Suicide is good policy as good citizenship.

In 1984, Colorado Governor Richard Lamm declared that elderly people who are terminally ill “have a duty to die.” He explains: “Like leaves which fall off a tree forming the humus in which other plants can grow, we’ve got a duty to die and get out of the way with all of our machines and artificial hearts, so that our kids can build a reasonable life.”[1]

Margaret Battin begins her essay, “Age Rationing and the Just Distribution of Health Care: Is There a Duty to Die?,”[2] with an ancient authority:

In the fifth century B.C., Euripides addressed “those who patiently endure long illnesses” as follows:

I hate the men who would prolong their lives
By foods and drinks and charms of magic art
Perverting nature’s course to keep off death
They ought, when they no longer serve the land
To quit this life, and clear the way for youth.

In Utopia, Thomas More writes of those with “incurable diseases”:

… but when any is taken with a torturing and lingering pain, so that there isn’t hope, either of recovery or ease, the priests and magistrates come and exhort them, that since they are now unable to go on with the business of life, are become a burden to themselves and to all about them, and they have really outlived themselves, they should not longer nourish such as rooted distemper, but rather choose to die, since they cannot live but in much misery: being assured that if they thus deliver themselves from torture, or are willing that others should do it, they shall be happy after death.[3]

Hume offers the following reasoning: “suppose, that it is no longer in my power to promote the interest of the public: Suppose, that I am a burthen to it: Suppose, they my life hinders some person from being much more useful to the public. In such cases my resignation of life must not only be innocent but laudable.” Even a criminal, he adds, may do a final public service by “ridding [society] of a pernicious member.” [4]

Battin establishes a seemingly intractable problem: greater numbers of people living into their 80s and 90s; ever improving medical technology and ever increasing costs; the scarcity of resources to distribute care justly; and competition between groups — elderly, infants, and everyone in between — for health and thus health care.

Each presents interests, the demand of quality of life, that seem inviolate. Everyone feels entitled to resources that will not go around. The outcome, Battin believes, is the irrationality of health care: the elderly consume the most resources — cancer treatments, coronary procedures, hip replacements, and nursing care — and benefit the least, especially when care prolongs living but does not enhance the quality of life.

And, Battin establishes, the problem is timidity. An unwillingness to confront the problem. “Our reluctance to look squarely at death and its often unpleasant circumstances may undermine both the rationality and the justice of the death-related policies we adopt.” We must: “look the circumstances of death squarely in the face.”

Her solution to an unvarnished appraisal? John Rawls and the veil of ignorance. The problem of present decision-making is that age groups compete with one another from the position of their present conditions and circumstances. Behind the veil of ignorance an individual would choose the fairest and most just distribution of resources without knowing their specific position.

They would view the problem from the individual’s standpoint over a complete life. Battin envisions a “scarcity-characterized ideal world”: “unable to know their own medical conditions, genetic predispositions, physical susceptibilities, environmental situations, health maintenance habits, or ages, they must decide in advance” the basic structure of society.

The new structure and distributive arrangements of society would increase the effectiveness of health care resources. Ten units of care, which would extend one elderly life by two years, would go instead to a child, allowing her to live another sixty-four years. And, the quality of an individual’s life would be maximized, not diminished. The effect is that life would be “physically, emotionally, and intellectually vigorous until just before its close.”[5]

The distributive arrangements, then, must be exacting. They entail the denial of health care to terminal patients. “That those of the elderly who are irreversibly ill, whose lives can be continued only with substantial medical support, ought not be given treatment; instead, their lives should be brought to an end.” They must be allowed to die.

And, they entail the denial of expensive palliative care. For one would linger one, without substantial benefits in the quality of life, while helping to drain resources that would benefit others far more. Battin establishes that these individual have a “duty to refrain from further use of medical resources.”

One may then linger in pain, terminally or otherwise. Or, one may suicide. Battin affirms the individual’s choice. But she also turns to anthropology by pointing to the Eskimos, the feudal Japanese, and the ancient Greeks, all of whom practiced variations on senicide: “abandonment, direct killing, or socially enforced suicide.” For Battin, these are not anachronisms, they are timeless solutions to timely problems. She writes:

…I wish to argue that rational self-interest maximizers in the original position would prefer the direct-killing practices which are the contemporary analogues of the historical and primitive practices of senicide, early euthanasia, and culturally encouraged suicide to those which involve allowing to die.

And, Battin establishes the importance of education to prepare the individual to decide. Due to custom, legal and religious restriction, and other social expectations, “as ordinary persons, we may fail both to realize what our own self-interests actually are and to choose the most efficient means of satisfying them.” Education must bring all to the original position of social policy.

Battin sees the felicitousness of this dynamic, individual and society. “It is not at all difficult to imagine the development of social expectations around the notion that there is a time to die, or, indeed, that it is a matter of virtue or obligation to choose to die.” The basic structure of society would fashion the duty to die.

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[1] Time, “Medicine: Question: Who Will Play God?,” 123, no. 15 (1984): 68.
[2] Margaret Battin, “Age Rationing and the Just Distribution of Health Care: Is There a Duty to Die?,” Ethics 97, no. 2 (1987): 317-40.
[3] Thomas More, Utopia, 58.
[4] Hume, “Of Suicide.”
[5] Battin quoting James F. Fries, “Aging, Natural Death, and the Compression of Morbidity,” New England Journal of Medicine 303 (1980): 135.