Thanks for such a thorough article. I don't know how you get so much thoughtful pieces out there. This hit me personally in 2 areas:
One, I spent 2 years as a hospice chaplain and saw so much of this first hand. I had to do lots of learning as I went along. I was thankful for colleagues who gave me good resources to read and conversations that made me wiser.
Two, we have an adult disabled son. He struggles with anxiety and depression. I could so easily see the medical establishment across the border not helping but encouraging suicide. I'm troubled by the number of people I meet in America who haven't thought through all these implications.
Thanks for putting this out. I'm sharing it with my network
Dave, thank you for the reminder that these issues are real and pressing or many people in every day life. I do pray that this article helps and supports and someway, not just you but all of yours and all of us who will face decisions in this context someday.
As far as writing, since I am in the midst of a series on platform and publishing, I will share that this was an article that was assigned to me almost a year ahead of writing it. And I had to calendar at least a month to research and write it well in advance. I actually worked on the research for much longer. I know I write a lot, but it takes a lot of effort and planning! Thanks for the opportunity to share a bit of that process.
Dave, if I might give an insider perspective, it is not, and was not, the medical establishment encouraging this. Enough vocal and influential members of the public wanted medically assisted dying to have driven it through the courts and then the legislature. The Supreme Court case that ruled that persons with incurable conditions have the right to die in the manner they choose was brought to the courts by two members of the public.
A decade and a half before the "right to die" ruling, the Court had ruled against another member of the public bringing the same request, saying it was not in the public interest. But in 2014, the court reversed its previous decision. Once the Court ruled, the Parliament had a certain amount of time to relegislate the law that criminalized assisting someone to commit suicide to allow for medically assisted dying - if they did not, the entire law would become null and void. The only way to avoid doing this was for the legislature to invoke the 'notwithstanding clause' to overrule the court. The then Conservative government held a majority in Parliament and might have been able to do so, but instead they called an election, with the result that a new Liberal government was elected. That new government passed the current law in 2016 - they took such a long time over it that the Court granted them one extension on the time limit, but refused to extend it again. I need to emphasize that neither political 'side', progressive or conservative, really stood against the idea. The Supreme Court which ruled for assisted dying in 2014 had a clear majority of Conservative appointed judges.
The public wanted this. There is an influential organization for middle and upper class baby boomers, called the Canadian Association of Retired Persons (yes, CARP). The editor of their publication was removed because she didn't want to make a statement in favour of MAiD when it was first legalized. This organization is associated with multiple privately owned media outlets and has a political lobbying wing. In a previous position, I had multiple clients casually inform me they would take the option if the treatments my colleagues and I were giving did not work. My boomer parents and Christian friends in their generation report that secular friends of the same generation, who have been diagnosed with an incurable condition, have told them they are going to chose the option. The boomer generation has very much lived life on their own terms, and now many wish to die on their own terms.
I was studying when the ethical directives for healthcare professionals on MAiD were handed done by their regulating bodies. An instructor reviewed them in class. The directives stated that professionals had the right to refuse to participate and ask for reassignment, in line with language from both the Court ruling and the legislated law. Our instructor said, "But we all know what will happen. The manager will say there is no one else to take the patient and if we refuse, we will be abandoning our patient". Abandoning our patient is the unforgiveable sin in my profession. With chronic understaffing - a decades long problem - lack of other personnel to take over is a reality. Later, in a previous position, I had a colleague who said that our then manager had talked this colleague, who was not religious but still reluctant, into assisting with a MAiD case.
The flood of MAiD deaths is actually triggering a progressive backlash, as those concerned about social justice issues see how it is affecting the vulnerable like the man Karen talked about. I work with every socioeconomic layer of the public, but I have observed just how invisible the disabled and low income are to the upper and middle classes. The Toronto Star, a publication with a progressive reputation (Canada's NYT, so to speak), has written multiple articles saying MAiD has gone too far. The national broadcaster, CBC - which many right wingers think is too leftists, and some leftists think is too right wing - has also run stories with that concern. The socially progressive NDP party has said that there needs to be a review of how the current law is impacting those with disabilities.
This past March, Parliament put the brakes on an extension of MAiD that would have included those with mental illnesses. The three-year delay was at the pleading of psychiatrists and other mental health professionals. Mental healthcare is not funded by the provincial public health plans (each province has its own public health insurance policy, it is not federally administered), so access to adequate mental healthcare is already limited. In addition, the First Nations and Inuit of Canada have an ongoing mental health and suicide epidemic among their youth, so that allowing MAiD for mental illness could be said to be yet another discriminatory colonial policy towards their communities. When MAiD was first passed in 2016, a First Nation member of Parliament for the ruling Liberals stood up in the legislature and accused his own government of 'valorizing suicide'. Mental health professionals expressed relief when the delay was reported, but media stories also quoted members of the public who expressed a wish for MAiD to be an option for their mental illness.
Holly, thank you so much for this extensive and illuminating background. There is just so much that news stories can’t cover. Life “on the ground” matters so much in even beginning to understand these matters in all their layers.
Karen, as you know, I currently live in Canada and work in healthcare. I have told employers and prospective employers that I will not participate in the deliberate termination of human life, and so far haven't had to choose - I am currently limited in my ability to work anyway due to health issues. But I do feel concern for younger colleagues of conviction trying to navigate the ethical minefield.
I wasn't given any help to know how to deal with it myself. When the legislation legalizing MAiD in Canada was passed, I was studying for a further professional degree. The church I attended while going to school had multiple distinguished physicians in attendance, the community being a hub for healthcare education and research. I tried to discuss my concerns with two of those I knew personally, one the head of a research department, the other the head of a surgical speciality. They were morally outraged, but it wouldn't directly affect them. When I expressed concern that nurses would find it much harder to avoid getting involved, as they were direct employees of hospitals working under management, while physicians were contract workers who could set their own terms, they suggested I really should discuss my concerns with a Christian nurses group.
I have never had a pastor ask me how they could help with ethical problems I face. I am not sure, given the opinion pieces I see by pastors and other Christian figureheads commanding "resist the culture of death" from evangelical media outlets, that they would give any practical help. Their income to survive doesn't depend on making moral choices in the face of ethical dilemmas that could mean professional and economical ruin.
I muddle along as best I can. But I can think of ways the church might help, avenues that don't involve using one of those right wing political funding juggernauts to fund a test case through court (even if I had to go to court, I wouldn't take the money of one of those organizations if they offered it - I have seen them outright lie to increase donations). Things like setting up private elder care institutions and hospices run by churches - a few of these exist, but not nearly enough. But I am a low-income nobody, nearly as voiceless as those disabled and impoverished people considering MAiD. I find the Canadian evangelical church is more occupied in lamenting the decadent culture while carrying on as normal - or worse, bellyaching over past COVID measures (concerning which their ire is all too often directed at the healthcare professions) - to listen anyway. Canadian Christians were once the spearhead of healthcare in this country - the first province to develop public healthcare had a Christian premier at the time - now they just complain about it. It isn't progressivism that is endangering Christian conviction in Canada, it is our own complacency [if individualism is the U.S.'s Achilles heel, then complacency is Canada's] that ignores any issue that doesn't directly affect us, whether it be COVID or MAiD.
Oh, Holly. We (as the church) are so ill-equipped and so little willing to really, honestly, and helpfully grapple with these issues. If I didn’t see it before the fall of Roe v Wade, I do see it now. I ache and lament reading this.
I passed her. I had years and years ago who is such a good and godly man served on an ethics board for a hospital facing these kinds of complicated decisions. What a wonderful opportunity it was for him to bring his faith to bear in a way that was meaningful and helpful. We need so much more of that kind of thing.
Thank you for being real and honest about that here.
"Their income to survive doesn't depend on making moral choices in the face of ethical dilemmas that could mean professional and economical ruin." As a pastor I've been acutely conscious of this when some (not the ones affected) have pressed for pulpit speech that would call, say, for certain workplace stances on contested issues - and I refuse to do so. Personal, pastoral counsel and non-directive prayer? Yes. Public calls to arms when it would cost me nothing? No.
Karen, I continue to enjoy The Priory during my convalescence, and between your posts I’ve been reading some of your book recommendations. Just finished your edited version of Frankenstein. I had never read it before. A very engaging read! Now a lot of what I knew from popular culture makes sense although correcting the name of the creature is, I’m sure, a lost cause.
My mother passed way almost a month ago after more than three months on hospice. I’m so grateful we do not live in a place where care-rationing pressured us to shorten that time. Every day we got to kiss her forehead and feel her hold our hands was a gift. Every day she answered my greeting with a whispered, “I love you, baby,” was a treasure.
Moreover, my dad, husband, and I were changed by the caregiving those months required. We had to depend on Christ more deeply than ever. In washing my mother’s feet, we washed the feet of Jesus. That offering of service as worship proved to be gospel witness to the hospice professionals who said they’d never seen a husband care for a wife and help their staff the way my dad did.
Thank you for calling attention to the work of Dame Saunders.
I look forward to your thoughts on my favorite Donne sonnet (actually all the Donne ahead) soon, and I do wish I could spy on your aesthetics class. ♥️
Holly , as a nurse at what stage do you feel that a patient is being artificially kept alive ? A situation that troubles me is that with the genuine wonders of modern medicine it must be harder to say when you are performing euthanasia or when you are releasing a patient to a natural death .
I am involved with fundraising fir our local hospice and it is a wonderful and peaceful place , with staff who are rightly proud of what they do . Somehow I can’t imagine anyone having a benefit evening for a MAID Centre . And I am fascinated and agree with your comment about Inuit communities
Miranda, it is a complex question, with many facets. I do not have all the answers, but there are some things I can speak to from a combination of my medical knowledge and personal experience.
As a prologue, it should be made clear that the Canadian legal term 'medical assistance in dying' (MAiD) only refers to the active administration of a lethal dose of medication at the express written and verbal consent of the patient, a consent that must be reiterated just before the dose is given [Note: certain members of the public have been advocating for advanced consent in cases of progressively debilitating disease that might interfere with the final consent]. It does not apply to the withdrawal or withholding of possible life extending treatments such as I will address in the following:
First, let's consider the scenario that most people have in mind, that of someone who is completely unresponsive and unconscious, and whose heart and lungs are kept functioning on life support. The common perception is that someone could be kept alive indefinitely on such machinery. I would say that was incorrect. I have personal experience with this, with a relative who became critically ill, went into a coma, and then had massive organ failure. I was there just before and as the ventilator was stopped. Holding my relative's hand before the machine was stopped, I could feel it was the hand of someone no longer living. A ventilator can force air in and out of the lungs, but as death approaches, the peripheral circulation shuts down. The heart cannot pump against a shutdown circulatory system. We knew circulation had shut down for my relative as the dialysis machine couldn't work due to the circulatory collapse. I have some ethical questions about using brain death as a gauge for life support removal in certain cases, but circulatory death is unmistakable, even with life support running.
Second, there is the question of whether feeding tubes are artificially keeping people alive. It is true that before modern medicine, people who lost the ability to swallow would have died for that reason, but so would diabetics without insulin, and asthmatics without inhalers. When I first went through school in the 2000s, I remember my instructors saying that the most recent medical literature on the topic suggested that while death from hunger was painful, death from thirst was generally painless (this was not long after the Terry Schiavo case in the U.S., so the question was on students' minds). I remember wondering if anyone had ever read a survivor's account of someone who was lost in the desert or on a lifeboat in the ocean, because those accounts describe the thirst as agonising. A few years later, the literature admitted that dying of thirst was not painless. I also have personal experience with this question, with a relative who was dying of cancer which eventually blocked their digestive system. As I later learned in school, when the body cannot pass anything down through the bowel, it will start to eliminate it by vomiting, even fecal matter. Once again, there comes a time when feeding tubes can no longer help and can rather increase suffering.
Finally, there is the question of whether refusing or denying life prolonging treatment is unethical. I have already touched on ways that removing life support or feeding tubes are not unethical, because they are no longer doing any good and may in fact be doing harm (there are other ways they can also harm). My relatives who have passed away were Christians, and those whose deaths were forseen all at some point said, that is enough treatment. Accepting this was their end, they let their life run out its natural course. That is very different from knowingly taking or having injected a fatal dose to terminate life.
As for refusing to provide treatment that might prolong life, the first medical ethical principle is nonmaleficence, "do no harm", then comes beneficence "do good". I remember from my youth an elderly Christian friend who was discovered to have metastisized cancer and the physicians said he was too fragile to have surgery and chemotherapy. At first this friend found not getting treatment difficult to accept, but then came to peace with it - he wrote about recalling the story of King Hezekiah in the Bible, who received a fatal diagnosis and pled for more years of life, but when those years were granted, did not make the best use of them. Nevertheless, the justice of refusing treatment to the elderly and frail remained a question in my mind to be answered. When I later had a minor surgery only under local anesthetic by my choice, the extreme discomfort I experienced from the minor internal manipulation taught me how much the human body suffers under surgery. Still later, I trained in the operating room and witnessed day long surgeries for metastatic cancer, seeing just how much extreme trauma the body goes through in such surgeries and realizing how it actually could hasten death for the frail. The same principle applies to chemotherapy, which is also very hard on the human body. Under the principle of non-maleficence, sometimes refusing treatment is necessary, when the treatment would do more harm than good.
There are still more and finer aspects to each of these points that I cannot fully address due to space, and time, and a finite knowledge. But I hope I have shown how each question differs from the question of actively giving a fatal injection. When I trained in operating room care, several years before the Supreme Court ruling in 2014, my instructor told us a true story of a disciplinary action against a nurse. The professional regulatory body uses a disciplinary panel of professionals and members of the public. The nurse was under discipline for having used a potassium injection from hospital supplies to euthanize a mouse that had been caught but not killed in a trap, after a terminator was delayed in coming to dispose of the mouse. The panel ruled the nurse must be stripped for life of their license to practice, not for misusing hospital stores, but because the nurse's willingness to euthanise a mouse because it was suffering indicated a potential willingness to similarly treat a suffering patient.
I never forgot that story, and when MAiD came about it staggered me that so many public members seemed fine with medical professionals having to overcome their natural unwillingness to willfully end human life. Shouldn't they have been afraid it might make us careless? Shortly before MAiD was legalized, a horrific criminal case broke of a nurse who confessed to having quietly killed multiple vulnerable patients with lethal insulin doses, yet even that didn't seem to give the public pause. Recently, I attended a forum on conscientious objection in healthcare, i.e. refusing participation in MAiD, and the speaker acknowledged that healthcare needed workers of conscience.
If I ever have to plead my case in court, I have one simple question. Healthcare workers did not create disease. Disease has existed since human history began. Healthcare was developed in an effort to relieve that long history of suffering. So, why are healthcare workers now being held responsible to kill our patients when we cannot cure their disease?
Holly, thank you very much for sharing all you did. I’m trying to absorb all this info. Medically assisted suicide has not come to Ohio yet, however, I am concerned about when it does. I am a suicide prevention coordinator and so far my organization says we take no stance on the issue. We are “neutral”. I spoke with her about it and said that it seems like the suicide prevention community in the US should be more prepared than saying “we are neutral. After all we are in the business of PREVENTION, yet, we are not factoring in med. assisted suicide. I’m fairly new to all this but I am thankful for your comments furthering the discussion.
In fairness to your organization, no one involved in mental healthcare in Canada knows the answer to that either - that is why they pleaded for the delay. But the delay is only for three years. I really do not think there is an answer. If MAiD is allowed for incurable mental illness, the parameters for what is incurable would be nearly impossible to draw, and the question of what is mental illness is also up for interpretation.
I see the Western world's drive toward medical assistance in dying is based on the human belief that some deaths are better than others. The term euthanasia literally means 'good death'. When we say of someone who died in their sleep, "that's a good death, that's how I want to go", we are concluding that some ways of dying are preferable to others.
Now, I understand that most people do not want to suffer certain sensations before dying - no one wants to burn to death - but that is different from thinking death can be welcomed if only it is painless. I personally hate the thought of drowning or otherwise dying while gasping for breath because I have come near death while struggling to breathe and it is terrifying. But that doesn't mean I don't also understand that whatever death I die, I will stop breathing. I also know that in the last breaths I breathe, known as 'agonal breaths', my body will be making its final attempts to stay alive.
That is something that it is important for the layperson to understand about death. The body will always fight to stay alive, whether it is dying after a long battle or brief illness or fatal injection. The body is hard wired to maintain homeostasis, a state of equilibrium, to maintain life. When it can no longer maintain equilibrium, it goes into a state of shock, a downward spiral that may be slow or rapid, but will end in death if not reversed. When I studied stages of shock in my pathophysiology classes, I quickly realized that I was learning the stages of death. Any assault, natural or unnatural, on the human body, will trigger shock. For example, both dehydration and a gunshot wound can cause hypovolemic shock, which is shock caused by too little blood volume to supply the body's needs. A fatal injection will still triggering the body to go into shock, and, however briefly, the body will try to fight back. From the U.S., we have heard reports of botched executions by fatal injection. There has already been some indication in the media from those involved that not all MAiD cases go as planned.
As a Christian, I believe death is "the last enemy" (I Corinthians 15:26) and I hope that my Lord, who has already died for me, will help me through its agony, how long or short the transition may be. I do not object to participating in MAiD because I would be sending unbelievers to hell - their eternal destiny is in God's hands, not mine. If that was my objection, then I would have no problem doing MAiD for believers. I object because I know humans are made in the image of God. Humans were given rule over the earth, but we were not given sovereignty over the lives of our fellow humans. There is nothing in my medical training that gives me the authority to violate that most basic of all commands, "Thou shalt not kill."
Karen, thank you. I was moved, informed and encouraged.
However, in your paragraph starting, “Canada is a current focus point for these discussions” you write, “Canada has some of the most liberal assisted death laws in the world.” May I be so bold as to challenge your word choice? Especially given the host journal’s position on Liberalism in economics, would it be equally (or dare I say more) accurate to call Canada’s position illiberal or regressive? When we use liberal as a pejorative we cede intellectual ground where we would be wiser to stand firm then with the belt of truth around our waists.
Please know that it is only because the rest of the piece was so good, that I would take time to comment.
Margaret, you raise a good point that I didn’t really think about. Descriptors about laws are usually described as “liberal” or “restrictive.” But I guess that is your point: that I just echo the common usage. I had to think for a bit about what other term could be used and the only one I came up with was “permissive.”
Yes, "permissive" seems like a good fit. You make an excellent case in your article that in certain social/ethical contexts giving permission risks translating to imposing an obligation. So laws expanding a person's freedom to take her life, may (likely will) result in her feeling less free to live. In that case, unless it is meant satirically, to name those laws "liberal" seems somehow wrong.
Permissive, on the other hand, has all sorts of "liberalism taken to the extreme and thereby distorted" valences - vis. permissive sexual ethics or permissive parenting. Readers who have Paul's reasoning "Everything is permissable but not everything is beneficial." at the back of their minds would perhaps pick up "permissive" as a signal that sometimes what seems like increased freedom (and therefore a good) turns out not to end in freedom.
Thanks for such a thorough article. I don't know how you get so much thoughtful pieces out there. This hit me personally in 2 areas:
One, I spent 2 years as a hospice chaplain and saw so much of this first hand. I had to do lots of learning as I went along. I was thankful for colleagues who gave me good resources to read and conversations that made me wiser.
Two, we have an adult disabled son. He struggles with anxiety and depression. I could so easily see the medical establishment across the border not helping but encouraging suicide. I'm troubled by the number of people I meet in America who haven't thought through all these implications.
Thanks for putting this out. I'm sharing it with my network
Dave, thank you for the reminder that these issues are real and pressing or many people in every day life. I do pray that this article helps and supports and someway, not just you but all of yours and all of us who will face decisions in this context someday.
As far as writing, since I am in the midst of a series on platform and publishing, I will share that this was an article that was assigned to me almost a year ahead of writing it. And I had to calendar at least a month to research and write it well in advance. I actually worked on the research for much longer. I know I write a lot, but it takes a lot of effort and planning! Thanks for the opportunity to share a bit of that process.
Dave, if I might give an insider perspective, it is not, and was not, the medical establishment encouraging this. Enough vocal and influential members of the public wanted medically assisted dying to have driven it through the courts and then the legislature. The Supreme Court case that ruled that persons with incurable conditions have the right to die in the manner they choose was brought to the courts by two members of the public.
A decade and a half before the "right to die" ruling, the Court had ruled against another member of the public bringing the same request, saying it was not in the public interest. But in 2014, the court reversed its previous decision. Once the Court ruled, the Parliament had a certain amount of time to relegislate the law that criminalized assisting someone to commit suicide to allow for medically assisted dying - if they did not, the entire law would become null and void. The only way to avoid doing this was for the legislature to invoke the 'notwithstanding clause' to overrule the court. The then Conservative government held a majority in Parliament and might have been able to do so, but instead they called an election, with the result that a new Liberal government was elected. That new government passed the current law in 2016 - they took such a long time over it that the Court granted them one extension on the time limit, but refused to extend it again. I need to emphasize that neither political 'side', progressive or conservative, really stood against the idea. The Supreme Court which ruled for assisted dying in 2014 had a clear majority of Conservative appointed judges.
The public wanted this. There is an influential organization for middle and upper class baby boomers, called the Canadian Association of Retired Persons (yes, CARP). The editor of their publication was removed because she didn't want to make a statement in favour of MAiD when it was first legalized. This organization is associated with multiple privately owned media outlets and has a political lobbying wing. In a previous position, I had multiple clients casually inform me they would take the option if the treatments my colleagues and I were giving did not work. My boomer parents and Christian friends in their generation report that secular friends of the same generation, who have been diagnosed with an incurable condition, have told them they are going to chose the option. The boomer generation has very much lived life on their own terms, and now many wish to die on their own terms.
I was studying when the ethical directives for healthcare professionals on MAiD were handed done by their regulating bodies. An instructor reviewed them in class. The directives stated that professionals had the right to refuse to participate and ask for reassignment, in line with language from both the Court ruling and the legislated law. Our instructor said, "But we all know what will happen. The manager will say there is no one else to take the patient and if we refuse, we will be abandoning our patient". Abandoning our patient is the unforgiveable sin in my profession. With chronic understaffing - a decades long problem - lack of other personnel to take over is a reality. Later, in a previous position, I had a colleague who said that our then manager had talked this colleague, who was not religious but still reluctant, into assisting with a MAiD case.
The flood of MAiD deaths is actually triggering a progressive backlash, as those concerned about social justice issues see how it is affecting the vulnerable like the man Karen talked about. I work with every socioeconomic layer of the public, but I have observed just how invisible the disabled and low income are to the upper and middle classes. The Toronto Star, a publication with a progressive reputation (Canada's NYT, so to speak), has written multiple articles saying MAiD has gone too far. The national broadcaster, CBC - which many right wingers think is too leftists, and some leftists think is too right wing - has also run stories with that concern. The socially progressive NDP party has said that there needs to be a review of how the current law is impacting those with disabilities.
This past March, Parliament put the brakes on an extension of MAiD that would have included those with mental illnesses. The three-year delay was at the pleading of psychiatrists and other mental health professionals. Mental healthcare is not funded by the provincial public health plans (each province has its own public health insurance policy, it is not federally administered), so access to adequate mental healthcare is already limited. In addition, the First Nations and Inuit of Canada have an ongoing mental health and suicide epidemic among their youth, so that allowing MAiD for mental illness could be said to be yet another discriminatory colonial policy towards their communities. When MAiD was first passed in 2016, a First Nation member of Parliament for the ruling Liberals stood up in the legislature and accused his own government of 'valorizing suicide'. Mental health professionals expressed relief when the delay was reported, but media stories also quoted members of the public who expressed a wish for MAiD to be an option for their mental illness.
Holly, thank you so much for this extensive and illuminating background. There is just so much that news stories can’t cover. Life “on the ground” matters so much in even beginning to understand these matters in all their layers.
Thanks for such a thorough reply. There is so much to this history that I didn’t know
Thank you for reading.
Karen, as you know, I currently live in Canada and work in healthcare. I have told employers and prospective employers that I will not participate in the deliberate termination of human life, and so far haven't had to choose - I am currently limited in my ability to work anyway due to health issues. But I do feel concern for younger colleagues of conviction trying to navigate the ethical minefield.
I wasn't given any help to know how to deal with it myself. When the legislation legalizing MAiD in Canada was passed, I was studying for a further professional degree. The church I attended while going to school had multiple distinguished physicians in attendance, the community being a hub for healthcare education and research. I tried to discuss my concerns with two of those I knew personally, one the head of a research department, the other the head of a surgical speciality. They were morally outraged, but it wouldn't directly affect them. When I expressed concern that nurses would find it much harder to avoid getting involved, as they were direct employees of hospitals working under management, while physicians were contract workers who could set their own terms, they suggested I really should discuss my concerns with a Christian nurses group.
I have never had a pastor ask me how they could help with ethical problems I face. I am not sure, given the opinion pieces I see by pastors and other Christian figureheads commanding "resist the culture of death" from evangelical media outlets, that they would give any practical help. Their income to survive doesn't depend on making moral choices in the face of ethical dilemmas that could mean professional and economical ruin.
I muddle along as best I can. But I can think of ways the church might help, avenues that don't involve using one of those right wing political funding juggernauts to fund a test case through court (even if I had to go to court, I wouldn't take the money of one of those organizations if they offered it - I have seen them outright lie to increase donations). Things like setting up private elder care institutions and hospices run by churches - a few of these exist, but not nearly enough. But I am a low-income nobody, nearly as voiceless as those disabled and impoverished people considering MAiD. I find the Canadian evangelical church is more occupied in lamenting the decadent culture while carrying on as normal - or worse, bellyaching over past COVID measures (concerning which their ire is all too often directed at the healthcare professions) - to listen anyway. Canadian Christians were once the spearhead of healthcare in this country - the first province to develop public healthcare had a Christian premier at the time - now they just complain about it. It isn't progressivism that is endangering Christian conviction in Canada, it is our own complacency [if individualism is the U.S.'s Achilles heel, then complacency is Canada's] that ignores any issue that doesn't directly affect us, whether it be COVID or MAiD.
Oh, Holly. We (as the church) are so ill-equipped and so little willing to really, honestly, and helpfully grapple with these issues. If I didn’t see it before the fall of Roe v Wade, I do see it now. I ache and lament reading this.
I passed her. I had years and years ago who is such a good and godly man served on an ethics board for a hospital facing these kinds of complicated decisions. What a wonderful opportunity it was for him to bring his faith to bear in a way that was meaningful and helpful. We need so much more of that kind of thing.
Thank you for being real and honest about that here.
*A pastor
"Their income to survive doesn't depend on making moral choices in the face of ethical dilemmas that could mean professional and economical ruin." As a pastor I've been acutely conscious of this when some (not the ones affected) have pressed for pulpit speech that would call, say, for certain workplace stances on contested issues - and I refuse to do so. Personal, pastoral counsel and non-directive prayer? Yes. Public calls to arms when it would cost me nothing? No.
Thank you for that.
Karen, I continue to enjoy The Priory during my convalescence, and between your posts I’ve been reading some of your book recommendations. Just finished your edited version of Frankenstein. I had never read it before. A very engaging read! Now a lot of what I knew from popular culture makes sense although correcting the name of the creature is, I’m sure, a lost cause.
So glad you enjoyed it, lost cause notwithstanding! Praying for you right now, too, Terri.
My mother passed way almost a month ago after more than three months on hospice. I’m so grateful we do not live in a place where care-rationing pressured us to shorten that time. Every day we got to kiss her forehead and feel her hold our hands was a gift. Every day she answered my greeting with a whispered, “I love you, baby,” was a treasure.
Moreover, my dad, husband, and I were changed by the caregiving those months required. We had to depend on Christ more deeply than ever. In washing my mother’s feet, we washed the feet of Jesus. That offering of service as worship proved to be gospel witness to the hospice professionals who said they’d never seen a husband care for a wife and help their staff the way my dad did.
Thank you for calling attention to the work of Dame Saunders.
I look forward to your thoughts on my favorite Donne sonnet (actually all the Donne ahead) soon, and I do wish I could spy on your aesthetics class. ♥️
Thank you so much for sharing a bit of that tender time with us. What a treasure indeed.
Holly , as a nurse at what stage do you feel that a patient is being artificially kept alive ? A situation that troubles me is that with the genuine wonders of modern medicine it must be harder to say when you are performing euthanasia or when you are releasing a patient to a natural death .
I am involved with fundraising fir our local hospice and it is a wonderful and peaceful place , with staff who are rightly proud of what they do . Somehow I can’t imagine anyone having a benefit evening for a MAID Centre . And I am fascinated and agree with your comment about Inuit communities
Miranda, it is a complex question, with many facets. I do not have all the answers, but there are some things I can speak to from a combination of my medical knowledge and personal experience.
As a prologue, it should be made clear that the Canadian legal term 'medical assistance in dying' (MAiD) only refers to the active administration of a lethal dose of medication at the express written and verbal consent of the patient, a consent that must be reiterated just before the dose is given [Note: certain members of the public have been advocating for advanced consent in cases of progressively debilitating disease that might interfere with the final consent]. It does not apply to the withdrawal or withholding of possible life extending treatments such as I will address in the following:
First, let's consider the scenario that most people have in mind, that of someone who is completely unresponsive and unconscious, and whose heart and lungs are kept functioning on life support. The common perception is that someone could be kept alive indefinitely on such machinery. I would say that was incorrect. I have personal experience with this, with a relative who became critically ill, went into a coma, and then had massive organ failure. I was there just before and as the ventilator was stopped. Holding my relative's hand before the machine was stopped, I could feel it was the hand of someone no longer living. A ventilator can force air in and out of the lungs, but as death approaches, the peripheral circulation shuts down. The heart cannot pump against a shutdown circulatory system. We knew circulation had shut down for my relative as the dialysis machine couldn't work due to the circulatory collapse. I have some ethical questions about using brain death as a gauge for life support removal in certain cases, but circulatory death is unmistakable, even with life support running.
Second, there is the question of whether feeding tubes are artificially keeping people alive. It is true that before modern medicine, people who lost the ability to swallow would have died for that reason, but so would diabetics without insulin, and asthmatics without inhalers. When I first went through school in the 2000s, I remember my instructors saying that the most recent medical literature on the topic suggested that while death from hunger was painful, death from thirst was generally painless (this was not long after the Terry Schiavo case in the U.S., so the question was on students' minds). I remember wondering if anyone had ever read a survivor's account of someone who was lost in the desert or on a lifeboat in the ocean, because those accounts describe the thirst as agonising. A few years later, the literature admitted that dying of thirst was not painless. I also have personal experience with this question, with a relative who was dying of cancer which eventually blocked their digestive system. As I later learned in school, when the body cannot pass anything down through the bowel, it will start to eliminate it by vomiting, even fecal matter. Once again, there comes a time when feeding tubes can no longer help and can rather increase suffering.
Finally, there is the question of whether refusing or denying life prolonging treatment is unethical. I have already touched on ways that removing life support or feeding tubes are not unethical, because they are no longer doing any good and may in fact be doing harm (there are other ways they can also harm). My relatives who have passed away were Christians, and those whose deaths were forseen all at some point said, that is enough treatment. Accepting this was their end, they let their life run out its natural course. That is very different from knowingly taking or having injected a fatal dose to terminate life.
As for refusing to provide treatment that might prolong life, the first medical ethical principle is nonmaleficence, "do no harm", then comes beneficence "do good". I remember from my youth an elderly Christian friend who was discovered to have metastisized cancer and the physicians said he was too fragile to have surgery and chemotherapy. At first this friend found not getting treatment difficult to accept, but then came to peace with it - he wrote about recalling the story of King Hezekiah in the Bible, who received a fatal diagnosis and pled for more years of life, but when those years were granted, did not make the best use of them. Nevertheless, the justice of refusing treatment to the elderly and frail remained a question in my mind to be answered. When I later had a minor surgery only under local anesthetic by my choice, the extreme discomfort I experienced from the minor internal manipulation taught me how much the human body suffers under surgery. Still later, I trained in the operating room and witnessed day long surgeries for metastatic cancer, seeing just how much extreme trauma the body goes through in such surgeries and realizing how it actually could hasten death for the frail. The same principle applies to chemotherapy, which is also very hard on the human body. Under the principle of non-maleficence, sometimes refusing treatment is necessary, when the treatment would do more harm than good.
There are still more and finer aspects to each of these points that I cannot fully address due to space, and time, and a finite knowledge. But I hope I have shown how each question differs from the question of actively giving a fatal injection. When I trained in operating room care, several years before the Supreme Court ruling in 2014, my instructor told us a true story of a disciplinary action against a nurse. The professional regulatory body uses a disciplinary panel of professionals and members of the public. The nurse was under discipline for having used a potassium injection from hospital supplies to euthanize a mouse that had been caught but not killed in a trap, after a terminator was delayed in coming to dispose of the mouse. The panel ruled the nurse must be stripped for life of their license to practice, not for misusing hospital stores, but because the nurse's willingness to euthanise a mouse because it was suffering indicated a potential willingness to similarly treat a suffering patient.
I never forgot that story, and when MAiD came about it staggered me that so many public members seemed fine with medical professionals having to overcome their natural unwillingness to willfully end human life. Shouldn't they have been afraid it might make us careless? Shortly before MAiD was legalized, a horrific criminal case broke of a nurse who confessed to having quietly killed multiple vulnerable patients with lethal insulin doses, yet even that didn't seem to give the public pause. Recently, I attended a forum on conscientious objection in healthcare, i.e. refusing participation in MAiD, and the speaker acknowledged that healthcare needed workers of conscience.
If I ever have to plead my case in court, I have one simple question. Healthcare workers did not create disease. Disease has existed since human history began. Healthcare was developed in an effort to relieve that long history of suffering. So, why are healthcare workers now being held responsible to kill our patients when we cannot cure their disease?
Holly, thank you very much for sharing all you did. I’m trying to absorb all this info. Medically assisted suicide has not come to Ohio yet, however, I am concerned about when it does. I am a suicide prevention coordinator and so far my organization says we take no stance on the issue. We are “neutral”. I spoke with her about it and said that it seems like the suicide prevention community in the US should be more prepared than saying “we are neutral. After all we are in the business of PREVENTION, yet, we are not factoring in med. assisted suicide. I’m fairly new to all this but I am thankful for your comments furthering the discussion.
In fairness to your organization, no one involved in mental healthcare in Canada knows the answer to that either - that is why they pleaded for the delay. But the delay is only for three years. I really do not think there is an answer. If MAiD is allowed for incurable mental illness, the parameters for what is incurable would be nearly impossible to draw, and the question of what is mental illness is also up for interpretation.
I see the Western world's drive toward medical assistance in dying is based on the human belief that some deaths are better than others. The term euthanasia literally means 'good death'. When we say of someone who died in their sleep, "that's a good death, that's how I want to go", we are concluding that some ways of dying are preferable to others.
Now, I understand that most people do not want to suffer certain sensations before dying - no one wants to burn to death - but that is different from thinking death can be welcomed if only it is painless. I personally hate the thought of drowning or otherwise dying while gasping for breath because I have come near death while struggling to breathe and it is terrifying. But that doesn't mean I don't also understand that whatever death I die, I will stop breathing. I also know that in the last breaths I breathe, known as 'agonal breaths', my body will be making its final attempts to stay alive.
That is something that it is important for the layperson to understand about death. The body will always fight to stay alive, whether it is dying after a long battle or brief illness or fatal injection. The body is hard wired to maintain homeostasis, a state of equilibrium, to maintain life. When it can no longer maintain equilibrium, it goes into a state of shock, a downward spiral that may be slow or rapid, but will end in death if not reversed. When I studied stages of shock in my pathophysiology classes, I quickly realized that I was learning the stages of death. Any assault, natural or unnatural, on the human body, will trigger shock. For example, both dehydration and a gunshot wound can cause hypovolemic shock, which is shock caused by too little blood volume to supply the body's needs. A fatal injection will still triggering the body to go into shock, and, however briefly, the body will try to fight back. From the U.S., we have heard reports of botched executions by fatal injection. There has already been some indication in the media from those involved that not all MAiD cases go as planned.
As a Christian, I believe death is "the last enemy" (I Corinthians 15:26) and I hope that my Lord, who has already died for me, will help me through its agony, how long or short the transition may be. I do not object to participating in MAiD because I would be sending unbelievers to hell - their eternal destiny is in God's hands, not mine. If that was my objection, then I would have no problem doing MAiD for believers. I object because I know humans are made in the image of God. Humans were given rule over the earth, but we were not given sovereignty over the lives of our fellow humans. There is nothing in my medical training that gives me the authority to violate that most basic of all commands, "Thou shalt not kill."
Thanks Holly, you have thought this through and I appreciate your perspective and agree with your line of thought in the last paragraph.
What a profound and important question…
Karen, thank you. I was moved, informed and encouraged.
However, in your paragraph starting, “Canada is a current focus point for these discussions” you write, “Canada has some of the most liberal assisted death laws in the world.” May I be so bold as to challenge your word choice? Especially given the host journal’s position on Liberalism in economics, would it be equally (or dare I say more) accurate to call Canada’s position illiberal or regressive? When we use liberal as a pejorative we cede intellectual ground where we would be wiser to stand firm then with the belt of truth around our waists.
Please know that it is only because the rest of the piece was so good, that I would take time to comment.
Warmly,
Margaret
Margaret, you raise a good point that I didn’t really think about. Descriptors about laws are usually described as “liberal” or “restrictive.” But I guess that is your point: that I just echo the common usage. I had to think for a bit about what other term could be used and the only one I came up with was “permissive.”
Yes, "permissive" seems like a good fit. You make an excellent case in your article that in certain social/ethical contexts giving permission risks translating to imposing an obligation. So laws expanding a person's freedom to take her life, may (likely will) result in her feeling less free to live. In that case, unless it is meant satirically, to name those laws "liberal" seems somehow wrong.
Permissive, on the other hand, has all sorts of "liberalism taken to the extreme and thereby distorted" valences - vis. permissive sexual ethics or permissive parenting. Readers who have Paul's reasoning "Everything is permissable but not everything is beneficial." at the back of their minds would perhaps pick up "permissive" as a signal that sometimes what seems like increased freedom (and therefore a good) turns out not to end in freedom.
Excellent points!