When does pressure become inappropriate?

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    The fear that someone might feel pressured into dying is a common argument against legalising assisted dying. But how compelling is this argument?

    The debate on assisted dying encompasses a range of ethical, political and practical issues. In the following, I do not take a position on the legalisation of assisted dying as such, but instead focus on one of the arguments frequently raised in this debate. This argument relates to concerns that the person who appears to want to die might have been pressured – or at least feels pressured – into ending their life. This pressure might stem from close relationships, such as when someone feels like a burden to their loved ones, or even in situations where family members explicitly encourage them to choose death. However, it just as often relates to (perceived) expectations from the health service and society. The argument was recently articulated in an opinion piece published in the Norwegian newspaper Aftenposten (1):

    'All legislation on assisted dying is based on the premise that the patient is competent to give informed consent and that they independently request help to die, without external pressure. [...] Clarification is needed of who is responsible for identifying external pressure and the process for doing so. Patients who are seriously ill or dependent on care already feel under pressure, perceiving themselves as a burden to their family, caregivers and society. There are also examples of direct pressure, such as from family members (heirs).'

    What is meant by pressure?

    What is meant by pressure?

    'Pressure' in this context can be understood in at least two ways. On the one hand, it can refer to coercion. However, outright coercion entails threatening to infringe someone's rights (such as the autonomy to make decisions about their own body), while leaving them with no reasonable alternative but to comply (2). Although it is possible to envision scenarios where a person is coerced into choosing death, this is not usually the type of pressure that fuels concerns about individuals being pressured into ending their life (3).

    However, it is important to note that being exposed to external pressure does not necessarily mean a person is influenced by it

    More often, pressure involves someone (like close friends and family) or something (such as norms and expectations) influencing a person's decision, without coercion in the strict sense of the word (3). The fact that the pressure is 'external', as described in the quote above, should be understood as either relational or structural; i.e. not from the person themselves. However, it is important to note that being exposed to external pressure does not necessarily mean a person is influenced by it. On the contrary, there are many historical examples of people who resisted the immense pressure they were under (4). The risk only arises, therefore, when the person starts being influenced by the pressure.

    At the same time, humans are relational beings; we do not live in a vacuum. Being influenced by something or someone is inevitable, and in many situations it is also desirable, such as in close relationships. Therefore, influence in itself is not the problem. When a person is persuaded to act against their better judgement or personal values, it is considered inappropriate influence (5). However, this also means that what constitutes inappropriate influence is subjective, context-dependent and varies from one person to another.

    Implications for the debate

    Implications for the debate

    Inappropriate influence is an inherent risk in all human interactions. Even discussion and rational arguments can inappropriately influence someone, depending on the situation, the person's state of mind and their personality. In the most extreme case, a doctor who argues against assisted dying to a patient who genuinely wants to die could also be exerting inappropriate influence. Conversely, there may be systemic factors within a group or situation that make individuals more susceptible to pressure and influence, even if they are otherwise capable of making decisions.

    Inappropriate influence is an inherent risk in all human interactions. Even discussion and rational arguments can inappropriately influence someone

    The point, however, is that if there are normative objections to assisted dying based on substantive rather than procedural arguments, it could be argued that individuals should not be offered the option of assisted dying at all (e.g. because it does not align with the purpose of the health service). Once the choice is there, we cannot avoid the risk of inappropriate influence. However, this also applies to all other choices in life. The risk of external pressure leading to inappropriate influence does not, therefore, appear to be the key factor in determining our position in the assisted dying debate.

    I would like to thank the participants at a seminar held by ETHME (The Ethics of Mortality Measurement), University of Oslo, for their insightful and constructive feedback on a presentation of the manuscript. The content of the debate article is entirely the responsibility of the author.

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