Article
Assisted dying
Care
Culture
Death & life
8 min read

The deceptive appeal of assisted dying changes medical practice

In Canada the moral ethos of medicine has shifted dramatically.

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. 

Review
Books
Culture
Leading
Politics
5 min read

Blair’s revelatory sermon to Starmer

What can the former Prime Minister teach about leadership?

Krish is a social entrepreneur partnering across civil society, faith communities, government and philanthropy. He founded The Sanctuary Foundation.

Tony Blair rests on the edge of a desk.
Tony Blair at rest.

The 1990s are enjoying a revival—from the return of baggy jeans and bucket hats to the reunion of Oasis, and, perhaps most significantly, a Labour government in power once again. Unlike the fervent optimism of 1997, when Tony Blair swept to victory with D: ream’s hit song Things Can Only Get Better as an anthem, today’s Labour government faces criticism for a perceived lack of vision. Luckily, Tony Blair has just released his new book: On Leadership—perhaps a timely read for the current Prime Minister. 

Blair's leadership credentials are, at one level at least, pretty impressive: he won three consecutive elections and was the first Labour Prime Minister to do so. His achievements include playing a crucial role in the Northern Ireland Peace Process, reducing NHS wait times, and making a substantial investment in public services. Blair also took a courageous stance with U.S. President Bill Clinton by intervening in the Kosovo conflict against the advice of the UN.  He remains however indelibly associated with the controversial 2003 invasion of Iraq that resulted in the deaths of 179 British personnel, and hundreds of thousands of Iraqi civilians.  

In this climate of scepticism toward political leaders, Blair's reflections on leadership invite critical questions: Who is this book for? Where is the vision? And even, intriguingly, do we now 'do God'? 

Who's it for? 

Blair’s book is not a typical guide to general leadership principles; rather, it’s an insider’s view on leading a country. For the average reader, it’s like overhearing a high-level seminar on statecraft—a glimpse into the “room where it happens.”  

Maybe there’s a bit of an audience reality check going on in the same way that a TV documentary on what-it’s-really-like-to-be-the-England-football-manager might deliver. Many football fans are happy to shout at our televisions when most have not got even the remotest clue of the challenges and pressures national coaches are under. So perhaps if Blair can tell us how hard it is to handle the myriads of competing challenges as the leader of a nation, readers might better understand the weight of leadership and approach politics – and politicians -with greater humility. 

One of the most helpful reflections the book offers was Blair’s self-analysis on three stages of leadership. The first is the new leader listening eagerly; the second comes when they think they know everything, and finally, there’s a third stage of maturity when “once again, with more humility, they listen and learn”.  He argues that his book’s purpose is to shorten the learning curve and get leaders to the third stage more quickly. 
This a noble cause, but there are times when this book feels like a sermon preached by a slightly unscrupulous vicar, in a church where everyone knows there’s only one person the preacher has in mind. This can make everyone else feel they are there just to fill up the pews so that the message gets delivered. For Blair, his message and his book seem to be very much for Sir Keir Starmer; a plea to him to listen and learn from others.  

Where’s the vision? 

Blair encourages leaders to make a meaningful impact with their time in office. Recalling a conversation with Shimon Peres, he writes, “Do you want to be in the history books or the visitors’ book?” For Blair, leadership is about pushing boundaries, meeting resistance with persistence, and making difficult choices when others hesitate. He writes, “If you, as a leader, are not a changemaker in this world, it is you who will be changed.” His words on taking risks and demonstrating resilience are certainly inspiring. However, he often focuses on how to lead effectively, with limited exploration of what motivates us to seek positions of leadership in the first place — a disappointing missing focus on moral purpose. 

This emphasis on strategy over ideology is evident in chapter titles: The Supreme Importance of Strategy versus The Plague of Ideology. Blair is critical of rigid ideologies, advocating instead for flexibility and pragmatism. He contrasts ideological rigidity with a more agile and pragmatic approach, which could sound like its own simply going-with-the-flow ideology, - a situational ethical approach. This feels very different to the Tony Blair that took on the United Nations over the Serbian genocide in Kosovo. He appeared to take a moral stance driven by a commitment to human rights rather than going with a more pragmatic laissez-faire solution. Blair’s emphasis on pragmatism, while useful, may leave readers wanting more on the values that shape a visionary leader. 

Blair includes a joke, a very good one, that feels accidentally pertinent: some people die and the Devil appears and asks them, before they settle for Heaven, to take a look at Hell, because it’s not as bad as they’ve heard. When they see the “drinking and debauchery” in Hell, they ask to be damned. But then they wake up in the real Hell – “cold, miserable and horrible” – and demand to know why it looks nothing like what the Devil showed them. “Ah well,” says the Devil, “back then I was campaigning.” 

He meant it as a joke, but the lack of moral clarity in the book made me feel he was sharing more than he intended about the state of political leadership right now. Perhaps sharing to many more than just those he wrote this sermon for. It certainly encapsulates the growing chasm between political promises and reality, as well as illustrating the reason why many people feel disdain, distrust and disappointment in all politicians who say whatever they need to say to get elected.  

Are we doing God now? 

Famously, when asked about his faith while Prime Minister, Blair was interrupted by his press secretary, Alastair Campbell, who declared, “We don’t do God.” Yet in this book, Blair invokes Moses as an example of leadership under difficult circumstances: “Never underestimate the degree to which people crave leadership. Back to Moses again. The Israelites simultaneously hated and craved his leadership. If you remember, they reached the promised land (though, yes, I know, he didn't).” 

Blair sees in Moses a leader who maintained strength and conviction, even in the face of public criticism—a relatable comparison for politicians navigating the pressures of modern social media. Whether or not Blair is “doing God” in this book, he draws inspiration from Moses as a model of resilience and substance, inviting readers to consider leadership as a balance between staying grounded in one’s values and withstanding external pressure. 

In the end, On Leadership is a reflective, sometimes provocative take on leading a nation, full of insights that swing from the practical to the idealistic. But it also raises important questions about the ultimate purpose of leadership and the need for a clear moral compass. For a public that remains sceptical of political motives, Blair’s leadership lessons may provide timely, if imperfect, revelation.