CHAPTER 4

THE RIGHT-TO-DIE MOVEMENT AND ITS ABLEIST/SANIST/AGEIST/SUICIDIST ONTOLOGY OF ASSISTED SUICIDE

Well, honestly, I feel like a freak. And that’s very difficult to live with. To be confronted with it [referring to his “unsuccessful” phalloplasty] every time you go to the toilet, every time you wash yourself in the morning, that’s just too much. [ . . . ] If you, being a man, have to put a sanitary towel in your pants because you are leaking, I don’t think most of the men would like that. The game is over now. Some people will think: “Nathan is a quitter.” Okay, maybe that’s true. But nobody feels what I feel. Nobody knows what I feel. And how hard I fight. [ . . . ] If you suffer every day, if you feel pain every day, if you die from sorrow all the time, well I think none can live that way. I decide about my own life. Nobody has to respect my decision [about euthanasia]. If they do, that’s fine. If they don’t, that’s alright too. [ . . . ] I contacted the LEIF-team before my operation already. I made it clear to them that I wanted to have the possibility to make all the necessary arrangements in case the operation would fail. And end my life in a dignified way. It has been a hard fight several times. I had enough medication in store. I could have made the perfect cocktail. [ . . . ] But my psychologist said: “Aren’t you afraid you’ll survive if you try to do it yourself?” And I thought: I have the advantage, I live alone. Nobody has a key of my apartment. I would have never warned anyone.

—NATHAN VERHELST, in an interview in Nathan, Free as a Bird by Roel Nollet

IN 2013, following what the international press described as a “failed sex-change operation” (Hamilton 2013) that turned him into a “monster” and a “freak” (according to his own words), in a quest to end years of physical and psychological suffering, forty-four-year-old Nathan Verhelst decided to resort to assisted suicide, commonly known as euthanasia in Belgium. Belgium allows people who experience unbearable suffering, be it physical or psychological, to be assisted in their death, even if they are not terminally ill (Cohen-Almagor 2016). Having lived through a traumatic childhood that included psychological abuse by his mother and sexual assaults by his brothers, Verhelst was already dealing with a long history of depression and suicidality even before the “failures” of some of the medical treatments related to his transition, which were then used as justifications to end his life (Hamilton 2013). While illustrating one person’s unique experience, the testimonial from the documentary Nathan, Free as a Bird (Nollet 2014) in the epigraph nonetheless brings together all the themes discussed in this book thus far—namely, heterosexist and cisgenderist social expectations, transness, physical disability, mental disability/madness, emotional suffering, suicide, and assisted suicide. Verhelst’s words reveal the porousness and entanglements of these themes, too often thought about in silos.

Verhelst embodied a set of contradictory and paradoxical discourses, according to which some identities, bodies, and practices are considered (ab)normal, (il)legitimate, (in)valid, and (un)acceptable. Indeed, a man whose body and genitals do not correspond to the dominant cisnormative and heteronormative standards, whose bodily functions are impaired (e.g., incontinence), and whose mental/emotional health is unstable is, from cisgenderist, heterosexist, ableist, and sanist perspectives, an abject subject for whom life does not seem worth living. In other words, from those dominant perspectives, failing to meet sexual and gender norms, being incontinent, and struggling with mental health issues can alter the quality of life to the point of justifying assisted suicide. Like all of us, Verhelst had most likely internalized these dominant discourses, as before his death he referred to himself as less than human—a “monster” and a “freak.” In that sense, Verhelst reproduces instead of subverts these ideologies and oppressive structures. At the same time, his transition represents a form of resistance against his sex assigned at birth and the cisnormative structures that would have confined him to an identity/body in which he did not feel comfortable. Similarly, the legitimacy Verhelst gives to emotional suffering, through the credibility he attributes to first-person accounts (“But nobody feels what I feel”), highlights the value of Mad people’s desubjugated knowledge (Foucault 1994) and represents a claim to epistemic and testimonial justice. Furthermore, his request for assisted suicide because of psychological suffering offers an alternative reading of sanist narratives in which people experiencing significant mental/emotional distress are denied mental competence and hence the ability to decide to end their lives. While anchored in an individualistic point of view and without claiming rights for suicidal people as an oppressed group, in his last words, Verhelst nevertheless unravels a set of preconceived ideas and prejudices about mental health, assisted suicide, and suicidal people, such as the stereotypes that they are weak, cowards, or quitters. Through his testimonial, Verhelst helps us recognize what too often remains unintelligible in society and in social movements: Suicide may be a viable option for some people, and suicides will still occur, no matter how much surveillance and control are exercised over suicidal people, and no matter how hard social movements fight for social justice. Indeed, Verhelst was so determined to die that had the option of euthanasia been unavailable, he would have kept his plans secret so as not to have them thwarted. While some people might interpret his assisted death as the crystallization of a culture of disposability, founded on heterosexism, cisgenderism, ableism, and sanism, and would have done anything to prevent it, I believe that Verhelst sought to be respected for his needs and decisions rather than “fixed” or forced to change his mind. Although I critique the crucial role of oppressive systems in people’s decisions to seek assisted suicide and in the ways in which some are granted access to assisted suicide and others not, the role those oppressions play does not constitute, in my opinion, a reason to invalidate Verhelst’s agency and testimonial. As I demonstrate later, while the right to die through assisted suicide rests on extremely problematic foundations, Verhelst’s ability to access assisted suicide allowed him, as we see in the documentary, a peaceful death, surrounded by those he loved and with the proper time to prepare this last phase of life. His story is a powerful testimonial from which to analyze assisted suicide and the conditions under which it is perceived as (il)legitimate.

As explored in Chapter 3, suicidology and critical suicidology rarely discuss assisted suicide and the right to die. In these fields, the question of suicidality seems disconnected from discussions on assisted suicide, which are relegated to other fields of study and to the realm of disabled/sick/ill/Mad people, who are themselves distinguished from suicidal people. In recent literature, such as the second edition of Suicide: An Unnecessary Death (Wasserman 2016), which has thirty-six chapters on a variety of topics related to suicidality; the second edition of The International Handbook of Suicide Prevention (O’Connor and Pirkis 2016), with forty-four chapters; and the two main edited volumes in critical suicidology (Button and Marsh 2020; White et al. 2016a), with eleven and thirteen chapters, respectively, not one chapter focuses on assisted suicide and the right to die. This fact is illuminating: In more than one hundred chapters in key volumes on suicidology and critical suicidology, not one addresses the question of the right to die. The discussions on assisted suicide are happening in disciplines other than (critical) suicidology and anti-oppressive social movements/fields of study, with the exception of the disability rights movement, which is often a vocal opponent to assisted suicide. Conversations about assisted suicide take place in the fields of philosophy and bioethics as well as in disciplines such as anthropology and sociology. However, in this philosophical, bioethical, and sociological literature, as well as in the right-to-die movement, the question of suicidality is often brushed aside and seen as a completely different topic.

Chapter 4 explores the right-to-die movement and discourses that support some forms of assisted suicide for some individuals. My goal here is not to provide an analysis of the abundant literature on this topic or a history of the right-to-die movement, since this work has already been done.¹ I am more interested in showing how the potential of the right-to-die movement to support suicidal people is underdeveloped. As surprising as it sounds (since the first thing that comes to mind when hearing the expression right to die is support for anyone’s decision to die), the right-to-die movement has not only excluded suicidal people but also articulated discourses that represent somatechnologies of life that aim to keep suicidal people alive. Indeed, despite internal diversity, one of the common themes in right-to-die discourses is the distinction between legitimate assisted suicides, usually reserved for terminally ill or disabled/sick/ill people, and illegitimate suicides by supposedly “irrational” and “impulsive” suicidal people. While the former compose the foundation of the social, political, and legal battles of the right-to-die movement, the latter are cast as practices to be prevented. In other words, by focusing on the crucial distinction between legitimate assisted suicides and illegitimate suicides, right-to-die discourses represent very powerful soma-technologies of life; the basis to justify assisted dying is anchored in a fundamental exclusion of suicidality, suicidal people, and their needs. In the end, the right-to-die movement and its discourses paradoxically endorse the same suicidist preventionist script as the various models of suicidality discussed in Chapter 1. They also reproduce direct forms of suicidism toward suicidal people. In sum, while (critical) suicidology ignores debates surrounding assisted suicide, conversations about assisted suicide in philosophy, bioethics, and the right-to-die movement are focused on disabled/sick/ill assisted suicide and set aside the question of suicidality. These erasures seem to be one of the biggest paradoxes of these fields of study and make it difficult to think about assisted suicide from an intersectional and anti-oppressive approach.

Chapter 4 is divided into four sections. The first presents, from a critical perspective, the main arguments of the right-to-die movement, based on autonomy, liberty, self-determination, control over one’s body, dignity, and the right to refuse treatment.² This section also explores the controversial question of extending the right to die by assisted suicide to people whose sole reason for requesting it is mental or emotional suffering (mentally ill or Mad people). I demonstrate that regardless of whether right-to-die proponents approve of the extension of assisted suicide to people who are mentally ill, they adhere to an “ontology of assisted suicide” (Baril 2022). As I establish in the second section, this ontology is anchored in individualistic and neoliberal conceptualizations of assisted suicide as well as in ableist and sanist presumptions. In the third section, I examine suicidist presumptions in the right-to-die movement and discourses, in which suicidal people are cast as “irrational” and “illegitimate.” The decision-making capacity of suicidal people is denied based on ableist and sanist conceptualizations of competence and rationality. In the last section, I pursue the work initiated in Chapters 2 and 3 of queering, transing, cripping, and maddening suicidality by applying these perspectives to assisted suicide. In the spirit of disability/crip/Mad studies, I mobilize critical reflections pertaining to accommodation and accessibility to theorize the right to die. I believe that queering, transing, cripping, and maddening assisted suicide involve working toward the creation of real accessibility to assisted suicide for suicidal people, such as through suicide-affirmative health care. Contrary to right-to-die proponents who exclude suicidal people and promote assisted suicide from an individualist, ableist, sanist, and ageist (among other -ists) point of view, I present a conceptualization of the right to die based on an anti-oppressive approach, which recognizes the centrality of the ableism, sanism, ageism, and suicidism at play in the legitimization and delegitimization of some forms of death.

4.1. Right-to-Die Discourses as Somatechnologies of Life

In his text “A Complete Treatise on Rational Suicide,” philosopher Al Giwa aptly represents the position of most philosophers, bioethicists, and right-to-die activists regarding suicide: It is fundamentally an irrational act, except in a few marginal circumstances.³ Among the exceptional circumstances that may transform the irrationality of suicide into a rational act is being severely disabled, sick, ill (physically or mentally), or old. Giwa (2019, 118–119) writes:

Rational suicide is a subset of suicidality by people who possess medical decision-making capacity. These cases are sometimes argued in courts of law, where it is often determined that the autonomous actions by autonomous individuals are competent and rational. Those presenting in this fashion, are not the mentally distraught and often-times intoxicated persons who might be reacting to a recent or series of stressors in their lives, and clearly lack decision-making capacity or competence. This is not the impetuous patient who may be “acting emotional” and/or “seeking attention” after a recent break up [sic] from their significant other. Nor is it a person who suffers from a truly volitional or cognitive disorder. My arguments focus on those people who have acted in a competent and rational manner up until the point where they decided to end their lives. They may be suffering from an incurable ailment or have emotional and/or physical pain that no medication or therapy can control, or they may just feel that they have lived long enough and feel it is time to end their lives.

This distinction between irrational and rational suicide is often mobilized in bioethical discussions to justify assistance for the latter.⁴ On the rare occasions that suicidologists discuss assisted suicide, the same distinction is reiterated. For example, in a 2017 document titled “Statement of the American Association of Suicidology: ‘Suicide’ Is Not the Same as ‘Physician Aid in Dying,’” the American Association of Suicidology (AAS) determines fifteen differences between suicide (to be prevented) and assisted suicide (to be supported). The AAS concludes that the terms used to refer to the latter practice—for example, “physician-assisted suicide, Death with Dignity, physician-assisted dying, or medical aid in dying” (Creighton, Cerel, and Battin 2017, para. 1)—should avoid using the term suicide and that deaths resulting from assisted suicide “should not be considered to be cases of suicide and are therefore a matter outside the central focus of the AAS.” This comment regarding the vocabulary used to describe assisted suicide is not benign; one of the central strategies of the right-to-die movement is finding alternative ways to name and advocate for the right to suicide for some people, while avoiding the stigma attached to the word suicide itself. As many studies show, the general public, politicians, health care professionals, and many others tend to accept the practice of assisted suicide more easily when the term suicide is not used and is rebranded as assistance in dying and a form of support at the end of life.⁵ Expressions containing the word suicide are disavowed, and scholars and activists associated with the right-to-die movement try to distance themselves from such terminology (Gandsman 2018b; Ogden 2001).

The multiplicity of expressions used to refer to assisted suicide—an expression that I deliberately use in the spirit of queering and cripping the stigma surrounding the term suicide—encompasses a variety of practices. From the withholding and withdrawing of life-sustaining treatments, to prescribing or providing drugs self-administered by the person who wants to die, to provoking death through the administration of drugs, the practices included under the broad umbrella of assisted suicide elicit various reactions, including among right-to-die proponents.⁶ Usually, the more actions required to actively hasten death, the less consensus there is, even when the person is terminally ill. For example, while withholding or withdrawing life-sustaining treatment is often seen as a common practice in capitalist, industrialized countries, in parallel with the fundamental right to refuse medical treatment, the idea of a physician injecting lethal drugs into a patient’s arm elicits more controversy (Sumner 2011). The distinction between voluntary and involuntary forms of assisted suicide is also noteworthy. This distinction in regard to volition is often discussed in the context of euthanasia.⁷ While it may be dogmatic to qualify involuntary euthanasia as a form of killing or murder in every instance (for example, in the context of someone who is in a coma), as this position does not take into consideration multiple factors, such as advance directives, I am cautious regarding involuntary euthanasia and assisted forms of death. I do not think that involuntary forms of assisted suicide performed on nonautonomous subjects should count as suicide, since the centrality of the will to die—namely, the volition and agency of the subject—is absent in these instances. Therefore, I focus on voluntary forms of assisted suicide, including all the practices named earlier.⁸

Assisted suicide has been decriminalized or legalized in various national contexts, but globally these countries still remain a minority. To name only a few, Switzerland, Belgium, Luxembourg, the Netherlands, Australia, and some U.S. states (including Oregon, Washington, and California) allow some forms of assisted suicide (Stefan 2016). In the Canadian context, the Carter case, broadly discussed in the media, prompted the federal government to pass Bill C-14 on medical assistance in dying (MAID) for terminally ill people in June 2016.⁹ While not excluding people with mental illness per se, this law is designed to exclude people whose request to die is solely based on mental illness. Despite major revisions made to the law in 2021 to remove, among other things, the criterion of reasonably foreseeable death, access to medical assistance in dying is still restricted in cases where the sole reason for the request is mental illness.¹⁰ In other words, if you are a disabled/sick/ill person in Canada, you can access this service. However, if you are a Mad person with a mental disability/illness whose suffering is strictly psychological, you cannot access this service. While numerous disputes pertain to the type of disability/sickness/illness that makes someone eligible for assisted suicide in various countries, including in Canada, the requests for assisted suicide made solely based on mental illness elicit the most controversy, even in the right-to-die movement (Gandsman 2018b).

Beyond the debates regarding eligible populations or types of procedures, one trait that clearly emerges from the vast literature on the right to die is the focus on disability/sickness/illness. Rifts and fraught discussions emerge only when it comes to the type or severity of the disability/sickness/illness. For example, terminal illnesses tend to generate more approval from the general public, policy makers, activists, and scholars than do nonterminal ones, since some think that assisted suicide only changes the time of death rather than inducing it (Braswell 2018; Kious and Battin 2019, 32). I argue that the criterion of terminality for assisted suicide eligibility is ableist and ageist. First, it is an ableist criterion since it targets only sick and ill people at the end of their lives, a point to which I return later. Second, it is also an ageist criterion because it creates a justification for assisted suicide based on longevity. Indeed, the longer one has to live, the more their life is valued and protected. It is not a coincidence that older adults are the only population that falls outside the scope of disability/sickness/illness (terminal or not) to be considered for assisted suicide, since aging is often associated with disability/sickness/illness through interlocking forms of ageism, ableism, and cogniticism. While it would be anathema to even imagine giving access to assisted suicide to youth or adults who are not disabled/sick/ill, this possibility is evoked when it comes to older adults (e.g., Gandsman 2018b; Palmore 1999; Westwood 2021), even among some gerontologists. As is the case with disability/sickness/illness, old age becomes, in some cases, a factor that transforms the irrationality of suicide into a rational act. As several scholars and activists have shown, I believe that the inclusion of older adults in assisted suicide laws is ageist (Balch 2017; Coleman 2020; McIntosh 1999). Additionally, I argue that this insistence on the importance of longevity is detrimental to disabled/sick/ill people, who sometimes have a shorter life expectancy, as well as to older adults who, being in the later part of their lives, generally have a shorter life expectancy than do younger people. Furthermore, the arguments used to justify assisted suicide for “special” groups of people—namely, disabled/sick/ill/Mad and sometimes old people—are never based on concerns about the structural oppression of suicidal people and disabled/Mad people, like those I put forward in this book. Quite the contrary: Assisted suicide is conceptualized in terms of choice, liberty, self-determination, autonomy, dignity, control over one’s body and death, and the right to refuse treatment.¹¹ As I demonstrate in the following subsections, these central values embedded in right-to-die discourses are usually conceived of as incompatible with disability/sickness/illness/madness or even old age in some cases.

4.1.1. The Right-to-Die Movement: A Social Movement like the Others?

Some authors, such as Fran McInerney (2000), identify the roots of the contemporary right-to-die movement as dating back to the late half of the nineteenth century, when eugenics discourses and laws aimed at eliminating disabled people emerged, as well as to the 1930s, when such discourses were revived with the creation of organizations dedicated to promoting euthanasia. Others, such as Margaret Pabst Battin (2005), identify the emergence of the right-to-die movement and discourses as taking place at the same time as the emergence of other new social movements in the late 1960s and 1970s. Interestingly, the “requested death movement,” as McInerney (2000) calls it, had no ties with these other movements, including the civil rights, feminist, and gay and lesbian movements. This trend has continued. In the current era marked by intersectionality and the desire for social movements to unify their strengths to fight against the interlocking effects of oppressions, it is noteworthy that the right-to-die movement has not made alliances with other social movements. This lack of alliances is bidirectional, as anti-oppressive social movements, such as the queer, trans, and disability/Mad movements central to this book, have not integrated right-to-die claims, and disability/Mad movements even rightly critique the right-to-die movement. The right-to-die movement has not included any critical perspectives on the various -isms faced by marginalized groups, which also leads me to question whether this movement, at least in its current form, can be considered a social movement like the others. Regardless of the sociological debates about what constitutes a social movement, contrary to other social movements founded on anti-oppressive and intersectional approaches, the right-to-die movement, at least in its current formulation, does not endorse values similar to other anti-oppressive social movements. The right-to-die movement has been strongly criticized for representing and being composed of society’s privileged: educated, wealthy, White people¹²—hence the relevance of queering and cripping the right to die, since the right-to-die movement and discourses, instead of combatting various oppressive systems, embody them through a logic of the disposability of abject subjects based on dominants norms.

Some authors who have interviewed right-to-die movement leaders, such as journalist Katie Engelhart (2021), provide a more complex portrait than mine. This is also the case with anthropologist Ari Edward Gandsman (2018b), who interviewed right-to-die activists in North America, Belgium, and Australia and demonstrates that, despite a discourse focused on neoliberal and individual rights, the right-to-die movement helps people connect with one another and may even represent an ethics of care. Gandsman shows, and I agree with him on this point, that it is impossible to cast all right-to-die activists as adhering to the same individualistic, ableist, sanist, and ageist values. Some activists explained to him that many people in the movement are motivated by values founded in care, compassion, and support. Gandsman also reports that the movement comprises reformist and radical activists; while the former tend to focus on terminally ill/sick people, the latter argue for the right to die for individuals not experiencing any kind of disability/sickness/illness, those who are simply older and tired of life. In other words, the latter defend a right to die that is focused more on age than on disability/sickness/illness.¹³ These radical activists call their approach a rights-based model of the right to die, in opposition to a medical right-to-die model.

Exit International (2021), an organization well-known for its radical activism on the right to die, promotes a “rational DIY suicide movement” that helps people around the world have access to information about peaceful ways of dying. Describing an interview with its founder, Philip Nitschke, Engelhart (2021, 266–267) writes:

Philip thought the right-to-die movement was speeding toward a historic shift that it would not and could not and definitely should not turn back from: a pivot from a medical model of assisted dying to a rights-based model. “I’ll explain the difference,” he said. “The ‘medical model’ is where we see this as a service that you provide the sick. If a person gets sick enough, and all the doctors agree, the person who is very sick and keen to die gets lawful help to die. [ . . . ] Now, the rights model, which I’m strongly in favor of, says that this has got nothing to do with sickness. The idea is: having a peaceful death is a human right. And as a right, it’s not something that you have to ask permission for. In other words, it’s something you have simply because you’re a person of this planet.” (emphasis in the original)

The unprecedented shift identified by Nitschke, from a medical to a rights-based model of assisted suicide, represents a radical departure from the rest of the right-to-die movement. Despite this step in the right direction, it is, however, premature to affirm, as Nitschke does, that the right-to-die movement is fully heading in this direction, as a close reading of right-to-die discourses proves the contrary. Furthermore, this rights-based model of assisted suicide is still missing some key components. First, as Nitschke states in the extract cited earlier, the rights model of assisted suicide does not necessarily involve the state, physicians, or laws, thus promoting a negative right to suicide involving noninterference from others rather than a positive right entailing a moral or legal duty to assist the person who wants to die. Second, this (negative) rights model is founded on a (neo)liberal and individualistic approach that does not translate into structural change. By focusing on individual rights, this position overshadows analyses that target more systemic issues, such as structural suicidism. Third, this rights-based model is grounded in nonintersectional perspectives. As some trans and disability justice activists/scholars have shown (see Chapters 2 and 3), discourses founded on rights in social movements tend to not only prioritize certain subjects—usually those more privileged in terms of racialized status, ability, class, education, and so forth—but also push to the margins those most affected by multiple intersecting forms of oppression (e.g., Puar 2017; Spade 2011).

According to Gandsman, radical activists such as Nitschke tend to promote underground and subcultural practices of assisted suicide that do not fit the law’s criteria founded on disability/sickness/illness. He writes (2018b, 215):

They present a challenge to more mainstream right to die organisations since they argue against medical control of the issue and believe in empowering people through making information available about means and methods to take their life by their own hands. They hold workshops and publish materials instructing people how to end their lives at the “time of their choice” via “exit bags” connected to Nitrogen canisters [ . . . ] or a deliberate overdose of imported Nembutal (a barbiturate).

The underground assisted suicide business has been documented by researchers and reporters (Engelhart 2021; Magnusson 2004; Ogden 2001). Some radical activists in the right-to-die movement believe that everyone considered “rational” should be allowed to complete suicide, regardless of their health status, as well as be provided with underground help (Engelhart 2021; Gandsman 2018a, 2018b). However, promoting underground assisted suicide for “rational” individuals raises multiple issues, including the following three. First, the “rationality” criterion, as I demonstrate later in this chapter, is deeply founded on forms of sanism and cogniticism; competency and decision-making capacity are attributed only to certain individuals, and distressed suicidal people are often excluded from the “sane” category from which rational decisions can be made. Second, providing individual help to people without safeguards or a proper process of accompaniment that allows them to make an informed decision, as well as without proposing a political agenda to end structural oppressions that contribute to distress in some marginalized communities, seems not only risky but also irresponsible. Indeed, it simply provides distressed individuals with a quick solution without providing the support that could be life-affirming and without doing the necessary work to reduce suffering at the structural level, as I propose in this book. In other words, even among the most radical right-to-die activists, none so far seems to have proposed supporting suicidal people through social, political, legal, or medical policies, and none has embraced a right to die based on anti-oppressive values. These radical activists privilege assistance through underground support and individual forms of help. Third, Gandsman’s (2018b, 181) study shows that even radical organizations, such as Exit International, officially adhere to strict criteria to provide help to their members, resonating with criteria promoted by more reformist activists, such as being over fifty years old and not being mentally ill.¹⁴ Therefore, even though Gandsman and Engelhart show how some radical right-to-die activists accept suicide in various situations that go beyond disability/sickness/illness/old age, the majority of right-to-die activists’ rationales seems to be fueled by a fear of becoming old, disabled, sick, or ill and losing autonomy and dignity. These rationales in turn lead to ableist/sanist/cogniticist/ageist discourses in the movement, as Engelhart’s (2021, 18–19) summary of right-to-die activists’ foundational arguments clearly reveals: “For them, planning death was often about avoiding indignity, something they imagined would be humiliating, degrading, futile, constraining, selfish, ugly, physically immodest, financially ruinous, burdensome, unreasonable.”

The claims made by the majority of right-to-die activists regarding support for assisted suicide for disabled/sick/ill/old people are aligned with values promoted in capitalist, industrialized countries. In various surveys over the past decades, the general public has endorsed the idea that disabled/sick/ill/old people should be able to determine the time and manner of their death and be supported in dying with “dignity” (Engelhart 2021; Stefan 2016), even though regarding Mad people, the discussions are more fraught, as I demonstrate in the next section. Philosopher Leonard Wayne Sumner (2011, 192) notes, “In Canada and the United Kingdom a strong majority appears to favour legalizing either [assisted suicide and euthanasia], while in the United States a stable majority can be found only for assisted suicide [performed by the person and not the doctor].” In the American context, physicians Timothy E. Quill and Bernard Sussman (2020) explain, “In most surveys, approximately two-thirds of the U.S. population approve of [physician-assisted suicide] as an option for terminally ill patients with intractable suffering.” This relative acceptance of assisted suicide for disabled/sick/ill/old people is confirmed through the endorsement by several countries of laws supporting forms of assisted suicide. This acceptance is also noticeable in the endorsement of assisted suicide by key professional associations (e.g., physicians or social workers) and practitioners (Chao et al. 2016; McCormick 2011). The support of a majority of people, as well as numerous governments, for the right-to-die movement indicates once again that this social movement differs from the others discussed in this book. While queer, trans, and disability/Mad movements disturb norms and call for structural changes that usually elicit opposition from various dominant groups and from the state, the right-to-die movement, despite some hostility from conservative pro-life groups, tends to have strong support, demonstrating that its goals do not seem to trouble dominant norms and structures. These norms and structures, founded on age, health status, productivity, and individualism, are reiterated in right-to-die discourses.

4.1.2. A Right to Die for Mentally Ill People?

Adam Maier-Clayton’s tragic story made headlines in the Canadian media a few years ago. After years of struggling with mental illness and repeated failed appeals to change the Canadian MAID law to include those for whom mental illness is the sole basis for their request, Maier-Clayton was forced to complete his suicide alone, without his friends and family, who were supportive of his need to die. He writes (2016, para. 2):

I’ve done everything that there is to do. I’ve tried eight or nine medications, I’ve done traditional Freudian psychotherapy, cognitive behavioural therapy, exposure-response prevention therapy, acceptance and commitment therapy. In a perfect world, I’d get better. But in real life, there’s a chance that my progress will continue to be as poor as it has been in the past three years. I’m not going to endure this agony indefinitely.

The media is replete with similar stories of right-to-die activists and other mentally ill people denied access to assisted suicide and left to fend for themselves. In some cases, these individuals do not fit the more restrictive criterion of imminent or foreseeable death upheld by some countries’ laws; in other cases, like that of Maier-Clayton, they are excluded because laws prevent assisted death for reasons based solely on mental illness, as is the case in Canada and most countries. Even in the rare countries where assisted suicide is allowed based on mental and emotional suffering, such as the Netherlands, Switzerland, Luxembourg, and Belgium, accessing the procedure is not straightforward. Contrary to other disabled/sick/ill people, most mentally ill people find their requests repeatedly denied. For example, in the Netherlands, two-thirds of people who have asked for access to assisted suicide based on emotional suffering have had their requests refused (Sumner 2011, 171).¹⁵ A study by clinician Lieve Thienpont and colleagues (2015, 1), who researched “100 consecutive psychiatric patients requesting euthanasia based on psychological suffering” in Belgium, shows that more than half of the hundred subjects (fifty-two) were not accepted. Six people completed a suicide without support; beforehand, some had said that the procedure to obtain permission was too long and difficult.

The profile of people requesting access to assisted suicide on the basis of mental illness is diverse, but in the various countries in which the practice is allowed, a majority suffer from depression and have endured years or decades of mental/emotional suffering.¹⁶ Thienpont and colleagues (2015, 5) note that their study included, among others, people with “treatment-resistant mood disorder,” “personality disorder,” “post-traumatic stress disorder,” “schizophrenia and other psychotic disorders,” “anxiety disorders,” “eating disorders,” “substance use disorders,” “somatoform disorders,” “autism spectrum disorder,” or “obsessive-compulsive disorders.” Interestingly, according to these authors, most people had multiple diagnoses, and most requests (77 percent) were made by women, a result confirmed in other studies. Indeed, scholars Scott Y. H. Kim, Raymond De Vries, and John R. Peteet (2016) discovered that 70 percent of people in their study in the Netherlands who requested access to assisted suicide based on mental illness were women with multiple diagnoses, long histories of psychiatrization, and often multiple suicide attempts. These numbers clash with the statistics available on unassisted suicide, an act mainly completed by men (Colucci et al. 2013; Kim, De Vries, and Peteet 2016; Stefan 2016; Wray, Colen, and Pescosolido 2011). The question of who seeks access to assisted suicide in various geographical contexts, whether related to gender identity, racialized status, or class differences, would be interesting to explore through an intersectional lens in future research. Some critics of the right-to-die movement see the overrepresentation of well-educated, middle- to upper-class, White individuals in the right-to-die movement as proof that it is founded on a culture of disposability toward the most marginalized individuals in our societies, such as racialized, poor, and disabled people (Coleman 2018, 2020; Kolářová 2015). While I endorse the argument about the presence of a culture of disposability in right-to-die discourses, I would add that it is possible to see the overrepresentation of privileged people in the right-to-die movement and in the statistics of those who access assisted suicide through another lens: structural barriers, such as racism or classism, that prevent some people from having access to certain health care services and from exercising their rights.¹⁷ We observe this phenomenon in relation to health and social service access more generally.¹⁸ Therefore, it would not be surprising if the disparities regarding who can access assisted suicide mirrored the exclusion of some marginalized groups from numerous institutions and services as well as from social movements. In other words, it is easier for educated, middle- to upper-class, White people to participate in social movements and to have access to health care. I return to the question of access in the last part of this chapter. However, what seems important to highlight here is that, on the one hand, there are disparities regarding who can access assisted suicide. On the other hand, several studies show that Mad/mentally ill people tend to be rejected more frequently in their requests to access assisted suicide as compared to physically disabled/sick/ill people, reproducing once again the hierarchies often seen between visible and measurable disabilities/illnesses versus invisible and unmeasurable disabilities/illnesses. While the former tend to elicit more pity, based on an ableist perspective, the latter tend to be disbelieved and discredited.¹⁹

Given the previous information, the extension of access to assisted suicide to mentally ill people is, unsurprisingly, extremely contentious, not only from a public health and lay perspective but also from the perspective of bioethicists and right-to-die activists.²⁰ Gandsman (2018b, 177) indicates that the activists he interviewed disagree on the question of extending the right to die to mentally ill people: Many find access to assisted suicide based on mental illness problematic, and those who would potentially consider it would do so only for those “who suffer greatly from incurable mental health problems” (my translation). Maier-Clayton (2016, para. 17) also insists on the seriousness of the mental suffering by those who should be given access to assisted suicide:

When I say giving access to the mentally ill, I’m not talking about someone who has a panic attack once every two years. I’m not talking about someone who has a tendency for melancholy when bad things go on in their life and they have a rough couple [of] months. I’m talking about refractory patients—that’s the term I always use, refractory or treatment-resistant patients. The people whom modern science can’t help.

The lexicon of suffering, irremediable pain, and incurable illness is central to the demand to extend assisted suicide to mentally ill people. Establishing a parallel between physical and mental illness, the parity argument is often endorsed by scholars and by mentally ill people themselves.²¹ For example, scholars Brent M. Kious and Margaret P. Battin (2019, 31) appeal to this parity argument based on the centrality of suffering with respect to physical and mental illnesses: “We think it is clear that the suffering associated with mental illnesses can sometimes be as severe, intractable, and prolonged as the suffering due to physical illnesses. Accordingly, it seems to us that if severe suffering can justify PAD [physician-assisted death] for some persons with terminal physical illnesses, it should justify PAD for some persons with mental illnesses, too.” Maier-Clayton (2016, para. 7) also mobilizes the parity argument: “Physical illness and mental illness can actually induce the same amount of pain. The only difference is the pain in a physical illness has a physical pathology. In a mental illness, the pain is called psychosomatic pain. To the patient, it feels exactly the same.” At the center of all these discourses is the notion of diagnosis.²² Activists and scholars who support the inclusion of mentally ill people in laws on assisted suicide insist that in no instance should assistance be provided to people with a broken heart, people experiencing temporary difficulties, or people who are simply depressed. The gravity of the condition must be irremediable, and everything possible should have been tried before arriving at this ultimate solution, “including polypharmacy, electroconvulsive therapy, and psychosurgery” (Kious and Battin 2019, 31). As we can see, some authors suggest that numerous treatments, such as what used to be called electroshocks and lobotomies, should be imposed before allowing mentally ill people to have access to assisted suicide, treatments described as extremely violent by Mad activists/scholars (see Chapter 3). Many mentally ill people who request access to assisted suicide also believe that everything should be tried before this access is given (Bayliss 2016; Maier-Clayton 2016; Scully 2020). With this focus on irremediable mental illness, a clear distinction is again made between “irrational” suicide, which would be performed by someone who does not suffer irremediably or has not tried every treatment possible, and “rational” suicide, which would be allowed for those who have “serious” medical/psychiatric diagnoses.

Mental capacity is one of the elements that makes the question of access to assisted suicide for mentally ill people so controversial (Engelhart 2021; Gavaghan 2017). From a suicidist point of view, the simple fact of expressing suicidal ideation can itself lead to one’s mental capacity being questioned or revoked, making it impossible to refuse coercive treatment. Opposed to the inclusion of mentally ill people in the Canadian MAID law, scholars Louis C. Charland, Trudo Lemmens, and Kyoko Wada (2018, 3) define mental capacity as follows: “In technical medical and legal terms, ‘mental capacity’ in this context concerns the decision-making capacity of persons to consent to MAID. Decision-making capacity is also sometimes referred to as ‘mental competence.’”²³ In many countries, mental capacity refers to the ability to appreciate pertinent information, express choices, and understand the medical implications of certain treatment decisions (Giwa 2019, 111). In theory, mental (in)competence is not broadly attributed to an individual but determined in specific situations case by case, based on each specific decision the person makes (Gavaghan 2017; Sumner 2011). In practice, however, some individuals are deemed globally mentally incompetent and treated accordingly, often based on sanist and cogniticist presumptions. In other words, there is a disparity between the law and the application of the law (Baril et al. 2020; Bernheim 2019). Suicidal people are among the groups often deemed globally mentally incompetent, along with people living with dementia or “severe” mental disability. In her research on psychiatrized people and their relation to the Canadian legal system, Emmanuelle Bernheim (2019, 35) demonstrates that being marginalized (e.g., being poor or mentally ill) and resistant to treatment is often sufficient proof to justify that the person represents a danger to themselves or to others and is thereby deemed incompetent.²⁴

Statements by key associations or organizations, such as the AAS (Creighton, Cerel, and Battin 2017) or, in the Canadian context, the Centre for Addiction and Mental Health (CAMH 2017), reflect this assumption of incompetence when it comes to suicidality: Instead of individually evaluating suicidal people to determine whether they are mentally competent, professionals generally assume their mental capacity to be “impaired” based on suicidality. For example, in a public statement about the possibility of extending assisted suicide to mentally ill people, CAMH (2017, 7–8) declares that although Canadian law presumes mental capacity for mentally ill people, in practice, those individuals, particularly if they express suicidal ideation, should be treated as globally mentally incompetent when it comes to assessing their desire for death:

All people, including those with mental illness, are presumed capable unless proven otherwise. A mental illness does not preclude capacity to make healthcare decisions. That being said, in cases where a person with a mental illness requests MAID [ . . . ] determining whether or not an individual has capacity to make this request for MAID is not an easy task. The concern is that many individuals with mental illness experience disordered insight or impairments in reasoning capacity that make it difficult for them to connect their symptoms with their illness, fully understand the risks and benefits of treatment, and/or make treatment decisions based on personal goals and values. [ . . . ] It is not uncommon for them to have severely distorted beliefs about themselves, the world, and their future. This can include the belief that death is a desirable option. [ . . . ] This distorted insight raises questions about the individual’s capacity to make a MAID request during both the acute and less acute phases of their illness.

While we might think that these kinds of statements come uniquely from institutions, associations, and organizations that endorse a medical model of suicidality, as I show in Chapters 2 and 3, many anti-oppression activists/scholars paradoxically endorse this individualistic and pathological view regarding the agency and mental capacity of suicidal subjects. When their mental capacity is not invalidated from a sanist point of view, it is often revoked based on the idea that their competency is compromised by internalized oppressions. However, it is not because structural factors shape our subjectivities and influence our choices that they are invalidated. Additionally, similar to the ways that Mad activists/scholars have contested sanist conceptualizations of rationality and mental competence, mentally ill people requesting access to assisted suicide have critiqued the prejudices and misconceptions denying them mental competency. As Graeme Bayliss (2016, para. 10), a Canadian journalist who argues in favor of extending MAID to mentally ill people (based on his own relationship to suicidality), notes, “More subtle and more insidious is the idea that the mentally ill [ . . . ] are, by definition, incapable of deciding rationally to kill themselves.” Similarly, journalist John Scully (2020, para. 6), who has struggled for years with mental illness and suicidality, states, “Even in death, those with mental illness in Canada are denied a voice,” referring to the fact that mentally ill people are not invited to testify or to join panels of experts deliberating on their fate when it comes to changing laws on assisted suicide. In sum, mentally ill people fighting for the right to die denounce the erasure of their opinions and voices in the public debates on assisted suicide. They demand more accountability and respect for their first-person experiences and ask for epistemic and testimonial justice for mentally ill people in their quest to die.

Mad activists/scholars have long demonstrated that the association of mental illness with mental incompetence is fundamentally ableist/sanist (e.g., Ben-Moshe 2020; Beresford and Russo 2022; LeFrançois, Menzies, and Reaume 2013). However, despite rare exceptions (e.g., Burstow 1992), they have not extended these critical analyses to suicidal people. Many authors outside disability/Mad studies have nevertheless worked to deconstruct the association between mental illness and incompetence in relation to suicidality.²⁵ While mental illness may temporarily impact decision-making and mental capacity, mental illness does not equal mental incompetence in all situations. Susan Stefan (2016, 9) believes that viewing suicidal people as mentally incompetent is prejudicial to efficient prevention strategies and that suicidal ideations do not themselves constitute a sign of mental incompetence:

The very small minority of truly incompetent people who try to kill themselves ought to be prevented from doing so. But the vast majority of people who are thinking about suicide, attempting suicide, and committing suicide are nowhere close to incompetent under our current legal standards. The best clinical and sociological research supports this assertion, and the law insists on it. Treating suicidal people as per se incompetent makes bad law and interferes with good clinical practice. [ . . . ] The intent to commit suicide, or a suicide attempt, does not, standing alone, constitute incompetence.

Some authors in the health sciences, such as Jeanette Hewitt, critique the delegitimization of mentally ill people’s autonomy, agency, and ability to make informed decisions about death. Hewitt (2013) distinguishes between temporary irrationality, which may periodically affect mentally ill people, and permanent global irrationality, as is the case for some people in the advanced stages of Alzheimer’s disease. She contends that people with “serious” mental illness, such as psychosis or schizophrenia, are not globally irrational, although they might be during some short periods. Although mentally ill people who wish to access assisted suicide may experience periods of temporary irrationality, during which authorizing assisted suicide would be dangerous, she argues that the desire to die cannot be delegitimized on the basis of pervasive irrationality. Despite plenty of scientific evidence that mentally ill people who are suicidal are not delusional and that the desire to die is not a spontaneous, temporary, or impulsive reaction, mentally ill people who request access to assisted suicide continue to be treated as threats to themselves and in need of enforced protection from the state.

In sum, two main positions exist in the debates regarding the extension of the right to die to mentally ill people. On one side are those who support the right to die only for physically disabled/sick/ill people, arguing that suicidality is caused by mental illness that impairs decision-making capacity and annihilates autonomy; thus, the desire to die in the absence of physical disability/sickness/illness is cast as abnormal or irrational.²⁶ On the other side are those who support access to assisted suicide for mentally ill people without concomitant physical conditions, mobilizing the parity argument to show that mental suffering can be as real and as irremediable as physical suffering.²⁷ However, in both cases, the ontology of assisted suicide remains unexamined.

4.1.3. The Ontology of Assisted Suicide

I have argued that the discourses among philosophers, bioethicists, and right-to-die activists surrounding assisted suicide are governed by an “ontology of assisted suicide” (Baril 2022), meaning a common understanding of the main defining features of assisted suicide, or, in other words, what assisted suicide is and is not. I argue that the ontology of assisted suicide is rooted in ableist, sanist, ageist, and suicidist presumptions. Right-to-die discourses supporting some suicides—namely, those considered “normal” and “rational,” such as that of Verhelst, described in the opening of this chapter—leave unexamined the ableist/sanist/ageist double standards behind this exceptionalism in relation to some groups of people as well as the injunction to live and to futurity imposed on suicidal subjects. In all these right-to-die discourses, the central focus on disability/sickness/illness/old age is foundational to arguments in favor of assisted suicide. Even when it comes to the extension of the right to die to mentally ill people, the role of illness remains central. The disability/sickness/illness and (often) old age component constitutes the core of the ontology of assisted suicide. My arguments about the existence of this ontology of assisted suicide are grounded in six observations based on my critical analysis of literature on assisted suicide. First, the ontology of assisted suicide anchored in disability/sickness/illness/old age can be found in almost all right-to-die discourses.²⁸ Second, this ontology of assisted suicide can be found in almost all philosophical and bioethical discourses on assisted suicide.²⁹ Third, this ontology of assisted suicide is mobilized by clinicians as a key criterion for distinguishing between “rational” and “irrational” (or despair) suicides. Fourth, disability/sickness/illness/old age also constitute key criteria in various countries for allowing some forms of assisted suicide. Fifth, this ontology is endorsed by many local and national organizations, associations, and groups, such as those discussed earlier in this chapter. Sixth, this ontology is endorsed by the general public, including many disabled people.³⁰ Without discussing this ontology per se but using a comparative example, Stefan (2016, 127) demonstrates how powerful this ontology of assisted suicide is, to the point of transforming the way death is understood, framed, and officially registered in public records:

If two people in Oregon on the same day each take the same quantity of the same prescription pills, each with the identical intention of ending his or her life, and they are discovered to have done so, one will be taken by ambulance to an emergency department and may have his or her stomach pumped or be involuntarily committed to a psychiatric ward. The other will not only be permitted to die but the death that he or she caused and intended won’t even be recorded as suicide. The only difference is that in one case a doctor ratified the decision and in the other case, the doctor did not.

Year after year, lists of criteria for who should qualify for assisted suicide are drafted by right-to-die proponents.³¹ Yet the ontology of assisted suicide, founded on disability/sickness/illness/old age, remains unexamined, and suicidism is reproduced through a systematic exclusion of suicidal people.

Some authors, such as Zohreh BayatRizi (2008, 153), seem to believe that requested death is “a mode of resistance against the excessive medicalization of life.” Others, such as scholars Kateřina Kolářová (2015) and Thomas F. Tierney (2006, 2010, 2021), show how the right-to-die movement and discourses reinforce, in a Foucauldian sense, biopower and governmentality, since “the suicide request [has to] be verified as reasonable by a physician and/or mental health professional” (Tierney 2006, 624). In other words, the ontology of assisted suicide requires control, surveillance, regulation, and gatekeeping. In addition, gatekeeping regarding assisted suicide, similar to the gatekeeping of medical transitions for trans individuals, is performed not only through the approval of physicians or mental health professionals but through a series of institutions, including the family and the law. Indeed, access to the right to die is structured by an array of procedures aimed at validating one’s diagnosis, illness, or intolerable suffering, such as legal wait time, multiple forms, third-party approvals, and medical and psychological exams. In other words, in countries where assisted suicide is permitted, having a diagnosis is far from being enough to exercise a right to die: Rigid gatekeeping is performed at every level to ensure that the decision is approved by multiple actors and institutions. Even in countries such as Switzerland, where assisted suicides are supported by private organizations and where the state’s role is minimal, people who request assisted suicide must meet a certain number of criteria and get prescriptions from physicians to obtain drugs. For example, in a brochure by Dignitas (2021, 6), a leading Swiss right-to-die organization providing assisted suicide, prerequisites are founded in this ableist/sanist/ageist/suicidist ontology of assisted suicide:

Because the co-operation of a Swiss medical doctor (physician) is absolutely vital in obtaining the required drug, further prerequisites mean that the person must have:

• a disease which will lead to death (terminal illness), and/or

• an unendurable incapacitating disability, and/or

• unbearable and uncontrollable pain.

Scholar Tania Salem (1999, 33) demonstrates how the legalization of assisted suicide and its management by the state and the medical system rest upon the idea that health care professionals know better than the affected people themselves what is good for them: “Someone other than the person requesting aid in dying has greater expertise in judging the appropriateness of that request. Medical authority, that is, is assumed to have the proper ability to unveil the ‘real truth’ behind the request to die.” Salem condemns the paternalism behind this state interference in individual rights and the negation of liberty, autonomy, and self-determination involved in the medicalization of assisted suicide.

I would like to condemn the gatekeeping surrounding assisted suicide on a basis additional to the one proposed by Salem and other thinkers. Not only does gatekeeping, as is the case with trans people and their transitions, negate forms of agency, bodily autonomy, and self-determination; it also rests upon structural forms of violence that remain hidden, even in the discourses of those who denounce gatekeeping practices surrounding assisted suicide. Trans scholars/activists have shown how cisgenderism and cisnormativity are at the core of a (cis)gender ontology (what gender is) underlying transition gatekeeping. The deconstruction of this ontology by scholars/activists should inspire us to propose a similar critique of the ontology of assisted suicide. Indeed, if assistance in suicide is subjected to a gatekeeping process similar to the one put in place for trans people from a cisgenderist/cisnormative perspective, it is possible to believe that the gatekeeping surrounding assisted suicide rests upon an oppressive system and its normative component: suicidism and compulsory aliveness. Contrary to the arguments of many activists or scholars, such as Salem—namely, that the regulations and restrictions surrounding assisted suicide represent first and foremost a violation of individual liberty, choice, and autonomy—I argue that this violation of individual rights would not exist without a structural oppression, suicidism, and its various components, be they economic, social, political, or normative. This oppression is additionally intertwined with several other oppressive systems, as demonstrated in previous chapters.

Suicidism is central to the ontology of assisted suicide, since suicidal people without diagnosable conditions are excluded and considered “crazy” from a sanist perspective for wanting to die. Ableism and sanism are also central since the ontology of assisted suicide specifically targets disabled/sick/ill/Mad people. Additionally, ageism is central, since, in many circumstances, terminality (and hence the length of life) is a determining criterion, and age itself is sometimes evoked as a good reason for allowing assisted suicide. Neoliberalism is also central, since the agenda of the right-to-die movement is founded on core libertarian values, such as individual (and not relational) autonomy, liberty, and choice. Capitalism is also central, since many right-to-die discourses refer to economic arguments about how assisted suicide would relieve societies and families of the financial burden of keeping alive individuals deemed nonautonomous (Engelhart 2021). The capitalist argument is often compounded with ableist/sanist and ageist arguments, since disabled/sick/ill/Mad and old people are often perceived as nonproductive subjects who burden social institutions and the economy (McGuire 2020). Finally, all other forms of -isms are also important in the ontology of assisted suicide, since, as I have mentioned, the right-to-die movement and discourses are supported by the most privileged people in terms of racial, socioeconomic, or education status. And while I do not dismiss the relevance of some political strategies to support individual rights, I think that it is crucial to remain critical of discourses founded on individual rights and liberties (Puar 2017; Spade 2011) and to insist on transforming the ideological and material structures that underlie our practices surrounding assisted suicide.³²

Furthermore, the ontology of assisted suicide underlies conversations among right-to-die proponents about the duty to support those in need of assistance in their “legitimate” suicides.³³ This duty to support assisted suicide clashes drastically with the duty to prevent suicide by those who do not fit within the ontology of assisted suicide. As demonstrated in this book, suicidal individuals who fall outside this ontology of assisted suicide are forced to live, symbolically and literally. Based on this ontological narrative, on the one hand, the duty is to support people who want to die if they fit this ontology of assisted suicide; on the other hand, the duty is to prevent suicidal people from completing their suicide. Interviews with people in the right-to-die movement demonstrate this dual duty to defend the right-to-die and to protect the suicidal, as one leader explains to Engelhart (2021, 154):

In addition to working as an exit guide [right-to-die organization], Brian volunteered at a suicide prevention hotline, trying to keep strangers alive for a few more hours, until the crisis passed and “usually they realize that they don’t want to die.” Those death wishes were different, Brian said, because they weren’t about control: they were about chaos. Disturbed minds. Minds that had shifted off-kilter. Brian knows how to talk a person out of it—and, in fact, many people needed to be talked out of it.

The ontology of assisted suicide reminds me of the ontology surrounding transness that has circulated widely in medical, psychiatric, and pop culture during the past decades and that still affects trans communities to this day. This ontology of transness is founded in the discourse of “being trapped in the wrong body”³⁴ and distinguishes between “real” and “false” needs to transition. In an analysis of the hierarchization about what was, and still is, considered to be “legitimate” and “illegitimate” reasons to transition, for trans and transabled people (people who want to voluntarily acquire a disability), I notice in my past work (e.g., Baril and Trevenen 2014, 392) that identity motives—that is, those anchored in some form of ontology (who a person is)—are usually given more credibility than other reasons, be they aesthetic, political, sexual, artistic, or other:

We argue again that these divisions can create a hierarchy between “real” and “false” desires for surgeries or body modification—the real desire constructed as coming from identity claims and the false desire coming from paraphilia [ . . . ] [or other motives]. We maintain that some contemporary research contributes to this distinction between real and false [motivations] [ . . . ], and also participates in the search for the “cause” of transsexuality and the desire for “disabling” body modification—a search that traps this research in a disease-oriented, individualistic model and one that leaves cis and normate bodies unexamined.

This reflection is applicable to the transition from life to death. The ontology of assisted suicide contributes to the hierarchization of “real” and “false” reasons for suicide, leading to the authorization of the former and the prevention of the latter. As was historically the case for transness, the centrality of a diagnosis or of “trouble” attested to by a medical professional is crucial to the procedure’s justification. As trans people often transform their narratives for health care professionals to get access to the care they need, suicidal people may be tempted to modify their narratives to make them fit into this ontology of assisted suicide, as I discuss in Chapter 1.³⁵ As is the case for trans people, who should be allowed to transition regardless of their motivations, I contend that many reasons lie behind the desire to die—and they are all equally valid. The medical-industrial complex should not determine which motives and reasons justify transitions, including the transition from life to death. However, the pressure to conform to this dominant narrative about assisted suicide is so powerful that even in right-to-die discourses, the possibility of justifying assisted suicide outside the dominant ontological script of disability/sickness/illness/madness/old age seems absent.³⁶ In sum, like trans subjects forced to frame their need to transition by using a cisnormative and transnormative script, suicidal subjects are forced to frame their desire to die by using an ableist/sanist/ageist/suicidist ontological script, where disability and suffering must be put forth, sanity and rationality must be proven, and suicidality must be dismissed as irrational. In addition, the closer to old age they are, the higher the chances that their decision will be approved. Therefore, the ontology of assisted suicide endorsed by right-to-die proponents constitutes a forceful somatechnology of life that aims to keep suicidal people alive and leaves unexamined ableism, sanism, ageism, and suicidism. I believe that an intersectional lens regarding suicide and assisted suicide that would include an anti-suicidist perspective could bring about a conversational shift from arguing for a right to die (a duty) for disabled/sick/ill/Mad/old people based on an individualist conceptualization of autonomy to advocating for positive rights, better support, and structural changes (a duty) for suicidal subjects (including access to assisted suicide) from an anti-oppressive approach and social justice perspective.

4.2. Ableist, Sanist, and Ageist Assumptions in Right-to-Die Discourses

My goal in this section is not to reiterate my arguments about the forms of ableism and sanism underlying assisted suicide and right-to-die discourses.³⁷ As explored in Chapter 3, critiques of disability/Mad activists/scholars rightly reveal a double standard regarding the legitimization of suicide for only a portion of the population—specifically, disabled/sick/ill/Mad people. Furthermore, as previously analyzed in this chapter, right-to-die discourses, be they those of philosophers, bioethicists, or right-to-die activists, all converge in an ontology of assisted suicide that rests upon disability/sickness/illness and sometimes old age, confirming the fears and preoccupations of disability/Mad activists/scholars and critical gerontologists that special treatment is reserved for marginalized groups when it comes to suicidality. I argue here that ableism and sanism are at play in three distinct but interrelated ways in the right-to-die discourses founded on this ontology of assisted suicide.

First, right-to-die discourses are ableist in their repeated claims that a right to die must be defended to avoid the “horror” of disability and the loss of autonomy. This ableism is often intertwined with ageism,³⁸ a component frequently forgotten when it comes to theorizing ableist violence. While space limitations prevent me from elaborating on the question of ageism, it seems crucial to highlight the intertwining of ableism and ageism as ageist stereotypes, founded on a narrative of “decline,” that assume that most older adults are, or will become, disabled/sick/ill (Gallop 2019). One of Gandsman’s (2018b, 215) right-to-die activist interviewees, Cath, endorses this “decline” ideology and discusses the case of a friend who wants to complete suicide:

She doesn’t want to be old. Old age is cruel. Everything starts failing. You have pain all the time. You’ve got joint problems. You’ve got eyesight problems. You’re going deaf. Everything goes. It’s not just one thing that’s wrong with you. It’s a multitude of things. It’s all losses with old age. All losses. Anyone who says old age is beautiful is a fucking idiot. Old age is ugly and horrible and it destroys you to watch people getting old.

Gerontologists have been trying to disentangle the automatic association between aging and disability for years, unfortunately often at the expense of disabled communities.³⁹ While it is important to dissociate the process of aging from disability/sickness/illness, it is equally (if not more) important to do so while remaining critical of the forms of ableism reproduced in mainstream gerontology through discourses of “successful aging” that exclude disability/sickness/illness (Gallop 2019; McGuire 2020). Other unproblematized associations must also be deconstructed, such as those between disability/sickness/illness and pain, suffering, and death. Scholar Joel Michael Reynolds (2017, 153) cleverly argues that a dangerous syllogism is made in relation to disability, suffering, and pain and that it is important not to fall into this “ableist conflation.”

Simultaneously, as scholars such as Susan Wendell (1996, 2001) and Alison Kafer (2013) remind us, pain and suffering are also part of the experiences of some disabled/sick/ill/old people. Furthermore, as some disability activists and scholars articulate, it is important to be able to comprehend the complexity of the notion of pain itself (Patsavas 2014; Siebers 2008). In her brilliant cripistemology of pain, which deconstructs its ontology as an individual, subjective, and biological experience (in the case of physical pain), Alyson Patsavas (2014, 208) writes, “Dominant discourses of pain [ . . . ] frame pain as a problem that renders life unworthy of living.” However, Patsavas argues that pain cannot be reduced to a simple negative experience and must be conceptualized in all its complexity. Pain and suffering are at the heart of right-to-die discourses, but their conceptualizations are reductive and ableist. Unlike Patsavas’s work, these conceptualizations of pain and suffering fail to take into consideration the nuances and complexities of the narratives of people living with chronic pain and suffering. In brief, the false associations and syllogisms too often made by right-to-die proponents, such as disability = pain = suffering = miserable life = life not worth living = allowing assisted suicide as a deliverance from this misery, are founded in ableist stereotypes.

Second, right-to-die discourses are sanist when it comes to assisted suicide for mentally ill people. For many proponents of the right to die, extending assisted suicide to mentally ill people is a moot point: Since mentally ill people are deemed incompetent in deciding for themselves, their wish for suicide is cast as irrational. Therefore, right-to-die activists and scholars who refuse to extend assisted suicide to mentally ill subjects adhere to stereotypes about the “craziness” and “madness” of suicidal people guided by impulsivity, uncontrollability and danger, and they endorse sanist assumptions that equate mental illness with mental incompetence.⁴⁰ As discussed earlier, a vast literature has emerged during the past decades in Mad studies and bioethics to show that irrationality due to mental illness is not constitutive of the subject and that the decision-making capacity of people living with mental illness is not necessarily globally affected.⁴¹ In other words, dismissing mentally ill people’s requests for assisted suicide solely on the presumption that they are irrational and incapable of decision-making is a form of sanism. Based on his observations and participant interviews, Gandsman (2018b, 176; my translation) concludes that “medically assisted death stems from a mind/body dichotomy: a ‘healthy mind’ in a ‘sick body,’ which is opposed to suicide, which stems from a ‘sick mind’ in a ‘healthy body.’” Even though Gandsman, Herington, and Przybylak-Brouillard (2016, 62; my translation) do not analyze this dichotomy from an anti-sanist perspective, I suggest that this dichotomy is sanist, as illustrated by many participants’ comments, including those of Paul, a radical activist in the underground euthanasia movement:

There are also crazy people, you know. I remember spending a whole afternoon with someone who turned out to be completely crazy. This person saw it all [suicide] as a romantic gesture. She was a young woman who was suffering from depression . . . not really rational. And of course, in that kind of situation you totally refuse, you know. We keep in touch, but we don’t do anything else.

This is one example among many that represents forms of sanism that are commonly put forth in the right-to-die discourses. I would even say that the division between “rational” and “irrational” suicide, endorsed by almost all proponents of the right to die, is founded on sanism, since mental illness is equated in this schism with mental incapacity and seen as robbing people of rationality, agency, self-determination, and the competence to make decisions. In sum, most authors in favor of “rational suicide” adhere by default to sanist perspectives, since rational suicide is seen as an act accomplished by rational subjects deemed competent to make decisions, usually defined in opposition to people with intellectual, cognitive, mental, or psychological disabilities or illnesses.

Third, while right-to-die discourses that advocate for an inclusive agenda of assisted suicide for mentally ill people may initially seem to be less sanist, these discourses are also founded on a more subtle type of sanism. They do not question the ontology of assisted suicide and its targeted population: people who are at the end of their lives, disabled, sick, or ill, including those who are mentally ill. They do not see that allowing assisted suicide only for a specific population through medical/psychiatric diagnosis implies a differential treatment for this group. In this case, like physical pain and suffering, mental pain and suffering are perceived, based on ableist/sanist presumptions, as making life unworthy, which justifies its termination through assisted suicide. Therefore, whether they claim to be for or against the inclusion of mental illness as a legitimate condition to qualify for assisted suicide, right-to-die proponents in each camp (and those in between) hold sanist presumptions.

In sum, right-to-die discourses are founded on three forms of ableism/sanism: (1) physical ableism directed against physically disabled/sick/ill people, often intertwined with ageism; (2) sanism directed against mentally ill people perceived to be mentally incompetent to make decisions about assisted suicide; and (3) sanism directed against mentally ill people who are seen, alongside other disabled/sick/ill/old people, as living unworthy lives. Suicide is recast here as a logical and rational response to “tragic circumstances” (Taylor 2014, 14), be they physical or psychological/emotional. Therefore, on the one hand, from an ableist, sanist, ageist, capitalist, neoliberal perspective, these discourses rationalize assisted suicide for subjects considered “abject” according to dominant norms. On the other hand, these discourses cast suicidal people and their wish to die as irrational. From this perspective, it is unthinkable that a young, able-bodied/healthy/sane person should receive medical assistance for their suicide.

4.3. Suicidist Presumptions in Right-to-Die Discourses

As demonstrated in this chapter, suicidal people’s voices have been systematically erased from philosophical, bioethical, and right-to-die conversations on assisted suicide, an act that could be qualified as epistemic violence as suicidal people’s legitimacy and credibility as knowledgeable subjects is denied. Additionally, current laws and regulations on assisted suicide do not recognize suicidal people’s right to assisted suicide, perpetuating a form of legal violence toward suicidal people. Although disabled/sick/ill people, and sometimes Mad and old people, are given access to assisted suicide, I contend that these people are not primarily those who want to die. As illustrated by many scholars/activists, disabled/sick/ill/Mad/old people contest the idea that their quality of life is so diminished that their lives are not worth living. An overwhelming majority want to live and denounce their lack of good living conditions (Clare 2009, 2017; Kolářová 2015). Is it not strange, therefore, that we offer assisted suicide to groups of people who, for the most part, do not request it and ask for better living conditions, while denying this service to the people who want to die and would benefit from the support to do so?

Additionally, as I have discussed, mentally ill people who want to access assisted suicide, such as Bayliss, Maier-Clayton, and Scully, often re-create in public discourses similar hierarchies regarding good and bad reasons for wanting to die, all of which exclude suicidal subjects. This exclusion reflects the position endorsed by right-to-die activists and organizations more generally. For example, Gandsman (2018b, 182; my translation) quotes one right-to-die activist: “One million people end their lives every year. Ninety-nine percent are tragic. We fight for the remaining one percent.” While Gandsman aims to bring nuances to the distinction between irrational and rational suicides made by the right-to-die movement, he recognizes that the history of the movement rests upon this distinction, one that, I argue, delegitimizes suicidal people. For example, in a post on its website titled “Why Medically Assisted Dying Is Not Suicide,” the organization Dying With Dignity Canada (2016, para. 3–5) insists on the importance of dissociating the movement from the stigmatized term suicide, since suicide and assisted suicide (called assisted death) are seen as different realities:

Why is referring to assisted death as “suicide” so inappropriate? One of the best explanations out there comes from a 2012 column by Globe and Mail health writer André Picard. “Suicide is an act of self-harm that is almost always a byproduct of mental illness like schizophrenia or severe depression,” he writes. “This is in no way comparable to hastening death via a methodical, sober process with a number of legal safeguards.” Calling assisted dying “suicide,” he continues, “is a lot like calling surgery a knife attack.” Talk about a vivid analogy. [ . . . ] As a society, we have a duty to respond to tragedies this heart-rending with robust prevention strategies and public awareness campaigns. In addition, while suicide is motivated by feelings of hopelessness, the push for the legalization of medically assisted dying has been driven by hope. Members of our movement want the comfort of knowing that, if worst comes to worst, they will be afforded the choice of a gentle death. Having the option available can help soothe some of the terror and uncertainty that comes with a terminal cancer diagnosis.

In addition to ableism and sanism, the suicidism in this passage is quite clear: Assisted suicide for suicidal people is compared to a “knife attack.” This text aims to construct suicide and assisted death as two totally different entities, from the chaotic versus the “methodical” process, to the “hopelessness” underlying suicide versus the hope of allowing assisted death. In one case, the intervention is seen as almost life-saving (like surgery), even though it paradoxically involves dying, while in the other case, it is considered a form of killing.

This distinction is endorsed not only by activists but also by scholars and proponents of the right to assisted suicide.⁴² I contend that by strongly distinguishing between suicide and assisted suicide and by repudiating the former while approving the latter, the right-to-die movement and discourses reproduce direct and indirect forms of suicidism. Not only do suicidal people remain the outcasts of the movement and of discussions that should be particularly focused on them; their voices are dismissed and invalidated through forms of suicidist epistemic injustices (intertwined with sanism). In sum, as paradoxical as it sounds, by their insistence on the radical difference between suicide and assisted suicide and the ontology on which this distinction rests, right-to-die discourses are among the most powerful somatechnologies of life analyzed in this book, since the entire foundation of the fight for assisted dying is built on delegitimizing suicidality, suicidal people, and their needs. Hence, it is through the negation of the validity of suicidality and the voices of suicidal people, or, in other words, through suicidist violence, that the right-to-die discourses are made possible.

4.4. Cripping Right-to-Die Discourses: Rethinking Access to Assisted Suicide

I argue that in their current forms, the right-to-die movement and discourses on assisted suicide rest upon a problematic ableist/sanist/ageist logic of accommodation for “special populations”—that is, disabled/sick/ill/Mad/old people. It is thought that these populations should be accommodated for their “particular needs” instead of making assisted suicide a truly accessible form of support for all of those who want to die. Rather than building a collective access to assisted suicide, this logic of accommodation for “special needs” rests on the type of binary opposition that crip and queer perspectives may help deconstruct, such as good versus bad suicides, rational versus irrational suicides, prepared versus impulsive suicides, and normal versus abnormal suicides. Queering and cripping assisted suicide also blurs the distinction between valid and invalid reasons for wanting to die and the hierarchies between physical and mental disability/sickness/illness, or “real” versus “false” desires to die. This logic of accommodation also rests on a cisnormative presumption. Cisnormativity is conceptualized here as a broad normative lens that postulates that it is more normal to not initiate a transition or a major transformation of any kind (for example, sex/gender, abilities, and so on; Baril and Trevenen 2014) and that keeping things “natural,” including a natural death rather than a provoked one, is better. In other words, suicidism and compulsory aliveness are deeply rooted in specific forms of cisnormativity that impose a “natural” and “normal” way to die, one aligned with the same way one is born—that is, involuntarily, as discussed in Chapter 2. Queering and transing assisted suicide helps blur those binary categories to conceive death beyond the cisnormative frame of dying naturally and involuntarily. Additionally, cripping and maddening assisted suicide helps us unpack the ableist and sanist presumptions at the roots of the ontology of assisted suicide that fuel this logic of accommodation for “special populations.”

Many authors in critical disability/crip studies, including Margaret Price (2011), Jay Dolmage (2017), and Aimi Hamraie (2017), have offered insightful analyses of the notions of accommodation and access. Although these authors’ reflections about disability, ableism, and accessibility are not intended to be applied to suicidality, suicidism, or the structures surrounding suicide and assisted suicide, my queering, transing, cripping, and maddening lens has led me to think about assisted suicide through the concepts of accommodation and access. In the spirit of the disability justice movement presented in Chapter 3, Hamraie (2017, 13) discusses the importance of “collective access” and “meaningful access” that go beyond questions of accommodation and dis/ability.⁴³ Through an intersectional lens applied to the growing field of “access studies,” Hamraie invites us to consider access as a generative concept for thinking about multiple marginalized identities in terms of gender, class, racialized status, sexuality, or age difference, to name only a few, and the ways that social, political, and legal structures, architectures, policies, and institutions are not designed with these marginalized groups in mind. I believe that access, as a generative and expansive concept, can also be used to rethink assisted suicide with suicidal people in mind.

Disability activists/scholars have shown how not only architecture but the entire world is built by and for able-bodied and able-minded individuals. This reality is what Dolmage (2017, 53), inspired by the notion of “structural racism,” calls a form of “structural ableism” that extends far beyond architectural choices and infiltrates all spheres of life, such as institutions, policies, laws and regulations, social and cultural representations, and interpersonal interactions. Ableism is embedded not only in buildings and their lack of access ramps or elevators but also in various forms of nonaccessible communications, interactions, and relations. This structural ableism can be found at every possible level of society: social, political, legal, economic, medical, and so forth. In such a world, disabled/sick/ill/Mad people repeatedly find themselves in situations of inadequacy or lack and are forced to ask for accommodation to have the same access as everyone else to space (e.g., ramps), culture (e.g., subtitles in movies or plays), or knowledge (e.g., more time to write exams and complete assignments), to name only a few examples. While such accommodations may be seen as excellent measures for providing improved access for disabled/sick/ill/Mad people, they simultaneously demonstrate how everything is designed and thought in a way that excludes them. Dolmage (53) writes:

Accommodation is thought of as something that always needs to be created, something that has a cost. This underlines the inherent inaccessibility of nearly all of society: seemingly, nothing is ever designed to be accessible in the first place. Accessibility itself is an exnomination, a negative or inverse term, existentially second to inaccessibility. [ . . . ] Nothing is inaccessible until the first body can’t access it, demands access to it, or is recognized as not having access.

Dolmage mobilizes various spatial metaphors to critique the logic of accommodation that does not fundamentally contribute to real or meaningful access for disabled/sick/ill/Mad people. One of those metaphors is the term retrofit, a verb and a noun. To retrofit is to add a component to a design or invention that was not included in the original conceptualization and creation. Therefore, a retrofit is an add-on to something preexisting. Dolmage argues that the logic of accommodation is founded on the idea of retrofit/retrofitting—that is, an add-on to a preexisting entity to accommodate the “special needs” of a minority.

While not entirely dismissing the relevance of retrofits or demonizing accommodations crucial to the lives of so many disabled/sick/ill/Mad people, Dolmage rightly points out several limitations and effects of access based on accommodations and retrofits, discussing five important flaws in this logic (2017, 67–97). First, accommodations and retrofits reinforce ableism/sanism because they cast disabled/sick/ill/Mad people as needy or demanding, while simultaneously pedestalizing those who accommodate them (bosses, professors, public policy makers, and so forth), who are perceived as charitable, flexible, and cooperative. Second, the accommodations and retrofits are only temporary solutions, made on a “special basis,” and they must be constantly renewed through lengthy and complicated procedures. The daily life of disabled/sick/ill/Mad people is made difficult, since disability is not holistically embraced but momentarily suppressed by accommodations. Dolmage notes, “When the accommodations that students with disabilities have access to, over and over again, are intended to simply temporarily even the playing field for them in a single class or activity, it is clear that these retrofits are not designed for people to live and thrive with a disability, but rather to temporarily make the disability go away” (70). Third, accommodations and retrofits are built in forms of exceptionality; they must be requested by certain people at certain times, contributing to the marginalization of those deemed to have “special needs,” who require exceptions to the norms. This exceptionality also reinforces the false idea that access issues do not concern everybody, only a minority. Fourth, Dolmage contends that one of the side effects of accommodations and retrofits is that they allow governments, institutions, and able-bodied and abled-minded people to feel good about themselves, yet these temporary solutions prevent them from instigating deeper structural changes that would provide real access to everyone without the necessity of accommodations or retrofits. Dolmage critiques the fact that many forms of accommodation are smokescreens representing politically correct answers for disabled/sick/ill/Mad communities without really transforming structural forms of ableism. Dolmage (76) writes, “Too many retrofits preserve or perpetuate exclusion rather than address it. They are about covering your ass, legally—not about creating anything like real access.” Fifth, accommodations and retrofits have many negative impacts on the groups they are intended to support, including adding undue burden. Dolmage discusses the gatekeeping of accommodation (such as meetings to attend, forms to fill out, or medical certificates to obtain) and the compliance required to benefit from them as well as the attitude of gratitude one is implicitly supposed to have about these accommodations. Dolmage concludes that accommodations and retrofits, while not completely useless, should not be seen as good solutions to access issues. Quite the contrary: They should be a reminder that the places, environments, structures, policies, and regulations requiring those retrofits and accommodations are inaccessible to start with. Dolmage (79) explains, “Too many retrofits do not actually increase access. Further, we must work to decouple the presence of accommodations from the notion of access. Accommodations are accommodations: they cannot promise anything like actual, real access. Finally, when accommodations are present, we need to better understand their true emotional and physical and temporal costs.”

In sum, the goal of accommodations and retrofits is to temporarily erase disability/sickness/illness/madness and assimilate people deemed to have “special needs” into mainstream institutions, structures, architectures, and cultures. I contend that the same is true for suicidality. Prevention campaigns testify to the pervasive conceptualization of suicidality as something pathological that, in an ideal world, would be eradicated entirely. The retrofits in this case, represented through various forms of assisted suicide offered to specific groups of people fitting narrow criteria, also aim to erase suicidality through the ontological script of assisted suicide. Accommodations and retrofits—in this case, assisted suicide for certain populations with “special needs”—allow structural suicidism to go unnoticed and unquestioned, along with compulsory aliveness and the injunction to live and to futurity that make these assisted suicide accommodations necessary in the first place. In societies marked by structural suicidism, suicidist violence, the injunction to live and to futurity, and compulsory aliveness infiltrate every part of existence: laws and regulations on suicide and assisted suicide, political and economic decisions based on national suicide rates, public policies surrounding suicide and assisted suicide, medical/psychiatric health care treatments, social service interventions, professional deontological codes, social understandings of and reactions to suicide and assisted suicide, cultural representations of suicide and assisted suicide, media campaigns, and institutional discourses, to name only a few. In all these spheres, as discussed in Chapter 1, we take for granted that people want to live, and to live as long as possible, and that suicide should never be pursued unless it fits the ontological script of assisted suicide. In other words, societal institutions and structures exclude suicidal people and are designed with the needs of nonsuicidal people in mind.

In the spirit of Dolmage’s theorizing regarding the five limits to the logic of accommodation in relation to disability, I argue that the same limits apply when it comes to suicidality. First, those requesting assisted suicide are cast as needy or demanding, while politicians, policy makers, doctors, or other health care professionals who allow or perform assisted suicide are seen as “saviors” and “heroes.” Additionally, suicidal people who fit the ontology of assisted suicide are themselves often cast as brave, in stark contrast with other suicidal people, who are seen as cowards or quitters. Second, assisted suicide for disabled/sick/ill (and sometimes Mad and old) people aims only to erase suicidality in an aseptic form through assisted suicide without addressing the extreme suicidist violence suicidal people face in their daily lives. Third, assisted suicide as a retrofit is based on forms of exceptionalism: Each case of assisted suicide is carefully examined, scrutinized, authorized, or rejected, and compulsory aliveness and the injunction to live and to futurity remain unquestioned. Fourth, assisted suicide as a retrofit allows people to have a clean conscience: Helping people at the end of their lives, supporting people in their death, and providing choices and options in the event of unbearable and irremediable pain and suffering are politically correct answers to demands made by so many citizens and organizations. However, as Dolmage reminds us, such decisions are based more on protecting the decision-makers from potential litigation than on truly providing meaningful access. Fifth, as demonstrated in this chapter, people who are accommodated must comply with rigid criteria, are trapped by forms of gatekeeping, and carry an important burden (temporal, affective, and financial in the many contexts where assisted suicide costs must be privately covered). Dolmage (2017, 93) discusses the concept of “access fatigue,” borrowed from the disability justice movement, to refer to the burden placed on the shoulders of disabled/sick/ill/Mad people who must fight for access. This access fatigue is literally deadly when it comes to access to assisted suicide, as was the case for Adam Maier-Clayton or for some mentally ill participants in Thienpont and colleagues’ (2015) study, who ended their lives by their own means before obtaining authorization or after being rejected.

The question of real and meaningful access, as Hamraie mentions, must also take into consideration intersectionality. Dolmage argues that accommodations are not only difficult to access for most disabled/Mad people but even more inaccessible for those affected by multiple forms of marginalization. This limitation is also the case for access to assisted suicide for groups that live at the intersection of multiple oppressions. As demonstrated in this chapter, assisted suicide remains the “privilege” of a few, usually those who are White, educated, or wealthy. As a retrofit, assisted suicide is inaccessible for the most marginalized: people who cannot afford costly procedures and drugs, who do not have access to the health care system (true of many trans, poor, and racialized people, either because they are refused care, cannot afford care, or prefer not to receive care because it is coupled with violence), who do not have the privilege of education and have difficulty navigating administrative forms and procedures, who are deemed mentally incompetent based on forms of ableism/sanism/ageism, and so forth. In that sense, assisted suicide, as a retrofit and accommodation for “special populations,” does not increase access to support and assistance for suicide, at least not meaningful and collective access. These accommodations also have important costs (temporal, affective, financial, and so forth) that make them even more inaccessible. To return to Lauren Berlant’s (2011, 1) notion of “cruel optimism,” discussed in Chapter 2, it is possible to say that current forms of assisted suicide represent cruel optimism, since they are something that suicidal people, like myself and many suicidal people I know, really want, but they represent an “obstacle to their flourishing,” to reuse Berlant’s words. Indeed, assisted suicide remains out of reach for suicidal people, as the ontology and mechanisms on which assisted suicide is founded aim to repudiate the possibility of suicide itself. Assisted suicide as a form of accommodation constitutes an important part of the violent suicidist system that denies suicidal people credibility, legitimacy, and access to the health care, social services, and support they so desperately need. In that sense, I contend that the various forms of assisted suicide represent “‘technologies of patience’ [and] suspend questions about the cruelty of the now” (Berlant 2011, 28) for suicidal people.

Meaningful access also involves not conceptualizing specific access measures in a simplistic way for certain types of disabilities but imagining how they can benefit multiple groups of people with diverse realities. As Price (2011, 122–123) writes, “For example, while it might be assumed that printed copies of papers are only for people with hearing impairments, in fact they may aid a wide range of people, including those who have difficulty focusing on, remembering, or processing oral language, whether that difficulty stems from fatigue, an illness, AD/HD, or a brain injury.” Similarly, developing a meaningful access to assisted suicide should be seen not as a process relevant only to suicidal people but rather as a practice that has the potential to help numerous individuals who might be suffering in silence but actually do want to live. As demonstrated in Chapter 1, despite good intentions, one of the worst consequences of suicide prevention measures is the silencing of individuals in distress, who are afraid of experiencing the consequences of suicidist violence if they are honest about their desire to die. Real access to assisted suicide would encourage the many people currently suffering in silence, especially those belonging to marginalized groups, to finally talk about their suicidality. In other words, thinking about assisted suicide through a disability justice lens of collective and meaningful access (Hamraie 2017) would have a positive impact on many marginalized communities beyond suicidal people. For example, it would invite various marginalized people to discuss their suicidality or mental health issues more openly. In sum, what could be called the thanatopolitical⁴⁴ potential of the right-to-die movement and discourses for suicidal people, a notion further explored in the next chapter, remains unexploited based on this accommodation logic, which is founded on the individualist ableist/sanist/ageist/suicidist ontology of assisted suicide. A meaningful thanatopolitics, deployed from an intersectional approach and an anti-suicidist perspective, would allow us to think about collective access to assisted suicide with an impact beyond suicidal people. Because access is about everyone.

4.5. Final Words

Whereas the first part of this book focuses on suicide, the second part redirects the focus to assisted suicide. As explained in this chapter, in the right-to-die movement and discourses, assisted suicide has been rethought, reframed, and rebranded with various names that aim to sharply distinguish it from suicidality. Assisted suicide becomes recast as assisted death, medical assistance in dying, and even end-of-life care in an attempt to be everything that suicide is not. Indeed, in its battle to legalize assisted death, the entire foundation and rationale of the right-to-die movement and its discourses are the establishment of clear boundaries between the practice of suicide, often described as reckless, selfish, impulsive, irrational, or hurtful to others, and the practice of assisted death, often described as wise, organized, altruistic, cautious, premeditated, rational, and helpful. In that sense, right-to-die discourses embody biopower and biopolitics in a radical way: the maximization and protection of the life of the population (making live) depend on letting die abject subjects, those deemed as irrecoverable. The queering and transing approach mobilized here helps us not only identify the sociopolitical roots underlying the binary constructions opposing suicide and assisted suicide but also deconstruct them altogether. Indeed, what remains implicit but omnipresent in this chapter is my abandonment of the distinct division between suicide and assisted suicide. From my perspective, suicide and assisted suicide belong to the same category, as they both involve suicide. While one is carried out without support, the other is carried out with the support of the state, the medical system, the family, and so on. The presumption that suicide and assisted suicide belong in different categories is one of the main reasons why critical suicidology and anti-oppressive social movements/fields of study (except the disability/Mad movement, which is largely opposed to it) mostly ignore the questions raised by assisted suicide and why suicidality remains absent from right-to-die discourses, in the best-case scenario, or is used as an “othering” device to lend more legitimacy to assisted suicide, in the worst. In both cases, the realities, preoccupations, needs, hurdles, and forms of violence faced by suicidal people are ignored or, worse, reproduced. As I have argued in this chapter, while suicidist preventionist discourses on suicide, like the ones presented in the first part of this book, constitute somatechnologies of life forcing suicidal people to remain alive, paradoxically, right-to-die discourses represent even more insidious and powerful soma-technologies of life. By promoting a right to die for “special groups” only, anchored in an individualist, ableist/sanist/ageist/suicidist perspective, the right-to-die movement and discourses put forth a logic of accommodation providing a smokescreen for real, meaningful, and collective access to assisted suicide for everyone, and particularly for suicidal people. In that sense, assisted suicide in its current forms could be conceptualized by using the notion of cruel optimism. Through a retrofit vision of adding a right to die only for those who fit specific medical/psychiatric requirements, the right-to-die movement and discourses avoid troubling the entire structural system on which the assisted suicide accommodation is built: suicidism. By doing so, they leave unexamined compulsory aliveness and its various injunctions, including the injunction to live and to futurity imposed on living subjects deemed worthy of being alive and embedded in every level of society. In addition to being neoliberal, individualistic, ableist, sanist, ageist, and suicidist, I believe that the logic of accommodation to which the right-to-die movement and discourses cling represents a missed opportunity to develop a strong intersectional thanatopolitics. While in their current form the right-to-die movement and discourses endorse values that I strongly oppose, I believe that there is an underexploited potential to think about a right to die and assisted suicide from an anti-oppressive approach. Chapters 4 and 5 constitute an invitation to seize this opportunity to rethink assisted suicide through our queering, transing, cripping, and maddening lens.