Three years ago, Spain became the fourth nation in the European Union to legalise assisted suicide for people with incurable or debilitating diseases (now there are five: Belgium, Luxembourg, the Netherlands, Spain, and Portugal). 

The issue has been documented in a feature-length film, Señor llevame pronto (Lord, Take Me Soon), by the talented Spanish director Guillermo Florez, who followed Carmen Gil del Pino, a feisty 86-year-old former nun who became determined to end her life even though she didn’t qualify under the law.

While not terminally ill, Gil dell Pino was suffering from ailments in her knee, spine, and hip.  Her conviction that she had lived long enough forces us to ask an uncomfortable question: Should older adults have the right to end their lives simply because they feel ready?

In the film, Florez collects moments of humour and gravity in the six months before the nun prepared to take her own life. He documents her preparations: she burns her old photos, gives away kitchen cabinets to a neighbour, and informs a friend of her plans. The nun recounts all this in front of the camera, while the director listens in unsettling silence. “I eventually came to the realisation that I was making this film because I’m afraid of death and she was not,” he says in an interview.

A familiar story

In some ways, this is a story that is already familiar to us.  Many of us have heard seriously-ill relatives tell us they didn’t want to continue living.  Once, when I visited my own wife in her own battle with the Big C, I heard another woman tell her daughter that her visits were wonderful but didn’t outweigh the pain she suffered all day. Many of them also feel guilty about the burden they put on their own famiies.

But it isn’t just terminally-ill people who question why their human lifespan cannot be terminated.  I had an aunt who, despite the fact that she loved us, often asked me why she should continue living when her beloved husband had already died.  She asked the question of everyone around her.  It even triggered an alarm when she went up on the roof of the old people’s home and one of the carers decided my aunt was about to throw herself down on the street. 

Extending human life

The wish to extend human life has a long tradition in many cultures. This has materialised through the latest developments in medicine, which are prolonging life by slowing or even arresting ageing on the one hand and combating all sorts of diseases on the other.  The focus on life expectancy results from a deep conviction that there is intrinsic value in living much longer than we presently do.

But an increasing number of people believe that there is a fundamental difference between the desireability of being alive within the limits of the average life expectancy and the desireability of being alive beyond those limits. In the first case, we deal with the possession and continuation of something we have a right to maintain. In the second case, we are dealing with a kind of enhancement to which the concept of a “right to” is ill‐suited, and that raises a series of philosophical and ethical questions.

A healthy discussion

The issues of euthanasia and assisted death were raised during the campaign prior to the last general election, when it was said that there should be a healthy discussion about them.  Typically, there has been none, though that does not exclude that some wise guy might not wake up tomorrow morning and announce some legislative initiative.

I personally believe that any debate should not be just on religious grounds or on socio-economic, psychological, and cultural ramifications, but starting from moral and ethical reflections about justice, the community, and the meaning of life. The three reflections differ in terms of their nature and cogency.

The “unequal death” issue

The most obvious moral problem is the already existing “unequal death”.  There is a huge inequality between lifespans in rich and poor countries.  How can we ethically justify trying to extend the lives of those in rich or developed countries beyond 70-80 years when life expectancy is less than 40 years in Africa?  Not to mention that this applies to advanced countries, where people with a lower income per capita and/or lower education have a lower life expectancy than more prosperous and educated ones.

On the basis of observed patterns of mortality by educational level in 2004, the number of life years lost because of deaths that could be attributed to health inequalities in the European Union as a whole were estimated at about 11.4 million.

One might argue that the existence of this inequality simply is not a problem for bioethics. Income and health disparities may be scandalously unfair but are the responsibility of politicians, governments, and non‐governmental organisations, not of bioethicists. This way of shrugging off bioethical responsibility, however, is based on a concept of bioethics that closes its eyes to the morally relevant complex interrelation between the health of populations and justice.

Moreover, if immortality or increased life expectancy is a good, how is it good ethics to deny medicine or proper health care to some people because we cannot provide them for all?  This kind of reasoning has also been heard in Malta, with various governments pleading lack of resources in denying people of expensive treatment in State hospitals and having to rely on the Malta Community Chest Fund while richer people can get it privately.

The community question

Second to justice is the question of community.  Increasingly, in what has become a liberal society – in contrast with a socialist one – the good life is the good life for me, defined and measured by myself.  Primarily I am an individual motivated by self-interest and any other person only has an instrumental value to me, whether he/she is a friend, a competitor, or even an enemy.  The community is only there to facilitate my own life plan. Arguments in favour of life extension are often based on the presuppositions of liberalism.

But is this really the kind of society we want?  Contrary to liberal anthropology, the social context is not just an instrumental means to realise individual life plans, but the precondition for living a human life. Human beings cannot live without meaningful relations with others. Goods (income and health) that are essential for a good life, much like friendship, are essentially goods that are bound to the social dimensions of life.

Under the communitarian view, the extension of biological age is intrinsically valuable but only if it also extends our individual life as communal beings in meaningful relations with each other. The real ethical challenge for ageing societies, therefore, should be how to improve the conditions for life as a life in community, and not how to stop ageing as such.

Preservation of the ego?

The final argument is that the explicit aim of life extension is contrary to the wisdom of ages as contained in various religious and non‐religious spiritual traditions. Although all traditions agree that life is worthy and should not be taken (without good reason, or at all), there is always a notion that human beings miss the essence of life by focusing on the preservation of their self or “ego”.

In the Christian tradition, as propounded by Thomas Aquinas, for example, the notion of eternal life does not refer primarily to a prolongation of earthly life based on the conception of an immortal soul; rather, it refers to the fullness of a human life that can be reached to the extent that one’s goal in life is no longer the preservation of the self, but the communion with and service to God and one’s neighbour. The same thought is expressed in other monotheistic religions, such as Judaism and Islam. In the Eastern world, Hinduism, Buddhism, and non‐religious spiritual approaches, such as that of the Indian thinker Jiddu Krishnamurti, all point to the importance of letting go of the ego.

Reflecting on the three arguments

All three arguments differ in cogency. The argument of justice is the strongest, because it has a common‐sense force that is recognised in most ethical theories. The second argument, regarding the social nature of human beings, derives its cogency from the willingness to critically consider and complete the presuppositions of one’s moral theory. The third argument, introducing the meaning of life, is the most controversial: it is strongest for those who adhere to one of the traditions mentioned before but weakest for those who do not.

Is it possible, therefore, to argue that no individual should have the option for life extension if science progresses enough to offer it?  Personally, I don’t think so. The question must be discussed to what extent life extension contributes to the public good. The concept of “public good”, however, is slightly ambiguous. It comes close to “public interest”, framed as the aggregate of individual private interests of individuals. As opposed to this, the concept of the common good entails a society where individuals inextricably bind up their own good with the good of the whole.

This presupposes reflection on the question of whether living longer is good for me as a human being, and whether a society whose members have a much longer life than is the case at present would be a better society. With regard to a better society, in a globalising world as ours is, there is a moral challenge to expand our view of the common good to encompass good for all, both within our own society and worldwide. This expansion inevitably raises the urgent question of whether we can morally afford, as a question of moral integrity, to invest time and money in trying to extend our lives while sidelining the whole issue of unequal death.

Main photo: A screenshot from the film ‘Lord, Take Me Soon’ by Guillermo F. Florez