This is the second of three articles on the dangers surrounding the legalisation of euthanasia.  

Good facts are essential for good ethics and good ethics for good law. This means we must ask, what are the correct facts about euthanasia?

Should we sneer at the idea of ‘slippery slopes’?

Euthanasia advocates often propose that euthanasia will be rarely used and only as a last resort. Let us look at some recent Canadian statistics:

“As of April 30, 2021 there have been 7549 reported assisted deaths in Ontario since legalization [in June 2016]. 7547 were euthanasia deaths (lethal injection) and 2 were assisted suicide deaths (lethal prescription)”.

This is very important information that cries out for in-depth research. What could this astonishing disparity in numbers between euthanasia and assisted suicide tell us?

It is noteworthy that, so far, in the American states which have legalised physician-assisted suicide but have not allowed euthanasia the number of such suicides are orders of magnitude below the Canadian statistics. Might the explanation for the very high Canadian numbers include that euthanasia masquerades as medical treatment and we trust doctors and assume they are acting ethically and only doing good? To wisely judge the acceptability of euthanasia, we must take the medical cloak – the “white coat” – off it.

Then there are the claims of pro-euthanasia advocates that legalizing euthanasia does not open up “slippery slopes”. Let us look again at Canada’s experience:

“The number of assisted deaths has been continually increasing in Ontario. There was a 33% increase in 2020 with 2378 reported assisted deaths, up from 1789 in 2019, 1499 in 2018, 841 in 2017, and 189 in 2016. Euthanasia was legalized in June 2016. Ontario euthanasia deaths have increased, in spite of COVID lock-down. …[There have been] 24,000 estimated assisted deaths in Canada since legalization”.

Again, these statistics show that euthanasia will not be used only rarely and is very quickly normalized, that is, the number of cases of euthanasia that occur once it is legalized, rapidly increase in a very short time.

This is not surprising. Once we step over the clear line that we must not intentionally inflict death, there is no logical stopping point. From 2002 to 2019, over 22,000 people have been officially euthanized in Belgium and the real number is probably much higher. Currently around 5 percent of deaths in the Netherlands are by euthanasia and, if current trends continue, this number will increase very substantially within a few years.

The normalization of euthanasia and its frequent use, also opens up the unavoidable “logical slippery slope”, that is, once euthanasia is legalized the situations in which it is available and the people who may access it rapidly expand. Indeed, there is now discussion in Canada whether all restrictions on access to euthanasia should be abandoned. The argument is that the justification for euthanasia is respect for the individual’s right to autonomy and self-determination with regard to their own body and life and this right should not be limited.

We can also see this justification being put forward in the Netherlands where the government is considering proposals that being “over 70 years of age and tired of life” or feeling that one has “a completed life” should be sufficient grounds to provide the person with access to euthanasia.

The pattern is that legislators who first approve euthanasia do so with “strict safeguards”, but these are quickly dropped and the people who can have access and in what conditions are greatly expanded.

As is already the case in the Benelux countries, Canada has now deleted from the MAiD (Medical Aid in Dying) legislation a requirement that “death be reasonably foreseeable”. It did this, on the grounds that it discriminates against people with serious disabilities, who are not terminally ill and want euthanasia.

In 24 months’ time, the law will allow people with serious mental illness, but no physical illness, to access euthanasia. As American psychiatrist Dr Mark Komrad succinctly commented, “The proper role of a psychiatrist is to prevent suicide, not to provide it”.

The Canadian Parliament is also currently considering whether to amend the MAiD legislation to allow people with early dementia to give “advance directives” consenting to euthanasia to be carried out when they are incompetent to consent.

Moreover, whether some children should have access to euthanasia is also under consideration and some healthcare professionals at the renowned Toronto “Sick Kids” Hospital have already drafted and published a protocol to govern this were it to be legalized.

It had long puzzled me how pro-euthanasia advocates could constantly deny that there was any “logical slippery slope”, when faced with such evidence. I had  the opportunity to ask Andrew Denton, of Go Gentle Australia, about this, when we were on a panel together at a Victorian Australian Medical Association meeting in Melbourne. He explained that there was no “slippery slope” if the extension was a good and welcome development. Rather, it would only be present if that were not the case. 

In short, “logical slippery slopes” are not of concern  to pro-euthanasia advocates; rather, they are an inherent component of their platform.

Examples of the “practical slippery slope”, that is, once euthanasia is legalized it is provided not in accordance with the law, are legion. One study of doctors in the Flanders region of Belgium who had euthanized patients found that, by their own admission, 27 percent had done so on at least one occasion not in accordance with the law. When this evidence is presented in other jurisdictions pro-euthanasia judges and politicians reject its relevance to their jurisdiction, by claiming that “our doctors are not like Belgium doctors”.

In summary, even though they might lose the battles against legalizing euthanasia, the work of people who oppose euthanasia is not over. They must now work to prevent its expansion and abuse.

Who suffer and need support when a loved one is dying?

When a loved one is dying, not only the dying person can suffer, but also those close to them. Much of the patient’s suffering can be ameliorated with fully adequate palliative care and even those who have asked for euthanasia may change their minds in that regard, when provided with such care.

It is appalling that a very large percentage of people, who need and could benefit from palliative care, do not have access to it – for example, studies have shown that is true for up to 70 percent of such people in Canada  and, likewise, Australia. Especially if we believe that legalizing euthanasia is a terrible mistake, we must work to make high quality palliative care readily available.

Without access to good palliative care, accompanying a dying loved one can be a very traumatic experience, especially if they are in serious pain and there is poor pain management. It is easy to imagine that euthanasia could seem an attractive option in such circumstances. To remedy this situation, in 2010 the Declaration of Montreal was promulgated at a meeting of the International Association for the Study of Pain. It provides that for a healthcare professional knowingly and unreasonably to leave a patient in serious pain is a breach of fundamental human rights. The World Health Organisation and the World Medical Association  have endorsed this approach, as have many national Pain Societies, including Pain Australia.

Despite how it is described by its advocates, euthanasia does not necessarily avoid the problem of the suffering of loved ones of the dying person. Accompanying a person we love who is dying through euthanasia can also be a very traumatic experience, as I witnessed first-hand.

I have a friend in Toronto whose long-term partner, a specialist physician, was diagnosed with inoperable metastasized cancer. He arranged for a physician friend to come to his and my friend’s home to euthanize him only days after his being told that he was terminally ill.

She and I were having lunch in a busy Bistro and she started to speak of her partner and his death. Suddenly she burst into uncontrollable sobs and kept repeating, “It was horrible, it was horrible! I couldn’t stay with him! I ran out of the room!”. I was shocked, because she is a highly respected professional woman, known for her strong emotional control in difficult circumstances, and is adamantly secular. She was clearly deeply traumatised by witnessing the euthanasia of her partner. The book referred to previously, Euthanasia: Searching for the Full Story, recounts many similar narratives.

In short, euthanasia is not necessarily the “rosy picture” death its advocates portray it as being.

What is the impact of “time compression” on how we die?

We live in a world in which we expect instantaneous outcomes, we are not prepared to watch and wait. We have become “human doings”, obsessed with what we can achieve in the shortest possible time, rather than seeing ourselves primarily just as “human beings”, grateful for being alive. Life can be seen as no longer worth living, when we are no longer fit and healthy “human doings”. Euthanasia reflects this belief, which is one reason legalizing it is of such great concern to fragile elderly people and those with disabilities.

Another important reason is, however, that some experiences cannot be time-compressed without destroying their essential essence, which they can provide to those open to experiencing that. Yet again, the book Euthanasia: Searching for the Full Story and another called Dignity Therapy, which I discuss below, powerfully demonstrate that dying is such an experience and not just for the dying person, but also for those who love them.

Has our focus on rights to autonomy and “radical individualism” blinded us to the importance for humans of relationships and, possibly, nowhere more so than when we are dying? We seem to have a primal fear of dying alone and it is very common to hear people say they want someone they love to be holding their hand when they die. We want to be accompanied in our leaving of this world. We hope to die in a loving relationship.

There is a beautiful story told by an Australian Palliative Care physician, Dr Frank Brennan, about the death of one of his patients, when he was working in a palliative care unit in Dublin Ireland, which captures dying in such a relationship.

Dr Brennan was caring for a dying man, whose wife had been constantly by his bedside. She looked completely exhausted. Dr Brennan said to her, “I know you’ve been here all the time. It might be good to go and have a rest, even just for a little while.” After a long silence, she replied, “No. I’ll not be leaving him”. She then reminisced on her and her husband’s life together, which included rearing seven children. Dr Brennan says she “spoke of a love that was boundless, a union that was indissoluble and … gave us a momentary glimpse into the mystery at the heart of it all”.

Why is euthanasia euphemized?

In short, I believe it is because people do not want to face the reality of what is being done, intentionally killing a human being. We have natural inhibitions against killing other humans. Advocates of euthanasia even object to the words “assisted suicide”, arguing physician-assisted death is not suicide, and to euthanasia, saying it has harmful connotations and associations. They use terms such as Voluntary Assisted Dying (Victoria) (Voluntary Assisted Dying Act, 2017) or Medical Assistance in Dying (Canada) and reduce those to acronyms VAD and MAiD, respectively, which have even less negative emotional impact. In the same vein of whitewashing what is involved, they speak of euthanasia as “the final act of good palliative care”. The vast majority of palliative care professionals strongly reject the claim that euthanasia can be a valid component of this care.

Word changes can be subtle and nuanced. For instance, in promoting the legalization of euthanasia and physician-assisted suicide, euthanasia has become “physician assisted dying” or “a merciful act of good clinical care”, that is, even any reference to death is dropped. When more words are used to describe something that already had a name, we should know that we are being manipulated and something is being concealed. That something is the intentional infliction of death.

Words, descriptions and labels matter also because they activate or suppress many of our “human ways of knowing”, such as examined emotions, moral intuition, experiential knowledge and common sense that recent research shows play an important role in decisions about ethics. Moreover, our choice of words is closely linked to whether we activate, what physician-ethicist Dr Leon Kass called the “wisdom of repugnance” to guide us.

Consequently, to argue, as I have on occasion, that “we cannot afford to have doctors killing their patients”, evokes a storm of outraged protest from pro-euthanasia advocates. However, if that is not what euthanasia involves, what does it involve?

Likewise, any mention of what we might learn from the Nazi doctors and the warnings that history (human memory) can provide triggers furious opposition. This is the case, even when one can show articles in the New York Times in the early 1930s describing the introduction of euthanasia by the Third Reich in Germany, which recount eerily similar justifications of euthanasia to those put forward today by the pro-euthanasia advocates.

Then the media’s role in promoting euthanasia through its “woke washing” of words and the ubiquitous post-truth reality of the early 21st century must be taken into account.

Recently, I published an article hoping it might cause people to think differently about what euthanasia involves. The question I addressed was “Why, if one agrees with euthanasia, would they not support carrying it out by giving the person a general anaesthetic and removing their vital organs – heart, liver, lungs — for transplantation”?

Euthanized people are used as organ donors in Belgium and Canada is using such donors with their consent. In fact, it is reported that Ontario doctors notify the Ontario transplant authority in advance of planned euthanasia cases and the authority’s representatives call the patient or family to ask for consent to donating their organs after death.

In these cases, the person is first euthanized and then, after they die, the organs are taken. In my article, I questioned why combining euthanasia and organ donation into the same act, that is, giving the person a general anaesthetic and carrying out the euthanasia by removal of their vital organs, which results in more viable organs, was not employed. Many people, including those who support euthanasia, reacted very negatively to this possibility and I explored the possible reasons for their reaction. They included that it would make organ donation seem horrific and cause people to reject donating their own organs after death.

I believe it was also that it causes us to we see directly, “unsugar-coated”, what euthanasia involves – doctors killing their patients or, in milder terms, inflicting death on them.

Why have so many politicians voted in favour of euthanasia?

We hear constantly that polls show that a sizeable majority of the public want euthanasia to be legalized and politicians might be trying to win these people’s votes. However, just because a majority votes for something does not necessarily mean that it is ethical. Democracy and ethics can diverge. Likewise, just because something is legal does not necessarily mean that it is ethical.

Whether the members of the public understand what they are agreeing to in supporting euthanasia is a further question, because surveys have shown that often they hold a mistaken belief that refusing life support treatment or its withdrawal or providing necessary pain or suffering management are euthanasia. As we all do, they want these interventions to be available and believe that requires agreeing to the legalization of euthanasia. They are, however, not euthanasia and are already legal and, appropriately used with no primary intention to cause death, are ethical, indeed, treatment that is ethically required to be offered to the patient.

Politicians are often reluctant to have to deal with matters that involve conscience and, for some people, religious belief, and when they must deal with these matters, they can want to get rid of them quickly and with the least conflict and publicity possible, especially if an election is looming. Such issues can create “no win” situations for politicians, because whichever position they take they will lose some voters because of their choice.

Might politicians just “read the wind” and, if the polls show voters want legalized euthanasia and its legalization seems highly likely, they just go along with that, whatever their personal values or views?

All postmodern Western nations are currently in a period of uncertainty about the nature and sustainability of flourishing democracy and, hence, of the ethical basis on which political decisions should be made. This is especially the case when the decisions involve affirmation or rejection of fundamental shared values on which these societies are based.

Respect for human life, arguably our most important fundamental societal value, is the value at stake in the legalizing euthanasia debate.

In Part 3, Professor Somerville will discuss the alternatives to euthanasia. Part 1 was published on Monday. References will be supplied if requested.

© 2021 Margaret Somerville

Margaret Somerville AM, DSG, FRSC, FRSN, 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...