Anthropologies of Hope and Despair: Disability and the Assisted

Suicide Debate

Journal of Disability and Religion 22.1 (Fall 2018): 1-16

David Elliot, Ph.D.

Assistant Professor of Moral Theology and Ethics
The Catholic University of America, Washington, D.C.,
Research Associate, Von Hügel Institute
St Edmund's College, University of Cambridge

ABSTRACT

The physical criteria which determine who is and who is not eligible for assisted suicide imply that some lives –
such as lives with disability - are less ‘objectively’ worthwhile than others. Besides being degrading and
discriminatory, this view is self-deceived. Aging makes both the nondisabled and disabled prone over time to
experience increasingly serious disabilities, from impaired mobility to hearing loss. Anthropologies which
undermine life with disability therefore undermine our humanity as such, risking self-hatred and misanthropy. As an
alternative to this anthropology of despair, I consider hopeful models affirmed by disability rights activists and by
Christian theology.

KEYWORDS: disability, hope, assisted suicide, dying, end-of-life, misanthropy

Introduction

One of the remarkable features of physician-assisted suicide (PAS) bills in the Anglo-
American context is their general uniformity.1 From California to Colorado, from the United
States to the United Kingdom, assisted dying bills have recycled the same basic formula
pioneered in Oregon.2 Two major criteria govern this model. First, the patient must be ‘aged 18
or over’ and have ‘a voluntary, clear, settled and informed wish to end his or her own life’.
Second, the patient must suffer severe physical deterioration: specifically, a terminal illness from
which he or she ‘is reasonable expected to die within six months’.3 To avoid plodding
circumlocutions, I will describe each by way of synecdoche: calling the first the ‘autonomy
criterion’, and the second the ‘physical criterion’. The first builds autonomy safeguards to curb
slippery slope fears of coercion, and the second prevents suicide on demand by limiting PAS to
medically desperate cases. The autonomy criterion is therefore the necessary condition to which
the physical is the sufficient condition for PAS. The consequence is that patients who want lethal
drugs will only get them if the state decides that they are sick, incapacitated, or dying enough to

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make that wish reasonable. In Belgium, the Netherlands, and Switzerland, the physical criterion
is very elastic, and has included conditions ranging from terminal cancer to blindness. In Anglo-
American jurisdictions, the physical criterion is defined at present as a 6 month terminal illness
(though Oregon recently proposed expansion to 12).4 With only small variations, this model is
now legal is Oregon, California, Colorado, D.C., Vermont, and Washington. After repeated
defeats in Parliament, it is again before the House of Lords through Lord Hayward’s Assisted
Dying Bill, from which I cited above. Whereas much of the debate has addressed issues related
to what I call the autonomy criterion, my argument will focus on dangers latent in the physical
criterion, particularly as it bears upon people with disabilities.

The Physical Criterion of Physician Assisted Suicide

I begin with the fact that whatever the motives for it may be, the intention of assisted suicide is to
terminate a life. Since death is supposed to be in the patient’s interests – and not, for instance, a
grasping relative’s – the presupposition is that the patient’s life is no longer in the patient’s
interests. This is another way of saying that their lives are no longer worth living. Various
euphemisms have been devised to give this the appearance of featherbed respectability, but the
fact remains: terminating a life can only be judged a benefit rather than a harm to a patient (and
therefore as ‘medical’ treatment at all) if the patient is thought to be better off dead.5 The
willingness to assist suicide therefore presupposes and validates the patient’s belief that his or
her life is no longer worth living.6 In almost all jurisdictions, the state actively disagrees with this
belief, the policy arm of which is suicide prevention.7 Suppose this were rejected as paternalism,
and the state agreed that some people were not unreasonable to think that death was in their
interests, and was further willing to assist voluntary suicides. The state would still have to decide
whether those who voluntarily requested PAS could get it for any reason they deemed sufficient,
or only for some reasons which the state judged sufficient.
The former would lead to a rather ‘libertarian’ model of PAS which affirmed that one’s
life is one’s own, and that we should be able to end it when we see fit in a dignified manner free
from meddling of legal rearguards and moral scolds. But in terms of serious policy options, this
model has long since been deposed. Both legislators and PAS advocates say they utterly reject
suicide on demand, and propose strict safeguards to prevent it. Every UK and US bill seeking a
change in law has sought to severely limit access: rejecting the nightmare prospect of, say, a
suicidal teenager in romantic despair or a thirty-something whose career crashed obtaining a
lethal dose of secobarbital. 8 Autonomy itself would therefore be constrained by means of the
physical criterion. By it the state would judge that of those people who believe their lives are not
worth living and should be terminated, some will be treated as justified and some will not, based
on whether they have the stipulated level of physical brokenness. Depending on how debilitated
one was, the belief that one was better off dead would be treated as an error to be cured or an
insight to be implemented. That is why some patients will be subject to suicide prevention, while

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others will receive suicide facilitation; why fatal poisons will be ‘deadly’ for the many, but
‘medicine’ for the few.
Depending on the jurisdiction, the physical criterion might be a terminal illness, or a
severe and irreversible condition. In Anglo-American jurisdictions, it is currently defined as a 6
month terminal illness. As a defined, codified, and legally-binding standard that rests upon an
empirical diagnosis, the physical criterion aspires to be “objective:” to be separated from
anybody’s bias and partiality; to represent the impersonal perspective of medical science and law
themselves. It picks out aspects of ill-health that are taken to have no bearing upon one’s
personal value or moral status, allowing for technical and medical assessments that are not
supposed to carry harmful evaluative baggage. But this cannot be true, since the physical
criterion reevaluates the moral status of all groups and people who conform to it by implying that
it is reasonable and justified for people like them (but crucially, not for others) to believe their
lives are no longer worthwhile.9 Moreover, it does so based on an empirical diagnosis
proportioned to one’s bodily deterioration, concealing a discriminatory value judgment with the
rhetoric of clinical impartiality even while assigning that judgment ‘objective’ status by
affirming it from within medical science. Not only would this undermine the equal moral status
of those who want to die; it would degrade tens of thousands of sick, disabled, and dying people
in similar conditions who wish to live. This violates the respect which their lives are equally due,
and marks a degrading reevaluation of their moral status.
The point is hardly abstract, since the state would treat the physical criterion as legally
and lethally action-guiding. PAS would generate something like a new anthropology and politics
of comparative inequality. Let us suppose that a middle-aged person after a botched suicide
attempt and a terminally ill patient both ask for suicide assistance. The doctor will inform the
middle-aged patient he is not eligible, and he will subjected to suicide prevention with its
messages of hope and affirmation of one’s life. In comparison with this, the terminally ill patient
will experience something more like suicide facilitation, with the decision to die affirmed as
reasonable and choiceworthy (Elliot, 2018, pp. 21-23). 10 Plainly they are being treated unequally
with respect to the ongoing value of their lives. It is hard not to see this as deeply in tension with
central facets of democratic, egalitarian, human-rights culture.

Disability Otherwise Described

What does this have to do with disability? Why is it that every time assisted suicide bills are
debated, dozens of people in wheelchairs protest outside Westminster or state legislatures?11 Tim
Delamothe, the Deputy Editor of the British Medical Journal, thought this opposition gratuitous,
and claimed that the assisted dying debate had been wrongly ‘hijacked’ and needed ‘reclaiming
from disabled people’ whose ‘sloppy thinking’ had conflated important distinctions. He quoted
Baroness Mary Warnock, who argued in the debate over the Falconer amendment: ‘There is
confusion if we run the disabled as a class of people, members of society, into another class of

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people, the terminally ill, although they may overlap. There are two different concepts, and we
should not bring them together under the general heading of the vulnerable about whom we hear,
in my experience, all too much’ (Delamothe, 2009). Disturbed by all the air time devoted to
‘vulnerable’ people, Warnock ascribes the opposition of disability rights activists to an
elementary fallacy, and suggests that they be ignored. The patronizing tone and aloof unconcern
of both Delamothe and Warnock are striking. But are their claims false?

The high correlation between disability and euthanasia in Belgium and the Netherlands is
by now a commonplace. Whereas the Anglo-American model requires a six-month terminal
illness, the Belgian, Swiss, and Dutch models advert to the criterion of ‘unbearable and
irremediable suffering’. Originally identified by the Dutch Supreme Court as ‘terrible physical
pain, often as a result of cancer’, the concept proved elastic enough to encompass ‘mental
suffering’ and therefore mental illness. In Belgium, euthanasia has been granted for healthy
patients experiencing ‘unbearable grief’, unalleviated depression, feeling ‘unwanted and
unloved’, and so forth (see Wilkinson, 2009, Debois and Zeegers, 2014). Like the post-World
War I map of the Middle East, the definition of ‘unbearable suffering’ is ad hoc, and its
pretensions to legal-medical objectivity are hardly compelling. It adds to conceptual vagueness
the staggering task of trying to ‘objectively’ calculate the complex subjectivity of suffering using
criteria that are themselves unclear (Keown, 2008, pp. 103-124). This soon included cases of
disability.
As early as 1996, cases of disabled infanticide (without criminal convictions) were
reported in the Netherlands. The numbers steadily rose, and in 2013 the Netherlands
Commission on Euthanasia proposed to terminate up to 650 severely disabled infants (‘neonates
with very serious defects’) per year (Angier, 2016). The U.N. Human Rights Committee
registered formal dismay, being ‘gravely concerned at reports that newborn disabled infants had
had their lives ended’.12 In Belgium, disabilities such as deafness and blindness among adults
who are not terminally ill have likewise qualified as forms of ‘unbearable suffering’. In both
countries – and sometimes without the patient’s consent (Loenen, 2014, pp. 10-15, 71-77) -
disabilities are now considered sufficient grounds for termination.
The Anglo-American standard model of assisted suicide is less brazen, but similarly calls
life with disability into question. Lord Falconer has repeatedly introduced bills for assisted
dying. In 2011 his Commission on Assisted Dying was split over whether disability constituted
sufficient grounds for PAS. Though initially favouring it, opposition from disability rights
organizations which were well-represented in Parliament led the Commission not to recommend
the policy ‘at this point in time’. 13 But this was a triumph of expediency rather than a statement
of principle. Precisely such cageyness led the disabled peer Tanni Grey-Thompson to retort that
‘While I am not a potential candidate for assisted suicide right now, I am in the waiting room’.14
But why is disability being introduced as a relevant reason for thinking one’s life might
be regrettable and better off disposed of? Why is it granted any deliberative weight in the matter
at all? If Lord Falconer had suggested that being a certain gender or having a certain colour of
skin were relevant factors for why people might reasonably want to terminate their lives, it

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would be condemned as discriminatory and degrading. How is it any different with disability,
unless the unspoken thought is that the disabled life may not be worth living, or is at least on
balance probably less worthwhile? Unless that presupposition is operative, disability would be a
wholly arbitrary criterion: like saying that everyone with three R’s in their name might have
reason to kill themselves.15
The Cambridge philosopher Simon Blackburn articulated well why so many view
disability as relevant rather than arbitrary in this debate. Called in 2005 as expert parliamentary
witness to Lord Joffe’s Select Committee on Assisted Dying, he was asked: ‘What about the
severely disabled person who is bound to be, for the duration of their life, quite a heavy burden
on somebody’? Professor Blackburn argued that ‘it is one of the terrible things about imagining
the lot of the disabled those who do make great demands on other people. It is one of the terrible
things when one imagines the indignity of dependence… we recognise that as having something
inhuman about it itself. I think the sense of dependency is a curse and it is one of the curses that
the disabled bear’.16 In the context of a parliamentary committee, no less, the disabled life is
described as undignified, ‘cursed’, even ‘inhuman’, making it all too clear why many think it
relevant to this discussion.
Blackburn’s reasoning is far from idiosyncratic. The point is often made that advances in
medical technology have made remarkable levels of pain control available, up to and including
terminal sedation. The subtext is that insofar as the PAS argument is justified with reference to
unbearable pain, the argument as it stands is anachronistic. But Lord Falconer made the obvious
yet telling point in Parliament that physical pain does not account for all suffering. Even if pain
were adequately controlled, he stressed many would prefer death to some other unbearable
condition: specifically, they would rather die ‘than face a period of reduced function and
independence in their final illness’.17 This is disability otherwise described. The point being
made is that many people would rather die than face disability, with the subtext that this is a
reasonable judgment. As Baroness Ilora Finlay, past president of the Royal Society of Medicine,
perceptively noted: the ‘campaign to legalise assisted suicide for the terminally ill is being built
around someone who is disabled and chronically rather than terminally ill’ (Finlay, 2009). Is it
possible that this should not be degrading to people with disabilities?
The point is not simply conceptual and anecdotal. The empirical literature confirms that
what motivates assisted suicide is not so much pain as disability. Oregon has kept detailed
records on this since 1998. During a 16 year period, only 24% of PAS patients cited ‘inadequate
pain control’ as important to their decision. But a full 92% cited ‘loss of physical autonomy’,
making it the primary motive given for taking one’s life. This was followed by being ‘less able to
engage in activities’ the person valued (89%), followed by ‘losing control of bodily functions’.
This is a recognizable profile of a person with disabilities. Many of these patients, in line with
Simon Blackburn, saw themselves a ‘burden on family, friends/caregivers’ (40%), and the vast
majority (81%) interpreted these conditions as conferring ‘loss of dignity’.18
As this suggests, the overwhelming majority who sought assisted suicide did so not due
to excruciating pain or because they were dying, but due to symptoms arising from the

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disabilities caused by their underlying illness. The president of Not Dead Yet, the disability
rights movement founded by Baroness Jane Campbell, put it this way: ‘the individual’s
disabilities and physical dependence on others for everyday needs [are being] viewed as
depriving them of what nondisabled people often associate with ‘autonomy’ and ‘dignity,’ and
may also lead them to feel like a ‘burden’ (Coleman, 2010). The concern is that ‘death with
dignity’ to a significant degree means certain able-bodied people opting to die before getting too
disabled, since that would be ‘undignified’. The implied anthropology, I will suggest below, is
one of self-deception and despair.
Delamothe and Warnock argue that terminal illness and disability are ‘two separate
issues’ that should not be conflated. As an abstract proposition, they are technically correct; but
this hardly dispels the problematic empirical overlap between disability and value judgments
about what kind of life may reasonably be terminated. There is in fact pervasive correlation
between the two. To suggest otherwise would be disingenuous, like arguing that police brutality
and racist discrimination are ‘two separate concepts’, with the truly false subtext that they are not
viciously entangled.

An Anthropology of Despair

It would be false to think that such degrading views of the disabled are held only by
portions of our political, medical, and academic culture. We must avoid the illusion that this is
just an ‘elitist’ problem from which mainstream and popular culture are happily preserved. Of
course, many initiatives in mainstream society have sought to remove stigmas and increase
access for disabled people, resulting in real if limited improvements. At the same time, fatuous
attitudes and rank complacency still persist. To take one important example, our entertainment
and consumer culture routinely signals that beautiful, young, and able bodies are “normal” or
“proper;” with old, disabled, and dying bodies struggling to find recognition. As Nicholas Boyle
has argued, agency as reflected in popular culture unites a postmodernism which denies
existential limits to a global consumerism which makes entertainment and ‘life in the shopping
mall’ our spiritual center of gravity. This is entangled with the cult of youth and beauty which
seeks to indefinitely forestall aging through cosmetics and surgery, and obsessions with sport and
fitness that valorize the maximally functional body (Boyle, 1999, p. 86). The elderly and the
disabled are not just the losers in this game; they are largely rendered invisible by it.
Such marginalization is itself appalling, but it also has implications for everybody. It
reinforces a self-deceived anthropology which ignores the fact that aging and debility are
constituent parts of the human condition from which we cannot exit. As the aging process
advances, both the nondisabled and the disabled are liable to increasing disabilities. As the
British Geriatrics Society reports, aging results on average in 1-2% decline in functional ability
per year ( Health Promotion and Preventive Care, 2005). Growing deterioration over time of
hearing, sight, cognition, bones, joints, heart, liver, and so forth, conduces to recognizable

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disabilities, from cognitive impairments to loss of mobility, and these are generally accelerated
by terminal illness. All of us as we age are on a continuum toward increasing disability.
A realistic anthropology must account for such facts, construing disability not as
something ‘other’ to a ‘normal’ human condition, but precisely as an aspect of it. To reject a
realistic anthropology which makes important space for disability is to reject the human
condition as it exists in reality. To the extent they foster an overly-idealized anthropology,
mainstream popular and consumer culture harbor a deep and abiding misanthropy which
becomes depressingly apparent as aging and decline leave people on the nether side of their
amiable illusions. The resulting miseries are captured in Edward St. Aubyn’s remake of King
Lear, where he quips that care homes and the like can scarcely ‘keep up with the modern demand
for a place in which to neglect the mad, the old and the dying’ (St. Aubyn and Shakespeare,
2017, p. 28)

Anthropologies of Hope

But anthropologies of hope which do not succumb to this dismal vision are certainly
available. They come in secular forms compatible with contemporary law and society, as well as
in specifically religious and Christian forms. The best example of the former has, unsurprisingly,
been articulated by disabled people themselves. One influential survey of PAS patients attitudes
reported the following:

Symptoms and loss of function can give rise to dependency on others, a situation that was
widely perceived as intolerable for participants: ‘‘I’m inconveniencing, I’m still
inconveniencing other people who look after me and stuff like that. I don’t want to be
like that. I wouldn’t enjoy it, I wouldn’t, I wouldn’t. No, I’d rather die.’’

Participants frequently used the notion of dignity to describe the experiences associated
with disintegration: “You've become a bag of potatoes to be moved from spot to spot, to
be rushed back and forth from the hospital, to be carried to your doctors' appointments or
wheeled in a wheelchair, and it really does take away any self-worth, any dignity, or any
will to continue to live.”

Diana Coleman astutely commented as follows:

“These feelings are understandable for newly disabled people, whether due to a chronic
or a terminal condition. Disability groups, however, disagree that needing help in
dressing, bathing, and other intimate daily tasks robs a person of dignity. Unfortunately,
popular culture has done virtually nothing to educate the public about how people with
severe disabilities actually live autonomous and dignified lives. Our lives are portrayed as
tragedies or sensationalized as heroism, but the real-life issues and coping styles that

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 most people will need if they live long enough are left out of the picture. No wonder
people who acquire disabilities so often see death as the only viable solution.” (Coleman,
2010).

The hope implied in this statement is that newly disabled people – which is
characteristically what terminally ill people are or become – need not default to the ableist
anthropologies that would degrade their current condition, but can get past this to a far more
positive anthropology which affirms the value and dignity of life with serious disabilities. Hope
by its very nature strives for an arduous good whose acquisition or preservation is fraught with
challenges (Elliot, 2017). An anthropology which unambiguously affirms that the disabled life is
worth living while fully aware of challenges it may pose is in this sense hopeful. It has been best
articulated by people with disabilities themselves, in ways that powerfully critique the
assumptions behind the physical criterion of PAS (see for example the stories and documentation
in Pelka, 2012, pp. 151-196, 227-245)
A growing and important body of work in disability studies has stressed that people with
disabilities have much to teach all of us; including that an autonomy-centered anthropology
which stigmatizes physical incapacity is a disastrous illusion (Brock, 2011; Swinton, 2007). In
our society disabled people are the canary in the coal mine. They reject the anthropology
according to which loss of physical capacity and independence assigns life lesser value
(Coleman, 2010; Oliver, 2009, pp. 110-124; Pelka, 2012, pp. 48-93). This is an insight we should
retain from them. It makes a hash of the belief implied by the physical criterion that some kind or
degree of physical debility makes it reasonable to think your life may be less or not worthwhile.
Provided we can follow people with disabilities up to that point, we can see the physical criteria
of PAS as based on a false anthropology which wrongly sees high functionality and physical
independence as not just desirable, but as normative.

Christian theology also provides resources for a hopeful anthropology.19 The biblical tradition
construes human worth and moral status in very elevated terms. Believers claim that human
beings are created in a supreme act of divine love and in the very image of God. The Psalmist
declares that human beings are ‘made a little lower than the angels’, ‘crowned… with glory and
honour’ (Psalm 8: 5, NRSV; see Timothy Jackson, "The Image of God and the Soul of
Humanity', in Cuneo, 2005) This essentially positive and hopeful anthropology is further
heightened and ratified by the Incarnation, in which God assumes and thus incalculably dignifies
human nature. Augustine adds that the greatest warrant of human dignity is to be “shown how
much God loves us. Now what greater proof could we have of this than that God’s Son should
deign to unite Himself to our nature?”20 The Passion concentrates and intensifies such points in a
rousing a fortiori: “God shows his love for us in that while we were yet sinners Christ died for
us.” (Rom 5:7). The point is not just to make human beings feel themselves loved, but to
establish their inestimable value beyond doubt, since God’s valuation represents the most
accurate measure of a thing’s value.

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Such considerations are deeply coloured by the manner of the Incarnation. The human life that
God takes up includes poverty, exile, underappreciation, homelessness, persecution, and horrific
bodily destruction. It is a historical commonplace that crucifixion was practiced by the Romans
in part to utterly humiliate and degrade enemies in a spectacle calculated to deprive them of
dignity (Robison, 2002). Christianity utterly subverts this signification. The crucifixion of Christ
shows that a broken, frail, and dying body in no way loses its inherent dignity. Rather, it may be
an object of supreme reverence and is even made the chosen vehicle of redemption.21 Among
other things, the cross teaches that physical aging, illness, disability, and dying, however arduous
the challenges they may pose, in no way compromise our moral status and ontological worth.
This hopeful anthropology is further ratified by the belief that we are ordained to a
supernatural end. The moral work which belief in everlasting salvation does here is two-fold.
The first is to make possible a uniquely bracing kind of hope in situations of physical
brokenness. I noted earlier that the object of hope is a good which it is possible but arduous to
attain. As its title suggests, the good which “theological” hope seeks is perfect beatitude through
eternal union with God (theos).22 Theological hope considered as a virtue is resilient; Scripture
describes it as a ‘helmet’ (Eph 6:2). A mean between the vices of despair and presumption,
theological hope is not a feeling but a virtue—specifically, a virtue of the will which braces and
encourages us to persevere amid the challenges and suffering that make life’s journey arduous.
As I have discussed elsewhere, this makes theological hope a key resource for facing decline and
for cultivating an ‘art of dying’ (ars moriendi): itself a growing topic of considerable interest
(Elliot, 2016).
A second benefit of theological hope is to further elevate our embodied humanity via
immortality and the resurrection. In a memorable phrase, Augustine states that everlasting
salvation is ‘a greater work than the creation of heaven and earth’, because ‘heaven and earth
will pass away but the salvation and justification of the elect . . . will not pass away’.23 Such
considerations, added to the doctrines of the imago dei and the Incarnation, exalt human dignity
to transcendent heights. We are on this account not just objects of respect, but of reverence,
wonder, and awe (‘trailing clouds of glory do we come/ From God, who is our home’).24
The fact that Christian eschatology foresees ‘the resurrection of the body’ rather than
mere disembodiment further affirms the bodily aspect of transcendent human importance. No
matter how broken the body may be, from the eschatological perspective its best days are, God
willing, actually ahead of it. Precisely this point leads St. Paul to describe death as conquered
rather than as conqueror, saying of the body that ‘what is sown is perishable, what is raised is
imperishable. It is sown in dishonor, it is raised in glory. It is sown in weakness, it is raised in
power’ (1 Cor 15:42-43). From this perspective, aging, debility, and dying – however awful the
challenges they may pose – are not the slow, weary crumbling of embodied dignity. They are
instead its eschatological ‘birth pangs’: agonizing yet suggestive of new life, a Good Friday to be
succeeded by Easter Sunday. As such, they are not the conclusion of embodied dignity but rather
the prelude to its full flowering in the state of beatitude and resurrected glory. I claimed earlier

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that the physical criterion of PAS is implicated in a misanthropic and self-deceived anthropology
which valorizes high functionality and physical independence to the detriment of lives that do
not measure up to this ideal. By contrast, secular disability rights advocates and Christian
theologians both affirm, in different but mutually reinforcing ways, supremely positive and
hopeful anthropologies thickly fortified against possible doubts or denials of human dignity and
worth regardless of the circumstances.25

Conclusion

Different jurisdictions define the physical criterion of PAS differently, from a 6-month
terminal illness (Anglo-American ‘standard model’) to severe and irreversible conditions
(Belgian, Swiss, and Dutch model). But however defined, it will degrade those who meet it by
proposing that if people like them think their lives are not worthwhile, then they are justified in
that belief, though no one else is. This violates the equality of respect which their lives are due,
and is plainly degrading.
The irony is that the PAS was meant to accommodate the belief that suicide generally
should be prevented as tragic, and therefore as a token that the practice would tweak but not
destroy existing attitudes about the value of life. We could have our cake and eat it: legalize
Death with Dignity while retaining Suicide Prevention Month, help certain octogenarians toward
‘blessed release’ while retaining disgust for the crowd that shouts ‘jump’ at the suicidal figure on
the rooftop. But as sanctioned by the state, encoded in law, and assessed by a medical diagnosis,
the physical criterion in its various forms will be treated as impartial, empirical, and objective –
as our technological society’s equivalent of ‘the viewpoint of reason itself.’ A standard which is
treated as impartial and accurate can only be coherent if it reads the situation correctly even
when we are not partial to what it tells us. The physical criterion therefore says something about
the lives not just of those who do want to die; it comments by extension on the lives of those who
wish to live. Because it stipulates an empirical standard for deciding what kind of lives may
reasonably be thought a regrettable thing for which killing oneself is a sensible ‘treatment,’ it
unwittingly violates the equality of very many dying and disabled people who never wanted to
be defined in advance as unenviable wrecks.
I have specifically stressed that the physical criterion of PAS comments unfavourably
upon life with disability, by suggesting that it may not be worth it. This evaluation comes in two
forms. First, in the Netherlands, Belgium, and Switzerland, where disability may be regarded as
conferring unbearable suffering, and therefore treated as a sufficient reason for terminating one’s
life. Second, in Anglo-American jurisdictions, where it functions and is openly accepted as the
primary and reasonable motive for termination. To grasp how alarming this is, we need to
imagine our reaction if the state held that just being a racial minority or a woman constituted
reasonable grounds for terminating one’s life, and then ask why we do not similarly react when
the disabled are described this way.

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 As an alternative to this anthropology of despair, I considered two important sources of
hope. The first is the secular anthropology of disability rights activists which affirms the value of
life with disability, and rejects the physical criterion as a form of misguided purist zeal for the
maximally functional body. I noted earlier that disability rights advocates are often accused of
alarmism on this issue, but their concern does not just lie with a prophesied slippery slope. They
quite rightly note that the language, arguments, and physical criterion used to justify PAS
devalue them by implication, suggesting that life with disability may be ‘undignified’. This is
discriminatory and degrading to all people with disabilities, and should be widely exposed and
denounced as such.
Moreover, this anthropology of despair implicates all of us in it. Beyond the period of
youth, both nondisabled and disabled people are involved in a long and complicated process of
aging and decline in which we will over time become increasingly disabled. Disability needs to
be a constitutive part of everyone’s anthropology because (among other reasons) we all have a
latent tendency toward disability. To seriously resent this is to risk forms of self-hatred or
fatalism directed at the human condition itself insofar as it is subject to debility and decline –
which is to say, insofar as it actually exists. In light of PAS’ temptation to misanthropy, we
would all do well to learn or re-learn what many people with disabilities have long been saying:
that an anthropology in which lessened physical capacity and independence assigns life lesser
value is a false and inhuman model we would do well to be rid of.
A second resource is a Christian anthropology of hope which augments the above points
with theological considerations, such as the image of God and the Incarnation. I observed that
Christianity leverages belief in the imago dei and the Incarnation to ensure an extraordinary and
indelible level of human dignity and moral status. Such beliefs led Christians to carve out
important space for the sick and dying; from the earliest hospitals to the Christian-inspired
hospice movement of Cicely Saunders. The theological virtue of hope may also sustain believers
from the acedia and despair that harm their prospects for a ‘good death’. By hope we may draw
strength from grace in trials, and be refreshed at the thought that perfect beatitude draws near.
At the center of Christian faith is the broken body of Jesus on the cross: an object not of scorn
and revulsion, but of reverence and love, and a permanent ‘sign of contradiction’ to
anthropologies which fail to affirm vulnerable and broken bodies.
But Christians and other religious believers are not the only ones with reason to oppose
the degradation which PAS brings. Along with some successes, assisted dying bills have recently
suffered resounding defeats in secular and liberal contexts such as the United Kingdom, where
doctors and the disability rights activists led the way. This shows that opposition to assisted
suicide is not just ‘conservative revulsion,’26 but draws on wider cultural resources: providing us
with some grounds for hope. This should not take us entirely by surprise. The moral conscience
which sought to abolish slavery, advance the rights of women, and further the civil rights
movement should naturally see the disabled and the dying as groups in danger of being thought
unequal to the rest of us. This is just what assisted suicide would institutionalize, even if
accidentally and from compassionate motives. In the past we did not respond to the plight of

11
slaves, women, and oppressed minorities by offering them an easy way out. Instead, progress
came when we did a cultural examination of conscience and found fault with the policies and
rationalizations that let us discriminate against them in the first place.27 We should therefore
reject PAS with its degrading criteria lest we throw that crucial moral momentum into reverse.

REFERENCES

Angier, T. (2016). The Future in Our Hands? - A Dialectical Argument against Legalising
Euthanasia. Solidarity: The Journal of Catholic Social Thought and Secular Ethics 6.

Aquinas (2000). Summa Theologica 5 Vol Set (New York: Ave Maria Press).

Augustine, S., Bishop of Hippo (1988). Tractates on the Gospel of John (Washington, D.C:
Catholic University of America Press).

Brock, B. (2011). Disability in the Christian Tradition: A Reader (Grand Rapids, Mich: Wm. B.
Eerdmans Publishing Company).

Coleman, D. (2010). Assisted suicide laws create discriminatory double standard for who gets
suicide prevention and who gets suicide assistance: Not Dead Yet Responds to Autonomy, Inc.
Disability and Health Journal 3, 39–50.

Cuneo, T., 1969 (2005). Religion in the liberal polity (Notre Dame, Ind: University of Notre
Dame Press).

Debois, B, and Zeegers, J (2014). ‘Euthanasia of Newborns and the Groningen Protocol’
(Brussels: European Institute of Bioethics.)

Delamothe, T. (2009). Assisted dying: what’s disability got to do with it? BMJ 339, b3446.

Dworkin, R. (2011). Life’s Dominion: An Argument About Abortion, Euthanasia, and Individual
Freedom (Knopf Doubleday Publishing Group).

Dworkin, R., Nagel, T., Nozick, R., Rawls, J., Scanlon, T., and Thomson, J.J. (1997). Assisted
suicide: the philosophers’ brief. New York Rev Books 41–47.

Elliot, D. (2016). The Theological Virtue of Hope and the Art of Dying. Studies in Christian
Ethics 29, 301–307.

Elliot, D. (2018). Institutionalizing Inequality: The Physical Criterion of Assisted Suicide. Christ
Bioeth 24, 17–37.

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Elliot, D. (2017). Hope and Christian ethics (Cambridge, UK: Cambridge University Press).

Finlay, I.G. (2009). A baroness replies. BMJ: British Medical Journal 339, 647–648.

Keown, J. (2008). Euthanasia Ethics and Public Policy: An Argument Against Legalisation
(Cambridge, UK ; New York, NY: Cambridge University Press).

Lindenberger, H.S., 1929 (1964). On Wordsworth’s Prelude (Princeton, N.J: Princeton

University Press).

Loenen, G.M. van (2014). Do You Call This A Life?: Blurred Boundaries in The Netherlands’
Right-To-Die Laws (Ross Lattner).

Oliver, M. (2009). Understanding disability: from theory to practice (New York: Palgrave
Macmillan).

Pelka, F., 1954 (2012). What we have done: an oral history of the disability rights movement
(Amherst: University of Massachusetts Press).

John Robison, ‘Crucifixion in the Roman World: The Use of Nails at the Time of Christ’, in
Studia Antiqua 2.1 (2002): 36-37.

St. Aubyn, E., and Shakespeare, W. (2017). Dunbar (London;New York; Hogarth).

Swinton, J. (2007). Theology, Disability and the New Genetics: Why Science Needs the Church
(London ; New York: Continuum International Publishing Group - T & T C).

Wilkinson, J.E. (2009). Disability Stereotypes, International Human Rights and the Groningen
Protocol’s Recommendations for Ending Infants’ Lives.

Williams, B.A.O., Hawthorn, G., and ProQuest (Firm) (2008). In the beginning was the deed:
realism and moralism in political argument (Princeton, NJ;Woodstock; Princeton University
Press).

(2005). Health Promotion and Preventive Care - British Geriatrics Society.

1
Though much of what I say also bears upon euthanasia, my focus will be physician assisted suicide (PAS). This is
because every UK and US bill seeking a change in law has proposed PAS, meaning that euthanasia is marginal to
the Anglo-American debate, at least for the foreseeable future. Most jurisdictions (including the UK: see
https://www.legislation.gov.uk/ukpga/Eliz2/9-10/60) still refer to this procedure as “assisted suicide”, though
advocates have coined euphemisms such as “assisted dying,” “death with dignity,” or “medical aid in dying.” I think
that “assisted suicide” is the most conceptually clear and satisfactory term we have at this point. The topic would
take us too far afield, but obvious reasons are that “suicide” is an active verb which preserves the sense of agency
and therefore of voluntariness, whereas “dying” is a passive verb which does not normally refer to a chosen act at
all, creating a needless muddle which threatens to obscure autonomy.

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2
The Dutch, Belgian, and Swiss approaches differ very much from the Anglo-American approach, both in
permitting euthanasia and for assisting terminations using far less restrictive criteria. See Keown (2008, pp. 81-
150). The Canadian law, which permits euthanasia, is the one conspicuous exception in the Anglosphere to the
Anglo-American model. See: http://www.livinganddyingwell.org.uk/news/interim-report-issued-on-canadas-
medical-assistance-in-dying-law.
3
See https://services.parliament.uk/bills/2016-17/assisteddying/documents.html
4
See: https://gov.oregonlive.com/bill/2015/HB3337/.
5
It is false to describe the intention simply as ‘eliminating pain’, since if that were the specific aim, there are
alternatives to termination: e.g., morphine levels can be raised to the point where pain is neutralized, failing which
palliative sedation remains a final option. See http://aahpm.org/positions/palliative-sedation.
6
This is not to say that if a patient chooses to stay alive that those who would have validated the patient’s decision to
die (had that been his or her decision) must therefore assume that the patient is wrong to want to stay alive. But the
fact that only some patients are validated in the belief that they are better off dead (on the basis of their physical
debility) while others are not, suffices to show the degrading double-standard at work.
7
See, for instance, https://www.sprc.org/organizations/%20national-federal; and
https://www.gov.uk/government/publications/suicide-prevention-strategy-for-england.
8
See “Assisted Suicide: The Philosophers’ Brief” (Dworkin et al., 1997) by John Rawls, Ronald Dworkin, Thomas
Nagel, et al., an influential and representative paper which argued for strict safeguards and against suicide on
demand. Dworkin makes the argument more expansively in (Dworkin, 2011, pp. 179-218), as does Martha
Nussbaum’s essay in favor of PAS for the influential President’s Council on Bioethics. See:
https://bioethicsarchive.georgetown.edu/pcbe/reports/human_dignity/chapter14.html. Mainstream assisted suicide
advocacy groups likewise say they want strict safeguards and deny wanting a widely permissive policy. See, for
example, the Death with Dignity statement: https://www.deathwithdignity.org/terminology/#euthanasia.
9
For a full elaboration of this argument, see Elliot (2018).
10
On suicide facilitation, see http://www.bma.org.uk/news-views-analysis/news/2014/july/assisted-dying-loaded-
gun-warning. There are increasingly frequent reports of patients being ‘coached’ or even ‘bullied’ into choosing
PAS in subtle and not-so-subtle ways. See: http://www.huffingtonpost.ca/will-johnston/the-alarming-trend-of-
bullying-hospitals-and-hospices-into-assisted-suicide_a_23325941/
11
Assisted suicide is opposed by every major national disability groups which has any policy on the issue. See
http://notdeadyet.org/disability-groups-opposed-to-assisted-suicide-laws.
12
See the U.N. press release at: https://www.un.org/press/en/2001/hrct610.doc.htm
13
See p. 307 of the Commission’s Report, at
https://www.demos.co.uk/files/476_CoAD_FinalReport_158x240_I_web_single-NEW_.pdf?1328113363
14
Alarmingly, a patient at Queen Elizabeth the Queen Mother Hospital was given a do-not-resuscitate order
precisely because he had Down’s syndrome. See https://www.theguardian.com/society/2015/dec/08/hospital-says-
sorry-for-do-not-resuscitate-order-on-man-with-downs-syndrome. Grey-Thompson is quoted in The Spectator:
https://www.spectator.co.uk/2014/07/the-terminal-confusion-of-dignity-in-dying/
15
Though he applies it to a different subject, I owe this hypothetical to Bernard Williams (Williams, 2008, p. 100).
16
See https://publications.parliament.uk/pa/ld200405/ldselect/ldasdy/86/5011310.htm
17
Quoted in http://www.telegraph.co.uk/news/uknews/law-and-order/8987017/Lord-Falconer-assisted-suicide-law-
fails-to-protect-or-punish.html
18
See Oregon Public Health Division, ‘Oregon’s Death with Dignity Act—2014.’
https://public.health.oregon.gov/ProviderPartnerResources/EvaluationResearch/DeathwithDignityAct/Documents/ye
ar17.pdf
19
For present purposes, I am focusing on anthropology in the sense of human worth and value rather than in terms
of human capacities and operations. In this sense, an anthropology of despair is one that fails to affirm the worth and
value of the human condition in its full dimension, and an anthropology of hope is one that succeeds in doing so.
20
Quoted by St. Thomas Aquinas, Summa theologiae II-II 20.4 (Aquinas, 2000)
21
The Vatican II document Gaudium et Spes states that this not just good news for Christians since it states a truth
about human nature as such, since ‘by His incarnation the Son of God has united Himself in some fashion with
every man’. Available at: http://www.vatican.va/archive/hist_councils/ii_vatican_council/documents/vat-
ii_const_19651207_gaudium-et-spes_en.html.
22
My account of hope draws on the theology of St. Thomas Aquinas while making further detailed proposals (see
Elliot, 2017).
23
St. Augustine, In Joannis evangelio 72, 3:PL 35, 1823 (Augustine, 1988)

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24
William Wordsworth insisted that the downtrodden imago dei represented the pons asinorum, or point at which
many fail to grasp, this crucial truth. In poems with titles such as The Old Cumberland Beggar, The Pedlar, The
Female Vagrant, The Idiot Boy, The Leechgatherer, or The Beggarwoman, we learn to attend to ‘the heaven-
regarding eye and front sublime/ which man is born to’. Doing so is like being ‘admonished from another world’,
making our minds ‘turn round/As with the might of waters’. See (Lindenberger, 1964, p. 75).
25
This is not to say that human life must be preserved at all possible costs, a view known as ‘vitalism’ (for the
distinctions between extraordinary/ordinary treatment and intended/foreseen consequences, see Elliot, 2018, pp. 32-
33).
26
Ibid., Dworkin, 214.
27
Jeremy Waldron, ‘The Theoretical Foundations of Liberalism,’ The Philosophical Quarterly 37, no. 147 (1987):
127-150.

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