No, it is not your life to dispose of

What could not be said about the assisted dying debate

Steve Hellyer

Steve is the former vicar of St Matthew's Oxford.

Empty bus seats are lit in dark neon colours.

Vy Tran on Unsplash.

It is 1979. I am aged 23 and have been in great mental and emotional anguish and pain for years. I am on a pointless journey, on Greyhound busses, from the East coast of America to the West, and am presently sitting in a parked bus just outside a city in Arizona; the powerful engine idles as we wait for departure time, giving a gentle to-and-fro rocking motion to the bus. I have not eaten for days, am unspeakably tired of my life, and have made a written list of possible ways to end it.

But not on that list is one possibility I have not previously considered, but which is now before me. As I look out to my right, up into the Arizona desert hills, I realise that here is an option which perfectly fits with my desire, not so much to do away violently with myself, as simply to drift into a passive oblivion; I realise that I could simply rise from my seat right now, get off the bus, stumble off into the desert hills, lie down, and wait to die. I need not shoot or poison myself after all. I know I can do this, and fairly easily; to die will take time, but no matter. No-one knows where I am, no-one will know I am missing, no-one will come looking for me, and probably no-one will find me. It is suddenly an immensely attractive prospect, and I am seconds away from rising up from my seat...

There is one thing, one thing only, that makes me hesitate; it is what other people would call ‘a religious belief’, but to me it is simply a truth.

It is this; I am absolutely sure that there is a God. And suddenly there is something grimly, darkly humorous even, in what I thus believe will follow my death; I will find myself, not in peaceful oblivion, but in the presence of God. I will, as they say, ‘meet my Maker’. And what then will I say to God? I will say: “Apologies: I could not go on, there was no other way out for me”. But what, I reason, if God were then to say: “You are wrong. There was a way forward. Look: you could have stayed on the bus, and had you done so, let me show you how your earthly future would have panned out…” And I will listen, and I will watch, as the film rolls on, showing me an alternative future. But of course, by then it would be too late…

And suddenly, sitting on that bus, in a moment of cold clarity, I realise, with a kind of desolate logic, how I am caught. In a very real sense, my belief in God my Creator means that I am not in fact ‘free’ to dispose of myself; more, that what I refer to so glibly as ‘myself’ is not in fact MY self. The bus ticket in my pocket may be ‘my’ ticket, my rucksack ‘my’ rucksack, but my life is not after all my possession, mine to dispose of; it is a loan, a gift, from a Giver, to Whom I am responsible, answerable…

I remain in my seat. The bus continues its gentle rocking motion a while longer. The driver gives his familiar 1970s Greyhound driver’s recitation, the various admonitions and prohibitions I have heard so many times as I have crossed America, I could give the speech myself (ending with the words ‘and no marijuana’, which always raises a smile) – and the bus pulls out onto the freeway. I look back over my shoulder at the desert hills as they recede, and feel I am leaving more than the desert hills behind; I am still in deep pain, but know I have left a possibility behind me, for good. Months later I will reflect on this moment and realise with a smile that the name of the city where I had put death behind me by not rising was Phoenix.

And so my journey has continued – on, in due time, to a return to England, to a measure of healing, to getting ordained as an Anglican priest, to thirty-four years of Church ministry, to marriage to a very remarkable woman, to fatherhood of two children - and, at some future moment, to my own death: all in God’s time.

How shoddy, shrunken and lonely, is our much vaunted and trumpeted vision of the autonomous individual.

The word ‘God’ was probably used very little, if at all, in the MPs debate on assisted suicide - and this debate has really been about assisted suicide, not ‘assisted dying’, given that people will be given drugs to self-administer. Even the Christian MPs who spoke, did not mention God, as they knew what could be said, and what could not, in order for them to be heard at all. The public arguments for, and against, the legalisation of assisted suicide have almost without exception had to be premised on one agreed assumption, apparently the only one now permissible in a post-Christian, liberal humanist, agnostic/atheist society: the assumption that my life is mine. The arguments used for assisted suicide resolve down to: “It is my life: I should be allowed to decide when to end it”. Most of the arguments used against resolve down to: “Yes, of course, granted, agreed, it is your life: but there may be unintended consequences for others in allowing you to end it, others may feel obliged to end their lives”, etc. At no point could anyone say, as I so passionately would claim: “No, it is not your life to dispose of”; there is now, it seems, no public place for the apostle Paul’s blunt statement in his letter to the Church in Corinth: ‘You are not your own.’

Yet this is now one of the most fundamental beliefs of ‘my’ life: and I have found it to be totally liberating and beautiful. I think of those glorious sculptures on the outer walls of Chartres Cathedral, including the representation of the creation of Adam, presented as emerging from the very mind of God. I think of the glory of man and woman made in God’s image as stewards of creation. I think of the extraordinary wonder of the Incarnation, of God embodied in Christ. I think of the sufferings of Christ on the cross; and I think, yes, of course I think, of the sufferings of my fellow men and women and children, and of my own sufferings, and of the call to me to shoulder the burden, both of living, and of dying, in God’s time.

And, alas, I think I also see something of how shrivelled, how wizened in comparison, how shoddy, shrunken and lonely, is our much vaunted and trumpeted vision of the autonomous individual – “my life, my rights, my body, my choice” - in the dominant contemporary Western mindset, eating away steadily like a corrosive acid any wider conception of community and the social institutions that enshrine it, and any sense of a deeper accountability to God.

Where will the current assisted suicide decision ultimately lead? What is the destination? It is difficult to predict, but the signs from other countries who have gone down this road are not good.

But what do I know? Do I have answers to all the questions around assisted suicide? I confess I do not. But one thing has become clearer to me: I am on a very different journey from the one my nation is travelling now.

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.