Article
Assisted dying
Care
Culture
Death & life
8 min read

The deceptive appeal of assisted dying changes medical practice

In Canada the moral ethos of medicine has shifted dramatically.

Ewan is a physician practising in Toronto, Canada. 

A tired-looking doctor sits at a desk dealing with paperwork.
Francisco Venâncio on Unsplash.

Once again, the UK parliament is set to debate the question of legalizing euthanasia (a traditional term for physician-assisted death). Political conditions appear to be conducive to the legalization of this technological approach to managing death. The case for assisted death appears deceptively simple—it’s about compassion, respect, empowerment, freedom from suffering. Who can oppose such positive goals? Yet, writing from Canada, I can only warn of the ways in which the embrace of physician-assisted death will fundamentally change the practice of medicine. Reflecting on the last 10 years of our experience, two themes stick out to me—pressure, and self-deception. 

I still remember quite distinctly the day that it dawned on me that the moral ethos of medicine in Canada was shifting dramatically. Traditionally, respect for the sacredness of the patient’s life and a corresponding absolute prohibition on deliberately causing the death of a patient were widely seen as essential hallmarks of a virtuous physician. Suddenly, in a 180 degree ethical turn, a willingness to intentionally cause the death of a patient was now seen as the hallmark of patient-centered doctor. A willingness to cause the patient’s death was a sign of compassion and even purported self-sacrifice in that one would put the patient’s desires and values ahead of their own. Those of us who continued to insist on the wrongness of deliberately causing death would now be seen as moral outliers, barriers to the well-being and dignity of our patients. We were tolerated to some extent, and mainly out of a sense of collegiality. But we were also a source of slight embarrassment. Nobody really wanted to debate the question with us; the question was settled without debate. 

Yet there was no denying the way that pressure was brought to bear, in ways subtle and overt, to participate in the new assisted death regime. We humans are unavoidably moral creatures, and when we come to believe that something is good, we see ourselves and others as having an obligation to support it. We have a hard time accepting those who refuse to join us. Such was the case with assisted death. With the loudest and most strident voices in the Canadian medical profession embracing assisted death as a high and unquestioned moral good, refusal to participate in assisted death could not be fully tolerated.  

We deceive ourselves if we think that doctors have fully accepted that euthanasia is ethical when only very few are actually willing to administer it. 

Regulators in Ontario and Nova Scotia (two Canadian provinces) stipulated that physicians who were unwilling to perform the death procedure must make an effective referral to a willing “provider”. Although the Supreme Court decision made it clear in their decision to strike down the criminal prohibition against physician-assisted death that no particular physician was under any obligation to provide the procedure, the regulators chose to enforce participation by way of this effective referral requirement. After all, this was the only way to normalize this new practice. Doctors don't ordinarily refuse to refer their patients for medically necessary procedures; if assisted death was understood to be a medically necessary good, then an unwillingness to make such referral could not be tolerated.  

And this form of pressure brings us to the pattern of deception. First, it is deceptive to suggest that an effective referral to a willing provider confers no moral culpability on the referring physician for the death of the patient. Those of us who objected to referring the patient were told that like Pilate, we could wash our hands of the patient’s death by passing them along to someone else who had the courage to do the deed. Yet the same regulators clearly prohibited referral for female genital mutilation. They therefore seemed to understand the moral responsibility attached to an effective referral. Such glaring inconsistencies about the moral significance of a referral suggests that when they claimed that a referral avoided culpability for death by euthanasia, they were deceiving themselves and us. 

The very need for a referral system signifies another self-deception. Doctors normally make referrals only when an assessment or procedure lies outside their technical expertise. In the case of assisted death, every physician has the requisite technical expertise to cause death. There is nothing at all complicated or difficult or specialized about assessing euthanasia eligibility criteria or the sequential administration of toxic doses of midazolam, propofol, rocuronium, and lidocaine. The fact that the vast majority of physicians are unwilling to perform this procedure entails that moral objection to participation in assisted death remains widespread in the medical profession. The referral mechanism is for physicians who are “uncomfortable” in performing the procedure; they can send the patient to someone else more comfortable. But to be comfortable in this case is to be “morally comfortable”, not “technically comfortable”. We deceive ourselves if we think that doctors have fully accepted that euthanasia is ethical when only very few are actually willing to administer it. 

We deceived ourselves into thinking that assisted death is a medical therapy for a medical problem, when in fact it is an existential therapy for a spiritual problem.

There is also self-deception with respect to the cause of death. In Canada, when a patient dies by doctor-assisted death, the person completing the death certificate is required to record the cause of death as the reason that the patient requested euthanasia, not the act of euthanasia per se. This must lead to all sorts of moments of absurdity for physicians completing death certificates—do patients really die from advanced osteoarthritis? (one of the many reasons patients have sought and obtained euthanasia). I suspect that this practice is intended to shield those who perform euthanasia from any long-term legal liability should the law be reversed. But if medicine, medical progress, and medical safety are predicated on an honest acknowledgment about causes of death, then this form of self-deception should not be countenanced. We need to be honest with ourselves about why our patients die. 

There has also been self-deception about whether physician-assisted death is a form of suicide. Some proponents of assisted death contend that assisted death is not an act of deliberate self-killing, but rather merely a choice over the manner and timing of one's death. It's not clear why one would try to distort language this way and deny that “physician-assisted suicide” is suicide, except perhaps to assuage conscience and minimize stigma. Perhaps we all know that suicide is never really a form of self-respect. To sustain our moral and social affirmation of physician-assisted death, we have to deny what this practice actually represents. 

There has been self-deception about the possibility of putting limits around the practice of assisted death. Early on, advocates insisted that euthanasia would be available only to those for whom death was reasonably foreseeable (to use the Canadian legal parlance). But once death comes to be viewed as a therapeutic option, the therapeutic possibilities become nearly limitless. Death was soon viewed as a therapy for severe disability or for health-related consequences of poverty and loneliness (though often poverty and loneliness are the consequence of the health issues). Soon we were talking about death as a therapy for mental illness. If beauty is in the eye of the beholder, then so is grievous and irremediable suffering. Death inevitably becomes therapeutic option for any form of suffering. Efforts to limit the practice to certain populations (e.g. those with disabilities) are inevitably seen as paternalistic and discriminatory. 

There has been self-deception about the reasons justifying legalization of assisted death. Before legalization, advocates decry the uncontrolled physical suffering associated with the dying process and claim that prohibiting assisted death dehumanizes patients and leaves them in agony. Once legalized, it rapidly becomes clear that this therapy is not for physical suffering but rather for existential suffering: the loss of autonomy, the sense of being a burden, the despair of seeing any point in going on with life. The desire for death reflects a crisis of meaning. We deceived ourselves into thinking that assisted death is a medical therapy for a medical problem, when in fact it is an existential therapy for a spiritual problem. 

We have also deceived ourselves by claiming to know whether some patients are better off dead, when in fact we have no idea what it's like to be dead. The utilitarian calculus underpinning the logic of assisted death relies on the presumption that we know what it is like before we die in comparison to what it is like after we die. In general, the unstated assumption is that there is nothing after death. This is perhaps why the practice is generally promoted by atheists and opposed by theists. But in my experience, it is very rare for people to address this question explicitly. They prefer to let the question of existence beyond death lie dormant, untouched. To think that physicians qua physicians have any expertise on or authority on the question of what it’s like to be dead, or that such medicine can at all comport with a scientific evidence-based approach to medical decision-making, is a profound self-deception. 

Finally, we deceive ourselves when we pretend that ending people’s lives at their voluntary request is all about respecting personal autonomy. People seek death when they can see no other way forward with life—they are subject to the constraints of their circumstances, finances, support networks, and even internal spiritual resources. We are not nearly so autonomous as we wish to think. And in the end, the patient does not choose whether to die; the doctor chooses whether the patient should die. The patient requests, the doctor decides. Recent new stories have made clear the challenges for practitioners of euthanasia to pick and choose who should die among their patients. In Canada, you can have death, but only if your doctor agrees that your life is not worth living. However much these doctors might purport to act from compassion, one cannot help see a connection to Nazi physicians labelling the unwanted as “Lebensunwortes leben”—life unworthy of life. In adopting assisted death, we cannot avoid dehumanizing ourselves. Death with dignity is a deception. 

These many acts of self-deception in relation to physician-assisted death should not surprise us, for the practice is intrinsically self-deceptive. It claims to be motivated by the value of the patient; it claims to promote the dignity of the patient; it claims to respect the autonomy of the patient. In fact, it directly contravenes all three of those goods. 

It degrades the value of the patient by accepting that it doesn't matter whether or not the patient exists.  

It denies the dignity of the patient by treating the patient as a mere means to an end—the sufferer is ended in order to end the suffering. 

 It destroys the autonomy of the patient because it takes away autonomy. The patient might autonomously express a desire for death, but the act of rendering someone dead does not enhance their autonomy; it obliterates it. 

Yet the need for self-deception represents the fatal weakness of this practice. In time, truth will win over falsehood, light over darkness, wisdom over folly. So let us ever cling to the truth, and faithfully continue to speak the truth in love to the dying and the living. Truth overcomes pressure. The truth will set us free. 

Article
Books
Culture
Morality
Sin
7 min read

After the Salt Path revelations I’m liking it even more

We edit our own reality by the stories we tell ourselves

Roger is a Baptist minister, author and Senior Research Fellow at Spurgeon’s College in London. 

A newspaper front page shows its title and a falling sea bird
How The Observer broke the story.

The Observer held nothing back in its exposé headline:

“The real Salt Path: how a blockbuster book and film were spun from lies, deceit and desperation”

The truth behind the summer’s feel-good movie and the reputation of author Raynor Winn lie in tatters, shredded by the revelations unearthed by relentless investigative journalism.

The uplifting story of how a couple face financial ruin, homelessness and a terminal illness by walking the South West Coast Path has been an inspiration for many who’ve either read the book or seen the film, or both. The story works because it reflects back to us the life we know, the lives we live. And when you add the seaside of Somerset, Devon, Cornwall and Dorset, what’s not to love?

But now it needs to be seen in an altogether different light.

The article beneath the headline was thoroughly researched, carefully constructed and uncompromising in the allegations implied by the discoveries, observations and commentary of its narrative.

“… not her real name”

“… she was a thief … embezzled the money”

“… arrested and interviewed by the police”

“… five county court judgements”

“… they owned land in France”

“… nine neurologists … were sceptical”

Point by point the back story of the Salt Path is pulled apart.

First, Raynor and Moth Winn are not the “real”, “legal” names of Sally and Tim Walker.

Second, The Observer uncovered that the couple had money troubles for reasons other than the failed business investment they had claimed. Rather, as a part-time bookkeeper for an estate agent and property surveyor, Sally was accused of syphoning off £64,000 from the company’s accounts. Concerning which, it was reported that she was arrested and interviewed by the police.

Third, it was mounting debts from settling the matter with her former employer, alongside other debts, that actually led to the repossession of their home and their resulting homelessness. Not the failed business venture.

Fourth, they weren’t actually homeless as they owned a property in France, near Bordeaux. While it was in a state of disrepair and not habitable, they had previously stayed on site in a caravan.

And then finally, in a revelation that undermined the very heart of the story of their journey together, medical experts observed that it was extremely doubtful that Moth had suffered from corticobasal degeneration (CBD) for 18 years. The journalist had consulted nine neurologists, and this was the reported consensus. Not only were Moth’s presenting symptoms not what were expected, the normal life expectancy with the condition was tragically short at six to eight years.

Pulling the various strands of its investigation together The Observer thumps the tub about the importance of ‘truth’. It is not acceptable to be mis-sold an idea of truth where important passages of the book are invented. There are both “… sins of omission and commission”:

“The story, no doubt, has elements of truth, but it also misrepresents who they were, how they started out on their journey and the financial circumstances that provided the backdrop.”

However, life is complicated and there are always two sides to a story.

In a response posted to her website Raynor Winn answers each of the accusations in turn. Amid the storm of vitriol and threat unleashed online by the article, she protests that, “… [it] is grotesquely unfair, highly misleading and seeks to systematically pick apart my life.”

Most distressing has been how Moth has been traumatised by the suggestion his diagnosis was made up. Along with her online statement Winn has posted appropriately redacted letters from the neurologists treating Moth that confirm his diagnosis and the narrative of the book.

As for the charges of embezzlement, she does concede that there were difficulties with a former employer. Allegations were made to the police, and she was questioned about them. However, no charges were brought, and a settlement was reached that included her paying back money on a “non-admissions basis”.

“Any mistakes I made during the years in that office, I deeply regret, and I am truly sorry.” Raynor Winn

This, however, was not the failed business deal that lay behind their financial difficulties and which triggered their homelessness and the Salt Path story.

Winn reports that the property in France is an “uninhabitable ruin in a bramble patch” with its own, unrelated, back story. When they did explore selling it at the height of their difficulties, a local French agent valued it as virtually worthless and saw marketing it as pointless.

Ultimately, they chose not to declare themselves bankrupt and simply wipe out their debts. Rather, they made an agreement with their creditors for minimal repayments. The success of the book has enabled all their debts to be cleared.

Which leaves the implicit accusation of not being who they said they were, of hiding behind pseudonyms and not owning their “real”, “legal” names. She explains that the reasons Sally Ann and Tim Walker are Raynor and Moth Winn is really quite straightforward.

In the early years of their relationship she told Moth how much she disliked being called Sally Ann and would have preferred the family name, Raynor. Moth called her Ray from that point on. Winn is her maiden name. As for Moth, well his name is Timothy, get it? Friends and family use the names interchangeably, Sal/Ray, Tim/Moth.

Having read the book and seen the film earlier this summer I was particularly taken with The Salt Path. The humanity of their story, the journey they’d been on and the insights to a life well-lived that it offered.

Goodness, which one of us has never made a mistake, a bad call, or a wrong choice, “through weakness, through ignorance or through our own deliberate fault”?

When The Observer’s bombshell broke my heart fell. Moral high horses were being mounted and outrage expressed. Raynor Winn was being cancelled, literally cancelled.

She pulled out of her forthcoming Saltlines tour, which would have seen her perform readings from her books alongside the music of the Gigspanner Big Band during a string of UK dates. There were also calls for Penguin to cancel her next book, On Winter Hill, set for publication in October.

But do you know what? On reflection, after the revelations about the Salt Path story I’m liking it even more. And for exactly the same reasons I liked it before. Because it reflects back to us the life we know, the lives we live.

For a start, life is messy. Sometimes it’s even murky, full of misunderstanding, misinterpretation and constructed narratives. Goodness, which one of us has never made a mistake, a bad call, or a wrong choice, “through weakness, through ignorance or through our own deliberate fault”? Skeletons and cupboards come to mind.

Then, on the back of that, we all fashion the story of our lives. Whether it’s curating our online presence with the images we post to social media, or the anecdotes we share and the face we present to those who are part of our day-to-day lives. The pull is always towards a version that shows us in the best light.

In fact, it can even go right down to the stories we tell about ourselves, to ourselves. The interpretation of what has happened to us and why. Interpreting how much of our experience is down to what has been done to us or is the fruit of our own responsibility.

Now, I may not want to go as far as University of Sussex Professor of Neuroscience, Anil Seth, whose books, articles and Ted Talks see us living in a kind of ‘controlled hallucination’. An interpreted version of reality constructed and calibrated by our brains out of our experience. But there is no doubt in my mind that we edit our own version of reality by the stories we tell ourselves and each other.

This is how things are. This is what it means to be human. Some bits are edited in, others edited out. Some experiences we can interpret in one way, while others might view them very differently from where they stand.

When we feel the temptation to write someone off because of what they’ve done we do well to reflect on our own experience. Then we may well be grateful that we haven’t been cancelled because of our past indiscretions.  As the old saying goes, “There, but for the grace of God, go I.”

I’m reminded of how Jesus handled himself is such circumstances. When a self-righteous crowd were swiftly wanting to rush to judgement on a woman’s flawed sexual choices, Jesus encouraged those who were without fault to be the first to act. Slowly they all realised what he was saying and backeddown.

For myself, I have always found the prayer of confession to be profoundly helpful. It keeps us grounded in the reality of our own experience and should caution us about cancelling others and writing them off.

Almighty God, our heavenly Father,

we have sinned against you

and against our neighbour

in thought and word and deed,

through negligence, through weakness,

through our own deliberate fault.

We are truly sorry

and repent of all our sins.

For the sake of your Son Jesus Christ,

who died for us,

forgive us all that is past

and grant that we may serve you in newness of life

to the glory of your name.

Amen.

For our skeletons there is forgiveness.

For what lies ahead, we have the possibilities of starting over.

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