The dying decision: choice, coercion and community

Plan 75 reveals a lot about our relationlessness, says Siân Brookes as she reviews the Japanese drama about medical assistance in dying

Sian Brookes

Sian Brookes is studying for a Doctorate at Aberdeen University. Her research focuses on developing a theological understanding of old age. She studied English and Theology at Cambridge University.

In a retirement home, a older person sings karaoke while the person behind waves a hand.

Chieko Baishô plays Michi.

Happinet.

“Being able to choose when my life will end provided me with peace of mind. With no feelings of doubt. She led a good life on her terms, people will say”.

In Chie Hayakawa’s recent dystopian drama Plan 75, these are the words of a silver-haired, wrinkled woman in a promotional video for the eponymous plan – a government scheme which offers all over 75-year-olds the option of a pain-free death at the time of their choosing.

And yet for Michi, an older lady toying with the decisions around Plan 75 it doesn’t really feel like it is her choice which matters at all. Whether it is the $1,000 grant offered as an incentive to die, the luxury amenities on offer at the Plan 75 facility promoted in leaflets and magazines, or the young person employed to gently guide the candidates towards their death (but whose real job it is to make sure they follow through with it), this is a world which has a clear agenda – to rid society of older people. Indeed, it is clear that this is a vision of a world which believes it is better for old people to die than to put financial burdens on the economy or their families, and this is a culture willing to subtly coerce individuals to accept and act on that belief.

Plan 75 reveals an interesting point at the heart of the MAiD (Medical Assistance in Dying) debate. One of the primary reasons that MAiD is so attractive is the ability to take back control of one’s life and death, yet what happens when that seeming control isn’t really within the individual’s own control at all? For Plan 75, what is marketed as giving control back to older people, is really just a twist on a more sinister political policy to pressure individuals to sacrifice their “burdensome” lives for the greater good. Of course, this is a common argument for rejection of assisted suicide. This is the dangerous ‘slippery slope’, where MAiD begins as an option only for those who desperately need it to relieve intense physical suffering. Yet it quickly becomes a tool to remove people whose lives no longer seem worth living due to societal expectations and opinions, rather than any objective reality.

Do we ever truly choose to die totally independent of the expectations of those around us?

For many, this problem can be appeased through strict legal controls over MAiD – as long as the powers that be are regulated, MAiD is still OK. As long as it is the individual who maintains control over their own death (and not the state), the goal of personal autonomy is maintained and all is well. And yet this perspective fails to ask the question - is such control over our own death ever actually possible? Do we ever truly choose to die totally independent of the expectations of those around us? In a world which places so little value on old age, can older people really make choices unaffected by that (deeply flawed and inhumane) logic? And, indeed - the elephant in the room – no matter how much we try to control death, in the end is it not death that ultimately controls us? As fundamentally finite beings we can never escape it completely – it will always find us one way or another. Ultimately, we will all have to face the reality of death when it comes to us. Complete control and autonomy are never truly possible.

In light of this unveiling, the possibility that complete choice and autonomy around death isn’t really an attainable goal, what better options might we pursue?

Where previously we would find comfort and hope in being loved, known and held by others in our death, now all too often this isn’t the case.

One thing is clear in Plan 75, the isolation and loneliness of older people in a society that has rejected them is deeply problematic. The movie primarily follows the stories of Michi, who lives alone with no family and Yukio Okabe, an older man totally estranged from his remaining family. Both face life, and are facing death, alone. We live in a world where increasingly we are forced to face death alone. When our final days and hours rarely happen in the family home, surrounded by our loved ones, but in faceless institutions devoid of lifelong meaningful relationship the sense that we are no longer doing death together as a society is acute. Where previously we would find comfort and hope in being loved, known and held by others in our death, now all too often this isn’t the case.

At the same time, there is no doubt that our modern world is unceasingly committed to the ideal of individual personal agency and autonomy – “She led a good life on her terms”. As a myriad of philosophers and theologians have commented, belief in human autonomy has come to replace belief in God. And MAiD is one area which reveals this to be the case most acutely. Where previously we would turn to God to find comfort in the face of our finitude, instead now we turn to ourselves – the last hope we find in the face of death is our individual ability to control it.

Death and health should be a corporate phenomenon – when one person is ill, all of society is ill.

The German theologian Eberhard Jüngel described death in this broken world as “the occurrence of complete relationlessness”. In fact, Jüngel suggests that as human beings we are first and foremost made up of our relationships – we are truly human not by how we self-define in isolation but how we relate – how we relate to the God who made us, and how we relate to other people. This need for relationship is found most acutely in the face of death. As Ashley Moyse points out in his book, Resourcing Hope for Ageing & Dying in a Broken World, death and health should be a corporate phenomenon – when one person is ill, all of society is ill. And so, as death increasingly becomes the journey of the individual – when we face death in isolation from others and in isolation from God no wonder we feel such a strong desire towards control, towards ending our lives prematurely, towards science to help us avoid any more pain than we can bear alone.

In Plan 75 we see glimmers of hope in the possibility of relationship. As Michi and Yukio find rare moments of human connection with a long-lost nephew, with a young person working for Plan 75, with another older person going through the same questions around mortality you can’t help but feel deeply uncomfortable with their choice to apply for the scheme. It is in the hints of love, physical touch, smiles exchanged, even a simple conversation shared between two people that suddenly MAiD seems so disconnected with the hope that life still has to offer through relationship. Perhaps if we could imagine a world where death became no longer an occurrence of complete relationlessness, but a locus for relational dependence, for familial connection, for leaning on God and not ourselves, the need for MAiD would feel a little less necessary. It would be a world with a little more hope.

Article

Assisted dying

Life & Death

9 November 2023

4 min read

The cold truth of Canadian lives not worth living

Canada’s implementation of medical assistance in dying concerns M. Ciftci, showing that a society consider some lives not worth living. Part of the How to Die Well series.

M. Ciftci

M. Ciftci has a PhD in political theology from the University of Oxford. He is currently writing a book about church-state relations that will be published by Palgrave Macmillan.

A IV drip bag hangs from a medical stand.

Marcelo Leal on Unsplash.

Alan Nichols’ application for euthanasia mentions only one health condition as the reason for his request: hearing loss. “Alan was basically put to death,” according to his brother. He was hospitalized after being found dehydrated and malnourished in his house. He asked his brother to “bust him out” of the hospital as soon as possible. A month after being admitting, he was euthanized through MAID (medical assistance in dying), despite the desperate objections of his family and his primary health practitioner. They were informed of the procedure over the phone only four days before it took place. They have since reported Alan’s case to the police; they argue he was not in a fit state of mind to understand the procedure or make decisions for himself. He had no life-threatening conditions. He was vulnerable.

Canada’s relaxed laws around MAID came to international attention when CTV News reported that a fifty-one-year-old woman chose MAID after failing for two years to find housing that would allow her to manage her multiple chemical sensitivities. Despite the best efforts of friends and even her doctors to get her suitable housing in Toronto, letters left behind documented her desperate yet fruitless search for help. She begged officials at all layers of government to help find an apartment free from the chemicals and cigarette and marijuana smoke that worsened her symptoms. “The government sees me as expendable trash, a complainer, useless and a pain in the a**,” she said in a video days before her death.

These are only some of the terrible stories that have been reported after Canada became the first Commonwealth country to legalise assisted suicide and euthanasia. Advocates of MAID will point to how comfortable Canadians are with it. As a recent poll revealed, MAID is supported by 73 per cent of Canadians, with 27 per cent supporting MAID even if the only affliction is poverty, 28 per cent for homelessness, and 20% for any reason whatsoever. Those numbers may shift as disability activists and medical professionals continue to raise the alarm over the consequences of growing numbers choosing MAID, from 2,838 deaths in 2017 to 10,064 in 2021.

MAID was introduced in 2016... Only those suffering from incurable diseases whose death was “reasonably foreseeable” were eligible, initially.

There are two reasons why the Canadian example teaches us to remain firmly opposed to the legalisation of assisted suicide and euthanasia in the UK.

The first is that the slippery slope in this case is real. Campaigners for Dignity in Dying claim they want only the legalisation of assisted suicide, not of euthanasia. The latter involves a doctor directly administering lethal drugs, without requiring the patient’s participation. (MAID permits both, although euthanasia is the method used in 99 per cent of cases.) They argue there is no evidence that legalising assisted suicide in the UK would lead to a loosening of laws over time. But this is contradicted by the timeline of events in Canada.

MAID was introduced in 2016 following the Supreme Court of Canada’s ruling in 2015 that the criminalisation of assisted suicide violated the Canadian Charter of Rights and Freedoms. Only those suffering from incurable diseases whose death was “reasonably foreseeable” were eligible, initially. But the MAID evangelists did not wait long before complaining that this was too restrictive. The courts obliged, and in 2019 the court of Quebec found the “reasonably foreseeable” condition to contravene the Charter. In 2021 the laws were changed to allow MAID for those whose natural death was not foreseeable, but who have a condition considered intolerable by the applicant. Those suffering only from mental illnesses will be eligible for MAID in March 2024.

The slope becomes more slippery still: the government is considering further expansion to allow “mature minors”, vaguely defined as children mature enough to make their own treatment decisions, to ask to be killed, even against a parent’s wishes.

A society that kills those who ask to be killed has already made a choice to consider some lives not worth living,

The second lesson is about what kind of society we want to be. For a doctor to present the option of being killed, which Canadian doctors are now obliged to do whenever “medically relevant”, even if the patient does not bring it up first, does not expand patients’ freedom. It is rather an invitation to despair. This is frequently forgotten when some think that denying patients the choice to seek death is “imposing Christian values” as one cleric of the Anglican Church of Canada said. Roman Catholics, Evangelical Christians, and others have opposed MAID because a society that kills those who ask to be killed has already made a choice to consider some lives not worth living, and to invite those already made vulnerable by their pain and distress to see themselves as a burden to others. Not to mention the perverse incentives created to reduce medical and palliative care.

We can and should support those who are frail and in need of care at the end of their lives to die with dignity, without hastening their deaths, without deeming their lives no longer worth living. Dame Cicely Saunders and other pioneers of the hospice movement have shown us what an alternative to assisted suicide and euthanasia would look like. Hospices put into practice the parable of the Good Samaritan, who responded with pity to the man beaten by robbers, bandaging his wounds and giving him a place to rest and receive care. Jesus tells the parable to show what it means to be a good neighbour to someone and how to react with compassion to suffering. What would have been the message of the parable if the Samaritan had instead reacted to the sight of the suffering man by reaching for his dagger?