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. 

Explainer
Culture
Freedom of Belief
Migration
7 min read

From Nigeria’s killing fields to Europe’s shores, the data behind the domino effect

While Nigeria thrives, some left-behind are desperate to escape.

Chris Wadibia is an academic advising on faith-based challenges. His research includes political Pentecostalism, global Christianity, and development. 

A data map shows circles of varying size across a map of Nigeria
Fatal attacks map.
ORFA.

Just as every coin has two sides, every soul contains the equal capacity for good and evil. Just like affairs of the soul, migration has the ability to strengthen or weaken societies.  

Nigeria, the Giant of Africa, has one of the world’s largest and most professionally distinguished diasporas. Over 17 million Nigerians live in other countries. The most famous members of the Nigerian diaspora, figures like Ngozi Okonjo-Iweala, Chimamanda Ngozi Adichie, Anthony Joshua, John Boyega, Giannis Antetokounmpo, and Wally Adeyemo, have achieved stardom thanks to talents that impact or entertain millions of people globally.  

However, these famous figures merely represent the glorious one percent of the Nigerian diaspora. Their success can easily distract observers from the grim reality of why so many Nigerians desperately seek to leave a country known for producing world changers.  

Seeking data on violence 

In October 2019, researchers at the Observatory of Religious Freedom in Africa started a project exploring the nature and impacts of of religious violence in Nigeria. The project spanned four years and generated many significant findings. Terror groups in Nigeria killed 31,000 civilians in 7,000 attacks in just four years, the Fulani Ethnic Militia (FEM) accounting for 39 per cent of these killings (a figure dwarfing the killings perpetrated by ISIS and al-Qaeda affiliates),  So called “land-based community attacks,” a concept referring to instances when actors like FEM invade small Christian farming settlements to kill, rape, and abduct Christians and burn their homes, accounted for 82 per cent of civilian killings in the study, Christian death tolls far exceeding Muslim death tolls (2.7 Christians killed for every 1 Muslim killed) in the reporting period, and 6.5 times as many Christian murders compared to Muslim murders relative to average state populations.  

The methodology of the study set out to find data on all the people, regardless of their religion, negatively affected by terrorist violence. However, with every new batch of data collected, disturbing patterns emerged. Since the 2009 birth of the infamous Boko Haram insurgency, global media coverage of the terrorist violence has consistently argued Muslims rather than Christians disproportionately bear the brunt of this Islamist extremist violence. The findings of the study suggest otherwise.  

ORFA data map of fatal attacks across Nigeria.

A data map shows circles of varying size across a map of Nigeria
Source: ORFA.

Shouldn’t the government do something? 

Historically, Nigerian governments have been reticent, even reluctant, to condemn violence in the north associated with the Fulani ethnic group. Former presidents like Muhammadu Buhari, a member of the Fulani, have even gone as far as to dismiss the issue of Fulani ethnic violence as just “cattle rustling.” However, in Nigeria, mere “cattle rustling” to some is a seriously grave situation for others.  

Findings by the Observatory researchers suggest Nigerian security operatives, most of whom belong to the Fulani and Hausa ethnic groups, have a suspiciously selective way of engaging with terrorist violence in northern Nigeria, often leaving Christians distinctively vulnerable. Roman Catholics in Nigeria have even accused Nigeria's military of being a jihadist force. Churches in northern Nigeria live in a constant state of terror and acutely distressing fear.  

In Nigeria, the federal government alone, led by the president, has the final say on matters concerning security and the army. Incumbent President Bola Ahmed Tinubu has notably appointed far more Christians to senior government offices than his predecessor, Buhari. The Nigerian government is famously opaque. Despite its nominally democratic visage, family dynasties and networks continue to dominate political life and business affairs.  

Understanding the religious geography and reaction 

Religion in Nigeria is divided along geographical lines. The northern half is dominated by conservative Islam. Catholicism and Anglicanism reign supreme in the southeast. The southwest functions as a geographical melting pot of Islam (albeit a more secular variety compared to the north) and Christianity (especially Pentecostalism).  The north contains a surprisingly large number of Pentecostals. Many Pentecostal pastors and choirs in the north have been kidnapped by the mercilessly violent Islamist extremists.  

The overwhelming majority of Christians in Nigeria live in the southern half of the country. However, in a Nigeria which has suffered from one oppressive government after another for decades (most of these led by conservative Islamic military and civilian presidents), most Christians struggle to survive and lack the energy to speak up for their northern kin. Despite their weariness, the Southern Nigerian Church (the collective population of Christians living in the south) has a sacred responsibility to awaken and demand greater protections from the federal government and the military for Christians living in the north.   

Local causes, global effect 

Over the last two decades, commentators have routinely pointed to climate change as the primary factor facilitating violent encounters between Muslims and Christians. Fulani cattle herders, guided by the desire for better grazing lands for their livestock, have often encroached on land owned by Christian farmers in the north and middle regions. The findings by researchers at the Observatory suggest significantly more is going on to facilitate these violent clashes than just climate change. Ascribing the challenge of religious violence in Nigeria to just climate change provides a get-out-of-jail free card to the men of violence linked to the orchestrated killings of Christians. 

Ethno-religious violence has quietly become commonplace in northern Nigerian life. The single solution capable of curbing this violence is unprecedented, cross-party, interethnic, and interreligious security reform. Strength of security affects every person in Nigeria. From the richest to the poorest, no one is immune from a sudden kidnapping, suicide bomb, or violent act of banditry negatively changing their life forever.  

Nigeria's neighbours in Europe cannot afford to continue slumbering and must wake up. Readers in Europe feeling insulated from the violence the data records are just as susceptible to the shockwaves that a collapse of the Nigerian state as other West African neighbours. Such an event would imperil the security of citizens in countries like Italy, Spain, and Greece just as much as it would people living in Mali, Chad, and Cameroon.  

Nigeria has never been nearer to a civil war or state collapse since the Biafra War of the late 1960s. Ethno-religious violence disproportionately targeting northern Christians is one of the greatest and most overlooked factors contributing to Nigeria's dysfunctionality. In an unprecedentedly connected world, such a collapse would, in turn, trigger further collapses.  The European Union (EU) does not grasp the severity of how such a collapse would affect its own security and stability. At a time when every day brings news of small boats carrying migrants to European shores, Nigeria's collapse would trigger one of the greatest avalanches of mass migration in modern African history.  

A modern Middle Passage 

Nigeria has a population of over 235 million, the largest in Africa and sixth largest globally. If just 10 per cent of the population attempted to flee in the event of another civil war or a destabilising political event, that is 23 million Nigerians desperately fleeing into any country they reason might welcome them. Many of these millions would gamble by voyaging on the tempestuous Atlantic Ocean in small boats with the goal of beginning new lives in European countries. Some would inevitably perish in what might evolve into this century's Middle Passage. Nigeria’s collapse would destroy the EU by overwhelming its borders and social services. The average population of an EU country is just under 17 million, or the size of Nigeria's diaspora. The unprecedented connectedness of our world means catastrophic destabilisation in one country can have significant consequences for the stability of other countries globally. The EU has a geopolitical responsibility to invest in improving Nigeria's security situation. Abductions, killings, and displacements in Nigeria might trigger instability in Europe and beyond. 

However, the collapse of Nigeria would not only destabilise the EU. ISIS affiliates like ISWAP (Islamic State West Africa Province) have a strategic interest in Nigeria's collapse, because it would open the door for them to expand their control throughout West Africa.  

A team of researchers guided by the goal of better understanding terrorist violence in Nigeria simply followed the breadcrumbs of organically emergent data to show why the broader world should take seriously violence against Christians in the Giant of Africa. Living in an unprecedentedly connected world comes with new privileges and new responsibilities. To simply indulge in these new privileges without standing strong and shouldering these new responsibilities would be foolish, selfish, and nearsighted.  

English poet John Donne once famously wrote,

No man is an island,  
Entire of itself,  of the continent,  
A part of the main.  
If a clod be washed away by the sea,  
Europe is the less. 
Every man is a piece.

The “old self” understanding of global connectedness, ruled by selfishness and ignorance, must give way to the “new self” model of prosperity and security via proactive collaboration. For every one Okonjo-Iweala, Boyega, or Antetokounmpo, millions of Nigerians suffering from the effects of a rapidly destabilising state dream of emigrating abroad. Global Christianity and global security stakeholders each have an interest in a stable Nigeria. A stable Nigeria functions as a wellspring of human capital for the benefit of the entire world.  

Donne, in the same poem, wrote,  

Each man's death diminishes me, 
For I am involved in mankind. 
Therefore, send not to know 
For whom the bell tolls, 
It tolls for thee. 

The world is involved in Nigeria and Nigeria is involved in the world. The death of Nigeria would pave the way for the death of the EU. The bell tolls for the EU community to awaken from decades of neglectfully overlooking its interests in a stable and secure Nigeria.  

 

Further resources 

  • ORFA report summary.
  • ORFA full report.
  • 'No Road Home', a data study on those living in displaced persons camps. Download the study (PDF).