Assisted dying and the cult of kindness

I witnessed an assisted death. We need to be honest in the debate about it.

Matthew Hall

Matthew is an author and screenwriter.

A tableau shows minature figures of two people, one sitting on a life size syringe and the other stands

Etactics Inc on Unsplash.

The Assisted Dying Bill is likely to be passed into law this autumn, the government having promised to ‘rush it through’. The debate will invariably be conducted in a fog of euphemistic language in which ‘compassion’ and ‘dignity’ will feature heavily on both sides, while the main point is likely to be missed: the legalisation of euthanasia or AD, marks a tectonic shift from a Christian to a post-Christian society and should be a wake-up moment for dozing Christians.

I was recently present when my aunt, an artist who had become a Canadian citizen, died by euthanasia in her own home while in the very early stages of motor neurone disease. She was 72, divorced, living independently, fully mobile (although she had lost the use of one arm) and was laughing and joking up to the moments before the doctor (or ‘The Killer’ as her son called him) injected the first dose of the lethal cocktail. It happened at 7pm on a Tuesday evening. She had made the phone call requesting her death at 3pm the previous Sunday – yes, a Sunday. Service of a kind our NHS can only dream of.

As a reluctant witness to what I consider a murder-suicide, I was nevertheless beguiled by the relatively clean ending (although there was some disturbing gurgling that apparently occurs as a result of the lungs filling with fluid) to a life that was about to become very difficult. Her two older siblings, including my mother, are each currently several years into slow deaths from combined Parkinson’s and dementia.

I am an almost daily visitor and a secondary carer to my mother, and while she is mute, benign and seemingly contented, the toll on my stepfather and on me is enormous. I often pray for it all to be over – it’s an endless grind and her former self would be utterly horrified to see herself this way! – and yet, as a Christian, I have to see purpose in it. One thing it certainly does do, is force carers to be selfless and compassionate in the strict sense of the word, which is ‘to suffer with’.

Her decision to die was the ultimate consumer choice – she availed herself of a service that promised to free her from her ailing body as quickly and comfortably as possible.

Get updates

My aunt didn’t want the trial of becoming ill and dependent, and the Canadian government gave her an opt-out which she grabbed the instant she received her diagnosis. Confirmation by two doctors that she was terminally ill and of sound mind – almost a trifling formality – got her immediate approval. She was, to use her kind of language, ‘out of here’ a mere three months later.

How could she have been so cavalier and determined to die, despite the protests of her son, nephew and granddaughters? She was, in hindsight, a perfectly minted product of the 1960s who believed above all in doing her own thing - whatever felt right. Such notions were anathema to her Christian parents and their dutiful wartime generation but are now the norm.

Like many who came of age to the sound of the Beatles, she toured the spiritual supermarket and picked out the nice bits from Christian, pagan and Eastern religions – predominantly those that allow you to think that life is about ‘being in tune’ or feeling good about yourself. This did most definitely not include becoming immobile and having strangers change her nappy. She believed in an afterlife, ‘love’, aliens and reincarnation but definitely not in judgement or consequences for her suicide.

Her decision to die was the ultimate consumer choice – she availed herself of a service that promised to free her from her ailing body as quickly and comfortably as possible, with the added bonus of leaving her assets to her family.

The truth, as the Canadian experience demonstrates, is that AD is not a slippery slope but a cliff edge.

Polls in Canada and the UK show that the vast majority would consider this a win all round. According to Opinium, 75 per cent of British adults support AD. In political terms this a ‘bridge issue’ almost without comparison, uniting 78 per cent of Conservatives with 77 per cent of Labour supporters, yet no issue should more starkly dramatise the unbridgeable chasm between Christian and secular world views.

The sharpness of this divide has, however, been successfully obscured by the insidious (and to my mind, diabolical) Cult of Kindness that has inveigled itself into both secular and Christian space. Imitating Christian virtues, it subverts them by subtly perverting language - by using ‘compassion’ when what is meant is ‘convenience’, for example – and by making ‘happiness’ rather than self-sacrifice the highest good. This leads both sides into dishonesty and self-delusion.

The biggest pro-AD lie is that it is merely an escape route for the tiny few facing the most intolerable suffering with no additional consequences. The truth, as the Canadian experience demonstrates, is that AD is not a slippery slope but a cliff edge. It is now the fifth most common cause of death and climbing by 30 per cent each year. Every seriously ill Canadian now feels some pressure to address the option. Cases of people choosing AD out of despair, depression or at the suggestion of a lazy or uncaring State official are already numerous. Those who have signed an advance consent waiver setting a date for their euthanasia in the event of their mentally incapacity, are now being terminated. In some cases, the demented refuse to cooperate and are euthanised under forced sedation. The State is already saving money and families are saving their inheritances. Life itself has been downgraded.

The Christian side indulges in even bigger untruths. Windy episcopal speeches about advances in palliative care avoid the hard fact that denying AD involves many suffering prolonged and painful deaths while family finances are destroyed and carers worn down to a husk. The pill can’t be sugared: thou shalt not kill is absolute, not an invitation for an ethical discussion. The point is so fundamental that to avoid it and be drawn into discussing the minutiae of legislation is a betrayal of the faith.

Christians won’t save the secular world from AD and its consequences, but the current debate is an opportunity for honesty and for Christians to save themselves from the delusion that the true virtue of compassion can be inverted to justify killing.

The Christian religion began with an agonising death of a kind which its scriptures exhorts its followers not to fear. It’s a tough message: God doesn’t promise the comfort we would like in this life. We do have the means and the duty to alleviate much suffering, but death as a consumer choice is simply off the table.

Article

Assisted dying

Care

Culture

Death & life

13 November 2024

8 min read

The deceptive appeal of assisted dying changes medical practice

In Canada the moral ethos of medicine has shifted dramatically.

Ewan Goligher

Ewan is a physician practising in Toronto, Canada.

a doctor consults a tablet against the backdrop of a Canadian flag.

Once again, the UK parliament is set to debate the question of legalizing euthanasia (a traditional term for physician-assisted death). Political conditions appear to be conducive to the legalization of this technological approach to managing death. The case for assisted death appears deceptively simple—it’s about compassion, respect, empowerment, freedom from suffering. Who can oppose such positive goals? Yet, writing from Canada, I can only warn of the ways in which the embrace of physician-assisted death will fundamentally change the practice of medicine. Reflecting on the last 10 years of our experience, two themes stick out to me—pressure, and self-deception.

I still remember quite distinctly the day that it dawned on me that the moral ethos of medicine in Canada was shifting dramatically. Traditionally, respect for the sacredness of the patient’s life and a corresponding absolute prohibition on deliberately causing the death of a patient were widely seen as essential hallmarks of a virtuous physician. Suddenly, in a 180 degree ethical turn, a willingness to intentionally cause the death of a patient was now seen as the hallmark of patient-centered doctor. A willingness to cause the patient’s death was a sign of compassion and even purported self-sacrifice in that one would put the patient’s desires and values ahead of their own. Those of us who continued to insist on the wrongness of deliberately causing death would now be seen as moral outliers, barriers to the well-being and dignity of our patients. We were tolerated to some extent, and mainly out of a sense of collegiality. But we were also a source of slight embarrassment. Nobody really wanted to debate the question with us; the question was settled without debate.

Yet there was no denying the way that pressure was brought to bear, in ways subtle and overt, to participate in the new assisted death regime. We humans are unavoidably moral creatures, and when we come to believe that something is good, we see ourselves and others as having an obligation to support it. We have a hard time accepting those who refuse to join us. Such was the case with assisted death. With the loudest and most strident voices in the Canadian medical profession embracing assisted death as a high and unquestioned moral good, refusal to participate in assisted death could not be fully tolerated.

We deceive ourselves if we think that doctors have fully accepted that euthanasia is ethical when only very few are actually willing to administer it.

Regulators in Ontario and Nova Scotia (two Canadian provinces) stipulated that physicians who were unwilling to perform the death procedure must make an effective referral to a willing “provider”. Although the Supreme Court decision made it clear in their decision to strike down the criminal prohibition against physician-assisted death that no particular physician was under any obligation to provide the procedure, the regulators chose to enforce participation by way of this effective referral requirement. After all, this was the only way to normalize this new practice. Doctors don't ordinarily refuse to refer their patients for medically necessary procedures; if assisted death was understood to be a medically necessary good, then an unwillingness to make such referral could not be tolerated.

And this form of pressure brings us to the pattern of deception. First, it is deceptive to suggest that an effective referral to a willing provider confers no moral culpability on the referring physician for the death of the patient. Those of us who objected to referring the patient were told that like Pilate, we could wash our hands of the patient’s death by passing them along to someone else who had the courage to do the deed. Yet the same regulators clearly prohibited referral for female genital mutilation. They therefore seemed to understand the moral responsibility attached to an effective referral. Such glaring inconsistencies about the moral significance of a referral suggests that when they claimed that a referral avoided culpability for death by euthanasia, they were deceiving themselves and us.

The very need for a referral system signifies another self-deception. Doctors normally make referrals only when an assessment or procedure lies outside their technical expertise. In the case of assisted death, every physician has the requisite technical expertise to cause death. There is nothing at all complicated or difficult or specialized about assessing euthanasia eligibility criteria or the sequential administration of toxic doses of midazolam, propofol, rocuronium, and lidocaine. The fact that the vast majority of physicians are unwilling to perform this procedure entails that moral objection to participation in assisted death remains widespread in the medical profession. The referral mechanism is for physicians who are “uncomfortable” in performing the procedure; they can send the patient to someone else more comfortable. But to be comfortable in this case is to be “morally comfortable”, not “technically comfortable”. We deceive ourselves if we think that doctors have fully accepted that euthanasia is ethical when only very few are actually willing to administer it.

We deceived ourselves into thinking that assisted death is a medical therapy for a medical problem, when in fact it is an existential therapy for a spiritual problem.

There is also self-deception with respect to the cause of death. In Canada, when a patient dies by doctor-assisted death, the person completing the death certificate is required to record the cause of death as the reason that the patient requested euthanasia, not the act of euthanasia per se. This must lead to all sorts of moments of absurdity for physicians completing death certificates—do patients really die from advanced osteoarthritis? (one of the many reasons patients have sought and obtained euthanasia). I suspect that this practice is intended to shield those who perform euthanasia from any long-term legal liability should the law be reversed. But if medicine, medical progress, and medical safety are predicated on an honest acknowledgment about causes of death, then this form of self-deception should not be countenanced. We need to be honest with ourselves about why our patients die.

There has also been self-deception about whether physician-assisted death is a form of suicide. Some proponents of assisted death contend that assisted death is not an act of deliberate self-killing, but rather merely a choice over the manner and timing of one's death. It's not clear why one would try to distort language this way and deny that “physician-assisted suicide” is suicide, except perhaps to assuage conscience and minimize stigma. Perhaps we all know that suicide is never really a form of self-respect. To sustain our moral and social affirmation of physician-assisted death, we have to deny what this practice actually represents.

There has been self-deception about the possibility of putting limits around the practice of assisted death. Early on, advocates insisted that euthanasia would be available only to those for whom death was reasonably foreseeable (to use the Canadian legal parlance). But once death comes to be viewed as a therapeutic option, the therapeutic possibilities become nearly limitless. Death was soon viewed as a therapy for severe disability or for health-related consequences of poverty and loneliness (though often poverty and loneliness are the consequence of the health issues). Soon we were talking about death as a therapy for mental illness. If beauty is in the eye of the beholder, then so is grievous and irremediable suffering. Death inevitably becomes therapeutic option for any form of suffering. Efforts to limit the practice to certain populations (e.g. those with disabilities) are inevitably seen as paternalistic and discriminatory.

There has been self-deception about the reasons justifying legalization of assisted death. Before legalization, advocates decry the uncontrolled physical suffering associated with the dying process and claim that prohibiting assisted death dehumanizes patients and leaves them in agony. Once legalized, it rapidly becomes clear that this therapy is not for physical suffering but rather for existential suffering: the loss of autonomy, the sense of being a burden, the despair of seeing any point in going on with life. The desire for death reflects a crisis of meaning. We deceived ourselves into thinking that assisted death is a medical therapy for a medical problem, when in fact it is an existential therapy for a spiritual problem.

We have also deceived ourselves by claiming to know whether some patients are better off dead, when in fact we have no idea what it's like to be dead. The utilitarian calculus underpinning the logic of assisted death relies on the presumption that we know what it is like before we die in comparison to what it is like after we die. In general, the unstated assumption is that there is nothing after death. This is perhaps why the practice is generally promoted by atheists and opposed by theists. But in my experience, it is very rare for people to address this question explicitly. They prefer to let the question of existence beyond death lie dormant, untouched. To think that physicians qua physicians have any expertise on or authority on the question of what it’s like to be dead, or that such medicine can at all comport with a scientific evidence-based approach to medical decision-making, is a profound self-deception.

Finally, we deceive ourselves when we pretend that ending people’s lives at their voluntary request is all about respecting personal autonomy. People seek death when they can see no other way forward with life—they are subject to the constraints of their circumstances, finances, support networks, and even internal spiritual resources. We are not nearly so autonomous as we wish to think. And in the end, the patient does not choose whether to die; the doctor chooses whether the patient should die. The patient requests, the doctor decides. Recent new stories have made clear the challenges for practitioners of euthanasia to pick and choose who should die among their patients. In Canada, you can have death, but only if your doctor agrees that your life is not worth living. However much these doctors might purport to act from compassion, one cannot help see a connection to Nazi physicians labelling the unwanted as “Lebensunwortes leben”—life unworthy of life. In adopting assisted death, we cannot avoid dehumanizing ourselves. Death with dignity is a deception.

These many acts of self-deception in relation to physician-assisted death should not surprise us, for the practice is intrinsically self-deceptive. It claims to be motivated by the value of the patient; it claims to promote the dignity of the patient; it claims to respect the autonomy of the patient. In fact, it directly contravenes all three of those goods.

It degrades the value of the patient by accepting that it doesn't matter whether or not the patient exists.

It denies the dignity of the patient by treating the patient as a mere means to an end—the sufferer is ended in order to end the suffering.

It destroys the autonomy of the patient because it takes away autonomy. The patient might autonomously express a desire for death, but the act of rendering someone dead does not enhance their autonomy; it obliterates it.

Yet the need for self-deception represents the fatal weakness of this practice. In time, truth will win over falsehood, light over darkness, wisdom over folly. So let us ever cling to the truth, and faithfully continue to speak the truth in love to the dying and the living. Truth overcomes pressure. The truth will set us free.