Irresistible and immovable values

Ben Hoban is a GP in Exeter.

What happens when an irresistible force meets an immovable object? As a society, we want to be tough on crime, while also helping people whose variously disadvantaged and dysfunctional backgrounds make them more likely to offend. Similarly, we are waging war on disease and at the same time dealing with the consequences of overdiagnosis and health-related anxiety. We are caught between imperatives which should in theory be complementary, but tend to conflict with each other in practice: fix things, but look after people too.

The debate in the UK about assisted dying has broadened over the years, such that we are now discussing not just the principles involved, but also the practicalities: what would assisted dying look like in the National Health Service, especially in the context of the current attrition of general practice and palliative care services?^1-3 The thread that runs through the debate, however, seems to be a genuine desire on both sides to help people who are suffering, and the conflict between opposing views reflects not a greater or lesser degree of care, but rather the familiar tension between fixing things – dealing definitively with a problem – and looking after people, even though this may leave the problem unresolved.

Our culture places a significant premium on autonomy, the freedom of any individual to determine their own path in life without undue restrictions, even when their decisions seem unwise or detrimental to their own wellbeing. Terminal illness represents a slow bleeding-out of autonomy, a second childhood of dependence on others for the most basic elements of daily life, and the inability to end such a life at a time and in the manner of one’s choosing is perhaps the ultimate marker of this. The prior testimony of many patients who travelled to other jurisdictions and subsequently ended their lives legally is that they did this not because of the level of their suffering at the time, but because they would otherwise soon have lost the ability to take such action. The preservation of autonomy is our irresistible force.

Although we value autonomy, we also recognise its limits. These are largely determined by the point at which one person’s freedom starts to harm or burden other individuals or society as a whole, although this point, the boundary between private and public domains, is often indistinct or contested. Smoking and drinking are legal but restricted, for example, while most other forms of drug use are proscribed. An individual’s decision whether or not to be vaccinated against common pathogens affects not just their own risk of infection, but also the level of immunity within a population, and therefore the risk to others;  immunisation against Covid-19 was mandatory for health and social care workers during the pandemic, but not for the general public. The restriction of individual liberties for the benefit of society as a whole represents the social contract, which our prevalent norms of behaviour and legislation reflect, and to which all but the most committed hermits are signatories.

Our culture also places significant restrictions on the taking of life, and this is our immovable object. We have done away with capital punishment; revenge killings and vendettas are the preserve of criminal gangs; and even in warfare, we take pains to avoid harm to civilians and unnecessary violence against enemy combatants. Of all forms of killing, however, suicide holds a special horror for us, such that the merest thought of it is for many patients the reason they seek professional help, and its legacy is a distinctive bereavement laced with guilt and regret.

We are by nature social beings, inhabiting a social medium to which we all contribute, and on which we all rely.  Regardless of whether we know one another, and however indirectly, I can only be who I am because you are also who you are. We are defined as much by the web of immediate and more distant connections within which we exist as by our personal characteristics, and killing of any kind is therefore not just a negation of the individual, but also of those connections, a tearing of the fabric of which all our lives are woven.

Is it feasible, then, for the assistance of suicide to be an act of kindness, and for doctors to participate in it? Trying to help someone end their suffering when death is already fast approaching cannot help but seem reasonable when framed in these terms. We should consider, though, that suffering takes place over the whole course of a life rather than exclusively at its end, and that many people have little autonomy at any point in their lives: do the needs of the dying really diverge so far from those of the living that we are warranted in taking such a radically different approach to them? In our shared world, we can never be fully independent of each other, and the consequences of our actions often go further than we realise. Rewriting the social contract to promote the freedom of the private over the social self in terminal illness necessarily affects the equilibrium of society as a whole, as well as the decision-making of other individuals, including those whose freedoms are already limited by disability or adverse circumstances.

The existence of an irresistible force logically excludes the possibility of an immovable object, and vice versa: a single universe cannot contain both. Neither our respect for personal autonomy nor our taboo against killing represent absolute values, although it is clear in the context of assisted dying that we can only uphold one or the other entirely. We are all committed as doctors to relieving suffering, and yet we also accept on a daily basis that there are many things which we cannot fix, not just because we lack the means, but because the harms associated with them sometimes outweigh the benefits. We can nevertheless still look after people, even when they ask us to help them die, and even if we decide that on balance we cannot.

References

1. Lawson E, Papanikitas A. GPs and assisted dying. _Br J Gen Pract_ 2025; DOI: https://doi.org/10.3399/bjgp25X740409
2. Everington SS. The assisted dying debate: supporting GPs in a changing landscape. Br J Gen Pract. 2024 Feb 29;74(740):106-107. doi: 10.3399/bjgp24X736485. PMID: 39222413; PMCID: PMC10904124
3. Lamb L, Crossing the rubicon, assisted dying in general practice, BJGP Life, 4th January 2025, https://bjgplife.com/crossing-the-rubicon-assisted-dying-in-general-practice/ [accessed 6/1/25]

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