Recently, two Canadians relayed to me their experience of witnessing a doctor delivering a lethal injection to a person they loved. They described it as making death seem “so casual”. They said this perception concerned, even traumatised, them. The person euthanised was very old, not terminally ill, mentally competent, and had long been depressed.

Since our conversation, I have thought a great deal about whether exploring their description of the death as “casual” might provide valuable insights in relation to euthanasia and its practitioners.

By way of background, euthanasia (Medical Assistance in Dying, or MAiD) has been legal in Canada since June 2016. In the latest report, at the end of 2020 the official death toll from MAiD was 21,589 and 2.5 per cent of deaths in Canada were by MAiD. The number of deaths by MAiD increased by 34.2 per cent in 2020 compared with 2019.

The attitude of physicians providing euthanasia

It is well documented that providing euthanasia (a term I use to include physician-assisted suicide) can be psychologically traumatising for doctors, resulting in mental illnesses such as post-traumatic stress disorder (PTSD). For this reason, the Royal Dutch Medical Associations recommended doctors protect themselves by resorting to assisted suicide, rather than euthanasia.

Another approach to mitigating harm to doctors is the use of “terminal sedation”, also known as “slow euthanasia”, in which the primary intention is to inflict death, but not by lethal injection. All treatment, nutrition and fluids are withdrawn and the person is deeply sedated until they die.

This approach can be seen in the massive increase in the use of “terminal sedation” in Belgium. “Terminal sedation” must be distinguished from “palliative sedation” in which there is no primary intention to shorten life, but carefully titrated sedation is, in infrequent cases, the only reasonable means to relieve a person’s serious pain and suffering.

Yet another coping mechanism is to enlist a colleague, who has not been involved with the patient, in the delivery of the lethal injection.

Recently, I heard an Australian doctor who supports euthanasia explain that he had been involved in around 150 cases. He said that he makes sure all the legal requirements have been fulfilled, organises all the paperwork, obtains the patient’s informed consent and then “phones upstairs to the Anaesthetics Department for the anaesthetist to come and insert the cannula” into the patient’s vein. This is to facilitate the delivery of the lethal injection.

The doctor was not clear regarding who performed the final act of administering the lethal injection, but there are reports that in some Dutch hospitals between one and three anaesthetists carry out most of the euthanasias.

One such Dutch doctor, Dr Pieter Admiraal, in 1989, claimed to have carried out 1200 cases of euthanasia. When I asked him how he coped with the impact this had on him, he explained, “it is easy for an anaesthetist, you just give the first half of a general anaesthetic to paralyse the patient and you do not give the second half to resuscitate them”.

For some physicians who provide euthanasia — probably a majority of those known as “euthanasia providers”, some of whom have carried out hundreds of cases — it seems likely that euthanasia has been normalised, that it is just another way to die and a routine medical procedure. That could explain why their infliction of death seems “casual” to an observer and, indeed, might be such.

This normalisation could also be a coping mechanism for doctors, but it is especially dangerous for vulnerable and fragile people, those who are old, have disabilities, or are mentally ill. In short, for some physicians providing euthanasia can become routine.

Dr Yves Robert was the Secretary General of the College of Physicians and Surgeons of Quebec and initially a major advocate of the Quebec law allowing euthanasia. However, when he observed this normalisation phenomenon, which he did not support, he was appalled and described it as “Death à la carte”, a menu from which one could choose how one wanted to die.

He rejected this as “state-authorised suicide” in which physicians should play no part. He had envisaged euthanasia as being a rarely used medical treatment, when all other options had failed to relieve a terminally ill person’s unbearable suffering.

Losses of hope and meaning

The descriptor of death by euthanasia as “casual”, also brought to mind, for me, the term “casual sex”, by which I mean the “hook-up” or “friends with benefits” phenomena, which  function on a “no strings attached” to sexual intimacy basis.

What might “casual death” and “casual sex” have in common? Whatever one’s position on the morality of “casual sex”, it involves losses. They include a loss of commitment to the other person and an absence of any perception or experience that sex involves any mystery that needs to be respected, if we are not to do harm to ourselves or others.

Moreover, both “casual sex” and “casual death” involve a loss of a sense of meaning and of hope — in relation to the experience of sex or to the last phase of life, respectively. “Casual sex”, by definition, does not hold out any hope for a committed future relationship. Hope requires a sense of connection to the future and a belief that what one does in the present will beneficially affect that future.

Requests for euthanasia are connected to psychological states called “hopelessness” or “demoralisation”, which can cause or arise from the loss of the will to live. Specialist palliative care psychiatrists are researching treatments for these conditions as alternatives to euthanasia.

How do “casual death” and natural death differ?

We can also ask what insights we might gain by comparing “casual death” with natural death.

Natural death respects the mystery of death: we watch and wait for its occurrence and then, depending on our beliefs and culture, in different ways mourn the passing of a unique human being and our loss, and seek healing.

Euthanasia, by contrast, denies the mystery of death and converts it to the problem of death and provides a technological solution to that problem — namely, a lethal injection. One of the witnesses, who described the euthanasia death as “casual”, also called it “mechanistic”, which might reflect this approach.

This denial of mystery might be what social psychologists call a “terror management device”, a means people use to deal with their deep fears, in this case, fears both of mystery and of death. Euthanasia optimises choice and control under the banner of respecting individual autonomy, allowing the person to feel in control of their fear and its associated free-floating anxiety. They can “get” death before it “gets” them.

Every person’s death is a momentous event. The observers’ description of the death they witnessed as “casual” might be an intuitive and emotional recognition that this sense of its momentousness was lost when death was administered as just another routine medical procedure, no matter how worthy the reason for providing euthanasia.

Furthermore, I would suggest that we have always treated natural death as a sacred event and euthanasia ablates that sacredness. Let me explain.

Treating something as sacred requires that we hold it in trust, that we do not lay it waste or destroy it. Human life is sacred. I hasten to add that one need not be religious to believe some things are sacred. A good example are our obligations to hold our physical ecosystem on trust for future generations, to protect the Earth itself, in all its diversity.

There are two forms of the sacred: a “religious sacred” for those who are religious, and a “secular sacred” for those who are not. Allowing natural death respects both forms of the sacred; providing euthanasia, I contend, breaches both.

Some central life experiences cannot be time-compressed without destroying their essential essence, and what we might both give and receive, as well as learn, in those situations. Natural death is one of those experiences.

Respect for life

Civilised societies have always formed their most important, shared, fundamental values around the two great events in every human life — birth and death. What we do to the values governing one of these events unavoidably affects the values governing the other. Recognition of this connection can be seen in funeral rituals and ceremonies that have a twofold purpose of respecting the deceased person and reaffirming the value of life to the mourners.

Profound respect for human life at both the individual and societal level is a prime value. Consequently, another problem with converting the mystery of death to the problem of death is that it also converts the mystery of life to the problem of life. The loss this conversion entails, and could entail in the future, is immense and dangerous.

These dangers include, for example, introducing the unethical use of a “quality of life” criterion in deciding on the allocation of medical resources, especially when that quality is judged by someone other than the person needing the resources.

Another danger if euthanasia is expanded to people who are not terminally ill, as has happened in Canada, is that a message is sent to fragile and vulnerable people, who have comparable disabilities to those euthanised, that their lives are “not worth living” or even that they themselves are “worthless”.

This conversion of the mystery of life to the problem of life is yet one more reason why death becoming “casual” is a major issue for both individuals and society.

Reducing the harm

In homogenous societies of the past, religion used to carry the value of respect for life for the society as a whole. That is no longer possible in our secular, highly diversified societies. In secular societies, law and medicine carry the value of respect for life; the law prohibits intentionally inflicting death and physicians take an oath never to intentionally inflict death. While legalising euthanasia changes and unavoidably damages that carrying capacity of law and medicine, it remains important that the least possible damage be done to the value of respect for life.

This requires physicians never to regard the momentous act of the intentional infliction of death as a casual decision or procedure. To help to ensure that, in jurisdictions where euthanasia is legal there should be a strict low limit on the number of cases of euthanasia a physician may provide in any one year.

Alternatively — and preferably to having physicians involved in euthanasia — I would argue that it should be kept out of medicine altogether by establishing a cohort of specially trained non-medical professionals, who will provide it.

International helplines can be found at www.befrienders.org. In the US, the National Suicide Prevention Lifeline is at 800-273-8255 or chat for support. You can also text HOME to 741741 to connect with a crisis text line counsellor. In the UK and Ireland, Samaritans can be contacted on 116 123 or email jo@samaritans.org or jo@samaritans.ie. In Australia, the crisis support service Lifeline is 13 11 14.

Margaret Somerville AM, DSG, FRSC, DCL is Professor of Bioethics at the University of Notre Dame Australia School of Medicine (Sydney campus). She is also Samuel Gale Professor of Law Emerita, Professor...