A leading bioethicist questions the wisdom of legalising assisted dying.
Editor’s note. This appeared at Mercatornet and is reposted with permission.
The Covid-19 virus pandemic is a threat to our physical and mental health and wellbeing, as both individuals and societies.
The euthanasia “virus” pandemic is, likewise, a threat to our physical and mental health and wellbeing, as both individuals and societies. Most seriously, it is a threat to our “human spirit”, the intangible, invisible, immeasurable reality that all of us need to find meaning in life and to make life worth living, that deeply intuitive sense of relatedness or connectedness to all life, especially other people. The “human spirit” does not require a belief in the supernatural. Everyone has a “human spirit”, whether or not they are religious.
Like the Covid-19 virus, euthanasia seems to be contagious, at least in post-modern, Western democracies. (Note: I use the word euthanasia to include medically assisted suicide.) Jurisdiction after jurisdiction has considered or is considering its legalization, although some have expressly rejected it.
From one perspective, this spread is not surprising, because we know that suicide is contagious. In fact, general suicide rates — that is, exclusive of euthanasia — have risen in most and possibly all jurisdictions, which have legalised euthanasia.
As well, there is a well-established pattern, as we have seen in Australia, of pro-euthanasia advocates returning to legislatures and courts, time after time, until they achieve their initial goal of the legalization of euthanasia. Subsequently, as can be seen in the Netherlands, Belgium and, most recently, Canada, pro-euthanasia advocates persistently seek reduction of the requirements for its availability, that is, the initial safeguards, and expansion of the people who may have access to it.
In order to stem the Euthanasia pandemic, those of us who view this as a historic disaster and human tragedy must understand how it has arisen and where it is going. To do that we need to ask and seek answers to a multitude of questions. I can only very briefly mention a few of them here. I have spent over four decades researching and writing on them and still have many to address and new ones constantly emerge. We can think of this research as searching for an “anti-euthanasia vaccine”.
Before I do that, however, I want to emphasize that the people on both sides of the euthanasia debate are well intentioned and believe they are fighting for the greater good, it is just that we do not agree on what that is.
None of us on either side wants to see people suffer and the euthanasia debate is not about if we will die – we all will at some point. The debate is about how we will die and whether some ways of dying, namely euthanasia, are unethical and dangerous, especially to vulnerable and fragile people, and destructive of important shared values on which we base our societies.
We need to start our exploration of the euthanasia pandemic by asking the many questions, which could provide us with insights that will lead to understanding why the euthanasia pandemic has erupted and how we might deal with it. In the rest of this essay, I identify some of those questions.
Why now do people support legalizing euthanasia?
People have always become ill, suffered and died and, for millennia, our laws have expressly and clearly prohibited killing them, especially having doctors, who promise in their Hippocratic Oath “to cure where possible, care always and never to intentionally kill”, doing so. So why now, when there is so much more we can do to relieve pain and suffering, is euthanasia thought to be necessary and a good idea?
There is a perfect storm of causes functioning at all the levels of decision-making from that of individuals in relation to their own experience of suffering, to that of governments formulating health, social and public policy.
In post-modern societies, so-called “progressive values” have become ubiquitous. These values favour legalizing euthanasia and dominate the more traditional or conservative values, which oppose that. The progressive values advocates’ mantra is, “control, choice, change”.
Control. In the context of euthanasia, control translates to taking control of death. We cannot avoid death, but euthanasia allows a person to get it before it gets them. This eliminates uncertainty about the time, place and manner of death. It is psychologically difficult to live with uncertainty about outcomes that we dread, including because we do not know which psychological coping mechanisms we need to employ to deal with the fear we experience.
Taking control is what social psychologists call a “terror-reduction” or “terror management” device. Intense fear of death can be linked to a fear of mystery, the latter of which evokes profound free-floating anxiety. People who experience this can deal with their fear and anxiety by converting the mystery to a problem and seeking a technological solution to the problem. The mystery of death becomes the problem of death and the technological solution is a lethal injection – euthanasia.
Choice. Advocates justify euthanasia by claiming a right to choose to end one’s life, an overriding right to individual autonomy. “Intense or radical individualism” means the right to self-determination is given priority over any other considerations, such as what protecting the “common good” requires or the risks and harm to vulnerable people, such as fragile elderly people or those with disabilities. These harms include that euthanasia sends a message to them that they have “lives not worth living”.
Change. To have control and be able to choose death, the law must be changed to permit euthanasia.
Why has the pro-euthanasia case been so successful and the anti-euthanasia case so unsuccessful? *
The case for legalizing euthanasia is easy to make in contemporary post-modern Western democracies, especially those in which moral relativism and utilitarianism are the main philosophies informing the dominant worldview of a society.
Moral relativism takes a stance that nothing is absolutely or inherently wrong, rather what is right or wrong all depends on the circumstances and the individual person’s preferences. Utilitarianism in the context of euthanasia proposes that euthanasia is a means that has an outcome or end goal of reducing suffering and, therefore, can be justified and is ethical. The discussion and analysis of the impact of legalizing euthanasia is limited to only the present time – I call this restriction “presentism” – and its impact on the individual person who seeks it. What we could learn from our “collective human memory” (the past or history) and through employing our “collective human imagination” (the likely future outcomes of legalizing euthanasia) are ignored or rejected as irrelevant or invalid considerations.
The pro-euthanasia case is promoted and buttressed by stories of “bad” natural deaths – those where great suffering is experienced – and “good” euthanasia deaths – those where suffering is promptly and completely eradicated through the intentional extinguishing of life with euthanasia. The media, which overall has a bias towards legalizing euthanasia, are especially prone to presenting euthanasia as a topic for discussion in the public square in this manner, that is, with a focus on an individual suffering person and only taking into account the immediate impact in the present of providing that person with euthanasia.
The case against euthanasia is much more difficult to promote, not because it is weak – it is not – but because it is much more complex.
To convince people who do not believe that euthanasia is inherently wrong to reject it, requires looking, not just to the present, but also to our “collective human memory” for lessons from the past and to our “collective human imagination” to try to anticipate the full, wider and long-term consequences of legalizing euthanasia. Aboriginal and Torres Strait Islander people have much to teach us in these regards.
While the individual person and their wishes and respect for their right to autonomy are always important considerations, they are not alone sufficient, if we are to make wise decisions as a society with respect to the legalization of euthanasia or, if legalized, its governance. That requires, for example, taking into account the immediate and long-term, wider ramifications of authorizing physicians, and in some cases nurses, to end the life of another person through administering lethal medications with a primary intention to cause death.
These ramifications include the effects on healthcare professionals and the healthcare professions; on the institutions in which they practice, such as hospitals and aged care homes; on society and the shared values on which it is based and which create the glue that bonds us as a community; and even on our global reality. There is a dearth of literature in these regards. The 2021 book, The Other Side of Euthanasia, referred to above, recounting stories from frontline healthcare professionals in Belgium where euthanasia has been normalized as a way to die, makes an important contribution to starting to fill these lacunae.
Of particular concern in relation to the wider impact of legalizing euthanasia is the possibility of its being “thrust on” or “seeping into” the lives of fragile and vulnerable people – those who are poor, uneducated, or least vocal. For example, doctors in Belgium have admitted to euthanizing people in a coma on a ventilator, without any family present to defend their best interests. We cannot afford to trivialize or underestimate the dangers of the abuse of legalized euthanasia.
We must also keep in mind that in a secular society, such as Australia, law and medicine carry the value of respect for life for society as a whole. Euthanasia destroys their capacity to do that because the law is changed to allow intentionally taking life and medicine implements that permission in practice. If euthanasia is legal, it should be kept out of medicine and a new profession created to undertake it. Euthanasia is not medical treatment and it should have no role in palliative care. Indeed, the philosophical bases of palliative care – to live as well as possible until we die a natural death – and euthanasia – to choose death, rather than life – are in direct conflict.
It is also essential to recognize that the value of respect for life must be upheld at two levels: for the life of each individual person and for human life, in general, in society. Euthanasia damages respect for life at both these levels.
Good facts are essential for good ethics and good ethics for good law. This means we must ask, what are the correct facts about euthanasia?
Are pro-euthanasia advocates correct that euthanasia will be rarely used and there is no danger of “slippery slopes”?
Euthanasia advocates often propose that euthanasia will be rarely used and only as a last resort. Let us look at some recent Canadian statistics: “As of April 30, 2021 there has been 7549 reported assisted deaths in Ontario since legalization [in June 2016]. 7547 were euthanasia deaths (lethal injection) and 2 were assisted suicide deaths (lethal prescription)”.
This is very important information that cries out for in-depth research. What could this astonishing disparity in numbers between euthanasia and assisted suicide tell us? It is noteworthy that, so far, in the American states, which have legalised physician-assisted suicide, but have not allowed euthanasia, the number of such suicides are orders of magnitude below the Canadian statistics.
Might the explanation for the high Canadian numbers include that euthanasia masquerades as medical treatment and we trust doctors and assume they are acting ethically and only doing good? To wisely judge the acceptability of euthanasia, we must take the medical cloak off it.
Then there are the claims of pro-euthanasia advocates that legalizing euthanasia does not open up “slippery slopes”. Let us look again at Canada’s experience:
“The number of assisted deaths has been continually increasing in Ontario. There was a 33% increase in 2020 with 2378 reported assisted deaths, up from 1789 in 2019, 1499 in 2018, 841 in 2017, and 189 in 2016. Euthanasia was legalized in June 2016. Ontario euthanasia deaths have increased, in spite of COVID lock-down. …[There have been] 24,000 estimated assisted deaths in Canada since legalization”.
Again, these statistics show that euthanasia will not be used only rarely and is very quickly normalized, that is, the number of cases of euthanasia that occur once it is legalized, rapidly increase in a very short time.
This is not surprising. Once we step over the clear line that we must not intentionally inflict death, there is no logical stopping point. Currently around 5 percent of deaths in Belgium are by euthanasia, it is predicted that this number will increase to 25 percent within a few years.
The normalization of euthanasia and its frequent use, also opens up the unavoidable “logical slippery slope”, that is, once euthanasia is legalized the situations in which it is available and the people who may access it rapidly expand. Indeed, there is now discussion in Canada whether all restrictions on access to euthanasia should be abandoned. The argument is that the justification for euthanasia is respect for the individual’s right to autonomy and self-determination and this should not be limited. We can also see this justification being put forward in the Netherlands where the government is considering proposals that being “over 70 years of age and tired of life” or feeling that one has “a completed life” can be sufficient grounds to provide the person with access to euthanasia.
The pattern is that legislators who first approve euthanasia do so with “strict safeguards”, but these are quickly dropped and the people who can have access and in what conditions are greatly expanded.
As is already the case in the Benelux countries, Canada has now deleted from the MAiD (Medical Aid in Dying) legislation a requirement that “death be reasonably foreseeable”, on the grounds that it discriminates against people with serious disabilities, who are not terminally ill and want euthanasia. Canada is also legislating to allow people with early dementia to give advanced directives consenting to euthanasia to be carried out when they are incompetent to consent. In two years’, time, it will also allow people with serious mental illness, but no physical illness, to access euthanasia.
As American psychiatrist Dr. Mark Komrad commented, “The proper role of a psychiatrist is to prevent suicide, not to provide it”. Moreover, some children will have access to euthanasia and a group of healthcare professionals at the renowned Toronto “Sick Kids” hospital has already published a protocol, which could govern this.
Examples of the “practical slippery slope”, that is, once euthanasia is legalized it is provided not in accordance with the law, are legion. One study of doctors in the Flanders region of Belgium who had euthanized patients found that, by their own admission, 32 percent had done so on at least one occasion not in accordance with the law. When this evidence is presented in other jurisdictions pro-euthanasia judges and politicians reject its relevance to their jurisdiction, by claiming that “our doctors are not like Belgium doctors”.
In summary, even though we might have lost the battle against legalizing euthanasia, our work is not over. We must now work to prevent its expansion and abuse.
Why is euthanasia euphemized?
In short, I believe it is because people do not want to face the reality of what is being done, intentionally killing a human being. We have natural inhibitions against killing other humans. Advocates of euthanasia even object to the words “assisted suicide”, arguing physician-assisted death is not suicide, and to euthanasia, saying it has harmful connotations and associations. They use terms such as Voluntary Assisted Dying (Victoria) or Medical Assistance in Dying (Canada) and reduce those to acronyms VAD and MAiD respectively, which have even less negative emotional impact. In the same vein of whitewashing what is involved, they speak of euthanasia as “the final act of good palliative care”.
Words, descriptions and labels matter. They activate or suppress many of our “human ways of knowing”, such as examined emotions, moral intuition, experiential knowledge and common sense, that recent research shows play an important role in decisions about ethics. Our choice of words is closely linked to whether we activate, what physician-ethicist Dr. Leon Kass called the “wisdom of repugnance” to guide us.
Consequently, to argue, as I have on occasion, that “we cannot afford to have doctors killing their patients”, evokes a storm of outraged protest from pro-euthanasia advocates. However, if that is not what euthanasia involves, what does it involve?
Likewise, any mention of what we might learn from the Nazi doctors and the warnings that history (human memory) can provide triggers furious opposition. This is the case, even when one can show articles in the New York Times in the early 1930s describing the introduction of euthanasia by the Third Reich in Germany, which recount eerily similar justifications of euthanasia to those put forward today by the pro-euthanasia advocates. (See, for example, “Nazis Plan to Incurables to End Pain: German Religious Groups Oppose Move”, NYT 8 October 1933.)
Then the media’s role in promoting euthanasia through its “woke washing” of words and the ubiquitous post-truth reality of the early 21st century must be taken into account.
Recently I published an article hoping it might cause people to think differently about what euthanasia involves. The question I addressed was “Why, if one agrees with euthanasia, would they not support carrying it out by giving the person a general anaesthetic and removing their vital organs – heart, liver, lungs – for transplantation”?
Currently, 25 percent of lung transplants in Belgium are from euthanized donors and Canada uses such donors with their consent. In fact, it is reported that Ontario doctors notify the Ontario transplant authority in advance of planned euthanasias and the authority’s representatives call the patient – or family – to ask for consent to donating their organs.
In these cases, the person is first euthanized and then, after they die, the organs are taken. In my article, I questioned why combining euthanasia and organ donation into the same act, that is, giving the person a general anaesthetic and carrying out the euthanasia by removal of their vital organs, which results in more viable organs, was not employed. Many people, including those who support euthanasia, reacted very negatively to my suggestion and I explored the possible reasons for their reaction. They included that it would make organ donation seem horrific and cause people to reject donating their own organs after death.
I believe it was also that it causes us to we see directly, “unsugar-coated”, what euthanasia involves – doctors killing their patients.
Why have so many politicians voted in favour of euthanasia?
We hear constantly that polls show that a sizeable majority of the public want euthanasia to be legalized and politicians might be trying to win these people’s votes. Whether the members of the public understand what they are agreeing to in supporting euthanasia is a further question, because surveys have shown that often they hold a mistaken belief that refusing life support treatment or its withdrawal or providing necessary pain or suffering management are euthanasia and, as we all do, they want these to be available. However, they are not euthanasia and are already legal and, appropriately used with no primary intention to cause death, are ethical, indeed, ethically required treatment.
Politicians are often reluctant to have to deal with matters that involve conscience and, for some people, religious belief, and when they must deal with these matters, they want to get rid of them quickly and with the least conflict and publicity possible, especially if an election is looming.
Might they just “read the wind” and, if the polls show voters want legalized euthanasia and its legalization seems highly likely, they just go along with that, whatever their personal values?
All postmodern Western nations are currently in a period of uncertainty about the nature and sustainability of flourishing democracy and, hence, of the ethical basis on which political decisions should be made, especially when they involve fundamental shared values on which these societies are based, such as respect for human life.
In the final section, I will suggest some possibilities regarding what we might be able to do to limit or discourage the use or extension of legalized euthanasia.
If euthanasia is legal, our goal must be to reduce to the minimum the number of people requesting it. In order to achieve that, we need to understand the reasons for their requests and to find ways to make those reasons no longer important to them. We also need to try to prevent extensions of the people who may access euthanasia and the abolition of safeguards, which restrict access.
Why do people ask for euthanasia?
Many people believe that pain is the most common reason that people ask for euthanasia, but pain is well down the list.
The three most common reasons are feelings of loss of dignity, loss of independence and of being a burden on others. Palliative care research shows many ways to change these feelings. For example, Dr. Harvey Max Chochinov, a Canadian psychiatrist specializing in the care of terminally ill patients has developed a psychotherapeutic intervention called “dignity therapy”.
In a book of that name, he explains how helping the terminally ill person to review and record their life story to leave as a record for future generations of their family gives them back a sense of their own worth and hope, through eliciting a feeling that something of themselves will have a presence in the future.
Hope requires a sense of connection to the future. Hope is the oxygen of the human spirit. Without it our spirit dies, with it we can overcome even seemingly insurmountable obstacles. Dying people cannot have long-term hopes, but they can be given mini-hopes that make life worth living.
How can we help dying people find a ‘why to live’?
Dr. Chochinov speaks of a psychological state he calls “hopelessness” as being the trigger for the person seeking medical assistance to end their life. Professor David Kissane, an Australian specialist palliative care psychiatrist, has identified a similar condition he calls “demoralization” with its accompanying loss of the will to live, as having the same effect of triggering requests for euthanasia.
These findings are consistent with the powerful insight of Nazi Concentration Camp survivor, Victor Frankl, who famously said when asked how he helped other inmates to survive, “If you can give people a why to live, they can find a how”.
We all need to have hope and be able to find meaning in life, even when we are dying, indeed, especially when we are dying, if we are to have a “good death”. Euthanasia does not provide this, rather it eliminates the person and with that the possibility of finding hope and meaning. Helping dying people to find hope and meaning can be difficult and requires skilled carers interacting with both the dying person and their loved ones, which is one reason easy access to high quality palliative care is such an important safeguard against people choosing euthanasia.
What is the impact of ‘time compression’ on how we die?
We live in a world in which we expect instantaneous outcomes; we are not prepared to watch and wait. We have moved from primarily seeing ourselves as “human beings”, grateful for being alive, to becoming “human doings”, obsessed with what we can achieve in the shortest possible time. However, some experiences cannot be time compressed without destroying their essence. As the book, Euthanasia: Searching for the Full Story, powerfully demonstrates, dying is such an experience and not just for the dying person, but also for those who love them.
Who suffers when a loved one is dying?
When a loved one is dying, not only the dying person can suffer, but also those close to them. Much of the patient’s suffering can be ameliorated with fully adequate palliative care and even those who have asked for euthanasia may change their minds in that regard, when provided with such care.
It is appalling that a very large percentage of people, who need and could benefit from palliative care, do not have access to it – for example, studies have shown that is true for up to 70 percent of such people in Canada and, likewise, Australia. Especially if we believe that legalizing euthanasia is a terrible mistake, we must work to make high quality palliative care readily available.
Without access to good palliative care, accompanying a dying loved one can be a very traumatic experience, especially if they are in serious pain and there is poor pain management. It is easy to imagine that euthanasia could seem an attractive option in such circumstances. To remedy this situation, in 2010 the Declaration of Montreal was promulgated at a meeting of the International Association for the Study of Pain (IASP). It provides that for a healthcare professional knowingly and unreasonably to leave a patient in serious pain is a breach of fundamental human rights. The World Health Organisation and the World Medical Association have endorsed this approach, as have many national Pain Societies, including Pain Australia.
Despite how it is described by its advocates, euthanasia does not necessarily avoid the problem of the suffering of loved ones of the dying person. Accompanying a person we love who is dying through euthanasia can also be a very traumatic experience as I have witnessed first-hand.
I have a friend in Toronto whose long-term partner, a specialist physician, was diagnosed with inoperable metastasized cancer. He arranged for a physician friend to euthanize him only days after receiving this diagnosis. She and I were having lunch in a busy Bistro and she started to speak of her partner and his death. Suddenly she burst into uncontrollable sobs and kept repeating, “It was horrible, it was horrible! I couldn’t stay with him! I ran out of the room!”. I was shocked, because she is a highly respected professional woman, known for her strong emotional control in difficult circumstances, and is adamantly secular. She was clearly deeply traumatised by witnessing the euthanasia of her partner. The book referred to above, Euthanasia: Searching for the Full Story, recounts many similar narratives.
Why is it important to recognise the potentiality of euthanasia?
The potentiality of legalizing euthanasia requires that we consider what kind of world we will have left for future generations. Might it be one in which no reasonable person would want to live? What message does legalizing euthanasia send to vulnerable people – fragile elderly people and people with disabilities? It is that they have “lives not worth living” or, even more reprehensibly, that they, themselves, do not have any worth?
Paradoxically, euthanasia tells them that they lack dignity, when the pro-euthanasia case is that euthanasia is necessary to respect their dignity.
How will euthanasia affect healthcare institutions and professionals? We already know that many are psychologically traumatised by carrying it out, some developing PTSD. The Dutch Medical Society has recognised this problem and recommended, where possible, the use of assisted suicide, rather than euthanasia.
There has been a massive increase in Belgium in the use of “terminal sedation” (sometimes called “slow euthanasia”), where the patient is permanently deeply sedated until they die. (“Terminal sedation” needs to be distinguished from “palliative sedation” which is justified pain and symptom management, when means other than sedation are not sufficient, and there is no primary intention to shorten life.)
Moreover, what about respect for freedom of conscience of healthcare professionals and institutions, who believe euthanasia is unethical? This is a major field of conflict among a wide variety of people and institutions.
A momentous decision
I have been pondering a great deal lately about what we can do about stopping the “euthanasia virus” pandemic. What would vaccinate us, as both individuals and societies, against it? I have concluded that it is useless saying it is wrong or unethical or even dangerous and that we need a completely different approach, including along the lines of what we have to lose as individuals and societies by legalizing it.
Euthanasia is a very complex issue in terms of the forces that have led to the current situation, including such small yet hugely impactful changes as “time compression” – we expect everything to be instant. Applied to natural dying, which can take an extended period, euthanasia is the “quick fix”. I believe that the overall societal Zeitgeist has activated the push for legalized euthanasia and we have to change that Zeitgeist if we think, as I do, that legalizing euthanasia is a very, very bad idea.
I have written elsewhere that one step we need to take in order to move in that direction is to recover our sense of “amazement, wonder and awe” about both ourselves and our world. I believe that this experience will help to guide us ethically regarding what we should and most importantly should not do and the latter includes legalizing euthanasia.
I predict that History will see the decision whether to legalize euthanasia, as one of the two most momentous values decisions of the first half of the 21st Century. (The other decision is whether to allow the use of new molecular biology and genetic science and technologies to design our children and all their descendants, through alteration of the human germ line.) We need a new iteration of the old virtue of prudence, which can be re-named “wise ethical restraint”.
For all our sakes, both those who are dying and those who are not yet dying, we must kill the pain and suffering of dying people, not the dying people with the pain and suffering.
* This section is an edited version of Margaret Somerville and E Wesley Ely, Forward 2, in Timothy Devos, Editor, Euthanasia: Searching for the Full Story: Experiences and Insights of Belgian Doctors and Nurses, Springer Cham, Switzerland 2020 pp. ix –xv. The online edition is available free of charge.
An earlier version of this essay appeared in Eureka Street.