Anorexia shouldn’t be a death sentence Ethical activists conspire to enable suicide

As Kim Leadbeater’s Assisted Dying Bill returned to parliament, critics’ attention turned to a previously unsuspected cohort that might soon be rolling down the slippery slope. Evidence delivered to her committee revealed that at least 60 patients with eating disorders have died by physician-assisted suicide or euthanasia overseas, with many in their teens and 20s. These were mostly women, classed by virtue of their emaciated bodies and weight-fixated minds as “terminally ill” or in the grip of an “irremediable condition causing unbearable suffering”, and so reaching the threshold for eligibility.

An obdurate Leadbeater seemed to think her bill’s wording excluded this disturbing outcome in principle. Assisted suicide on the NHS, she insisted, will be reserved for the terminally ill, with a stipulation that “a person is not to be considered to be terminally ill only because they are a person with a… mental disorder”. But as Chelsea Roff, the lead author of the anorexia evidence pointed out, the disease is — by definition — a mental disorder with devastating physical effects. In particularly severe and prolonged cases, a doctor might well diagnose the case as hopelessly terminal with recovery impossible, in which case eligibility for an early exit would be nearly assured.

This would be a mistake, though an understandable one. In fact, with anorexia, you can only say with confidence that recovery genuinely was impossible and further treatment futile, if and when the sufferer actually dies from the disease. Until then — doctors’ illusions of omniscience aside — you don’t know for sure. Some will seem to be at this point and then later recover; for occasionally, even entrenched anorexia can loosen its grip, and fuel-starved minds start to change. If a sufferer opts for assisted dying, then, we will never know for sure whether the same could have been true of them.

Indeed, it is potentially worse than this; for it seems that a diagnosis of terminal illness in the case of anorexia might have a rigidifying effect on a sufferer’s intention to give up on life. This is one between-the-lines reading of a case history offered by US medic Jennifer Gaudiani concerning Alyssa, an anorexic who was eventually euthanised at her request. In an email to Gaudiani four days before her death, Alyssa insisted that her course of action was not being “pursued in isolation, but rather in the context of being in Hospice care following a terminal [diagnosis] of anorexia (i.e., estimated six months or left to live)… In my individual case, death was inevitable. I clearly understood my prognosis and accepted this. I saw [medically-assisted dying] as an opportunity to select a specified time and circumstances for my death.”

Gaudiani is herself supportive of assisted dying for so-called “terminal” anorexics; but relatively few general campaigners for assisted dying positively want this sort of outcome, as such. Still, the logic of their own position inexorably corners them into it. For, though it is often unnoticed, the assisted dying movement is a collaboration between two radically different ethical ideals, whose goals have only surface compatibility. The state-enabled deaths of willing anorexics is just one side effect of the underlying tensions.

First, we have the Freedom Lovers. These are campaigners whose buzzwords are “my choice”, “my right to die”, and the like. Freedom Lovers are steeped, whether knowingly or not, in a liberal tradition which emphasises freedom from interference from others in various personal domains. Their pronouns of choice are usually I/me/mine. They tend to think of death-seeking as a wholly private matter.

The vision of the Freedom Lover can be seen most clearly when away from the morally murky domain of assisted dying, considering suicides of the unassisted kind instead. Possibly the most hardcore Freedom Lover there ever was, was anti-psychiatry psychiatrist Dr Thomas Szasz. A Hungarian-American, he wrote many books railing against the coercive nature of the medical establishment. He thought that if you decide to kill yourself, you have a right to noninterference from everyone else, even in the case of severe mental illness. Any reason to end your life is a good one as long as it is yours, and any attempt to stop you is an infringement on personal autonomy. Inspired by the pejorative “Big Pharma”, he once coined the concept “Big Suicide Prohibition” — though for some reason it didn’t catch on.

Alongside Freedom Lovers, another archetype is also heavily involved in pro-assisted dying campaigns. I’ll call her the Altruistic Helper. Whereas the Freedom Lover is, at base, a suicide permitter, the Altruistic Helper is a suicide enabler: not so much interested in leaving people alone to do their thing, as positively helping them do it. Her preferred language mentions “compassion”, “humanity”, “mercy”, and “quality of life”. Her preferred pronouns are not first- but third-personal.

Unlike the Freedom Lover, she does not think of the value of a life as subjective, or that any reason to go is a good one, as long as it is yours. Some circumstances are more deserving of death than others. Though sometimes reticent to spell this out, it seems clear that Altruistic Helpers have firm views about what should happen, objectively, when a life contains so much suffering that it is not worth living. In that case, they think, its owner should be helped to die; it’s the morally correct thing to do.

While she pays due deference to the presence of consent to the assisted dying process, unlike the Freedom Lover the Altruistic Helper is not massively interested in it for its own sake. Rather, she simply takes consent as good proxy evidence for the presence of unbearable suffering in a person’s life. Her background thinking seems to go: if you have a terminal diagnosis, and you are deliberately seeking an early exit, the only possible reason for which you could be doing this is that you are suffering unbearably. (Indeed, Kim Leadbeater seems so sure of this fact that in her proposed process, the candidate won’t be asked about her personal reasons for seeking death at all.)

To say that the Freedom Lover and the Altruistic Helper are strange bedfellows is an understatement. Strictly speaking, what should interest the Freedom Lover according to the logic of his ideal is decriminalising private voluntary acts of suicide assistance, organised contractually between individuals. You want to die, for whatever reason; I want to help. It’s all voluntary, and nobody else’s business to interfere.

Yet thanks to the Altruistic Helper’s input, they tend to get something else entirely: a huge state-sponsored machine, involving thousands of healthcare employees, policies, and supposed safeguarding constraints upon who can access the service. Uber-Freedom Lover Szasz knew this, and was critical in his writing of assisted dying procedures, viewing them as constraining of personal autonomy. When he broke his back, aged 92, he killed himself alone a few days later.

Another weird feature of the awkward collaboration between these ethical archetypes is that the Freedom Lover can’t really justify why terminally ill people already able to kill themselves on their own, if wished, are deserving of state-sponsored medical assistance to help them do it. Though unpleasant to dwell on, many already have this freedom, as the example of Szasz demonstrates. It is perhaps why Freedom Lovers tend to focus so heavily on paralysed or otherwise incapacitated people in their motivating examples. In contrast, the Altruistic Helper has no trouble explaining why terminally ill people who ask for death are deserving of state assistance, however mobile they are. Namely: they are clearly suffering too much, and so it is the right thing to do.

The anorexic with suicidal intentions — for all we know temporarily — ends up as collateral, falling between the two stools of these ways of thinking. Anorexia is a relatively anomalous condition, hard to fit into familiar binaries of active cause versus passive effect. The mind produces a willed behaviour with devastating effects on the body. The physical effects of anorexia are not exactly voluntary, given the role of persistent, near-automatic habits of approaching food; but not exactly involuntary either, and certainly not involuntary like those of cancer or arthritis.

Effectively, anorexia acts as a Rorschach test for assisted dying campaigners. To a committed Freedom Lover, the behaviours associated with anorexia, including accompanying suicidal intentions, look active enough to count as an expression of free will — at least, assuming mental capacity has first been established, as was the case for Alyssa. (Purists like Szasz may not even require this.) Those who are Freedom Lovers by instinct are not particularly inclined to go out to bat for the exclusion of people from assisted suicide provision who appear to have rationally decided it is their time to go. To say otherwise would look like a kind of interference in personal autonomy, and Freedom Lovers can’t have that.

Meanwhile, the Altruistic Helper is likely to frame the terrible physical suffering produced by severe and prolonged anorexia as something that happens to a sufferer, rather than something she has any part in actively causing; an irrevocable, settled fact that merits a compassionate release into peaceful oblivion. As intimated earlier, Altruistic Helpers tend to see a person’s firm desire to die, accompanied by physical affliction, as an indirect indication that the amount of suffering present is objectively too hard to bear. This is supposed to be what justifies helping him to end his life. If Helpers were to admit that the physical torment of a severe anorexic, as awful as it is, is not enough to make an assisted death justified, they might just have to rethink their whole model.

And so, like the Freedom Lovers but for different reasons, Altruistic Helpers are also unlikely to argue forcefully for the exclusion of suicidal anorexics from an assisted dying service. Depending on who is looking, these troubled women and the occasional man will be seen as captains of their own ships or helpless victims of the storm. And either way, an artificially hastened exit from a sea of troubles will be theirs for the asking.

---