my past self. It is indeed what they call the “psychological connections” that I manage to trace between the different periods and experiences of my life that allow me to say that I am indeed one and the same person through time.
According to this conception opposed to that of Dworkin, a person who has lost his memory can no longer be considered to be the same person he was before. She is another, a stranger. Thus, in the same way that it is morally unacceptable to let any stranger (or third person, expert or professional) decide our own fate, it is morally unacceptable to observe without hesitation an anticipated request for medical assistance in dying written by the “previous self” that we were. As Dresser claims, only current experiential interests (which is in the present “best interest”) should guide the choice of medical treatment to be provided.
No strangers to ourselves
For a philosopher like Dworkin, a disease that affects and degrades memory capacity never makes us completely estranged from ourselves. Why do we prepare wills and arrange funeral prearrangements? Why do we sign a refusal of treatment form in advance in anticipation of an accident?
Why do we have the strong intuition that our interests would be harmed if, after our death, rather than offering our body to science as desired, our family sent it directly to the crematorium? Why do we have the feeling that we would be wronged then, even if we are no longer there to see that our last wishes have been ignored?
According to Dworkin, it is precisely because we have critical interests that we care about that the decisions that will be made about us after our death reflect as closely as possible the values that defined us. It is also because we have critical interests which survive our incapacity (and which even survive our unconsciousness, if by misfortune an accident makes us sink into a coma) that many are keen to write their anticipated wishes.
Amendments
For Dworkin, that the last scene of the theater of our life unfolds in accordance with the guiding principles that guided it is a matter of integrity. It is this same basic principle which gives its moral justification to the refusal and the withdrawal of treatment, and which requires that we can formulate an anticipated request for medical assistance in dying. Ignoring the critical interests of the incapacitated person would be tantamount to ending the last movement of a symphony on a false note, to brushing a skewed brushstroke on the canvas of his life.
Dworkin would therefore give his overall support to Bill 11. But he would first propose three amendments to it. First, he would suggest striking out the word “request” from the bill and replacing it with the word “advance directives”. These advance MAID directives should, according to him, be enforceable. This is what Sandra Demontigny, spokesperson for the Quebec Association for the Right to Die with Dignity, recently claimed, herself suffering from an early and hereditary form of Alzheimer’s disease.
Then, for Dworkin, the application of the advance request should be able to arrive earlier than provided for in Law 11. If desired, MAID should be able to be offered at the moderate stage of the disease, while the thread of memories that we link to our past and to those we have loved begins to wither away and we only have brief flashes of contact with our past and our loved ones, even if we are not yet living constant and unbearable pain. Indeed, for Dworkin, the anticipated request for medical assistance in dying should even be able to be applied in the potential phase of what is sometimes called “happy insanity”.
Finally, it is not certain that the philosopher would exclusively reserve the advance request for MAID to people who have already been diagnosed with a disease leading to incapacity, as provided for in the bill. Insofar as other factors are likely to lead to incapacity, in particular high doses of medication ingested to soothe the pain caused by cancers and irreversible respiratory or cardiac diseases, it should be possible to sign an advance application for medical assistance in dying from the moment one suffers from a serious and incurable illness, even if it does not, by itself, lead to incapacity to consent. Regardless of the nature of the disease from which we suffer, in moments of extreme fragility, we should be able to count on our anticipated wills to relay our demands when our voice is weakened to the point of becoming inaudible.
Suggestions ? Write to Robert Dutrisac: [email protected].