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Professor Margaret Somerville taught medical law and ethics for nearly 40 years at McGill University in Canada. Few people are better qualified to comment on Canada’s embrace of euthanasia.
After having spent most of your professional life in Canada, you must have a special insight into its cultural tectonics. Why does euthanasia appear to have so much support there amongst doctors and the judiciary?
Margaret Somerville: Recently, I read that the beginning of wisdom is to know when one should say “I don’t know”. Certainly, I cannot give you a comprehensive answer to this question.
What we do know is that approval of physician-assisted suicide (PAS) and euthanasia is highest among highly educated, high socioeconomic status persons — sometimes described as “elites” — in a society. Doctors and judges belong in this group, although I hasten to point out that far from all doctors and judges support euthanasia.
Those who do support it often adopt so-called “progressive values” on a range of issues including reproductive technology decision-making, abortion, same-sex marriage, and so on. “Progressive values” adherents are characteristically intensely individualistic – they give almost absolute priority to the value of individual autonomy, which can mean that they fail to take into account what is needed to protect the “common good” and, in particular, vulnerable members of the society. They also focus just on the present – they do not take into account warnings from history (“collective human memory”) or probable future consequences that can be recognized through “collective human imagination”. I call this approach to decision-making of excluding what considering the past and the future can teach us, “presentism”.
I’ve often described the mantra which informs progressives’ worldview as “control, choice and change”: They want control over what happens, especially to them personally; choice that accommodates the outcomes they seek; and the changes, for instance, in the law or cultural norms, that will make such control and choice possible.
Is there widespread popular support as well?
Well, there certainly seems to be in Canada, especially when we look at the statistics on how many people are using MAiD (Medical Aid in Dying the euphemism used for PAS and euthanasia in Canadian law). For example, in the Province of Ontario, as of 30th September 2019, 3,822 people accessed “assisted dying”, 3821 in the form of euthanasia, one assisted suicide. (It’s an interesting question as to why, in jurisdictions where both PAS and euthanasia are legal, PAS is very rarely used.) Accurate overall statistics for Canada are not available, but it’s estimated that 1.12% of all deaths now involve MAiD and is known that there have been over 8000 such deaths since its inception.
Initially, when legalizing euthanasia was being proposed and euthanasia advocates were lobbying for its legalization, I believe that many members of the general public – and even a substantial percentage of healthcare professionals – were confused as to what was and was not euthanasia, which inflated the statistics showing the public’s approval of euthanasia. Rights to refuse all medical treatment, including life-support treatment when this would result in death, and rights to fully adequate pain management, even if it ran the risk of shortening life, but was necessary to relieve pain, are not euthanasia, but many people classified them as such. This confusion was not, however, accidental; it was a strategy used by pro-euthanasia advocates to advance their cause through showing strong public support for legalizing euthanasia.
The idea of an end-of-life slippery slope is ridiculed by many politicians and doctors. But in the case of Canada, it seems relevant. What is the next development, do you think?
Canada is already considering whether to allow access to euthanasia to children, to people with serious mental illness but no physical illness, and to people with dementia through their advance directives. In light of the widespread normalization of euthanasia and the large number of people accessing it, I believe all of these expansions are likely to be allowed.
The reason such expansion is unavoidable is that once one steps over the line that says it is never ethically acceptable to inflict death on another human being, the sole exception being where that is the only reasonable way in which to save innocent human life, as in justified self-defence, there is no logical stopping point.
I have mused about the denial of slippery slopes by euthanasia advocates, such as Andrew Denton here in Australia, when it is so well documented that once introduced access to it expands rapidly. I realized that these deniers take an approach that there is no slippery slope if they regard any given expansion of access to euthanasia as a good decision, but only such a slope if they see the expansion as a bad decision, which seems to be a rare classification.
It merits mentioning that there are also doctors who initially supported the legalization of euthanasia who are now publically speaking out against it. A prominent example, is Dr Yves Robert the registrar of the College of Physicians and Surgeons of Quebec (the medical licensing authority in the Province) who wrote an open letter under the College banner with the headline “Death a la carte” (that is a menu of choices among the options for how one wants to die) withdrawing his support for euthanasia.
Dr Robert was a major proponent of legalizing euthanasia and in 2009 the College was one of the main instigators of the movement to do so in Quebec. At that time, Dr Robert rejected anti-euthanasia proponents' claims that effective safeguards could not be put in place to regulate euthanasia. And, as in the current Australian debate, he accepted the usual claim of pro-euthanasia advocates that it would be rarely used. The estimate given by physician proponents, including the Quebec Minister of Health who was a specialist physician, was about 100 cases a year in the province. As can be seen from the Ontario statistics above that is very far from the reality which has emerged, including in Quebec.
Dr Robert changed his mind about euthanasia when calls were made to have “death on demand” declared a constitutional right. A very recent Quebec case that has struck down as unconstitutional the requirement that “natural death must be reasonably foreseeable” as a condition for access to MAiD is a step towards this possibility.
This claim that there is a right to “death on demand” is consistent with the arguments used to legalize euthanasia: that people have a right to autonomy and self-determination concerning their own bodies and lives.
In his letter, Dr Robert notes that opinion leaders and the media have denounced cases where people who do not fulfil the conditions for access to euthanasia in Quebec have been refused it. He also notes the paradoxical discourse that calls for safeguards to avoid abuse of “medical aid in dying” which are meant to limit its availability, while asking doctors to act as if there were no restrictions. He continues that if euthanasia is an unfettered right, then it’s not within the scope of “medical aid to die”, but simply “assisting dying” and he says the society must consider other options than involving the medical profession in that.
Dr Robert says that the law was a “major opening” to euthanasia and expresses surprise at how quickly public opinion seems to have judged the opening insufficient. In short, euthanasia has become normalized with astonishing rapidity and that has caused calls for access to it to be expanded, indeed, calls to have no restrictions at all on access to it.
The question that this development leaves us with is why so many Canadian doctors and lawyers of goodwill and professional integrity, such as Dr Robert, so adamantly disagreed that such expansion would occur.
Some Canadian doctors have suggested that euthanasia organ donation would be a good idea. Could you explain what’s wrong with that if the patient wants both to end his life and to give his organs? It seems like a good way to make the best of a difficult situation.
I have recently written an article dealing with this issue in The Linacre Quarterly, “Does It Matter How We Die? Ethical and Legal Issues Raised by Combining Euthanasia and Organ Transplantation“.
For a variety of reasons I conclude that the ethical dilemmas are such that euthanasia and organ donation should not be connected in any way. These reasons include uncertainty regarding the definition of death which could be more critical in the context of euthanasia. Then there is disagreement about what constitutes conscientiously objecting healthcare professionals’ involvement in euthanasia. Would a transplant surgeon using organs from a euthanized person be complicit in the euthanasia of that person? Similarly, would the recipient of an organ from a euthanized person need to be told that and give informed consent to receiving that organ? And does connecting euthanasia and transplantation makes conflicts of interest for healthcare professionals unavoidable?
The reality is, however, that euthanasia and organ transplantation already are connected in Canada: the Ontario Coroner reported that the organs of 30 of the 3822 people who died by MAiD in the province were donated for transplantation.
Some suggestions are more radical, aren’t they? The patient would be killed by the act of donation, ensuring that the organs are as fresh as possible. Is this ethically worse than other forms of euthanasia?
Yes, there are more radical suggestions. Some people who agree with euthanasia and organ donation after death by euthanasia are arguing that death by donation is ethically acceptable. This would involve giving the person a general anaesthetic and carrying out euthanasia by removing their vital organs, such as the heart, to be used for transplant. Additional ethical issues raised by death by donation include breach of the “dead-donor rule” – that the person must be dead before removal of vital organs and the donation must not be the cause of death. Other considerations include what would constitute informed consent to euthanasia by donation and what impact its acceptance would have on important foundational societal values, especially respect for human dignity and for human life.
It’s often mentioned that euthanasia patients might feel that their life becomes worthwhile by donating organs. Your thoughts?
That’s a possibility that I discuss in my article referred to above. It’s a sad thought that one is only valuable and has a purpose when one is dead. It’s true, as Ely Wiesel said, that people need a “why” to live, but surely we should not be promoting a “why” to die.
What can put a brake on the rapidly expanding boundaries for euthanasia in Canada?
Once the barn door is open and the horses have escaped shutting the barn door does not confine them, so I’m not at all sure that a brake can be put on the expanding boundaries of euthanasia in Canada. It will take possibly many generations for the full tragedy of the legalization of euthanasia to become obvious, at which time initially small voices will be magnified by others joining them and there could be a ground swell of opposition. Perhaps the reverse of how euthanasia has come to be legalized.
I sometimes think of the outrage of a young woman who made a lasting impression on me. She was born from artificial insemination by an anonymous donor and was searching for her father because she felt that “half of her was missing”. She angrily shouted at a conference panel of which I was a member, “How could society have allowed this? How could they have let this happen to me?” Societies came to see anonymous sperm donation as unethical. The law was changed in many jurisdictions to make anonymous sperm donation illegal. Perhaps the same will happen with euthanasia, except that, unlike that young woman, dead people are no longer able to shout at a society that authorized doctors to intentionally inflict death on them.
Does the Canadian experience hold any lessons for other jurisdictions – like the Australian states – which are debating whether or not to legalise it?
Yes and here are some that I would suggest:
Recognise that we live in a post-truth era, so the first lesson should be get the real facts. Good facts are essential for good ethics and good ethics for good law.
Move beyond making public and social policy decisions — and there is no more important one than whether to legalize euthanasia — only on the basis of respect for individual autonomy and its impact in the present.
I believe that if people have the facts on euthanasia and on its alternatives, and look not only to what individuals want, but also to the protection of vulnerable people and the common good, and take into account what human memory can teach us and human imagination tell us about future consequences, we will decide that legalizing euthanasia is a very bad and dangerous idea.
Margaret Somerville is professor of bioethics in the school of medicine at the University of Notre Dame Australia.