The Royal Society of Canada Expert Panel on End-of-Life Decision Making recently released its Report to much media attention. The parts of that report we can all agree on, for instance, the need for much better access to palliative care and pain management for terminally ill patients, was not the media’s focus. The panel’s recommendation that euthanasia and physician-assisted suicide (PAS) should be legalized was.
It has generated many calls for a national debate in Canada on these latter issues – mainly, I would guess, if not entirely, from people advocating the legalization of euthanasia. In entering such a debate and deciding whether they agree with this recommendation, it’s important for Canadians to understand the weaknesses of the Report.
The Panel’s mandate included the following direction: “The public would… benefit greatly from having a careful, balanced review of various pros and cons of decriminalization of physician-assisted death from well-reasoned ethical and legal standpoints.” The Report comes nowhere near fulfilling this mandate. It’s a pro-euthanasia manifesto – to paraphrase an advocate for disabled people speaking in another context, it’s “thinly veiled euthanasia and assisted suicide propaganda disguised as an expert report”.
This is not surprising in view of who the authors are. Many are well-known pro-euthanasia advocates and, as the Report is unanimous, one can assume all agree with this stance. The people I know whom the Panel lists as consulting to them are, likewise, pro-euthanasia — three of them world-leading advocates.
It’s important to understand this is not a Report of the Royal Society of Canada, as many have mistakenly assumed, as that gives it an unmerited credibility. It’s a Report of an expert panel (only one member of which is a fellow of the Royal Society) set up by the Royal Society. The fairness and wisdom of the Royal Society’s choice of panel members must, however, be questioned.
The Report is very far from being a “balanced review” or adequately comprehensive. The arguments against the legalization of euthanasia and PAS are almost entirely absent. Issues are considered almost entirely at the level of the individual. There is almost no discussion of the impact of legalizing euthanasia and PAS at the institutional level — in particular, the impact on healthcare institutions and professions, and the law – or at the societal level, in particular, on important shared values, such as respect for life. In fact, this value is not discussed, an extraordinary omission considering the topic of the report.
Discussion of abuses is deficient and selective
The discussion of the practices in jurisdictions that have legalized or allow euthanasia and assisted-suicide are seriously deficient and very selective so as to minimize the Report’s coverage of abuses, expansions of justifications for the practices, and other problems or controversies.
For example, the Report indicates there has been one case of the use of euthanasia on disabled babies in the Netherlands. This is probably correct in the short time since the Groningen protocol allowing such euthanasia was formally accepted. But, prior to that, an article in the New England Journal of Medicine documents 22 cases of babies with spina bifida being euthanized, which is not mentioned. Such “pro-euthanasia presentations” of the facts are concerning and misleading. Likewise, the availability in the Netherlands of euthanasia for children is not mentioned. The combination of euthanasia and donation of organs for transplant in Belgium and the recent case in Flanders of “joint euthanasia” of a terminally ill man and his healthy wife are ignored. And a survey of Belgian physicians who had carried out euthanasia, published in the Canadian Medical Association Journal, which showed 32 percent of those physicians had carried out euthanasia without the patient’s request or consent is never mentioned.
The system set up under the Oregon Death with Dignity Act is presented as largely problem-free. The literature describing problems, for instance, articles and book chapters by renowned pain specialist and head of palliative care at Memorial Sloane Kettering, Dr Kathleen Foley, and Dr Herbert Hendin, a New York psychiatrist specializing in suicide prevention, is likewise totally ignored.
And although Canadian psychiatrist Dr Harvey Max Chochinov’s research is referenced, his ground-breaking work in the psychiatry of dying people, what helps them and what they want, is not discussed.
Through the lens of individual autonomy
The authors make an assumption that individual autonomy, implemented through “informed choice”, is always the prevailing value and construct their case for euthanasia and PAS from there. They do not consider that for many people some other value might prevail – for example, respect for human life which requires that we don’t kill each other, except when unavoidable to save life — and what line of argument and decision outcomes that would result in.
In short, the authors have adopted a basic assumption, from which, as they state, everything else they accept and recommend flows, without adequately justifying doing so and not even mentioning the possible alternatives.
The essential difference between the pro and anti euthanasia positions is that the former gives priority to individual autonomy over respect for life, the latter does the opposite. We should keep in mind, here, that we are not just talking about the value of respect for each individual human life, important as that is, but also, respect for human life in general. The authors refer to the Charter as the primary source of our shared values: Apart from any other claims on behalf of the value of respect for life, it is one of the values enshrined in the Charter.
There is a strong emphasis in the Report on the burden and healthcare costs of an aging population and the Report gives the impression that euthanasia and PAS will help to resolve this “problem”. The authors note that euthanizing people “in advanced stages of dementia” will be an issue to be addressed in the future. In other words, they don’t reject the possibility that this might be acceptable.
The Report doesn’t mention survey results, such as those from an Environics poll, which last year (2010) asked over 2000 Canadians what the government priority should be – legalizing euthanasia or improving end-of-life care, or both. Seventy-one percent said improving end-of-life care and 19 percent said legalizing euthanasia, and 5 percent said both (the remainder were Did not know/Neither).
What about elder abuse?
Because the Report seems to have a special focus on aging, I note that the Environics polls also showed Canadians are very concerned about elder abuse if euthanasia or PAS is legalized. The 2011 poll expressly asked about “elder abuse” and 76 percent of respondents said they were concerned about it, if euthanasia were legalized. The 2010 poll did not expressly ask about “elder abuse”, but did ask a question where 78 percent of respondents said they were concerned that elderly persons (disabled and sick persons too) would be euthanized without consent. To another 2010 question, 63 percent said they were concerned elderly persons could be pressured to accept euthanasia in order to reduce health care costs.
The authors recognize their position involves an inconsistency in that they champion individual autonomy as the prevailing value, but clearly will place limits on its exercise and not recognize the validity of the choice to die of all autonomous, competent adults.
But, if individual autonomy trumps all other considerations, then why is there a need for any other justification for euthanasia? Simply wanting to be dead and consenting to it should be sufficient: “Over 70 and tired of life”, as proposed in The Netherlands, would suffice. And why, even, does the person need to be “over 70”? What about the broken hearted 18-year-old whose first love has abandoned her; why can’t she exercise her autonomy to have assistance committing suicide?
And if there’s a right to commit suicide, then there is a duty not to interfere with people exercising that right. How then can we justify treating people brought to an emergency room who have attempted suicide?
The usual “confusions” used to promote the case for euthanasia are all present in the Report: equating all acts and omissions; arguing there is no difference between killing and allowing to die; conflating intention and motive in relation to desired and unwanted consequences of pain relief treatment; and so on. The opposite arguments are not presented. And the fact that courts and others rely on these distinctions daily in making legal and ethical decisions is ignored.
The section on dignity, which the authors recognize is a prominent concept in the euthanasia debate, is especially biased to the pro-euthanasia arguments and inadequate. In particular, a 2008 major and very comprehensive research report on the concept by the US President’s Commission on Bioethics is not even mentioned.
The above criticisms are not comprehensive, many more could be articulated. Fortunately, in my view, there is a wealth of grounds on which the Report can be easily dismissed.
Margaret Somerville is founding director of the Centre for Medicine, Ethics and Law at McGill University.
Editor’s note: for a discussion of similar report in the UK, see David Alton’s “The New Year should begin with ideas for saving lives, not for ending them” (Jan 5)