McGill Centre for Medicine, Ethics and Law

THE ETHICS OF PHYSICIAN-ASSISTED THE ETHICS OF PHYSICIAN-ASSISTED SUICIDE AND EUTHANASIA SUICIDE AND EUTHANASIA

Understanding the arguments Understanding the arguments for and against legalizationfor and against legalization

MARGARET SOMERVILLEMARGARET SOMERVILLEAM, FRSC, A.u.A (pharm.), LL.B. (hons), D.C.L.,

LL.D. (hons. caus.); D.Sc.(hons. caus.); D.Hum.L.(hons. caus.)

William F. Mitchell Bioethics Seminar 2014 Catholic Health Association of Saskatchewan

and St Thomas More College, University of SaskatchewanSt Paul's Hospital,

SaskatoonNovember 4th, 2014

Copyright©2014 Margaret SomervilleNot to be copied or cited without permission of the author

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PART IPART I

SETTING SETTING THE EUTHANASIA SCENETHE EUTHANASIA SCENE

History will view the current euthanasia debate as the most important values debate of 21st Century.

Whatever its outcome, it will be seen in retrospect, as a critical point in determining the shared

values handed on to future generations to become the values on which they will base their Canadian society.

The euthanasia debate focuses attention on the importance to humanity of putting into practice the belief that all human life has dignity

and deserves respect and protection.

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Many current attitudes and values could affect how terminally ill, dying,

and vulnerable people are treated

For example, if materialism and consumerism are priority values, euthanasia fits with the idea : "When you are past your 'use by' or 'best before‘ date, you should be checked out as quickly, cheaply and efficiently as possible.”

But we are not products to be checked out of the supermarket of life

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Consider the cumulative effect of how we treat vulnerable people, in general,

and the impact of that on the shared values that bond us as a society

and in setting the “ethical tone” of our society.

It’s wisely said that “We can’t judge the ethical tone of a society by how it treats its strongest, most privileged, most powerful members, but by how it treats its weakest, most vulnerable and most in need”.

Dying people belong to the latter group.

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Levels of impact of euthanasiaLevels of impact of euthanasia

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Physician-assisted suicide and euthanasia raise the question:

CAN HUMAN LIFE HAVE DIGNITY CAN HUMAN LIFE HAVE DIGNITY IN THE CONTEXT OF SUFFERING?IN THE CONTEXT OF SUFFERING?

Answer depends on

how we define dignity and

whether we can find meaning in suffering. Intrinsic dignity – everyone has it - can’t be lost

compared with

Extrinsic dignity – depends on abilities - can be lost

 

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Suggest euthanasia seenas appropriate response to suffering when no meaning can be found in it.Note: meaning can be secular or spiritual

In euthanasiaeliminating a life seen as appropriate response to eliminating suffering.

Euthanasia greater threat to the lives of vulnerable persons than to those not labeled in that way.

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Conflict of euthanasia as a response to suffering

and suicide prevention:In Carter case trial judge relies heavily on fact

not a crime to attempt or commit suicide, and asks,

why then is it a crime to assist it?

Answer is decriminalizing suicide

intended to protect life; decriminalizing assisted suicide

does the opposite.

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We try to prevent suicide and, importantly, there is no right to commit suicide

The difference between suicide and physician-assisted suicide is

fundamental.

Physician and societal complicity in assisted suicide

- ethics of complicity10

Carter case reasoning on Charter’s sec 7 right to life:

“[Rodriguez] leaves open whether the legislation [prohibiting assisted suicide] infringes Ms. Taylor’s right to life....[The Criminal Code’s prohibition] affects her right to life because it may shorten her life.  Ms. Taylor’s reduced lifespan would occur if she concludes that she needs to take her own life while she is still physically able to do so, at an earlier date than she would find necessary if she could be assisted.”

Converts a “right to life” to a right to assisted suicide- a right to be killed

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THE ESSENTIAL QUESTION:THE ESSENTIAL QUESTION:Should society change its laws

to authorize physicians

(most people think physicians would be the “assisters” or “euthanizers”)

to help people to kill themselves

through suicide

or to kill them with a lethal injection euthanasia?

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Part IIPart II

CONCEPTS, ARGUMENTS CONCEPTS, ARGUMENTS AND AND REASONS REASONS

IN THE EUTHANASIA DEBATEIN THE EUTHANASIA DEBATE

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1. INHERENTLY WRONG 1. INHERENTLY WRONG vsvs. MORAL RELATIVISM. MORAL RELATIVISM

Inherently wrong for one human being intentionally to kill another orhelp them to kill themselves – assisted suicide

Utilitarians and moral relativists disagree - rightness or wrongness depends on

circumstances, values and preferences

They argue euthanasia should be legal, when benefits for individual persons

outweigh its risks and harms14

2. SANITIZING LANGUAGE 2. SANITIZING LANGUAGE - INTENTIONALLY CAUSES CONFUSION - INTENTIONALLY CAUSES CONFUSIONFor instance, don’t speak of killing

or euthanasia or even suicide, but, as in An Act respecting end-of-life care

(Bill 52) and Quebec government reports, “medically assisted death”

(MAD). This euphemistic, concealing use of language

creates confusion re what euthanasia involves, which is a strategy used to promote it

- see Ipsos Marketing survey IF EUTHANASIA IS NOT KILLING, WHAT IS IT?

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3. “NO DIFFERENCE” ARGUMENT 3. “NO DIFFERENCE” ARGUMENT - LEGALIZING THROUGH CONFUSION- LEGALIZING THROUGH CONFUSION

Pro euthanasia argue refusals of treatmentthat shorten patient’s life recognize a right to die. Argue such refusals are ethical and legal, therefore, to be consistent euthanasia should be ethical and legal.

Related argument euthanasia just another medical treatment

- Bill 52 defined MAD as palliative care; Act does not - terminal/continuous palliative sedation

defined as palliative careConfuses TS (is euthanasia) and PS (is not euthanasia)

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But right to refuse treatment is not a right to die;

Both intention of the physician and causation of death are radically

differentin refusals and euthanasia;

And most physicians do not regard inflicting death as medical

treatment- provincial jurisdiction an issue

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i) Nature of the rights involvedrefusals of treatment respect right to inviolability, does not recognize right to die

let alone, a right to be killed;at most, a right to be allowed to

die.

ii) Intentionrefusals of treatment,

physician no primary intention to kill; euthanasia

physician has primary intention to kill18

iii) CausationWhen patients refuse life support treatment

die a natural death from their underlying illness.

In euthanasia, they die from the lethal injection

iv) Ends vs. meansPro-euthanasia “no difference” argument focuses

on ultimate outcome – death - which occurs “anyway” whether or not euthanasia involved.

But issue is not if we die – we all die - it’s how we die and whether are valid ethical and legal distinctions between well-accepted medical practices at the end-of-life and euthanasia.

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4. VALUES CONFLICT4. VALUES CONFLICTAnti-euthanasia proponents give priority

to value of respect for life pro euthanasia advocates give priority to value of respect for individual autonomywhen these values conflict as in euthanasia

i) Autonomy is it possible?“relational autonomy”

ii) Respect for lifelabeled as religious and passé in secular society

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5. LEVELS OF ANALYSISPro-euthanasia focus on the individual person

who wants euthanasia: valid focus, but not sufficient

Euthanasia is not just a matter of personal decision-making

What we decide about euthanasia will affect others, important institutions and society.

Law and medicine carry value of respect for life

- especially in a “secular society” euthanasia requires changing the law to allow it

and authorizing physicians to carry it out 21

Legalizing euthanasia makes society complicit

in inflicting death on some of its members.

What long term effects might result from complicity?

How will our great great grandchildren die?

We realize we could destroy our physical ecosystem and must hold it in trust for future

generations, must also hold our metaphysical ecosystem in trust for them - collection values, principles, beliefs, attitudes, shared stories, that bind us together as a society.

That requires we kill the pain and suffering,

not the person with the pain and suffering.

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6. SLIPPERY SLOPES6. SLIPPERY SLOPESPro-euthanasia advocates deny is any evidence

slippery slopes resulted in Netherlands or Belgium

Deny a ‘logical’ slippery slope – situations in which euthanasia available expand–

or a ‘practical’ slippery slope –euthanasia will be used abusively.

Latter is major concern re vulnerable people, including old, disabled or dying persons

But evidence for the existence practical & logical slopes very convincing

Slippery slopes are inevitable and unavoidable

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7. HOW PRO- AND ANTI- EUTHANASIA7. HOW PRO- AND ANTI- EUTHANASIA VIEW DYING AND DEATH… VIEW DYING AND DEATH…

A true story: my understanding of

“End Credits” – a documentary on the practice of euthanasia in Belgium ten years after it was legalized in 2002.

It follows the dying and death of two people, whom the film makers describe as follows: “Adelin, 83, and Eva, 34, two very different people, who are at the dawn of the end of their lives, ask for help with and care for a decent passing away.”

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End Credits provides an opportunity to understand some of the ways in which people who are pro-euthanasia and those who are anti-euthanasia radically differ in how they view both dying and death, and what euthanasia involves.

And those differences reflect profound differences in what we believe it means to be human and what respect for both individual human life and human life, in general, in our society requires that we not do.

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That leads to the question:

Might the strongest argument against euthanasia relate, not to death, but to

life?

That argument is that normalizing euthanasia would destroy a sense of

the unfathomable mystery of life and seriously damage our human spirit, especially our capacity to find meaning in life.

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CONCLUSIONCONCLUSION“The world of the 'consenting adult', the world

remade in accordance with the 'social contract' of the enlightened liberal conscience, is, in the last analysis, a world too timid for love.”

Roger Scruton

Sexual Desire: A Philosophical Investigation, p. 358.

Is euthanasia the outcome of our failure to be able to love those who are dying?

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DOES LEGALIZING EUTHANASIAresult from

a failure of the ethical imagination on the part of our law makers?

To legalize euthanasia is not an incremental change as they seem to think it is.

It’s a seismic and radical change in one of the most important values on which

our society and civilization is founded, respect for human life.

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