Voluntary assisted dying: Solving the impossible trolley problem

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(Image CC BY-SA 3.0 Nick Youngson)

Bills introduced to the New South Wales and Victorian state parliaments argue that voluntary assisted dying should be legal. Beach philosopher Dr Samuel Douglas considers this vexed issue.

WE LIVE in a society where we are told we have the right to make choices about our lives and our bodies. But are there circumstances where we should be allowed to make that most radical of choices about ourselves — when and how our lives should end?

Bills introduced to both New South Wales and Victorian state parliaments argue that, in certain limited circumstances, voluntary assisted dying should be legal. While there are differences between them, both suggestions detail that the patient must be an adult of sound mind (25 in NSW), that at least two medical practitioners must assess them as having a limited time left to live, and that a range of psychological and judicial safeguards be in place to ensure patient competency and freedom from coercion.

Members of the respective lower houses seem to be struggling to decide on how to vote and how to articulate a coherent position on this. It is a complex and emotionally charged issue, but at its core, I think what is going on (and how they should vote) is pretty straightforward.


The classic way (by internet standards) to approach this issue is illustrated using the trolley problem.

For those who haven’t studied ethics or whose news feeds aren’t full of unfeasibly nerdy trolley problem memes, this is through a thought experiment where a runaway "trolley" (such as a streetcar or a tram) is heading down a track towards a junction. One track has five people tied to it, the other only one. If it continues its current course, it will run over and kill the five people. If it’s diverted, the trolley will only kill one person. You are standing next to the lever – what do you do? If you do nothing five people die, but you did not technically act to cause their deaths. If you pull the lever, only one person dies, but you arguably have played a more active role in their death.

It’s typically portrayed thus:


In the case of voluntary assisted dying, this isn’t at all like what’s going on.

In a single instance, there is only one person on the track: a terminally ill patient who is deemed capable of autonomously making important decisions. In the oversimplified world of rail-based thought-experiments, the trolley is going to run them over sooner or later. The person at the lever (representing at least two medical practitioners), decides nothing more than when the trolley arrives and perhaps how painful the end is when it does. The patient tied to the tracks would pull the lever themselves if they could, but they can’t. Because of this, they are exercising their autonomy and asking the person to pull the lever for them.

So, it’s more like this, where the trolley continuing straight and then around the loop represents 12 months of suffering, and the diversion represents a shorter time-frame of the patient’s choosing:

This is an extreme simplification of a practice that involves significant moral gravity, and is in no way intended to detract from the seriousness of the issue. Nonetheless, if we respect this patient’s right to autonomy over their body and life and if we accept that they are probably going to die within a year or so anyway, then it seems the right thing to do to pull the lever and divert the trolley to the shorter track.

Importantly, this illustration also shows that objections to voluntary assisted dying all boil down to reasons why it’s never OK to pull the lever, even if the person tied to the track is going to get run over at some stage anyway. I’m not convinced by any of these arguments but some of them do highlight the need for certain safeguards.


I’m not going to seriously entertain objections grounded in religious prohibitions on taking one’s own life, because that life belongs to God and no one else. This justification simply isn’t appropriate in a modern pluralistic society (though I’m sure it’s behind much of the campaign against this legislation).


Nor do I have much truck with the idea that it is never okay to end a human life. Unless you are a total pacifist (which I do respect), you will have at least one exception to that rule.

Somewhat less well thought out is NSW Opposition Leader Luke Foley’s protest that he would never support "the state sanctioning the taking of human life".

I gather that Mr Foley now thinks that Man Haron Monis should not have been shot dead during the Lindt Café siege — which makes his push to change NSW shoot-to-kill laws somewhat mysterious.


Despite some physicians’ concerns, I don’t think there is any serious suggestion they could be forced to participate in voluntary assisted dying, especially given that the legislation in both states guards against this.

That said, if we are going to respect autonomy, it seems fair that doctors not be compelled to undertake these activities against their will. If we allow doctors the choice to not prescribe contraception, we aren’t going to make them do this.


Related to this is the notion that such legislation changes doctors from life savers to life-takers. This is wrong for two reasons.

For one thing, doctors in palliative care already sometimes medicate their patients in a way that inadvertently shortens their life at the very end — although they also argue that this does not constitute euthanasia. From this perspective, maybe the change is not as radical as certain lobbyists would have you believe.

Secondly and more importantly, with voluntary assisted dying it’s not the doctor that ends a life — it’s the patient themselves.


Some doctors have expressed a concern that it is too difficult to ensure that terminally ill patients are, in fact, freely choosing to hasten their end — a concern echoed by Gladys Berejiklian. 

Again, both bills emphasis the need to ensure that patients are of sound mind and that they are not being coerced; this would come under the duty of care that both doctors and psychologists involved in such cases would have to satisfy. If we accept it’s possible to asses someone as being free enough from coercion to refuse treatment or sign a do not resuscitate order, then while such concerns are a reason to be very careful, they aren’t a reason to say no.


Once the lever is pulled under one set of conditions, it becomes increasingly likely to be pulled under a broader range of circumstances — or so slippery slope arguments would tell us.

In other words, if we allow terminally-ill adults the right to request assistance in dying, this leads to a chain of events where all sorts of other activities somehow become inevitable, or at least more probable. These include involuntary euthanasia, where a life is medically ended against the wishes of the patient. An extreme version of this argument even points to euthanasia as leading to the Holocaust.

Is this right though? Logically, it can only be inevitable if each step in the chain from voluntary assisted dying to the nightmare scenario is inevitable. This seems unlikely, given that government sanctioned involuntary euthanasia and ethnic cleansing have yet to break out in places that allow this, such as the Netherlands. Not to mention the fact that the Nazi euthanasia regime was always about eugenics, not relief from suffering.

A weaker version of this argument is that voluntary assisted dying will lead to a chain of events that make involuntary euthanasia more psychologically acceptable. To be remotely plausible, this would require that people are unable to distinguish between reality and these hypothetical undesirable end-points. I’m sure I could tell the difference between the highly regulated and proscriptive plans suggested in these bills, and people being killed against their wishes.


Outside of academic philosophy, moral arguments against voluntary assisted dying that don’t rely on anything covered above are rare. There’s good reason for this.

These arguments are complicated and they don’t really work. Kant, for example, argues that our highest duty as humans is to freely choose to do moral things. Since people can’t do good things if they choose to remove this capacity by ending their life, choosing to die sooner is wrong. We might accept that we should be good while we are alive. The problem is that Kant seems to imply we should try to live as long as possible. To cut a long story short, this contradicts his idea that it’s a very good thing to fight and die for one’s country. So even one of the greatest philosophers of all time doesn’t provide a knockout argument against this.

Where does all this leave our various state MPs in deciding how to vote? If you are one of these MPs, or are thinking of contacting them to encourage them to vote either way, let me leave you with the following.

Look at the second trolley picture again: The person suffering on the tracks isn’t just one patient — it’s every patient in NSW and Victoria who would end their lives with dignity, if only they could. The person at the lever isn’t a couple of doctors, it’s the MPs voting against this, along with the churches and lobbyists urging them to do so. Every moment of suffering, indignity and fear that goes on longer than a terminally-ill patient would prefer is on them.

That trolley is coming for all of us eventually, we should have the right to have some small measure of control over when and how it does so.

You can follow Dr Samuel Douglas on Twitter @BeachPhilsophy.

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