The Pairodocs have been on a bit about euthanasia recently, but please indulge us. It’s a deep subject - literally life-and-death. Since my first piece on euthanasia (“MAiD”), and then again since Julie’s more recent piece about extending it to the mentally ill, several interesting issues have bubbled up through comments and discussion. I thought these were worth fleshing out. Did someone order MAiD service? What’s in a name? A lot. MAiD used to be a name for someone who cleans your house. And in the same way that a maid can sanitize your bathroom, the term “MAiD” sanitizes suicide. By coining such a clean and optimistic term, euthanasia proponents seized the linguistic high ground. But despite the obfuscatory name, “MAiD” actually means a person committing suicide (or being suicided). This was until very recently considered an extreme act. Perhaps the single most extreme act there is. At worst, suicide is a mortal sin that prevents that individual from being buried on hallowed ground and leaves his soul in purgatory. Now it’s just a medical procedure. Euthanasia is not assisted suicide There is an important distinction between euthanasia and assisted suicide. These terms are often used interchangeably, but are in fact distinct. Euthanasia is passive on behalf of the party being euthanized (with the exception in humans of taking part in the decision to be put down). The hamster that was gasping and suffering was euthanized by a whack from my dad’s shovel before we buried it in our backyard. It wasn’t a case of assisted suicide. Assisted suicide is a human-specific way to end a life, as lesser life forms can’t ask to be killed. Jack Kevorkian never “killed” anyone, he just set it up so the patient could easily kill himself. With assisted suicide, the doctor or nurse might put in an IV and get the meds ready, or provide the pills in a cup by the bedside, but in the end the patient has to push the plunger or swallow the tablets. Assisted suicide, unlike euthanasia, is an active act. Far from being a distinction without a difference, assisted suicide is very different philosophically and practically from euthanasia. A very interesting natural experiment has been underway since California legalized assisted suicide at almost the same time that Canada legalized euthanasia. In California, the doctor puts the suicide meds out for you but you have to take them. In Canada, you just lie there and let the doctor perform a “medical procedure”. And what a difference it makes. Being euthanized in Canada is about 19 times more common than committing assisted suicide in California. The euthanasia slope is more slippery than assisted suicide It’s hard to kill yourself. Atheists might recognize this difficulty as the strong evolutionary urge to live. The religious among us might see it more as a recognition that our life is a gift, and ending it by our own hand is a sin against God. Either way, I can’t tell you the number of people I’ve seen in the ER through the years who had stood on the edge of a cliff, stared down the barrel of a gun, tied a rope in a tree, or looked at the cup full of pills and then changed their mind. They deeply felt that suicide was the wrong choice. But when the patient is a passive recipient of “medical care” as with MAiD, this epiphany cannot happen. It’s easy for “MAiD recipients” to think of themselves as having a medical procedure, whereas it is more clear to the person who is required to swallow a lethal overdose – even if it was put on the nightstand by a doctor – that he is committing suicide. Your right to die is not the same as the state’s obligation to kill you Another distinction that is important, and that was a source of controversy and misunderstanding amongst commenters on various forums, is the difference between arguing to have the “right to die” versus the need to have a program run by the state and funded by the taxpayer that approves, facilitates, and even performs the killing. There is actually a wide difference between these two arguments. The libertarian dream is freedom of choice, not state-administered and funded programs to control and provide those choices. You absolutely have the right to die. You can stop eating and drinking. You can jump off a cliff, shoot yourself in the head, hang yourself, or take pills. Even though I think it is a sin to commit suicide, I can’t stop you in the end even though as a physician - and a human being - I will certainly try to convince you not to. After 27 years in ER, one of “Milburn’s Laws” is “Patients who really want to kill themselves, kill themselves” despite our best efforts to prevent them from doing so. Despite (and some would argue perhaps because of) a proliferation of therapists and counsellors, self-esteem promotion, suicide prevention, “wellness” initiatives and more, suicide rates have increased. In practice, choosing euthanasia is about hopelessness and not the medical condition A number of commenters supported euthanasia in people with terrible physical diseases, but felt that we cross a line when we offer it to depressed patients. But in my experience, people who choose to be euthanized always do so because of hopelessness, whether or not we call that hopelessness “mental illness”. The vast majority of those with cancer, dementia or sore joints want to live their lives out to the fullest. They want to spend time with family and friends, see more sunsets and sunrises, play music, write their life story for their grandkids, clean the junk out of their house, finalize their finances, and more. The ones who want the express checkout lane are the ones who feel they have nothing left to live for. It has been said that “He who has a why to live for can bear almost any how.” So although many commenters on our previous pieces see that euthanizing mentally ill patients has crossed a line, they don’t see that the distinction between hopelessness caused by mental illness and hopelessness caused by physical illness is actually artificial. In my experience, we are already euthanizing depressed people. And, if one agrees that the criteria for “being approved for MAiD” should be that one’s suffering is intolerable, how can we deny euthanasia to those suffering from mental illness, which in my experience causes suffering at least as severe as those with physical diseases. Furthermore, in a system where real care is routinely delayed or even unavailable, providing rapid access to suicide services seems doubly immoral. One of my patients with a neurodegenerative disorder faced an 18 month wait to be reassessed by a neurologist, but could talk to a MAiD assessor within 48 hours. There is no such thing as “necessary suffering” if one believes in suicide Several commenters said that they supported assisted suicide because it prevented “unnecessary suffering”. But “unnecessary” suffering is a tautology for people who believe in suicide. The Buddhists say it best. “Life is Suffering”. If one lives, one suffers. Life is a sexually transmitted disease with a 100% fatality rate. We all die. And we will all suffer before we do. If we believe in preventing unnecessary suffering, the solution to any physical or emotional pain is always clear. Girlfriend breaks up with you? Kill yourself. Wife sleeps around and then leaves you? Kill yourself. Your knees ache every morning for hours? Kill yourself. Every patient I’ve seen choose to be euthanized chose it because of hopelessness, not because of the disease. Well-adjusted people with good relationships, even when they have terrible cancers, ALS or other conditions that cause suffering, want to squeeze every drop out of this precious, short existence that they can. If you have a painful, progressive cancer but could live another 6 months or year with it, why put up with the pain? Why not end it now? That is what MAiD enthusiasts suggest is most rational. And in a strictly rational sense, it is true: why suffer? It is part of the same rationalism that led the Nazi regime to feel virtuous when euthanizing “useless eaters” such as the disabled. They only suffer anyway, and who would want to live like that, after all? Overcoming challenge, pain, and grief makes us who we are We can and do learn to deal with pain. Many people, for instance, will say that they would rather die than be paraplegic or quadriplegic. But it turns out that most paralyzed people learn to live with their injury and find joys in their new life. I have known many people who died of cancer who told me near the end of their life that their time of dying was incredibly meaningful and beautiful. Facing mortality and pain is frightening, but seems to bring appreciation for the beauty and joy in life. How can we objectively regulate something that is inherently subjective? The careful attempts to formulate logical and sensible MAiD regulations resulted in gobbledegook. The original legislation demanded that death be “reasonably foreseeable”, but of course death is not just “reasonably foreseeable”, but inevitable for us all – even a healthy newborn baby. The updated wording only demands that the person have a “grievous and irremediable” medical condition. But any medical condition could be considered “grievous and irremediable” as this is subjective. Most diseases that I deal with in family practice are “irremediable” - Crohn’s disease, emphysema, and arthritis are just 3 examples. Nobody can cure them, so most people will die with them if not of them. “Grievous” is not an objective word, but rather depends on the person’s subjective view of the severity and tolerability of his symptoms. Uncle Joe might weep bitterly over his sore knees while Aunt Mary goes golfing with worse. One can’t make an objective standard for suffering and grief, which are inherently subjective and personal
