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Medical Assistance in Dying (MAID): Pros and Cons
By Hendrik van der Breggen
Canada's government
has decided to expand the scope of medical assistance in dying (MAID). MAID has
been legal in Canada since June 2016. During the next few months the restriction
that natural death must be reasonably foreseeable will be removed, and this
summer the possibility of offering MAID to mature minors (children) and people
with mental illness will be seriously considered.
Unfortunately, public
discourse on MAID has been skewed: arguments in favor of MAID seem more prevalent
than arguments against. Call me old-fashioned, but I think citizens—informed
citizens—should look at pros and cons, not just pros. Let's do
that.
(Spoiler alert: I
think the cons outweigh the pros.)
Clarification
First, some
clarification. “Medical assistance in dying” is a euphemism—and thus is
misleading at the get-go.
When certain words
are considered too blunt, harsh, painful, or offensive, people sometimes
substitute a euphemism, that is, a more acceptable term, a term with fewer
negative connotations or with more positive connotations, than the blunt,
harsh, painful, or offensive term.
Here are some
examples of useful but harmless euphemisms. “I’m sorry that Sam passed away.”
These words allow us to be sensitive to Sam’s grieving wife and are infinitely
kinder than saying, “I’m sorry about Sam’s getting slowly crushed to death by
the gravel truck.”
Another example: “May
I use the washroom?” Yes, as any parent knows, these words allow children to be
sensitive to those around the dinner table. Respect and politeness are good, to
be sure.
Euphemisms are
sometimes helpful (as in my examples), but they can also desensitize us
emotionally and hide reality—including moral reality.
Interestingly, the
dangers inherent in euphemisms were almost prophetically envisioned by George
Orwell in his famous novel 1984 and in his lesser known essay
“Politics and the English Language.” Orwell put forward the idea that an
effective mechanism of political control is the manipulation of euphemisms
employed in public discussion.
Back to MAID: Yes,
of course, we all want medical assistance in dying. Please, doctors and nurses,
provide us with clean sheets, proper nutrients, and morphine (as needed) as we
die. Please, doctors and nurses, provide us with comfort as natural death takes
its course. But, wait, when politicians and policy makers are talking about
MAID, they're actually talking about doctors and nurses actively causing death. MAID is physician-assisted suicide—killing.
Dying and killing are
not the same. It's important to be clear about this distinction and not be
bamboozled by euphemisms.
Pro MAID: Personal autonomy
A major pro for
MAID (physician-assisted suicide/killing) is the exercise of personal autonomy,
that is, the individual's choice in general and, in particular, the
individual's choice in response to suffering. Suffering can be terrible, to be
sure. And freedom is precious, truly. So—yes—personal autonomy is important.
But, and this often gets neglected, the freedom to exercise one's autonomy is
not absolute. For example, I enjoy smoking a pipe. But it turns out that I do
not have the freedom to smoke my pipe in my local pub (at least not in Canada).
Also, I do not have the freedom to drink beer while I drive my car. Also, I do
not have the freedom to drive my car on the sidewalk. Nor do I have the freedom
to swing my fist without regard for the tips of other people's noses.
In other words, although personal autonomy is important, the individual does
not live in a social vacuum. In public
policy matters we should think about the individual's freedom AND the possible consequences—possible
negative consequences—for our
neighbors, that is, for our larger society (more on MAID's possible negative consequences
later).
Upshot: Merely
appealing to personal autonomy as a justification of MAID is not enough. We've
got to step out of our self-centered bubbles.
Pro MAID: Unbearable suffering
Another major pro
for MAID is the popular argument that either we have MAID or we face an
unbearably painful death, but an unbearably painful death is horrible, so we
should have MAID.
A counter-consideration
is that this popular argument is fallacious. It presents us with a false dichotomy. It presumes that
there are only two options: death by assisted suicide, or death with unbearable
suffering. But there's a third option: palliative care.
In my years of
teaching ethics (I'm a recently-retired philosophy professor) I've noticed that
many people—young and old—simply don't know what palliative care is. Behold,
then: palliative care is a branch of medicine that focuses on relief of
physical and mental pain without curing the disease.
Enter Doris
Barwich, M.D., President of Canadian Association of Palliative Care Physicians:
“Pain is rarely the reason patients ask for hastened death—it more often comes
out of a desire to control the circumstances surrounding death. Fortunately, we
can assure our patients that with Palliative Care tools and resources, pain and
other distressing symptoms can usually be controlled and support provided to
ensure comfort and quality of life.” (Focus
magazine, April 2013, p. 17.)
Along with palliative
care, there is something called dignity therapy. According to Dr. Harvey
Chochinov, a psychiatry professor at the University of Manitoba and a Canada
Research Chair in palliative care, “Dignity therapy really tries to look at
what are the sources, what are the things that might cause or undermine dignity
toward the end of life,” and it works to alleviate those things. (Blaise
Alleyne and Jonathon Van Maren, A Guide
to Discussing Assisted Suicide [Toronto: Life Cycle Books, 2017], p. 83.)
What about the difficult
cases? First, keep in mind that with advances in palliative care and dignity
therapy, difficult cases are becoming rare. Second, keep in mind that focusing
only on rare cases doesn't make for good general policy decision-making. Third,
keep in mind that instead of MAID—active killing—there is, for the rare
difficult cases, palliative sedation.
What is palliative
sedation? According to the Journal of the
American Medical Association, “Palliative sedation is the use of
sedative medications to relieve extreme suffering by making the patient unaware
and unconscious (as in a deep sleep) while the disease takes its course,
eventually leading to death. The sedative medication is gradually increased
until the patient is comfortable and able to relax. Palliative sedation is not
intended to cause death or shorten life.”
Significantly, if,
foreseeably, palliative sedation hastens death, it needn't be judged unethical.
According to ethicist Margaret Somerville, just as death isn't the intended
effect of high risk surgery (needed to relieve pain), and so such surgery isn't
immoral if death occurs, so too if death isn't the intended effect of high risk
pain management, yet death occurs, then such pain management isn't immoral
either. (Margaret A. Somerville, “Euthanasia is never necessary,” Citizen, June 1999, p. 6.)
Here's the rub: There's
an important moral difference between engaging in a procedure with intent to
kill (i.e., MAID's active killing) rather than not (palliative sedation). MAID
takes the lower moral ground.
Pro MAID: Extraordinary and burdensome medical technology
Another major pro
for MAID is that when we're dying we (including myself!) don't want to be
forced to live because of all the marvelous albeit extraordinary and burdensome
medical technology that's now available.
A con or
counter-consideration here is that allowing terminally ill patients to die from
their illness via termination of life support by withdrawing/withholding
extraordinary, burdensome, or medically useless treatment is already a legal and ethical part of
palliative care—and doesn't require MAID. And we can make advance requests for
this.
Ethicist Scott Rae:
“Physicians need not always 'do everything' to stave off death, especially when
it involves no more than simply delaying an inevitable death…. Choices about
CPR, respirators, and intravenous procedures in the last weeks of life should
not be viewed as choices for death.” (Scott B. Rae, Moral Choices: An Introduction to Ethics, 3rd edition [Grand
Rapids, Michigan: Zondervan, 2009], p. 221.)
Authors Blaise Alleyne
and Jonathon Van Maren: “No one is obligated to undergo burdensome treatment.
This is to be distinguished from providing the basic necessities of life, like
water and nutrition—it's not okay to starve someone to death.” (Alleyne and Van
Maren, Guide to Discussing Assisted
Suicide, p. 76.)
MAID's possible negative consequences
What about the
possible negative consequences of MAID for our neighbors and the larger society
that I mentioned? These possible consequences are especially important for thinking
about any decision to expand MAID. Here are seven to ponder.
Possible negative consequence 1: Got
a problem—get MAID.
With the acceptance and expansion of MAID,
our society will see suicide more and more as a legitimate way of solving an
individual's problems. Got a problem that makes you suffer? Don't forget you can
get help to kill yourself!
At one of the universities I attended (not too many years ago), I worked as a
teaching assistant in an ethics course for a fellow doctoral student who told
the class (a) he had advised his roommate that suicide was an option as a
solution to the roommate's problems and (b) subsequently the roommate committed
suicide. My fellow doctoral student displayed no qualms about the advice. Nor
did most of the students in the ethics course. Some of those students planned
to become doctors and lawyers.
Possible consequence 2: Life will no
longer be seen as society's default position.
This means that our most
vulnerable—the elderly, terminally ill, disabled, and whoever else is suffering—must
justify the continuation of their lives. Why, after all, should we spend so
many healthcare dollars on you—the elderly, terminally ill, disabled, and
whoever else is suffering—when you've become unproductive? This may not be stated
explicitly, but will be an unspoken assumption (it is already, I believe) and,
as law professor Carter Snead correctly points out, a “subtle coercion.”
In other words, into the darkness of
suffering, we add more darkness. But surely this is a nasty burden to place on
people when they're already down. In fact, it's a kick in their teeth.
Possible consequence 3: Adding insult
to injury.
When we decide not to accept life as
our society's default position, say, by expressing out loud (e.g., via public
consultations in Canada) that we want MAID if we were to become handicapped or
infirm, we insult
the most vulnerable by communicating this message to them: We would rather be
dead than be like you! If that isn't an insult, what is?
Possible
consequence 4: A big chill.
If the choice or
autonomy of the sufferer constitutes acceptable personal and legal grounds for
the sufferer to end his/her life—a legal right—then will suicide interveners
have to add to their script some directions as to where MAID is available? Will
National Suicide Prevention Week include some Suicide Promotion Days? Will Bell
Let's Talk encourage referrals to MAID? Will suicide intervention or counseling
against suicide become grounds for a lawsuit against the intervener or counselor?
Possible consequence 5: Slippery slope.
With the acceptance of MAID, a
non-fallacious, logical-legal slippery slope looms large—in
fact, we're sliding down the slope already.
Reasons for one
action sometimes also justify other actions that are unintended to be justified
by those reasons.
Here's a fun
fictional illustration that I used in my ethics and logic courses which helped students
better understand the slippery slope at hand.
Let's say that I approach my college president and propose that our school
should make a policy of giving philosophy students the right to free tuition if
they choose to accept it. My reason: philosophy students are people who must
think very hard and aren’t guaranteed jobs after graduation. There would be a
slippery slope here, for sure!
Once the rest of the student body heard about this policy, students would
appeal to a principle of fairness (and would be motivated by greed perhaps) and
would argue that all students should receive free tuition, not
just philosophy students. Why? Because all students must think very hard and
none are guaranteed jobs.
In other words, if thinking hard and having no guarantee of a job after
graduation are sufficient grounds for a student to receive free tuition, then
whether a student is taking anthropology, business, history, philosophy,
psychology—or whatever—doesn’t make a relevant difference. The principle of
fairness is fundamental, and the differences between academic disciplines,
though real, are incidental. Fairness demands consistency.
Thus, if my college makes a policy (the legal bit of the legal-logical slippery
slope) that gives philosophy students free tuition on the basis of hard
thinking and lack of a job guarantee, then, in the name of fairness and
consistency (the logical bit of the legal-logical slippery slope), the college
should ensure that all students receive free tuition.
If my boss doesn't want to be unfair or inconsistent (and doesn't want our university
to go broke), then he shouldn't give philosophy students the proposed deal.
Our lesson: The above non-fallacious, logical-legal slippery slope argument
ensues because the reason behind my proposal justifies much more than intended.
Back to MAID: The
alleged right to end one's life because of suffering justifies not only the
situation of the terminally ill, but also those situations of the elderly, the
disabled, the parent suffering the loss of a child, the person suffering
chronic back pain, the depressed teenager, the person suffering existential
despair/ meaninglessness/ feelings of being a burden, etc.
Enter: So-called
safeguards—and their failure. Significantly, if we have already
accepted individual autonomy as a legal justification for MAID, how
can we deny anyone MAID? (Think of the experience of Belgium and The Netherlands and, again, The Netherlands.)
Courts will do what
courts do: promote consistency. But consistency requires that MAID's
fundamental justifying principle—i.e., that the sufferer has the right to
choose MAID to end his/her suffering—will carry more legal weight than the
situational differences. The situational differences will (with the help of a
good lawyer or activist judge) be seen to be incidental.
In other words, legal acceptance of MAID puts gobs of logical-legal grease onto
the path that leads to killing as a solution to suffering. The result:
eliminating sufferers becomes equated with eliminating suffering, and legality
becomes an accomplice to normalization of practice.
What, then, should
we do? The best safeguard, it seems to me, is to eliminate the autonomy
principle as paramount and instead have our doctors and nurses return to the Hippocratic Oath: “I
will neither give a deadly drug to anybody who asked for it, nor will I make a
suggestion to this effect.” And we
should provide excellent palliative and hospice care (without killing) for all.
Possible consequence 6:
Caring becomes killing.
If we kiss good-bye the
above portion of the Hippocratic Oath, then we invite a deep change of
character to the practice of medicine.
Healers will be asked to
be killers. Health care becomes careful killing. And those conscientious persons
who refuse to kill will be discouraged from practicing medicine. Sound
far-fetched? It isn't. To those doctors who merely refuse to provide information
about MAID as an option, highly-respected University of Manitoba ethicist
Arthur Shafer says this: “perhaps you should be practicing in a different
branch of medicine or perhaps you shouldn't be practicing as a doctor.” (CBC News
Manitoba, July 16, 2016.) Keep all this in mind when you think about the next
possible consequence.
Possible consequence 7. Sometimes
history repeats itself.
Consider these insights from Dr. Leo
Alexander, medical consultant for U.S. Chief Counsel for War Crimes at
Nuremberg, in his summation of the Nazi German experience:
“Whatever proportions
these crimes finally assumed, it became evident to all who investigated them
that they had started from small beginnings. The beginnings at first were
merely a subtle shift in emphasis in the basic attitude of the physicians. It
started with the acceptance of the attitude, basic in the
euthanasia movement, that there is such a thing as life not worth to be
lived. This attitude in its early stages concerned itself merely with the severely
and chronically sick. Gradually the sphere of those to be included in this
category was enlarged to encompass the socially unproductive, the ideologically
unwanted, the racially unwanted, and finally all non-Germans. But it is
important to realize that the infinitely small wedged-in lever from which this
entire trend of mind received its impetus was the attitude toward the
non-rehabilitatable sick.” (The New
England Journal of Medicine, 14 July 1949.)
By accepting and
widening the scope of “medical assistance in dying” (a euphemism if there ever
was one!), I don't think we Canadians will become Nazis, but I do think we
significantly increase the risk of becoming a dark, morally-calloused,
death-embracing society.
Conclusion
Ideas have
consequences—and sometimes the consequences of bad ideas can be disastrous.
In view of the above
pros and cons, I think it would be wise for Canadians not to
embrace or expand medical assistance in dying. Instead, we should do a better
job of providing excellent palliative care—pain relief and life-enhancing
dignity—for all who suffer.
We should embrace a
culture of life, not a culture of death, for goodness' sake.
Hendrik van der
Breggen, PhD, retired last year as Associate Professor of Philosophy at
Providence University College, Manitoba, Canada. The views he expresses do not
always reflect the views of Providence.
Postscript
Dr. Harvey Chochinov— Canada Research
Chair in Palliative Care, Distinguished Professor of Psychiatry at the
University of Manitoba, Director of the Manitoba Palliative Care Research Unit—wrote
what follows in 2015. In view of the fact that MAID became legal in Canada one
year later and as of the end of 2019 approximately 13,000 Canadians have died via MAID, Canadians should ask: Was our government
morally and criminally negligent?
Despite the impressive
strides that palliative care has taken—in areas such as pain and symptom
management, and sensitivities to the psychological, existential and spiritual
challenges facing dying patients and their families—at their time of licensure,
physicians have been taught less about pain management than those graduating
from veterinary medicine. Once in practice, most physicians have knowledge
deficiencies that can significantly impair their ability to manage cancer pain.
Doctors are also not
generally well-trained to engage in end-of-life conversations, meaning that
goals of care often remain unclear; and patients may not receive the care they
want or the opportunity to live out their final days in the place they would want to
die. …
To be clear, dying badly
in Canada will rarely be the fallout of not having access to a lethal overdose
or injection, and will almost invariably be the result of inadequate or
substandard end-of-life care…. For 70 to 80 percent of Canadians, palliative
care is not available and hence, not a real choice.
Suggested
resources for further thought
Additional writings
by Hendrik van der Breggen:
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