Article

Assisted dying

Care

Culture

Death & life

13 November 2024

8 min read

The deceptive appeal of assisted dying changes medical practice

In Canada the moral ethos of medicine has shifted dramatically.

Ewan Goligher

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.

Molly Worthen on the charismatic leaders of America's cosmic drama

The plots and plotters that hold us spellbound

Nick Jones

Nick is the senior editor of Seen & Unseen.

Viewed from behind, Trump raises a fist.

Trump on the stump.

White House via Wikimedia Commons.

What happens when Americans lose faith in their religious institutions—and politicians fill the void? In Spellbound: How Charisma Shaped American History from the Puritans to Donald Trump, Molly Worthen sweeping history helps us understand the forces that create leaders and hold their followers captive.

Everyone feels it. Cultural and political life in America has become unrecognizable and strange. Firebrands and would-be sages have taken the place of reasonable and responsible leaders. Nuanced debates have given way to the smug confidence of yard signs. Worthen asks just how did we get here?

Worthen, a historian argues that we will understand the present moment if we learn the story of charisma in America. From the Puritans and Andrew Jackson to Black nationalists and Donald Trump, the saga of American charisma stars figures who possess a dangerous and alluring power to move crowds. They invite followers into a cosmic drama that fulfils hopes and rectifies grievances—and these charismatic leaders insist that they alone plot the way.

Author and historian Tom Holland loved this book.

“The great story of charisma in American history, from the Massachusetts Bay Colony to MAGA, has never been more thrillingly told, never more learnedly explicated.”

In this extract, entitled Plotlines, Worthen introduces her four categories of charismatic leader: Prophets. Conquerors, Agitators, and Gurus.

Plotlines

Over the past several years, whenever I told friends or family that I was writing a book about charisma, they responded with a reasonable question. Which charismatic figures would I include? They peppered me with suggestions: What about Elvis Presley, or Dolly Parton? Michael Jordan or Muhammad Ali? Surely I had to say something about Taylor Swift, right?

None of these fascinating people appears in this book. As you read it, you will probably think of a dozen others whom you wish I had included, and I’m sure you’ll have a point. I have mostly stuck to individuals who worked to build a movement in organized religion or politics, rather than musicians, artists, or athletes. Even within the spheres of religion and politics, I’ve been selective in order to craft a manageable story and bring into focus the patterns and transformations of charismatic leadership over the course of American history.

Sometimes this is an inspiring story, because charismatic leaders often turn up—and people decide to follow—out of a desperate response to alienation and injustice. People in anguish seek a savior. Yet charisma has no fixed moral standing. It can carve a path to freedom or to enslavement; it can lead people to embrace the rule of law or to sneer at it. Charisma causes problems for democracy as well as for authoritarian regimes. Without a sustained analysis of charisma over the long haul of American history since European settlement began, we are doomed to bumble along, blandly observing that ordinary people declare many allegiances that seem to contradict their own material interests and sabotage democracy—but never understanding why.

Over the past four centuries, five types of charismatic leaders have surged to dominance, each offering a variation on the great paradox, a different way for followers to hand over control while feeling liberated. I use these categories both to classify leaders and their movements, and to chart historical change: each type reacts to the type that came before, and responds to the pressures and anxieties of its own era. Like all typologies, this one maps imperfectly onto real people. Almost no one is a “pure” example of these categories, and some leaders are interesting precisely because they react against their age’s dominant type. But these categories have compelled even leaders who defied easy labels—that’s most of them—to respond to the ascendant charismatic style of their age.

The Prophets take us from the end of the Middle Ages into something beginning to resemble our own world. They drew on ancient patterns of contact with the divine to challenge authorities and captivate followers with the terror and ecstasy of God’s presence. They hewed close to tradition, operating in a time when Old World strictures still constrained life in the New World rather tightly. But some used those traditions to undermine reigning institutions, whether by violent rebellion or illicit gatherings—and so provoked a backlash. If the Prophets conceived of freedom in terms of divine salvation, they often harnessed mystical power for this-worldly ends. Usually this meant dismantling any structure that stood in God’s way.

The Prophets were, essentially, destroyers. In their wake they provoked an age of builders.

The Conquerors rose to prominence in the early nineteenth century—an age of mythology, mass media, and frontier enthusiasm in the European American imagination. They swung away from the age of the Prophets, who had so much to say about how powerless humans are.

Some of the Conquerors wielded military power, but all of them pursued what we might call metaphysical conquest. They fought to control spiritual forces. As the predestinarian Puritanism of earlier generations lost its appeal, more people placed an almost fundamentalist faith in the power of free will. It was tempting to think of spiritual forces—perhaps even the Holy Spirit— as a kind of technology, ready for manipulation. The stakes in these campaigns were high at a time when new advances in science impinged on everyday life. Waves of immigration made the country more religiously and ethnically diverse. Americans felt both freer and yet more confined than ever before.

The Agitators gained sway at the turn of the twentieth century, protesting modernity as a raw deal and democracy as tyranny in disguise. The Conquerors had, overall, expanded government authority over Americans’ lives and advanced a golden idea of progress. Now the pendulum swung back toward calls for destruction. The Agitators found a market for attacking the state and denouncing so-called progress as a lie. They defined themselves as outsiders whether they were or not, and discovered that gaining material power does not mean that one must stop telling a story of exile and affliction. This proved to be an important lesson in an age of world war and economic disaster: global crises have a way of transfiguring an outcast dissenter into a credible threat tot he standing order. Meanwhile, Christians grew wilder in their displays of New Testament charisma—because, paradoxically, it was easier to grapple with what Max Weber called the “iron cage” of modernity by embracing ever more outlandish signs of divine power.

The Experts were, on the face of things, the Agitators’ opposite in charismatic style. They were builders. In the wake of World War II, they capitalized on a backlash against the nightmare years of fascist demagogues, embraced the zenith of traditional institutions’ authority across Western culture and politics, and nurtured Americans’ faith in the power of technology and bureaucracy to solve large-scale problems.

They claimed the mantle of reason and procedure and did their best to relegate the political or religious clout of charisma to the distant past or primitive cultures.

But in fact, the three decades after World War II witnessed an explosion of religious revival in America—led by Christians who spoke in tongues, looked for the end times, and claimed to heal through the power of the Spirit. Even in the domain of credentialed and supposedly secular healing, the line between medicine and spirituality grew fuzzier. These years were the Experts’ apogee of cultural prestige, but Americans’ long- standing ambivalence about intellectual elites persisted. The most successful leaders capitalized on those mixed feelings. They nursed the tension between the Cold War celebration of science and freedom and, on the other hand, the lurking sense that technological leaps obscured eternal truths and needed the organizing power of a good story.

By the end of the twentieth century, as Americans lost faith in established media, churches, government, and nearly every other bulwark of modern society, the destructive strain of charismatic leadership re-surfaced in the form of the Gurus: preachers of self-actualization and get-enlightened-quick schemes, promoting God’s new temp job as personal assistant. Old-fashioned Pentecostal revival persisted too, but its leaders struggled to prevent the culture wars from capturing the Holy Spirit.

The Gurus looked, at first glance, like the Prophets and the Agitators. But in the generations since those earlier eras, it had become harder to pay obeisance to tradition—which was just fine, since the erosion of institutions had weakened traditions anyway, and opened a path for Gurus to achieve more influence than their destructive predecessors. Religious and philosophical tradition, in the hands of the Gurus, was no longer a firm guide but a palette for painting illusions of independence. Sometimes they used it to depict a new reality impervious to fact-checkers.

“Guru,” which means “remover of darkness” in Sanskrit, was originally a religious term. But in the third decade of the twenty-first century, the most prominent guru in the country was a businessman named Donald Trump. Trump was not, personally, a paragon of conventional religious devotion. Yet his political career depended on a hunger among his most dedicated supporters that can only be called spiritual. Like so many relationships between charismatic leaders and their followers, it stumped and angered those on the outside. Against the backdrop of the American charismatic tradition, however, his success makes perfect sense.

How, then, did early modern mystics and Puritan heretics who heard the voice of the Holy Spirit give way to devotees at a modern presidential rally, jostling toward the candidate iPhone-first, praying for a selfie? By the early twenty-first century, most religious institutions in the West had declined into husks of their former authority—at least by the usual measures. Today commentators turn more than ever to materialist explanations for political dysfunction, polarization, and the culture’s general crisis of confidence. They cite growing social inequality, impassable disagreements on policy, persistent racism and xenophobia, evil automated forces lurking on the internet. All true—yet all insufficient accounts. If we define the religious impulse as a hunger for transcendent meaning and a reflex to worship, then it is a human instinct only slightly less basic than the need for food and shelter, and Americans are no less religious than they have ever been. They will always find a way to satisfy these desires, even if charisma carries them down strange and costly paths.

Spellbound: How Charisma Shaped American History from the Puritans to Donald Trump, Penguin Random House, 2025.