Letting go and welcoming in

Your new life will cost you your old one. It's OK.

Mica Gray

Mica Gray is a wellbeing practitioner working in adult mental health. She is training to be a counselling psychologist.

A family with a mother holding a small child, look up and to the left.

Eduardo Fernando on Unsplash.

Last week my family laid my great-grandmother to rest. A few hours afterwards, we celebrated my cousin's birthday.

It felt strange to go from a place of death to a place of life in the space of a day. One minute I was throwing flowers into the open grave of a woman whose earthly life has come to an end and the next I was in a restaurant handing flowers to a girl whose life as a woman is just beginning. The contrast was a bit surreal, but much of life is like that; beginnings and endings flowing into each other. The transition between the two events was made easier by the fact that the funeral did not really feel like one. In alignment with my great-grandmother’s spiritual beliefs, the ceremony was very simple. It was over in less than four hours and featured a short reading of spiritual texts and quiet, reverent reflection. There were no solemn looks, no songs of lament, no dirt shoveling, no loud wailing or aunties and uncles dancing to Beres Hammond at the reception. Instead, there was just the quiet nod of acknowledgement that her spirit has journeyed on.

Though I missed the eulogies and shared tears that usually detail funeral services, I appreciated the simplicity of the ceremony. I appreciated the way death was described as a transition of the spirit into a new kind of life, the way it was treated as something so normal. Which in fact it is. Death is happening around us every day yet as a society it is something that we struggle with - whether it’s the death of a loved one, a career, a relationship or a part of ourselves. Our attempts to curate eternity with anti-aging procedures and technological permanence betray how deeply uncomfortable we are with the inevitability of endings in our modern world.

And to be honest, of course we are. The loss of loved ones shakes entire worlds. Job losses throw our lives into instability and leave us feeling unsafe. The loss of youth and power challenges long held ideas of identity and invites existential anguish. Divorce carries with it its own special grief. The pain of these experiences makes it hard for us to embrace when things are ending in our lives and make it hard for us to let go, even when we need to.

And we do often need to.

What fears, habits, thoughts or behaviours need to be given to the earth? What cycles or patterns do we need to bury and mourn so that we can usher in new and better ways of being?

Lately I’ve been thinking about the saying ‘your new life will cost you your old one’ and how true that is in many areas of our lives. In my own life, I recently started a new role at work that has cost me the comfort of my old one. I have had to give old versions of myself to the ground and shed skin so that I can continue to grow into the space of it. This new year of doctoral study has cost me Saturdays spent lazing around with friends, new relationships have cost me old patterns of behaviour and new depth in old relationships have cost me pride and ego.

At each point of transition, I have been asked to leave something behind to experience something new and it seems like so many of us at the moment are being asked to do the same. People are moving houses, leaving jobs, leaving seats of power, churches, ending relationships, wrestling with friendships, forming new ones and experiencing ego-deaths.

Like my cousin, some people are exchanging adolescence for adulthood. Others, like my great-grandmother, are exchanging their earthly bodies for their spiritual ones.

In this moment individually, politically and spiritually - it seems like we’re collectively being asked the question: what are we needing to let go of? and then what do we need to welcome in? What fears, habits, thoughts or behaviours need to be given to the earth? What cycles or patterns do we need to bury and mourn so that we can usher in new and better ways of being?

When life asks us questions like this it can feel overwhelming or intimidating to confront, but it is always necessary. I have found that when you do not allow yourself to grow out of old skin you will suffocate within it. The times of transition that we find ourselves in ask us to trust that something greater is unfolding. They ask us not to resist change but to flow with it. Not to forsake the present or the future by holding on to what has gone to the grave, but to be open to what is next.

As strange as it was last week to celebrate a birthday after a funeral, it was a reminder that though endings are painful we can embrace them because they usher in new beginnings. It was a reminder that funeral clothes can be exchanged for dancing shoes and that mourning can be exchanged for joy.

Overall, the day was a reminder that if we make room for it, life can follow death, both in this earthly life, and into the next.

Selah.

This article was first published on Substack. Follow Mica there.

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.