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Read and vote: Should patients be allowed to request suicide?

The Debate

The Supreme Court of Canada this week is hearing arguments on one of the most difficult legal and moral questions: Should patients be allowed to request that their doctors help them end their lives? Assisted suicide, or euthanasia with consent, is permitted in a number of countries, including Belgium and the Netherlands, and some U.S. states; there, it has become widely requested among patients with terminal illnesses and those in constant pain, but remains highly controversial and has raised fears of a widening of assisted suicide into euthanasia against the disabled and vulnerable. Here we have two of Canada’s best-known experts offering the best-articulated arguments for and against the legalization of assisted suicide. Read their arguments, comment, and vote on the argument you find most persuasive.

The Debaters

Debate contributor
Margaret SomervilleFounding Director of the Centre for Medicine, Ethics and Law at McGill University and professor in faculties of Law and Medicine
Assisted suicide leads to normalization of euthanasia, harms the vulnerable and degrades our respect for the value of human life
Debate contributor
Arthur SchaferDirector of the Centre for Professional and Applied Ethics at the University of Manitoba.
If we truly value life, we should allow people to end it in a way and at a time of their choosing

The Discussion

Debate contributor

Margaret Somerville : Euthanasia and assisted suicide go beyond personal ethics to involve social ethics. Advocates frequently resort to a personal story, often that of a suffering relative, to explain their stance. They avoid asking the question, “What does it say about a society that deals with the big problems of human existence by legalizing the ‘quick fix’ of inflicting death?” Such a society is abandoning the great philosophic traditions of Western civilization. Everything now depends only on majority opinion and technological capacity.

Moreover, euthanasia differentially implicates the most vulnerable members of a society. 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.

The strongest case for legalizing euthanasia and physician-assisted suicide is at the level of the individual person, such as Sue Rodriguez or Dr. Donald Low, whose heartbreaking pleas for euthanasia rightly move us.

But we must also consider where such legalization would lead and what its impact would be on other people, the institutions of law and medicine, and the foundational values of society. And we must take into account, not just its impact in the present, but also in the future. Ask yourself: “How do you not want your great-great grandchildren to die?” As current reports from the Netherlands and Belgium, where euthanasia and assisted suicide are legal, show, euthanasia will be normalized and we will see an exponential increase in its use in ever broadening circumstances. That is, slippery slopes are unavoidable.

Initially, claims are made that euthanasia will be used only in rare cases on competent, consenting, dying adults who are in unrelievable pain and suffering. But these requirements don’t last. In the Netherlands, at least 4 percent of all deaths are by euthanasia and in Belgium on average there are five cases a day. It’s not rare. Children with disabilities can be euthanized (with their consent) as can those who are mentally, but not physically, ill or who wish to avoid future suffering. Belgium is currently debating euthanasia for people with Alzheimer’s Disease. Euthanasia is now so normalized only extreme cases make the media, such as two very recent ones, a prisoner who received euthanasia for unbearable suffering caused by imprisonment and an old lady who chose euthanasia instead of a nursing home, which she dreaded.

People are afraid to accept palliative care or necessary pain management because they fear euthanasia. We must be able to reassure them that we will kill their pain, but never intentionally kill them and we can’t do that if euthanasia or assisted suicide are legalized.

Seeing death as an appropriate response to suffering raises serious problems with respect to suicide prevention in general. It establishes suicide as an appropriate response to suffering. And society’s agreement to help elderly and vulnerable persons to kill themselves or to allow physicians to kill them sends a powerful message that their lives are not worth living. State-sanctioned suicide and euthanasia ask not that we attempt to preserve life -- the normal role of medicine and the state -- but that we accept and act communally upon a person’s judgment that his or her life is unworthy of continuance and become complicit in ending it.

And legalized euthanasia is abused. Just as we don’t report driving through a red light, doctors and nurses acting outside the law don’t report those cases. Abuse of old people with euthanasia is especially likely and should be seen as a major public-health threat. The combination of an ageing population, scarce healthcare resources and euthanasia is a lethal cocktail.

Confusion is used to promote public acceptance of euthanasia: Concealing language such as the euphemism “medical aid in dying.” An Ipsos marketing survey showed 60 per cent of 1000 Quebecers did not understand that this phrase meant a lethal injection and 40 per cent of just over 2000 Canadians did not comprehend that euthanasia meant that. Similarly, the “no difference” argument that assisted suicide is only an incremental extension of rights to refuse treatment that result in death promotes euthanasia through confusion. There is a radical difference between allowing a natural death to occur and killing a person.

This debate involves a clash of the values of respect for life and respect for individual autonomy. Anti-euthanasia advocates give priority to respect for life, pro-euthanasia to respect for individual autonomy.

But all societies in which reasonable people would want to live need to uphold respect for both each individual human life and for human life in general. The Charter of Rights and Freedoms affirms this for Canada. And legalizing euthanasia would harm the ability of medicine and law to carry the value of respect for life, as they must do for a secular society.

Just as we now realize our actions could destroy our physical ecosystem and we must hold it in trust for future generations, we must also hold our metaphysical ecosystem — the collection of values, principles, beliefs, attitudes, shared stories, and so on that bind us together as a society —likewise, in trust for them. That requires that we reject euthanasia, but always react to pain and suffering with deep compassion and assistance to relieve it -- that we kill the pain and suffering, not the person with the pain and suffering. That requires that everyone who needs it receives good palliative care. At present at least 70 percent of such Canadians have no access, which is appalling and a serious breach of ethics.

Might, however, 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 universal “human spirit,” especially our capacity to find meaning in life, that which makes life worth living.

To legalize assisted suicide and euthanasia is not an incremental change. 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 and its protection. We must employ our ethical imaginations to appreciate that and act accordingly.

Debate contributor

Arthur Schafer : In its ruling in the case of Sue Rodriguez (1993), the Supreme Court of Canada narrowly upheld the ban on assisted suicide. Speaking for the majority, Justice John Sopinka claimed that there was “no public consensus”. That was then.

But: In a comprehensive opinion poll published last week, Ipsos-Reid found that 84 per cent of Canadians now favour physician-assisted suicide. Even more remarkable: 85 per cent of those who identified as disabled were in favour, as were 80 per cent of all Christians, including 83 per cent of Catholics. So, it turns out that in contemporary Canada this most controversial of moral issues isn’t really so controversial.

There have been other important social changes since the Supreme Court ruled 5-4 against Ms. Rodriguez. In 1993 no jurisdiction in the world had legalized either assisted suicide or mercy killing (euthanasia). In consequence, lawyers and judges could only speculate about possible negative consequences. Over the course of the past 21 years, however, five U.S. states (including Oregon and Washington State) and several European countries (including the Netherlands, Belgium and Switzerland) have opted to regulate assisted dying instead of imposing a total ban. Their experience has been closely studied and there is now a substantial body of empirical data needing interpretation.

Suicide was de-criminalized in Canada forty-two years ago. So, if you are a competent adult you already have the right to end your own life. After the British Columbia Supreme Court heard the case of Lee Carter in 2012, Madam Justice Lynn Smith ruled that the Criminal Code prohibition against assisted suicide discriminates against people who are unable to take their own lives. If we truly value life, we should not force patients to choose between a life of prolonged suffering or killing themselves prematurely -- while they are still capable of suicide, that is, before their illness makes suicide impossible without assistance.

Gloria Taylor, one of the plaintiffs in Lee Carter, put the central point eloquently: “What I want is to be able to die in a manner that is consistent with the way that I lived my life. I want to be able to exercise control and die with dignity and with my sense of self and personal integrity intact. I want to be able to experience my death as part of my life… I do not want the manner of my death to undermine the values that I lived my life in accordance with.”

In other words, autonomous individuals should be free to decide their own fate. When an important life choice concerns a private matter and when the individual making that choice is near death and suffering unrelievably then the state should not interfere unless it can prove that interference is necessary to protect vulnerable third parties.

If you are dependent upon technology to stay alive – a breathing machine, say, or dialysis – you already have the legal right to say “enough is enough; pull the plug.” No one can force life-prolonging treatment upon a competent adult patient. However, if your life is not technology-dependent then a doctor cannot legally assist you to die. Gloria Taylor sees this as illogical and unfair.

Of course, you can always choose to stop eating and drinking; but death by starvation and dehydration is not everyone’s idea of a good death. You can also opt for continuous palliative sedation, in which case you will be sedated to unconsciousness, food and fluids will be discontinued, and you will never regain consciousness.

Unsurprisingly, many terminal ill patients find these ways of dying unattractive.

The Supremes acknowledged in Rodriguez that the prohibition against assisted death violated her constitutional liberty. Autonomy rights are not absolute, however, and the Court ruled against Ms. Rodriguez because the majority feared that even careful safeguards would not adequately protect the most vulnerable members of society against error, abuse or exploitation.

In Lee Carter, by contrast, the B.C. trial court accepted evidence that there was “no … heightened risk for the elderly… the poor, the physically disabled …, people with psychiatric illnesses, including depression or racial or ethnic minorities.” Indeed, the opposite appears to be the case: Patients receiving physician-assisted suicide in Oregon (and the Netherlands) tend disproportionately to be socio-economically privileged.

In Oregon, only a tiny fraction of overall deaths are physician assisted – on average, about 1 in 500. Patients granted assistance to die mostly have metastatic cancer. They are very close to death and are suffering unrelievably, despite excellent hospice care. The rate of physician-hastened deaths in the Netherlands has remained constant over the years, ranging between 3 per cent and 4 per cent.

Despite regular “scare stories” from opponents, the safeguards appear to be working well in both Oregon and the Netherlands. Doctors in the Netherlands do not always follow the rules, but that’s true everywhere, including Canada. Published studies show that vulnerable patients are better protected in both Oregon and the Netherlands after legalization than they were before. Regulation works better than prohibition.

Much has been made of the fact that the Belgian parliament recently allowed dying children to opt for hastened death. “Aha”, say the critics. “The slope is slippery.” But they neglect to mention that this applies only to children “with discernment” and only when parents and doctors agree. It seems unreasonable to turn compassion for the pain of dying children into a weapon against mercifully hastened death for competent adults.

Very few Canadians will want or need physician-assisted suicide. But many would take comfort from the knowledge that if things get really bad their physician could help them to achieve a quick and peaceful death.

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