Similarly, Velleman argues, establishing a 'right to die' (as per physician-assisted suicide or voluntary euthanasia) replaces the option of staying alive by default with the significantly different option of explicitly choosing to stay alive. Velleman continues:
[I]f others regard you as choosing a state of affairs, they will hold you responsible for it; and if they hold you responsible for a state of affairs, they can ask you to justify it. Hence if people ever come to regard you as existing by choice, they may expect you to justify you continued existence. If your daily arrival in the office is interpreted as meaning that you have once again declined to kill yourself, you may feel obliged to arrive with an answer to the question, "Why not?"
There's something intuitively distressing about this, though it's surprisingly difficult to pin down. After all, isn't it a good thing to conform one's actions to what's justified? I see two potential worries here. Firstly, demands for justification can be experienced as burdensome in a way that threatens to suck the joy and value out of life if they become too ubiquitous. But perhaps situations of terminal illness and the like are sufficiently rare and high-stakes that moral mindfulness here would be justified on rule utilitarian grounds.
The second concern, and Velleman's main worry, is that others might respond unreasonably in ways that change what the terminally ill patient has most reason to do. Suppose that the patient could still find value in his continued existence, so long as he could continue to interact with his friends and family in a happy and dignified manner. "Unfortunately," Velleman says, "our culture is extremely hostile to any attempt at justifying an existence of passivity and dependence."
[The patient] can therefore assume that his refusal to take the option of euthanasia will threaten his standing as a rational person in the eyes of friends and family, thereby threatening the very things that make his life worthwhile. This patient may rationally judge that he's better off taking the option of euthanasia, even though he would have been best off not having the option at all.
A curious thing about this argument is that it seemingly depends upon most people rejecting it. If everyone shared Velleman's positive attitude towards care-dependent life, then there would be no such problem of misguided social pressure to worry about. On the other hand, those who consider the terminal patient unjustified in extending his life might not be so bothered by the outcome of his feeling pressured towards doing what is (by their lights) the right thing.
Or would they? Matters are complicated by the fact that the (dis)value of the outcome is massively dependent upon the patient's attitudes. So, even if it would be best if the patient were happy to die now -- leaving more resources for his grandkids' college funds, or for other citizens with curable health problems -- our preference ordering might change upon learning that the patient isn't yet ready to die. For we may plausibly think that it's so egregiously bad for a person to feel pressured into a premature death (whether from social pressure or an alienating sense of 'duty') that this disvalue outweighs the costs of continued terminal care.
This seems pretty plausible to me. No loving family could possibly want Grandma to die before she was ready, just to save a few lousy bucks. On the other hand, if she has gotten all that she can out of life, and cares deeply about providing her descendants with the opportunity for a better life, then she might quite reasonably prefer to die now rather than deplete her grandchildren's college funds -- even if her experience is still intrinsically pleasant enough (such that she would have happily continued it a bit longer if there had been no such cost to doing so).
Such an attitude seems entirely admirable, and even perhaps 'ideal'. But if we acknowledge this, it leaves us in the awkward position of seeming critical of the terminal patient who clings to life, and hence of potentially depriving them of the respect that makes their life still worth living at all. Tricky. (Though this problem doesn't seem altogether inevitable, given that an ideal may be supererogatory, not 'required' or expected.)
Then again, the assumption that continued existence is a "given" seems so deeply ingrained in our ordinary thoughts that Velleman's worries may well be moot. Even if our political institutions introduced a 'right to die', would that really make it such a live question that we would come to reconceptualize of living as an explicit 'choice' that needed to be justified? The default expectation may persist even as alternative options are provided for those who want them.
P.S. It is said that old Eskimos, when they felt their time had come, would go for a "long walk" out into the snow. Does this alternative cultural expectation seem worse? Would it likely be experienced by many as a burdensome, alien 'duty' as they approached old age? Or, if internalized to seem an entirely appropriate and even welcome way to conclude one's life, might it even be more dignified than the drawn-out hospitalized endings more common in our culture?
When considering this topic, it does seem essential to ask both:
(1) What is the best option now, holding fixed local attitudes towards death?
(2) What would be the best attitudes towards death for a society to inculcate?