Assisted Dying and the Right to Choose: A Moment for Agency and Ethical Reflection
The debate over the Assisted Dying Bill in the Scottish Parliament feels like one of those rare political moments where the outcome is genuinely uncertain. There’s a sense of moral weight to it—stories of deep suffering, reflections on dignity, and questions about what it means to live, and indeed to die, with agency and choice. It’s not neat, and it’s not easy, and perhaps that is exactly why it matters. It’s a free vote, so party politics as usual is suspended.
Listening to the arguments being made in the chamber unfold as I write this, I’m struck by the profound moral questions being asked, not only of politicians but of society itself. Can the choice to die be a form of self-actualisation? How do we safeguard the vulnerable from coercion? What role might therapy play when the conversation shifts from preventing death to supporting choice? I’m also struck by the difference that it is making to the conversation to have inputs from elected members who have disabilities, who have experience of navigating inadequate systems that test their ability to live in this world with dignity.
Rogers' Actualising Tendency: A Radical Reframe?
Carl Rogers, the founder of Person-Centred Therapy, grounded his approach in the belief that every person has an actualising tendency—an inherent drive towards growth, self-understanding, and fulfilment. For Rogers, this drive is not externally defined; it is deeply personal, emerging from the individual's subjective experience.
The debate around assisted dying invites a radical question: Could the choice to end one’s suffering be an act of self-actualisation? Traditionally, actualisation is associated with life-enhancing growth—pursuing purpose, deepening relationships, and realising one’s potential. Yet, if we take Rogers’ perspective seriously—that actualisation is about congruence with one’s own experience—then choosing to end life under certain conditions may be seen as an expression of autonomy and authenticity.
For someone facing irreversible suffering, the decision to die may not reflect a rejection of life but rather an alignment with their own sense of dignity and self-understanding. “My only choice is suffer or die…and I don’t want to suffer.” In that sense, it could be argued that the choice to die might emerge from the same actualising drive that compels others to seek meaningful existence.
New Ethical Considerations: Coercion and Vulnerability
Of course, this is not without complexity. The potential for coercion—whether overt or subtle—is significant. During the Parliamentary debate, the issue of coercion has been raised repeatedly. Critics of assisted dying argue that legalisation might open the door to subtle pressures on vulnerable people—those who may feel they are a burden, those who lack financial resources, or those whose social networks communicate, intentionally or not, that their suffering is inconvenient.
The current frameworks in countries where assisted dying is legal, like Belgium, the Netherlands, and parts of the United States, have attempted to address this. They include:
Capacity Assessments: Designed to ensure that the person requesting assisted dying is doing so without impairment to their judgement.
Cooling-Off Periods: To allow for reflection and the opportunity to change one’s mind.
Third-Party Reviews: Independent verification to explore the presence of coercion or external pressure.
These are structural safeguards, but what about the therapeutic space? For Person-Centred practitioners, there are layered considerations:
How do we explore the locus of evaluation—whether the person’s decision is emerging from their own internal sense of self, or influenced by external pressures?
How do we recognise conditions of worth that might be subtly influencing someone’s perception of their own dignity or burden?
How do we remain fully present with unconditional positive regard when the person’s sense of self-actualisation involves ending their life?
From Safeguarding to Signposting?
If the law changes, the landscape for therapists may shift. Right now, conversations about ending one’s life are framed almost entirely within safeguarding—intervention, protection, and prevention. This is familiar territory for me. I have these conversations with people who are reflecting on death—their own death, and sometimes the belief that others around them would be better off if they were gone. These moments are raw and challenging, and they often surface out of deep emotional pain.
There is a distinct difference, however, when someone discloses that they have a plan and a timeframe. In those instances, I’m transparent from the outset: if that is shared with me, we are going to slow right down. We pause the counselling process and move into safeguarding. I tell people that clearly before we get together—and so, when they do share, I understand that they are telling me for a reason. It’s an act of trust, even if it’s a call for intervention.
If assisted dying becomes legal, this boundary may blur. Rather than intervening to prevent death in all cases, therapists might instead find themselves supporting people in navigating their decision, offering support as they navigate what this means for them.
This is where Person-Centred principles are truly tested. Rogers’ core conditions—empathy, congruence, and unconditional positive regard—demand that we meet the person exactly where they are, even if that place is one of preparing for death. It is not about leading or persuading; it is about being with. And yet, the risk of coercion remains ever-present, especially for those who may feel like their suffering is a burden on others.
For those countries where assisted dying is legal, such as Belgium and the Netherlands and parts of the United States, there are structured safeguards designed to prevent coercion and ensure true autonomy:
Capacity Assessments: Multiple physicians assess mental capacity to ensure decisions are not driven by untreated mental illness.
Cooling-Off Periods: In places like Oregon, there is a waiting period between the request and the administration of life-ending medication, designed to allow for reflection and reconsideration.
Third-Party Reviews: Independent reviews are sometimes required to explore the presence of coercion or external pressure.
These measures are not perfect, and they don’t eliminate the possibility of external influence. However, they represent attempts to balance autonomy with protection. If Scotland legalises assisted dying, these types of protections would need to be robust—not just to protect individuals, but to preserve the integrity of the choice itself. A choice made under pressure is not a choice at all.
The Person-Centred Challenge: Staying With the Process
If Person-Centred Therapy is about anything, it is about trust in the individual’s capacity for self-determination. It is about holding space for the person to explore their experience without judgment, without agenda, and without conditions. And yet, assisted dying introduces a new frontier for that trust—one that asks us to hold space for choices that are final and irreversible.
For practitioners, this may mean grappling with our own sense of what is actualising and what is despair. It means exploring what dignity, agency, and burden mean to the person we are working with, without imposing our own conditions of worth onto their decision.