Dying as the Last Great Act of Living

In accordance with disclosure of potential conflict of interest requirements for continuing education credits, I want to inform you that, in the last two years, I have consulted to Bayer Inc., Pfizer Inc. and Sanofi Aventis Inc., and that I have given lectures sponsored by pharmaceutical companies at conferences.

Summary

1. The difficulty of making the case against euthanasia
   
   Trying to convince medical and law students of the risks
         and harms of euthanasia.
   
   
2. Confusion as a means of legalizing euthanasia
   
   a) The deliberate confusion of pain relief treatment and
         euthanasia to promote the legalization of euthanasia
   
   We can always relieve pain
   
   b) The confusion between rights to refuse treatment and euthanasia
   
   Why is withdrawing treatment to allow a patient to die ethically acceptable and
         euthanasia is not?
   
   c) Confusion in language
   
         Words, especially definitions, matter. Defining dignity.
   
   d) Confusion between the respect owed to animals and to humans
   
   Humans deserve "special" respect. Addressing the argument that we euthanize our
         pets out of compassion, so why not humans we love. The short answer is we
         are not just another animal.
   
   
3. The unstoppable expansion of justifications for euthanasia
   
         The 30 year experience with euthanasia in The Netherlands shows that once
         introduced criteria for its use inevitably expand.
   
   
4. Euthanasia would hurt medicine and physicians and nurses
   
         We must consider the damage to medicine if physicians are allowed to kill.
         Physicians' and nurses' absolute rejection of intentionally inflicting death is necessary
         to maintaining people's and society's trust in their own physicians
         and the profession of medicine as a whole.
   
   
5. Hope: Keeping the human spirit alive
   
   What do dying people need?

Conclusion

What would happen if we don't keep euthanasia in a moral context?

I have researched and written on euthanasia and physician-assisted suicide for over thirty years. It's impossible, of course, to communicate to you in the short time I have available today, all the facts on which I have concluded that legalizing euthanasia or physician-assisted suicide is a bad idea and my reasons for coming to this conclusion. I'm going to assume that you have probably heard all the usual arguments for and against euthanasia[1], many of which are very important and prominent in this debate. But I want to focus on some aspects that might not yet have been presented.

Before doing so, however, I want to point out that we need to look at the impact of legalizing euthanasia at three, and probably four, levels.

The micro or individual level; the meso or institutional level; the macro or societal level; and the mega or global level.

The case for euthanasia focuses on rights to autonomy and self-determination and relief of suffering and is made, almost entirely, at the individual level – the right of individuals to decide how and when they will die.

While there are arguments against euthanasia at the individual level, in particular, realistic and valid concern about its abuse, there are strong arguments against it at the institutional and societal levels.

How we die is never just a private matter when euthanasia is involved. It necessarily involves other people and society and what it allows or prohibits, and some of society's most important values and institutions.

Society would be complicit in euthanasia or assisted suicide in legalizing them and in allowing medicine to be involved. Law and medicine are the two main institutions in a secular society that carry the value of respect for life. That value would be unavoidably seriously harmed.

As I hope I can show you, even utilitarians, who base their ethics on whether benefits outweigh risks and harms, should decide against euthanasia and assisted suicide because the harms outweigh the benefits, especially on the slippery slope these interventions open up.

1. The difficulty of making the case against euthanasia

Trying to convince law and medical students of the risks and harms of euthanasia

The euthanasia debate in Canada and Quebec is part of a trend in western democracies of increasing activism over the last decade to legalize euthanasia and physician-assisted suicide. In short, we are not unique in needing to deal with this issue.

Understanding the arguments both for and against these interventions is of crucial importance. But that's not necessarily easy to accomplish, if my own experience holds true more generally.

I taught a course, "Ethics, Law, Science and Society," to upper year and graduate law students at McGill in which euthanasia and physician-assisted suicide was one of the topics we studied. I came away from the class feeling that I had completely failed to communicate to most of my students what the problems with euthanasia were. I felt the same with the medical students whom I have taught. They did not see euthanasia as raising major problems – at least any beyond preventing its abuse – a reaction I found very worrying. Moreover, hardly any students spoke against euthanasia.

My concern goes beyond failing to convince my students there was, at the least, a strong case to be made against euthanasia. It includes the fear that their response was likely to be true also for the wider society.

The difficulty of communicating the case against euthanasia and the ease of communicating the case for it is a serious danger, in the current debate about whether we should legalize euthanasia in Canada.

So why is the case against euthanasia so hard to establish?

When personal and societal values were consistent, widely shared and based on shared religion, the case against euthanasia was simple: God commanded "Thou shalt not kill."

In a secular society based on intense individualism, the case for euthanasia is simple: Individuals have the right to choose the manner, time and place of their death.

In contrast, in such societies the case against euthanasia is complex. It requires arguing that harm to the community trumps individual rights or preferences.

One student explained that she thought I was giving far too much weight to concerns about how legalizing euthanasia would harm the community and our shared values, especially that of respect for life, and too little to individuals' rights to autonomy and self-determination, and to euthanasia as a way to relieve people's suffering.

She emphasized that individuals' rights have been given priority in contemporary society, and they should also prevail in relation to death. Moreover, legalizing euthanasia was consistent with other changes in society, such as respect for women and access to abortion, she said.

To respond to such arguments, we need to be able to embed euthanasia in a moral context without resorting to religion – that is, formulate a response that adequately communicates the case against euthanasia from a secular perspective.

That requires, first, countering the belief that individual rights should always prevail – a task I failed at in class.

We must show, as well, there are solid secular arguments against euthanasia, for example, that legalizing euthanasia would harm the very important shared societal value of respect for life, and change the basic norm that we must not kill one another.

It would also harm the two main institutions – law and medicine – that paradoxically are more important in a secular society than in a religious one for upholding the value of respect for life.

And, it would harm people's trust in medicine and make them fearful of seeking treatment.

So why now? There is nothing new about people becoming terminally ill, suffering, wanting to die, and our being able to kill them. So why now, after we have prohibited euthanasia for millennia, are we debating whether to legalize it?

Although the euthanasia debate usually centres on a dying, identified person, who wants euthanasia, I believe the answer to what has precipitated the debate lies in understanding a complex interaction of certain unprecedented changes in society. Identifying these factors can also help us to see what is needed to make the case against euthanasia clearer and stronger.

Dying alone or unloved seems to be a universal human fear. In democratic western societies many people have a sense of loss of family and community: relationships between intimates have been converted into relationships between strangers. That loss has had a major impact on the circumstances in which we die. Death has been professionalized, technologized, depersonalized and dehumanized. Facing those realities makes euthanasia seem an attractive option and easier to introduce. Euthanasia can be seen as a response to "intense pre-mortem loneliness."

We engage in "death talk" in order to accommodate the inevitable reality of death into the living of our lives. That talk helps us to live reasonably comfortably with that knowledge, which we must do if we are still to be able to find meaning in life.

"Death talk" (and other morals and values talk) used to take place in religion and its churches, synagogues, mosques and temples and was confined to an hour or so a week. Today, it has spilled out into our daily lives, especially through media. The euthanasia debate is one example of such "death talk."

Moreover, "secular cathedrals" – our parliaments and courts – have replaced our religious ones. That has resulted in the legalization of societal ethical and moral debates, including in relation to death. It is not surprising, therefore, that the euthanasia debate centres on its legalization.

Mass media and the mediatization of societal debates, including euthanasia, also have major impact. Media focus on individual cases: People, such as Sue Rodriguez – an ALS sufferer who took her fight to die to the Supreme Court of Canada – pleading for euthanasia, make dramatic, personally and emotionally gripping television.

The arguments against euthanasia, based on the harm that it would do to individuals and society in both the present and the future, are very much more difficult to present visually.

Moreover, the vast exposure to death that we are subjected to in both current-affairs and entertainment programs might have overwhelmed our sensitivity to the awesomeness of death and, likewise, of inflicting it.

But one of my students responded, "If anything, I think many of our reactions come not from an overexposure to death, but from an aversion to suffering, and an unwillingness or hesitancy to prolong pain."

Finding convincing responses to the relief-of-suffering argument used to justify euthanasia is difficult in secular societies. In the past, we used religion to give value and meaning to suffering. But, now, suffering is often seen as the greatest evil and of no value, which leads to euthanasia being seen as an appropriate response.

Some answers to the "suffering argument" might include that:

• even apart from religious belief, it's wrong to kill another human;
  
  
• euthanasia would necessarily cause loss of respect for human life;
  
  
• it would open up an inevitable slippery slope and set a precedent that would present serious dangers to future generations. Just as our actions could destroy their physical environment, likewise, we could destroy their moral or metaphysical environment. Both environments must be held on trust for them;
  
  
• recognizing death as an acceptable way to relieve suffering could influence people contemplating suicide; and
  
  
• there are many ways to relieve pain and suffering without killing the person who experiences them.

Might the strongest argument against euthanasia, however, relate not to death but to life? That is the argument that normalizing euthanasia would destroy a sense of the unfathomable mystery of life and seriously damage our human spirit[2], especially our capacity to find meaning in life.

2. Confusion as a means of legalizing euthanasia

a) The deliberate confusion of pain relief treatment and euthanasia to promote the legalization of euthanasia

There is a saying in ethics that "good facts are essential to good ethics." That is especially true of definitions – we need accurate definitions if we are to have good analysis of ethical issues, including those related to euthanasia.

The Quebec College of Physicians and Surgeons "tentatively proposed" legalized euthanasia. The college said that it could be seen "as part of appropriate care in certain particular circumstances."

But it seems that Dr. Gaétan Barrette, the president of the federation of Quebec medical specialists and Dr. Yves Lamontagne of the Quebec College of Physicians do not understand what does and does not constitute euthanasia.

Dr. Barrette confuses palliative sedation with euthanasia and believes that in caring for terminally ill people, "doctors are aware they can be charged with murder if they administer a 'palliative sedative' before a patient is on his or her last breath." Palliative means the sedative was necessary to relieve pain and suffering and was not given with an intention of killing the patient. That cannot result in a murder charge, or any other legal charge, unless the patient refused it.

Indeed, unreasonably failing to provide necessary treatment for pain and suffering could constitute unprofessional conduct with resultant disciplinary measures, medical malpractice, and, in extreme cases, criminal negligence. It is now also widely recognized that for a healthcare professional to negligently leave a patient in serious pain is a breach of fundamental human rights.

The Montreal Gazette reported that Barrette and Lamontagne "told the committee that doctors do not want to perform assisted suicides."

"We are not there to execute people," Lamontagne said.

This boggles the mind. What do they think euthanasia involves? And if, as they are proposing, killing patients is acceptable, why is helping those patients to kill themselves not acceptable? At least accepting both would have the virtue of consistency.

People in pain have a right to fully adequate pain relief treatment. But that does not entail endorsing euthanasia, as pro-euthanasia advocates propose.

The pro-euthanasia lobby has deliberately confused pain relief treatment and euthanasia in order to promote their cause.

Their argument is that necessary pain relief treatment that could shorten life is euthanasia; we are already giving such treatment and the vast majority of Canadians agree we should do so; therefore, we are practising euthanasia with the approval of Canadians so we should come out of the medical closet and legalize euthanasia.

Indeed, they argue, doing so is just a small incremental step along a path we have already taken.

It's true and to be welcomed that the vast majority of Canadians agree we should give fully adequate pain relief, but the pro-euthanasia lobby is wrong on all its other claims.

We need to distinguish treatment that is necessary to relieve pain, even if it could shorten life (which is a very rare occurrence if pain relief is competently prescribed), from the use of pain relief treatment as covert euthanasia. The former is not euthanasia, the latter is.

And in the small number of cases in which pain cannot be controlled palliative sedation is an option. This is not euthanasia as 49 percent of Quebec physicians recently polled mistakenly thought it was.

The distinction between pain relief treatment and euthanasia hinges on the physician's primary intention in giving the treatment and the patient's need for the treatment given.

Pain relief treatment given with a primary intention to relieve pain and reasonably necessary to achieve that outcome is not euthanasia, even if it did shorten the patient's life. Any intervention, including the use of pain relief drugs, carried out with a primary intention of causing the patient's death and resulting in that outcome, is euthanasia.

Acting with a primary intention to kill is a world apart from acting with a primary intention to relieve pain. And this is not a novel or exceptional approach. The law recognizes such distinctions daily. If we accidentally hit and kill a pedestrian with our car, it is not murder. If we deliberately run him down with our car intending to kill him, it is.

It is a tragedy for patients, especially those who are terminally ill and in pain, and a major disservice to physicians, nurses and humane and good medical care to confuse these situations as the college seems to do. Physicians and patients become frightened of giving and accepting adequate pain relief.

The proper goal of medicine and physicians is to kill the pain. It is explicitly not their role to kill the patient with the pain to become society's executioners which is what euthanasia entails, no matter how merciful or compassionate our reasons.

Even most people who support legalizing euthanasia believe its use needs to be justified, usually as being necessary to relieve pain and suffering. Surveys of the general public that ask the question "Do you believe people in terrible pain should have access to euthanasia?" reflect that belief. But again this approach causes confusion between pain relief and euthanasia. It makes euthanasia the treatment for pain, and it makes it impossible for people to agree that all necessary pain relief must be provided, without also endorsing euthanasia. Respondents have either to agree to both pain relief and euthanasia or to reject both. Of course, to have the public endorse euthanasia might be the goal of some of these surveys.

Rights to pain relief treatment will, however, be nothing more than empty words unless that treatment is accessible. If, as I do, we believe legalizing euthanasia or physician-assisted suicide would be a terrible mistake for society, we have serious obligations to ensure fully adequate pain relief treatment is readily available to all Canadians who need it.

b) The confusion between rights to refuse treatment and euthanasia:

Why is withdrawing treatment to allow a patient to die ethically acceptable and euthanasia is not?

Many people also seem to be confused with respect to the ethical and legal differences between withdrawal of treatment that results in death and euthanasia, and why the former can be ethically and legally acceptable, provided certain conditions are fulfilled, and the latter cannot be. This is a central and important question in the euthanasia debate.

Primary intention...

First, the primary intention is different in the two cases: In withdrawing life-support treatment it is to respect the patient's right to refuse all treatment; in euthanasia it is to kill the patient. The former intention is ethically and legally acceptable; the latter is not.

Rights...

Patients have a right to refuse treatment, even if that means they will die. This is an exercise of their right to autonomy and self-determination. The content of that right is a right not to be touched without their consent – a right to inviolability.

Pro-euthanasia advocates use recognition of the right to refuse treatment even when it results in death, to argue that, likewise, patients should be allowed to exercise their right to autonomy and self-determination to choose death through lethal injection.

They say that there is no morally or ethically significant difference between these situations, and there ought to be no legal difference.

They found their argument by wrongly characterizing the right to refuse treatment as a "right to die", and then generalize that right to include euthanasia and physician-assisted suicide. But the right to refuse treatment is not a "right to die" and does not establish any such right, although death results from respecting the patient's right to inviolability. The right to refuse treatment can be validly characterized as a "right to be allowed to die", which is quite different from a right to be killed that euthanasia would establish.

This particular pro-euthanasia line of argument is just one more example of promoting euthanasia through deliberate confusion between interventions, such as valid refusals of treatment, that are not euthanasia and those that are.

Causation...

Which brings me to the issue of causation, which also differentiates refusals of treatment that result in death from euthanasia. In refusals of treatment that result in death, the person dies from their underlying disease – a natural death.

The withdrawal of treatment is the occasion on which death occurs, but not its cause. If the person had no fatal illness, they would not die. And, moreover, sometimes patients, who refuse treatment and are expected to die, do not die.

In contrast in euthanasia, death is certain and the cause of death is the lethal injection. Without that, the person would not die at that time from that cause.

Confusion as to the issue...

The fact that the patient dies in both refusing treatment that results in death and in euthanasia is one of the causes of the confusion between the two situations. If we focus just on that outcome of death, we miss what the real point of distinction between the two situations is.

The issue in the euthanasia debate is not if we die – we all eventually die. The issue is how we die and whether some means of dying, such as euthanasia and physician-assisted suicide, should remain prohibited. I believe they should.

c) Confusion in language

Definition of words matters. Take the concept of human dignity.

Pro- and anti-euthanasia advocates use different interpretations of the concept to bolster their arguments.

Euthanasia advocates argue respect for human dignity requires that euthanasia be legalized and opponents of euthanasia argue exactly the opposite, that respect for human dignity requires it remain prohibited. In short, the concept of human dignity and what is required to respect it is at the centre of the euthanasia debate, but there is no consensus on what we mean by human dignity, its proper use, or its basis.

American political scientist Diana Schaub says "we no longer agree about the content of dignity, because we no longer share ... a 'vision of what it means to be human'." She's correct. So what are the various interpretations of dignity and what can they tell us about "what it means to be human"?

Intrinsic dignity means one has dignity simply because one is human. This is a status model – dignity comes simply with being a human being. It's an example of "recognition respect" – respect is contingent on what one is, a human being.

Extrinsic dignity means that whether one has dignity depends on the circumstances in which one finds oneself and whether others see one as having dignity. Dignity is conferred and can be taken away. Dignity depends on what one can or cannot do. Extrinsic dignity is a functional or achievement model – dignity comes with being able to perform in a certain way and not to perform in other ways. It comes with being a human doing. This is an example of "appraisal respect" – respect is contingent on what one does.

These two definitions provide very different answers as to what respect for human dignity requires in relation to disabled or dying people, and that matters in relation to euthanasia.

Under an inherent dignity approach, dying people are still human beings, therefore they have dignity. Opponents of euthanasia believe respect for human dignity requires, above all, respect for human life and that while suffering must be relieved, life must not be intentionally ended.

Under an extrinsic dignity approach, dying people are no longer human doings – that is, they are seen as having lost their dignity – and eliminating them through euthanasia is perceived as remedying their undignified state.

Pro-euthanasia advocates argue that below a certain quality of life a person loses all dignity. They believe that respect for dignity requires the absence of suffering, whether from disability or terminal illness, and, as well, respect for autonomy and self-determination. Consequently, they argue that respect for the dignity of suffering people who request euthanasia requires it to be an option.

Importantly, to respect human dignity we must have respect for both the human dignity of each individual and for the worth of humanity as a whole. That means that even if we accepted that individual consent could justify taking human life, it is not necessarily sufficient to ensure human dignity is not being violated. For instance, a French court ruled that the "sport" of "dwarf throwing" was in breach of respect for human dignity and banned it, even though the dwarfs involved consented.

Words also matter because they affect our emotions and moral intuitions, which play an important role in good ethical decision making.

Legalizing euthanasia and assisted suicide causes death to lose its moral context and us to lose our proper emotional response to it, a loss which recent research shows detrimentally affects our ethical judgment.

An article in Nature, "The Moral Brain", provides scientific evidence to that effect. People with damage to the parts of their brains that process emotions, but who have intact centres for rational judgment, made ethically inappropriate decisions. To quote: "The study provides evidence that [good] moral decision-making is based on emotion as well as rational thought".

Moreover, to the extent that euthanasia is a utilitarian response we might keep in mind that another study, also reported in Nature, showed that people with damage to the front part of their brain – the cortex – have "an abnormally utilitarian pattern of moral judgments".

People respond differently if they are asked in surveys whether they agree with euthanasia, physician-assisted suicide or physician-assisted death. And describing euthanasia as "the last act of good palliative care" or "merciful clinical care" leaves one with a very different impression of what it involves than "doctors killing their patients".

It's a controversial suggestion, but I propose that if we were to legalize euthanasia, we should take the "medical cloak" off it, that is, physicians should not be the ones to carry it out.

One reason, among many, is that it causes people to fear physicians, accepting pain relief treatment, and hospice and palliative medicine and care.

As well, placing a medical cloak on euthanasia makes it seem safe, ethical and humane, because those are the characteristics we associate automatically with medical care, when, in fact, we all need to question the acceptability of legalizing euthanasia.

One suggestion for alternative practitioners, that has shocked even people who are euthanasia advocates, is to consider having specially trained lawyers. I was giving a speech on euthanasia at a national medical association conference in Australia. I stated on two or three occasions that "we can't have physicians killing people". A pro-euthanasia palliative care physician in the audience leapt to his feet and shouted, "Margo, will you stop using that word killing; it's not killing, it's VAE [voluntary active euthanasia]".

Later in the speech, I addressed the issue of, if we were to legalize euthanasia, who should carry it out. I argued against physicians, because that makes people frightened of consulting physicians and reluctant to accept pain relief treatment, because they fear being euthanized. The solution I suggested would be to have a specially trained group of lawyers.[3] The justification put forward for this choice is that they understand how to properly interpret and strictly apply laws and, for pro-euthanasia advocates, ensuring that is the major concern, not euthanasia itself. The same physician who had objected to my using the word "killing", again jumped to his feet and this time exclaimed, "Margo are you crazy? We can't have lawyers killing people." I agree wholeheartedly, and neither should we have physicians killing people. With the medical cloak on the act it was not killing; with the cloak off, the same act was killing.

I faced similar objections to using the word killing to describe what euthanasia involves, when I gave evidence before the Quebec Legislative Assembly committee hearings on "Death with Dignity". After I had completed my evidence, an observer, who is involved with a pro-euthanasia group in Quebec, accused me of being unethical for using the word killing. He said he was appalled that an ethicist would use such a word to describe euthanasia. Similarly, one of my pro-euthanasia medical students argued long, hard and passionately that euthanasia did not involve killing.

d) Confusion between the respect owed to animals and to humans

We must protect humans' special status 

If certain animals become persons, as some philosophers argue, human persons become animals, which has consequences for how we treat each other, including with respect to euthanasia.

Addressing the argument that we euthanize our pets out of compassion, so why not humans we love. The short answer is we are not just another animal.

Some ethicists, philosophers and scientists have suggested we should confer personhood on at least some animal species for the purpose of protecting them through ethics and law, including by attributing rights to them.

My reasons for rejecting personhood for animals include that it would undermine the idea that humans are "special" relative to other animals and, therefore, deserve "special respect."

Whether humans are "special" – sometimes referred to as human exceptionalism or uniqueness – is a controversial and central question in bioethics, and how we answer it will have a major impact on what we view as ethical or unethical with regard to our treatment of humans and of animals.

Currently, we use the word "person" as a synonym for human and to indicate, communicate and implement the concept that humans are different from other animals and "special." It can no longer fulfill that function if it does not refer exclusively to humans. In other words, if animals become persons, human persons become animals. The line between humans and other animals is blurred and the idea that humans are "special" and deserve "special respect" is eliminated.

That means that what we do or don't do to "animal persons" should be the same as we do or don't do to "human persons." So, for instance, if we have euthanasia for animals, we should, likewise, have it for humans. If we don't eat humans, we shouldn't eat animals.

This is Professor Peter Singer's approach. He argues that distinguishing humans from other animals and, as a result, treating them differently, is a form of wrongful discrimination he calls "speciesism." He rejects the stance that all human beings are persons and no animals are persons; rather, he argues some human beings are not persons and some animals are.

For Singer, personhood depends on being self aware, having a sense of one's history and, perhaps, of a future, and a capacity to relate to others. Consequently, he argues some seriously mentally disabled humans and babies are not persons and, therefore, do not have the protections personhood brings. Not being a person means that a baby, for instance, does not have a right to life and, therefore, the parents of a disabled baby could consent to her being euthanized.

The notable feature of Singer's approach is that whether or not a living being is a person depends on its measuring up to a certain standard. This is an attribute approach to who or what is a person and, therefore, deserves the respect and protections that come with that characterization.

Applied to humans, this approach means that those who don't have a certain level of physical, mental or emotional functioning are not persons and, as a result, don't have the same rights as others. In short, it creates different categories of human beings and those in some categories are not regarded as persons.

The contrasting approach, which I believe is the one we should continue to uphold, is that all humans are persons (at least, as the law stands at present, those humans who have been born) and only humans are persons.

Currently, we also use the word person to distinguish humans from animals, in order to establish that every human deserves "special respect" as compared with animals.

We used to regard humans as special on the basis that they had a soul, a Divine spark, and animals did not. Far from everyone accepts that today. But most people at least act as though we humans have a "human spirit," a metaphysical, although not necessarily supernatural, element as part of the essence of our humanness. The beautiful Sanskrit farewell, loosely translated, "The Light in me recognizes the Light in you," captures this reality.

3. The unstoppable expansion of justifications for the use of euthanasia

For millennia, euthanasia has been considered morally and legally unjustifiable.

People who oppose euthanasia still believe it is inherently wrong – it can't be morally justified and even compassionate motives do not make it ethically acceptable – the ends do not justify the means.

But what are the attitudes of pro-euthanasia advocates to the question of whether its use needs to be justified, were it to be legalized? And, if justifications are required, what are they?

People who would accept euthanasia, but only in some circumstances, usually limit access to it to people who are terminally ill and in serious pain and suffering that can't be relieved (which are exceptional cases) and require that euthanasia be used as a last resort. These limitations show these people believe each case of euthanasia needs moral justification to be ethically acceptable.

But although the need for euthanasia to relieve pain and suffering is the reason given to justify it, and is the justification the public accept in supporting its legalization, research shows that dying people who request euthanasia do so far more frequently because of fear of social isolation and of being a burden on others, than pain.

In short, loneliness and social isolation are strongly associated with requests for euthanasia. So, should avoiding loneliness or grief count as a sufficient justification?

More recently, some pro-euthanasia advocates are arguing that respect for people's rights to autonomy and self-determination means competent adults have a right to die at a time of their choosing, and the state has no right to prevent them from doing so. That means, if euthanasia were legalized, the state has no right to require a justification for its use by competent, freely consenting adults.

For example, they believe an elderly couple, where the husband is seriously ill and the wife healthy, should be allowed to carry out their suicide pact. As Ruth Von Fuchs, head of the Right to Die Society, in Canada, stated, "life is not an obligation."

But though Ms. Von Fuchs thought the wife should have an unfettered right to assisted-suicide, she argued that it would allow her to avoid the suffering, grief and loneliness associated with losing her husband – that is, she articulated a justification.

We can see this same trend towards not requiring a justification – or, at least, nothing more than that's what a competent person over a certain age wants to do – emerging in the Netherlands. A group of older Dutch academics and politicians very recently launched a petition in support of assisted suicide for the over-70s who are "tired of life". They quickly attracted over 40,000 signatures, enough to get the issue debated in parliament under citizens' initiative legislation.

And what about avoiding healthcare costs as a justification? Although this question has largely been avoided – one could say "religiously" – by pro-euthanasia advocates, euthanasia could be used as a cost-saving measure and is likely to be if legalized.

Half of the lifetime healthcare costs of the average person are incurred in the last six months of the person's life. Euthanasia would be a way to implement a "reasonably well or dead" approach – what is sometimes referred to as "squaring the curve" of health decline at the end of life, so the person drops precipitously from being reasonably well to dead, we could call it a "lemming approach" – which would avoid those costs.

The medical authority of the U.S. state of Oregon (where physician-assisted suicide is legal) seems to have adopted this approach. It "has acknowledged that when it turns down an application to cover the cost of an expensive new drug, it sends out simultaneously a reminder that the state's assisted suicide program is available at an affordable cost". As Montreal journalist, the late Hugh Anderson comments, "What a great way to put a crimp in medical costs. Have the patients kill themselves when the cost of keeping us alive gets too high."

The Netherlands' 30-year experience with euthanasia shows clearly the rapid expansion, in practice, of what is seen as an acceptable justification for euthanasia.

Initially, euthanasia was limited to terminally ill, competent adults, with unrelievable pain and suffering, who repeatedly asked for euthanasia and gave their informed consent to it.

Now, none of those requirements necessarily applies, in some cases not even in theory and, in others, not in practice. For instance, in addition to the proposed "tired of life" justification for euthanasia, I've already mentioned:

• The recent Groningen protocol allows parents of disabled babies to request euthanasia for them.
  
  
• Children aged 12 to 16 years can request and obtain euthanasia with their parents' consent and those over 16 can give their own consent.
  
  
• There are more than 500 deaths a year from euthanasia (and possibly many more) where the adult was not competent or whose consent was not obtained.
  
  
• A middle-aged depressed woman, who was not terminally ill, was given euthanasia by her treating psychiatrist. A court ruled this was justified.
  
  
• An old man, who was not terminally ill or in unrelievable pain and suffering, had a dread of being put in a nursing home was given a choice by his family between a nursing home and euthanasia. He chose euthanasia.
  
  
• Old and disabled Dutch citizens are seeking admission to nursing homes and hospitals in Germany, because of fears about euthanasia.
  
  
• Recent research showed that in the Netherlands the rate of suicide in late middle-aged men (a group at increased risk for suicide) had dropped, but the rate of euthanasia in this same age-group had risen. Is euthanasia being used as a substitute for suicide?

Indeed, one of the people responsible for shepherding through the legislation legalizing euthanasia in the Netherlands recently admitted publicly that doing so had been a serious mistake, because, he said, once legalized, euthanasia cannot be controlled. In other words, justifications for it expand greatly, even to the extent that simply a personal preference "to be dead" will suffice.

Legalizing euthanasia causes death and dying to lose the moral context within which they need to be viewed. We can see what might happen as a result, by looking at what has happened with abortion. Abortion has gone from being a rare exception to the norm – around 30 percent of pregnancies in Canada end in abortion. The same would happen with euthanasia.

Maintaining death and dying in a moral context is crucial in light of an aging population and scarce and increasingly expensive healthcare resources, which will face us with many difficult decisions about who lives and who dies.

Legalizing euthanasia is presented by its advocates as being a progressive stance, a necessary modernization of values and practice. In response, I suggest that we should ponder the wise words of C.S. Lewis: "We all want progress, but if you're on the wrong road, progress means doing an about-turn and walking back to the right road; in that case, the man who turns back soonest is the most progressive."

4. Euthanasia would hurt the institution of medicine and doctors 

We must consider the damage to medicine if physicians are allowed to kill. Physicians' and nurses' absolute rejection of intentionally inflicting death is necessary to maintaining people's and society's trust in their own physicians and the profession of medicine as a whole.

We must consider the impact legalizing it would have at institutional, governmental and societal levels.

We need to explore not only the practical realities, such as the possibilities for abuse, that allowing euthanasia would open up, but also, the effect that doing so would have on important values and symbols that make up the intangible fabric that constitutes our society.

For example, what would be its likely impact on major societal institutions, such as medicine and law, which help to establish those values and carry the message of the need to respect them?

Legalizing euthanasia would damage the foundational societal value of respect for human life. If euthanasia is involved, how we die cannot be just a private matter of self-determination and personal beliefs, because, as American philosopher Daniel Callahan says, "Euthanasia is an act that requires two people to make it possible and a complicit society to make it acceptable." The British House of Lords, likewise, rejects euthanasia because of the harm it would cause to societal values and institutions: "The prohibition on intentionally killing is the cornerstone of law and human relationships, emphasizing our basic equality."

One important reason to protect health-care institutions is that they are value-creating, value-carrying and consensus-forming for society as a whole.

In a secular, pluralistic society, medicine and law are the principal institutions that maintain the value of respect for human life in society as a whole. Changing the law to allow physicians to carry out euthanasia – making an exception to the norm that we must not kill each other – would seriously damage these institutions' capacity to carry that value.

In short, we need to be concerned about the impact that legalizing euthanasia would have on the institution of medicine, not only in the interests of protecting it for its own sake, but also because of the harm to society that damage to the profession would cause.

And what might be the impact of the legalization of euthanasia, internally, on the profession of medicine and its practitioners?

A Personal Matter Justin Press

As the Canadian Medical Association wrote in a letter distributed to all members of Parliament just before the first debate on Bill C-384, "CMA's policy on this matter is clear: 'Canadian physicians should not participate in euthanasia or assisted suicide'."

And surveys consistently show that physicians in various countries are more opposed to euthanasia than the general public. For instance, a 2009 survey by the British Royal College of Physicians showed 73 per cent of its members opposed euthanasia, whereas up to 82 per cent of the British general public approved of it. Important insights could be gained by pondering the causes of such disparities.

Euthanasia takes physicians and medicine beyond their fundamental roles of caring, healing and curing, whenever possible. It involves them, no matter how compassionate their motives, in the infliction of death on those for whom they provide care and treatment. As I've explained already, it can be described as "a merciful act of clinical care," and, therefore, it may seem appropriate for physicians to administer, but the same act is also accurately described as "killing." This means, as American psychiatrist and ethicist Willard Gaylin put it, that euthanasia places "the very soul of medicine on trial."

There are very few institutions in today's secular societies, if any, with which everyone identifies except for those – such as medicine – that make up the health-care system. These, therefore, are of unusual importance when it comes to carrying values, creating them, and forming consensus around them. We must take great care not to harm their capacities in this regard and, consequently, must ask whether legalizing euthanasia would run a high risk of causing this type of harm.

The kinds of questions we need to ask include: How would legalizing euthanasia affect medical and nursing education? What impact would physician role models carrying out euthanasia have on medical students and young physicians? Would we devote time to teaching students how to administer death through lethal injection? (There has been a medical malpractice case in The Netherlands for "botched" euthanasia – the patient didn't die.) Would they be brutalized or ethically desensitized? (And we cannot afford to underestimate the desensitization and brutalization from carrying out euthanasia.) Do we adequately teach pain-relief treatment at present? Would euthanasia be a required procedure, that is, a student must perform it competently, in order to graduate? Can we even imagine teaching medical students how to kill their patients?

A fundamental value and attitude that we reinforce in medical students, interns and residents, and in nurses, is an absolute repugnance to killing patients. It would be very difficult to communicate to future physicians and nurses such repugnance in the context of legalized euthanasia.

Physicians' and nurses' absolute rejection of intentionally inflicting death is necessary to maintaining people's and society's trust in both their own physicians and the profession of medicine as a whole. This is true, in part, because physicians and nurses have opportunities to kill that are not open to other people.

Physicians and nurses need a clear line that powerfully manifests to them, their patients, and society that they do not inflict death. Both their patients and the public need to know with absolute certainty – and be able to trust – that is the case. Anything that blurs that line, damages that trust, or makes physicians or nurses less sensitive to primary obligations to protect and respect life is unacceptable. Legalizing euthanasia would do all of these.

Moreover, it is a very important part of the art of medicine to sense and respect the mystery of life and death, to hold this mystery in trust, and to hand it on to future generations – including future generations of physicians. We need to consider deeply whether legalizing euthanasia would threaten this art, this trust, and this legacy.

5. Hope: Keeping the human spirit alive 

What do dying people need?

Dr. Harvey Chochinov of the University of Manitoba is a psychiatrist who specializes in psychiatry for terminally ill people. In one project, he was among the researchers who developed an approach that allowed them to distinguish from clinical depression, a condition they called "hopelessness." They found that hopelessness, not clinical depression as such, was the characteristic that best identified people who wanted euthanasia or assisted suicide.

This is very important information for those who think legalizing euthanasia is a bad idea. It means that giving hope is part of the treatment dying people need. Long-term hopes are not possible, of course, but "mini-hopes" are.

Hope is dependent on having a sense of connection to the future, even if that future is very short-term. It is generated by having something to look forward to.

In the case of a terminally ill person, that could be a visit from a loved one or friend, seeing a grandchild on their graduation or wedding day, or perhaps just hearing the "dawn chorus" as the sun rises the next morning. Palliative care specialists tell many stories of the power of such mini-hopes to keep our will to live alive, until we die naturally.

Hope is the oxygen of the human spirit; without it our spirit dies. With it, we can overcome even seemingly insurmountable obstacles, including in our last great act of living, our dying.

It's a true tragedy when our spirit dies before our bodies. But the answer is not to kill our bodies with euthanasia; it's to do our best to keep alive our human spirit with hope.

Conclusion

Legalizing euthanasia and assisted suicide causes death to lose its moral context and us to lose our proper emotional response to it, a loss which, as I've explained already, recent research shows detrimentally affects our ethical judgment. As I mentioned previously, we now have scientific evidence that people with damage to the parts of their brains that process emotions, but who have intact centres for rational judgment, made ethically inappropriate decisions.

Euthanasia delivers a "better off dead" message that treats dying humans as disposable products. As one Australian politician expressed this: "When you are past your 'use by' or 'best before' date, you should be checked out as quickly, cheaply and efficiently as possible."

An aging population, scarce health-care resources and legalized euthanasia or assisted suicide would indeed be a lethal combination, not only for individuals, but also for important societal values and institutions, such as medicine and law, that uphold those values and the overall ethical tone of our Canadian society.

We must have greater respect for all life, and, in particular, human life. Euthanasia will take us in the opposite direction towards loss of respect for human life. And if we lose our respect for life, we lose our humanity.

That will be the tragic outcome if we fail to keep death and dying in a moral context, which requires that all of us reject euthanasia and try to persuade our fellow Canadians to do the same.

Endnotes:

1. Note: Unless the contrary is indicated, I use the term euthanasia in this text to include both euthanasia and physician-assisted suicide.
2. I define the human spirit as "the intangible, immeasurable, ineffable, numinous reality that all of us need to have access to find meaning in life and to make life worth living – a deeply intuitive sense of relatedness or connectedness to all life, especially other people, to the world, and to the universe in which we live; the metaphysical – but not necessarily supernatural – reality which we need to experience to live fully human lives." See, Margaret Somerville, The Ethical Imagination: Journeys of the Human Spirit.
3. This is not my original idea. See R.M. Sade and M.F. Marshall, "Legistrothanatory: A New Specialty for Assisting in Death", Perspectives in Biology and Medicine 1996; 39 (4): 547-549.