Trauma and Neurodivergent Coach

Who Gets to Decide Whether a Life Is Still Worth Living?

The debate over assisted dying becomes particularly difficult when the person asking to die is not terminally ill.

What if someone has severe depression, chronic psychiatric illness, profound psychological suffering, autism, chronic pain or another non-terminal condition—and has reached the conclusion that they no longer want to continue living?

There is an understandable instinct to say:

"We must save them. Their desire to die is a symptom of their illness."

Sometimes that is absolutely the right response. A person experiencing an acute suicidal crisis may be overwhelmed, impulsive, intoxicated, psychotic, severely depressed or temporarily unable to see alternatives that would otherwise be meaningful to them.

But there is another possibility that deserves to be taken seriously.

What if the person has been suffering for years?

What if they have asked for help repeatedly?

What if they have tried medication, psychotherapy, hospitalisation, rehabilitation, alternative treatments and every intervention reasonably available to them?

What if their family, friends, doctors and society have genuinely tried to help?

What if they have been given opportunities to change their circumstances—and nothing meaningfully changes?

And what if, after all of that, a competent adult says:

"I know what my life is like. I know what the alternatives are. I know that you want me to continue living. But I have decided that I do not want to continue."

At that point, the ethical question becomes much harder.

Because who ultimately owns the decision about whether someone else's life is worth continuing?

Autonomy cannot only apply when we agree with the decision

We generally consider bodily autonomy a fundamental principle in medicine.

Competent adults can refuse treatment even when doctors strongly disagree.

A person can refuse chemotherapy.

They can refuse surgery.

They can refuse dialysis.

They can decline ventilation.

They can choose palliative care rather than an intervention that might prolong their life.

And in many circumstances, they are allowed to make these decisions even when clinicians believe the decision is unwise.

Why?

Because the person is the one who has to live with the consequences.

Their body is theirs.

Their life is theirs.

Their experience of suffering is theirs.

This creates a difficult question for assisted dying:

Why should autonomy suddenly disappear when the decision a person makes is to end their life rather than refuse a treatment?

There are important reasons to treat the two situations differently. Death is irreversible, and a wish to die can sometimes be a symptom of an illness that is itself treatable.

But those considerations do not automatically establish that the person's wishes are invalid.

They establish that we should take great care in determining whether the decision is autonomous.

That is different from assuming that it isn't.

Mental illness does not automatically make someone incapable of deciding

One of the most uncomfortable assumptions in this debate is that a psychiatric diagnosis somehow invalidates a person's judgment.

But mental illness exists on an enormous spectrum.

A person can have depression and still understand:

A psychiatric diagnosis does not automatically eliminate decision-making capacity.

Indeed, if we automatically treated every desire expressed by a person with a psychiatric diagnosis as invalid, we would be taking away their autonomy in countless areas of life.

We would not accept:

"You have depression, therefore you cannot decide whether to have surgery."

We would assess their capacity for that particular decision.

The same principle deserves consideration here.

The relevant question should not simply be "Does this person have a mental illness?"

It should be:

"Does this person have the capacity to make this particular decision?"

What if they have tried everything?

This is where the argument becomes particularly difficult.

Imagine someone who has lived with severe psychiatric suffering for twenty years.

They have tried:

Perhaps their family has spent years supporting them.

Perhaps friends have repeatedly intervened.

Perhaps the healthcare system has genuinely tried to help.

Perhaps society has provided disability support, housing assistance, financial assistance and other resources.

And despite all of this, the person's suffering remains unbearable.

At some point, continuing to say:

"You haven't tried enough"

can become its own form of cruelty.

There will always theoretically be another possibility.

Another medication.

Another therapy.

Another doctor.

Another treatment being developed.

Another lifestyle change.

Another year.

But human beings do not live in the realm of theoretical possibilities.

They live in actual circumstances.

And if someone has spent decades trying to make their life bearable, we should be cautious about assuming that the next intervention will finally fix everything.

"But what if they recover?"

This is one of the strongest arguments against assisted dying in psychiatric cases.

Mental states can change.

A person who wants to die today may genuinely be grateful to be alive five years from now.

That possibility cannot simply be dismissed.

But there is a corresponding problem.

If we say:

"You might change your mind someday,"

we are effectively asking the person to sacrifice their present autonomy for the possibility that a future version of themselves may want something different.

We don't normally apply that principle everywhere else.

Adults are allowed to make decisions that their future selves might regret.

People can leave relationships.

Move countries.

Refuse treatment.

Have children.

Decline fertility treatment.

Make financial decisions that dramatically affect their future.

We accept this because autonomy includes the right to make decisions that carry risks and consequences.

The fact that someone might change their mind does not automatically mean their current decision is invalid.

The question is whether they are making the decision freely, competently and with adequate information.

There is a crucial difference between "I want to die" and "I want this suffering to end"

This distinction is important, but it should not be used to erase the person's autonomy.

Someone saying:

"I want to die"

may indeed be communicating:

"I want the pain to stop."

If the pain is treatable, we should absolutely offer treatment.

But suppose the person responds:

"I know. I've spent twenty years trying to make the pain stop. I've tried everything available to me. This is still my life, and I have decided that I no longer want it."

At that point, continuing to insist:

"No, you don't really want to die—you just want the suffering to stop"

can become presumptuous.

The person may know the distinction better than anyone else.

They are the person experiencing the suffering.

The danger of turning hope into an obligation

Hope is valuable.

But hope can become coercive when it is imposed on someone.

We sometimes tell people:

"You never know what tomorrow might bring."

And that is true.

But it doesn't necessarily answer the ethical question.

Someone who has suffered for decades may reasonably respond:

"I know tomorrow might be different. I've heard that for twenty years. I am making my decision based on the life I have actually experienced."

We should be careful not to turn the possibility of improvement into an obligation to remain alive indefinitely.

There is a profound difference between offering hope and requiring hope.

What about autism?

Autism makes this discussion particularly sensitive.

Autistic people should never be considered appropriate candidates for assisted dying simply because they are autistic.

Autism is not synonymous with suffering.

Nor does autism mean that a person lacks capacity to make decisions.

But autistic people can experience profound suffering.

Sometimes this comes from co-occurring psychiatric conditions.

Sometimes from chronic pain or other physical illness.

Sometimes from years of bullying, abuse, masking, isolation and misunderstanding.

Sometimes from environments that are profoundly incompatible with their needs.

And sometimes from combinations of all of these.

The appropriate response should therefore begin with a much more fundamental question:

What exactly is making this person's life unbearable?

If the answer is:

"I cannot survive because I have no sensory accommodations, no appropriate support, no accessible housing and no way to live according to my needs,"

then society has a responsibility to address those conditions.

It would be profoundly disturbing if assisted dying became easier to obtain than the support necessary to live.

But imagine the opposite situation.

An autistic adult has received appropriate accommodations.

They have access to healthcare and social support.

They have been treated for co-occurring psychiatric conditions.

They have been given opportunities to build a life compatible with their needs.

They have had time to consider their decision.

They understand the alternatives.

They consistently say:

"I have considered all of this, and I still do not want to live."

At that point, autism itself should not be used as a reason to assume that the person does not know their own mind.

The danger of confusing protection with paternalism

Protecting vulnerable people is an essential function of society.

But protection can become paternalism when we stop listening to the person we claim to be protecting.

There is a difference between:

"We want to make sure nobody is pressured into dying."

and:

"We don't believe you are capable of deciding whether your own suffering is worth continuing."

The first is a legitimate safeguard.

The second requires much stronger justification.

A person should not have to prove that their life is objectively unbearable according to somebody else's standards.

They experience their life.

They know what their suffering feels like.

They are the one who would have to continue living it.

But autonomy requires real alternatives

This is where the strongest argument against assisted dying becomes particularly important.

A choice is not genuinely autonomous if someone is choosing death because every alternative has been systematically denied to them.

If an autistic person wants to die because they cannot obtain basic support, society should not respond:

"Then you can choose assisted dying."

It should respond:

"Let's make sure you have the support necessary to make living a genuinely available option."

The same applies to someone whose desire to die is driven by:

Autonomy requires options.

A person cannot meaningfully choose between life and death if society has made a decent life inaccessible.

So what would meaningful safeguards look like?

If assisted dying is to be available to people with mental illness or non-terminal conditions, safeguards should not be designed around the assumption that the person's choice is wrong.

They should be designed to answer a different question:

Is this genuinely their choice?

That means carefully assessing:

Capacity

Can the person understand and reason about the decision?

Persistence

Has the wish remained stable over time rather than appearing during a transient crisis?

Voluntariness

Are they free from direct or indirect pressure?

Information

Do they understand their diagnosis, prognosis and available alternatives?

Treatment

Have reasonable treatments actually been offered and made accessible?

Support

Have disability, social, financial and environmental factors been addressed?

Alternatives

Is the person choosing death because there genuinely are no acceptable alternatives for them—or because society has failed to provide those alternatives?

Consistency

Does the person's decision remain stable when the acute crisis has passed?

These safeguards don't have to mean:

"We will keep trying to convince you to live until you give up."

They can mean:

"We will make absolutely certain that this is your decision, rather than a decision imposed by illness, coercion or deprivation."

The question society ultimately has to answer

The debate is often framed as:

"Do people have a right to die?"

I think the more difficult and meaningful question is:

"Who should have the final authority over whether a person's life must continue?"

If a person lacks decision-making capacity, society has a legitimate reason to intervene.

If someone is being coerced, society has a responsibility to protect them.

If someone is experiencing an acute, potentially reversible crisis, creating time and safety may be the most compassionate response.

If someone is suffering because they cannot access basic healthcare or disability support, society has an obligation to address those failures.

But what about the person who does have capacity, who has been informed, who has been supported, who has tried repeatedly to improve their circumstances, who has had access to treatment, who has considered alternatives, and who has persistently concluded that they do not want to continue living?

At some point, continuing to say:

"We know what's better for you than you do"

becomes difficult to reconcile with the principle of autonomy.

We may disagree with their decision.

We may desperately wish they would choose differently.

We may find their decision heartbreaking.

But disagreement is not the same thing as incapacity.

Taking suffering seriously also means taking the person seriously

There is a danger on both sides of this debate.

One danger is giving up on people too quickly:

"You're suffering, so perhaps death is the answer."

The other is refusing to accept someone's experience of suffering because we desperately want them to live:

"You can't really mean that. There must be something we haven't tried."

Both approaches can fail to listen.

A genuinely autonomy-centred approach would do something harder.

It would say:

"I don't want you to die. I want to help you find a life you can genuinely choose. I will do everything reasonable to make that life possible. But I also recognise that your life ultimately belongs to you, and I cannot simply assume that my desire for you to continue living gives me ownership over your decision."

That does not make assisted dying simple.

It does not mean every request should be granted.

It does not mean suicide prevention is unnecessary.

And it certainly does not mean that every expression of suicidal thinking represents an autonomous decision to die.

It means something more fundamental:

A person should not lose their autonomy simply because their suffering makes other people uncomfortable.

If society is going to override someone's decision about their own life, it should be able to explain not merely why it disagrees with them, but why it has compelling reason to believe that the decision is not genuinely theirs to make.

And if we are going to permit assisted dying, the same principle should apply in the opposite direction:

We should make absolutely certain that the person is choosing death—not because they were abandoned, unsupported, coerced or convinced that their life was a burden, but because, having been given a genuine opportunity to choose another path, they have freely and persistently decided that this is what they want.

That is where the hardest ethical question lies.

Not simply in whether suffering is physical or psychological.

Not simply in whether someone is terminally ill.

But in how seriously we are prepared to take another human being's autonomy when their decision is one we profoundly wish they would not make.