Supporters of assisted suicide make a seductive argument: granting the right to an assisted death will greatly improve the wellbeing of those who want to die without taking anything away from those who do not. It is, therefore, a win-win policy change. There are no trade-offs required. Under this framing, the only objection one could have is a paternalistic one: that one thinks it is not good for people to be assisted to die. And that, so they say, is a cruel imposition of one’s ideology over another.

Seductive as this argument is, it simply does not work. By that I do not merely mean that I disagree with it. Rather, the framing is just wrong: there are clear trade-offs and the situation is not a win-win one.

The basic premise of the argument is that having more options is a good thing — or at any rate, not a bad thing. At first sight that seems true but think about it a bit longer and it might not be so obvious. We live in a world in which there are so many options even for the most basic of products. We’ve all had the experience of going to a supermarket and wondering whether there really was any difference between all the brands being presented to us. And I am sure we’ve all thought at times that we would prefer having fewer options or having the choice made for us. To put it simply, one consequence of having more options is that one has to choose between them, and the fact of having to choose is not cost free.

This is comparatively trivial but the key insight, that more options is not always a good thing, was deemed to be worthy of granting the Nobel Prize in Economics to Prof Thomas Schelling. One example he gave is that a union leader who lacks the option of binding his members is a stronger negotiating position than one who does have that option. Fewer options can make you stronger. 

The philosopher J David Velleman applied this framework to the debate on assisted suicide. He identifies at least three costs to giving the option of assisted suicide.

The first is that having the option of assisted suicide might subject one to pressure — a pressure which would not have exited without that option being available. Whilst supporters of the Bill stress the presence of safeguards, no one has said that they would be 100 per cent effective. When asked about it by Newsnight the sponsor of the Bill, Kim Leadbeater MP, simply said that we had to trust our medical professionals and the training they receive. By contrast, Lord Sumption has been very honest that the risk cannot be eliminated and indeed that it would increase in a world where “medically assisted dying is normalised”. And Lady Hale thinks that there is nothing problematic with someone committing suicide because they feel like a burden. Whatever one might say about their view they at least confront the issues in a way Leadbeater has not. 

But even if perfect safeguards could be designed, there would still be other costs to offering the option of assisted suicide.

The second cost is that giving this option changes the default for those who do not want assisted suicide. Instead of living and fighting until their natural death automatically, this would now become a choice that they have made. Them being alive would no longer be a simple matter of existence (e.g. the retort “well excuse me for living” comes to mind) but would instead be the result of choice: they are alive because they haven’t opted for assisted suicide). And once you are regarded as having chosen a state of affairs, others will hold you responsible for it. Therefore, even if family, friends and the NHS do not utter a single word, people who are terminally ill will feel guilty for being a burden. That will make their feelings in relation to that worsen and will thereby reduce their quality of life during their final months. Ironically, giving them this option would rob them of their dignity. 

Indeed, that concern can and does apply more widely: by changing suicide from something that society will always try very hard to prevent to something which is a respectable option (even a human right) to exercise, we make it harder for people who are suicidal to resist acting on any suicidal ideation that they may have. This is not a far-fetched hypothetical. A disability support group told me of a young woman with suicidal depression that they support who said that if the law passes, she will want to take advantage of it, arguing that her condition is incurable and that it is terminal as she would otherwise kill herself anyway. Legitimising suicide has real consequences.

The final cost is that offering an option to a subset of people (as opposed to everyone) communicates something to the offeree and that communication can be harmful to them. The example Velleman gives is an offer of catch-up lessons to a student: this communicates that the student is struggling and that might have a negative impact on the confidence of that student. So making the offer imposes a cost on that student. 

It has real costs for the majority of people who would not want to avail themselves of that option

The Leadbeater Bill proposes that only those who are terminally ill would be eligible for assisted suicide. That restriction is somewhat hard to square with the commitment to autonomy the proponents of the Bill profess to have, but this has the clear implication that it communicates that the State does not believe that those who are terminally ill have a life worth living for their final few months. How so? Let’s ask ourselves how the State would justify not giving that option to say those who are chronically but not terminally ill? The obvious answer is that it believes that the value of their life outweighs autonomy concerns but the flipside of that is that for those who are terminally ill their life is not seen as being as valuable. And that’s an awful thing for the law to communicate. The point though is not that it is offensive but rather that it is harmful to those who are terminally ill to communicate that to them (especially if they have no desire to exercise the option of assisted suicide). If that still does not resonate with you, imagine how the Canadian Paralympian who simply wanted a ramp but was offered assisted suicide must have felt. Or consider the powerful letter in the Irish Times from someone who would be offered assisted dying but would not be eligible for help living: the law communicates to them that it is not willing to help them live but is willing to help them die.

Therefore, it is not the case that offering the option of assisted suicide is a win-win scenario. It has real costs for the majority of people who would not want to avail themselves of that option. 

Paradoxically, those who deploy that argument for assisted suicide realise that making choices is hard. By presenting us an argument without trade-offs they say that we do not need to choose between assisted suicide and greater palliative care for everyone. The fact that one wouldn’t have to choose is what makes the argument seductive.

But in reality there are very few policy problems which do not have trade-offs and this is not one of them.

I do not pretend that this is a knockout blow against assisted suicide. One can perfectly well acknowledge those costs, as Lord Sumption did, but nonetheless argue that on balance the benefits of alleviating the suffering of the minority who would want this option outweighs the risks of others being pressured into it, of their feelings of being a burden being increased and of their confidence being shaken by a law that communicates to them that their lives are less valuable. I do not agree with that case but it has the merit of intellectual honesty, unlike the pretence that giving this option to some has no downsides for everyone else.