Keywords: assisted dying, ethics, trolley problem, death egalitarianism, altruistic assisted dying, global life expectancy

Introduction

Halloween, All Souls’ Day, Samhain, and the Mexican Day of the Dead are fast approaching. It’s an appropriate time, therefore, to reflect on death in general and our own individual mortality. This is my take on it from an effective altruist viewpoint.

According to a report on the international legal situation concerning assisted dying, published in 2024 by the Swedish National Council on Medical Ethics (Smer) (1), assisted dying is legal in 15 countries, nine of them European. And an assisted dying bill is currently making its way through the UK parliament, which, if successful, would take the total to sixteen. Though 15 out of 195 recognised countries in the world is a very small percentage (0.077%), the upward trend is not neglible, and may accelerate.

The report frames the assisted dying debate as follows:

“Although assisted dying is one of the oldest debates in medical ethics it is now more topical than ever. This is so largely because of an inherently positive development, namely our improved capacity to cure and alleviate medical conditions, which in turn is part of the explanation we now enjoy longer lives than previous generations did. However, a downside to our longevity is that dying too has become more protracted. In a developed country, people tend to die in hospitals, hospices, care homes and other healthcare facilities. Compared to in the past, death nowadays does not come quite as often in the form of a sudden unforeseen incident or as the end of an inevitable course of events. more often, death now comes as something enmeshed with a string of medical decisions and balancing of various factors, the precise timing of which largely depends on these decisions and factors. Death and dying are thus becoming matters in which ethics is playing a bigger role precisely because we have much more control over death and dying than before. Consequently, it is of importance that we think about and discuss how we want to die, and what kind of death we are prepared to furnish for others.”

Note that the authors of this report state that it is important to discuss how we want to die, but the option of making an individual, positive choice as to when we want to die is not mentioned. The possibility that someone may wish to consciously limit their lifespan for altruistic reasons, for the greater good of humanity - indeed, of all life on Earth - is not yet on anyone’s radar. I’m going to try and illuminate a little of that blind spot.

Background: The Trolley Problem

The arguments I present here can be viewed as a restatement of the trolley problem thought experiment on a larger scale, and from a slightly different perspective. In one variation of the classical case, an onlooker has the choice to save five old people in danger of being hit by a trolley, by diverting the trolley to kill just two people, a young mother and her baby.

Here, the trade off is between number of lives saved, in which case five lives would be more valuable than two, or value of lives saved, in which it could be argued that the lives of five old people, who have already experienced their fair share of life, should be considered of less value than that of a baby, which has barely started in life, and a mother, plus the lives of her potential future children.

The altruistic assisted dying case can be seen as a variant on the trolley problem in which the five older people are waving to the onlooker in control of the trolley and shouting, “Here! Over here!”

Global vs. Individual Life Expectancy - A Personal Comparison

The website ‘World Life Expectancy 1950-2024’ (2) states that the current world average life expectancy in 2024 is 73.33 years, a 0.23% increase from 2023. Right now, on October 26 2024, I myself am 65 years, 8 months, and 23 days old, i.e. 10 days short of 65.75.

This means that I have about 7 years and 7 months to go before I reach the current average lifespan of a human being on Earth. My actual life expectancy, according to several calculators, including one based on nine blood test values and an extrapolation of these to telomere length, which is considered pretty accurate, is around 92 years. That means that I can expect to live for another 26.25 years, which is 18.67 years longer than the average human.

Let's allow that to sink in a little.

I am expected to live more than 18 years longer than the average human on this planet. I have already, as a person living in the developed world, consumed more of the planet’s resources than the average global citizen, regardless of my attempts to live lightly upon the Earth. And in my final years, according to the 2024 paper, ‘End-of-life expenditure on health care for the older population: a scoping review’, I will consume disproportionately more resources (3):

“People close to death constitute a small part of populations, but health care expenditure on them is usually disproportionately high and this is especially the case for the population of older people. For example, Gastaldi-Menager et al. assessed that in France, decedents represent annually 3.5% of the group aged 65, but they account for 10.3% of total health expenditure on this group [1]; Medicare spending on decedents in the US was estimated to be 21%, 22%, or even 27.4% of total yearly spending ([2,3,4] respectively). Naturally, the highest number of deaths is observed among the older population: in Europe in 2019 over 75% of deaths concerned people aged 65 and over [5].

Population ageing is a universal phenomenon around the world. According to the UN World Population Prospect, the share of the population aged 65 and over in the world will increase by about 6.5% points (to 15.9%) in the next 30 years to rover 1.5 billion people [6]. The growth of the older population and its share of the total will be observed in all countries, without any exception. Taking into account the growing number of older people, health expenditure analyses in this population group are becoming more and more important for adequate health policy decisions.

The existing evidence shows that the pattern of health expenditure differs considerably between people at the end of life (EoL) and people in other periods of their lives. Expenditure usually increases rapidly in the time close to death; consequently decedents’ expenditure is much higher than survivors’ (e.g. [7, 8]). The awareness of these differences, combined with detailed analysis of future mortality rates is one of the key pieces of information needed for health spending prognoses.”

But why should all this money be spent in extending my life, the life of a person in a developed country, with an advanced health system, when those resources could be better spent saving the lives and improving the health outcomes of children in developing countries? Admittedly, there is as yet no mechanism for transferring those resources directly, should someone make this moral choice to limit their lifespan to that of the average as a form of egalitarianism - death egalitarianism. But, given the welcome decline in birth rates, which will reduce the burden of humanity on ecosystems but is leading to a higher burden of care upon the younger generation, is it not a moral choice that effective altruists should at least consider?

Currently, the assisted dying debate assumes that everyone will want to live as long as they possibly can but only want to end it when the quality of life due to illness and pain makes life no longer liveable. The possibility of ending your life earlier voluntarily on altruistic grounds for the sake of future generations - and the desire not to consume Earth's resources disproportionately in a time of climate breakdown and ecological crisis - is not being considered. Though perhaps it should. It deserves emphasising, of course, that in no way should anyone be coerced to end their lives earlier for the good of others. The question is one of individual moral values and choices.

One could furthermore differentiate between strong death egalitarianism, whereby one decides to limit one’s lifespan exactly to the global average; balanced or medium-strength death egalitarianism, taking the midpoint between one’s own life expectancy and average human life expectancy; and weak death egalitarianism, choosing to end one's life one or two of five years, say, before the expected end. Theoretically, one could negotiate a win-win situation with healthcare providers, in which they get to keep 50% of the expected cost savings and you get to donate the other 50% to save the lives of children in developing countries.

Theory vs. Practice

Of course, I’m not at all sure if I could actually go through with this and end my life prematurely on these altruistic grounds. It’s a natural impulse to want to cling on to life by one’s fingernails to the bitter end.

Also, my partner was horrified when I tried to persuade her this morning of the moral argument for altruistic assisted dying. “You’re not leaving me!” she shouted. At which point I retreated into the safe haven of moral abstraction, stuttering something about ‘thought experiment’ and ‘the trolley problem’. Mollified, she grudgingly conceded part of the argument. At which point we collapsed into a laughing fit together. (A typical scene from our marriage.) Afterwards, she even provided the illustration for this post.

As always, your comments are welcomed. Sacrificing a part of one’s own life for the sake of others is a whole different ball game to donating a few dollars to buy bed nets, is it not? I’ve started the countdown on my own decision, anyhow, and will let you know in 7 years and 7 months time whether I chickened out and/or conceded defeat to my loved one.

References

(1) Assisted Dying: An International Survey, A report from the Swedish National Council on Medical Ethics (Smer), July 2024: https://smer.se/wp-content/uploads/2024/09/smer-2024_4_eng_web.pdf

(2) World Life Expectancy 1950-2024 | MacroTrends: https://www.macrotrends.net/global-metrics/countries/WLD/world/life-expectancy

(3) End-of-life expenditure on health care for the older population: a scoping review - Health Economics Review https://healtheconomicsreview.biomedcentral.com/articles/10.1186/s13561-024-00493-8