Living with euthanasia: the ethical imperative of providing alternatives

If, like me, you argued that legalising euthanasia was a very dangerous and unwise idea, you lost the battle to prevent its legalisation in Canada as the euphemistically labelled “Medical Assistance in Dying” (or MAiD) law, and, most recently, in all the Australian states as the “Voluntary Assisted Dying” (or VAD) laws.

These ordinary sounding acronyms are neither neutral nor accidental. They suppress our moral intuitions about what these interventions involve: namely, physicians, and, in Canada and some Australian states, nurse practitioners, intentionally inflicting death on their patients – stated more bluntly, killing them. That results in the normalisation of euthanasia.

I will use the word “euthanasia” for both MAiD and VAD, and, except where otherwise indicated, both euthanasia strictly so-called (i.e. a lethal injection) and physician-assisted suicide (in which the physician provides the patient with a lethal medication to self-administer). Normalisation has occurred at “warp speed” in Canada, but it is too early to assess that phenomenon in Australia. Euthanasia becomes just another way to die, as the Canadian statistics demonstrate so powerfully.

Logical and practical ‘slippery slopes’

The arguments against legalizing euthanasia include the unavoidable “logical” and “practical” slippery slopes that result. Experience shows that once legalized, euthanasia very quickly becomes normalized and both the “logical slippery slope” (i.e. the major expansion of who may have access, and on what conditions, and in which circumstances) and the “practical slippery” slope (i.e. failure to comply with the law in administering euthanasia) are unavoidable.

The logical slippery slope is dramatically evidenced in the implementation of MAiD in Canada and the practical slippery slope in the Flanders region of Belgium. In less than four years, Canada moved from relatively restrictive initial limitations on MAiD to some people speaking of going to court to argue that there is a right to euthanasia on demand – in effect, a right to die. The Canadian Parliament repealed the need for “death to be reasonably foreseeable” because a Quebec court ruled that this requirement breached persons’ constitutional rights to “life, liberty and security of the person,” as well as “equality rights.” The court held that it constituted wrongful discrimination insofar as people who were terminally ill could have access to euthanasia while those who were not terminally ill, even though they fulfilled all the other requirements for access, could not. This is an unusual ruling in that people without a required disability are seen as the victims of discrimination – based on the absence of a disability rather than the presence of a disability.

Euthanasia by advance directives (often referred to as “living wills”) that give health care instructions in advance for a future time when the person will lack the capacity to do so (e.g. instructions given by people with early dementia while they are still mentally competent) are under consideration by a Canadian Parliamentary committee. This committee is also considering euthanasia for children. The MAiD law has been changed, but not yet implemented, to make euthanasia available for people with mental illness, who are not physically ill.

Dr Guy Robert, the Secretary-General of the College of Physicians and Surgeons of Quebec, the province’s medical licensing authority, was a prominent advocate of legalizing euthanasia. He strongly supported euthanasia as medical treatment, arguing that it would be necessary only in very rare cases. At one conference, he replied to my prediction that we would not be able to control euthanasia once it was legalised, by contending that, at most, there would not be more than 100 deaths per annum in Quebec and never more than 200. When Dr. Robert saw the initial numbers for MAiD deaths in Quebec reported, he was shocked and proclaimed, “This is not medical treatment, but state authorised suicide and medicine should have no role in implementing it” [translation]. He described the stunningly rapid normalization of MAiD in the province as “La mort à la carte.” “Here’s your menu for ways to die, choose which you prefer” [translation].

My understanding is that he still supports legalised euthanasia, although I wonder whether the very recent report that Quebec has the highest rate of euthanasia deaths in the world (per total number of deaths in the province) might have made him reconsider. I had a strong urge on seeing the 2021 MAiD statistics, below, to say to him, “I told you so.”

It merits noting that characterising euthanasia as “medical treatment” or just “health care” is a powerful strategy in both normalising it and expanding its use. The “medical treatment” designation is used to argue that physicians have no right to refuse to provide MAiD to “qualified” candidates, even on the grounds of the provider’s ethical objection or right to freedom of conscience. The pro-euthanasia claim is that physicians have duties to provide all approved, medically indicated treatment.

Reports that MAiD has been administered in a Winnipeg United Church accompanied by a “Euthanasia Prayer” and in some funeral parlours could be seen as undermining the claim that it is medical treatment. The “health care” designation of MAiD is employed as a way to argue that all Canadians have a right to health care, which includes MAiD.

A contrary trend has increasing numbers of doctors arguing that MAiD has no place in medicine and is destructive of medicine’s ethic and ethos. This trend is especially prominent among psychiatrists facing the prospect of MAiD being allowed for patients with serious mental illness – but no physical illness. As American psychiatrist Dr Mark Komrad pithily said, “This is to convert the role of psychiatrists from one of preventing suicide to one of providing it.” A particular concern of psychiatrists is their freedom – or, as some argue, even their obligation – to suggest to mentally-ill patients that euthanasia, especially physician-assisted suicide, is a treatment option, even when the patient has not raised this subject.

Some jurisdictions, for example, the Australian state of Victoria, have included so-called “gag clauses” in their euthanasia legislation to prohibit the healthcare professional from doing this. Instead, the patient must be the one to introduce the topic.

According to the most recent Health Canada report, the official death toll from MAiD to the end of 2021 was 31,664 — and that is almost certainly an underestimate. 3.3 percent of all deaths in Canada were by MAiD. The number of deaths increased by 32.4 percent in 2021 compared with 2020. After the law was changed to delete the requirement that death be reasonably foreseeable, 2.2 percent of MAiD deaths were patients whose deaths were not reasonably foreseeable. In at least 1,740 MAiD deaths, the people who were euthanized gave loneliness and isolation as reasons for wanting euthanasia.

In short, euthanasia cannot be contained once it is legalized, because once we step over the clear line that we must not intentionally kill another human being, there is no logical stopping point.

Unfortunately, I predict that we will see the same rapid expansion of VAD in Australia as has occurred in Canada with respect to MAiD. One reason this expansion might not be as great is that in some Australian states (Victoria, Queensland and South Australia) but not others (New South Wales, Western Australia and Tasmania), “euthanasia” (a lethal injection) is restricted to people who are unable to undertake “assisted suicide” (a physician prescribes a lethal substance, which the person self-administers). That requirement might mean that it will be less used in the states in which it applies. This requirement does not apply in Canada, and “[as] of April 30, 2021 there has been 7,549 reported assisted deaths in Ontario since legalization of MAiD [in June 2016]. 7,547 were euthanasia deaths (lethal injection) and 2 were assisted suicide deaths (lethal prescriptions)” (Schadenberg, 2021).

What might this enormous discrepancy in numbers tell us? At the very least, it requires in-depth research. Researchers could investigate the relatively low total numbers of physician-assisted suicide cases in Oregon, in comparison with Canada’s MAiD death toll, in the over 25 years since assisted suicide, but not euthanasia, was legalised in that state.

The practical slippery slope (namely, that once euthanasia is legalized. it is provided not in accordance with the law) is well documented. In one study, 27 percent of Belgium doctors surveyed, who had provided euthanasia, had done so not in accordance with the law. This is probably an underestimate, as to admit it leaves them open to criminal prosecution.

What does this mean for people, who oppose euthanasia and believe that it is an unwise and dangerous social and health policy?

We should not give up trying to have the ways in which people choose to live the final period of their lives (what MAiD/VAD supporters call “end-of-life choices”) be the most ethical ones. And we should persevere in giving people reasons not to choose euthanasia.

In fact, we have more work to do than ever now that euthanasia is legal. That work must offer people alternatives, which they will want to choose instead of euthanasia. To understand what we need to do to achieve that, we need to know the nature of the challenges we are facing, because “good facts are essential for good ethics” and “good ethics are essential for good law.”

Here are some matters we need to keep in mind.

We must balance concern and respect for individuals with protecting the “common good.” In making decisions about euthanasia, we must take into account the ensuing damage to others (including future generations and vulnerable people), as well as damage to important shared societal values, and not only what individuals want. As pointed out regarding Covid, “our individual flourishing is bound up in collective well-being.” Euthanasia will seriously harm our collective well-being.

We can learn from our First Nations fellow citizens. In Australia, decision-makers in the Aboriginal culture look beyond the immediate impact in the present of the decisions they take by considering likely future consequences through “collective human imagination” and seeking wisdom from the past through “collective human memory.” They also consider protection of “the mob,” not just of individuals. We should redefine autonomy as “relational autonomy,” a feminist concept. How we view what it means to be human affects our decisions. For instance, we are social beings, which means that our links to others must be protected and not laid waste. That requires thinking beyond just upholding a right to individual autonomy.

Dying people need compassionate accompaniment, not a lethal injection. Even many of those who have requested euthanasia change their minds when given good palliative care. Such accompaniment takes time, and we see ourselves as “time poor.” Euthanasia is a time compressor. We need to ask what is the impact of “time-compression” on how we die? Are we are not prepared to watch and wait in order to accompany the dying person? Has radical individualism blinded us to the importance of relationships for humans? Have we become “human doings,” rather than human beings? Some experiences cannot be time-compressed without destroying their essential essence: dying in relationship is one of them.

Therefore, it is an ethical imperative for each of us, for our health care system, and for our governments to ensure that high quality palliative care is readily available for all who need and could benefit from it. That is required – not just to act ethically, but also in order to obtain an informed consent to euthanasia (which is a legal requirement). People must be offered all reasonably indicated treatment options if their consent to the one they choose, including euthanasia, is to be legally valid – and for its administration to be ethical. We must support healthcare professionals caring for dying people. Palliative care is an emotionally stressful branch of medicine.

We need to ask why people ask for euthanasia and address those reasons. They include: loss of independence, loss of dignity, feeling like a burden on others, loneliness, isolation, loss of purpose and meaning in life, hopelessness, demoralization – all of which are matters we can address. Austrian psychiatrist Viktor Frankl, when asked how he helped people survive the Nazi concentration camps, replied, quoting Nietzsche: “Give people a ‘why’ to live and they can find a ‘how.’” People need hope.

We must provide better care for people with disabilities – both to protect them from coercion or persuasion to accept euthanasia and also to ensure that they do not feel that their present life circumstances are so unbearable that euthanasia is their only option. We must also ask how we can limit the use or extension of legalized euthanasia. To reduce to the minimum the number of people requesting euthanasia, we must understand the reasons for their requests, find ways to make those reasons loom less large, and provide alternatives they will choose instead of euthanasia.

The necessary considerations include:

  • We must ask what is required to provide easy access to high quality palliative care for everyone who needs it. To make this a reality requires adequately funding such care.
  • We should identify the ways in which we can prevent further extensions of the eligibility criteria defining the people who may have access to euthanasia and the reduction or abolition of safeguards which restrict access to it.
  • We must ensure compliance with the law allowing euthanasia and establish the well-functioning institutions necessary to achieve this in practice – not just on paper.
  • We should identify and articulate, especially to the public, the damage euthanasia does to our shared fundamental societal values – most importantly, the value of respect for life at both individual and societal levels. Euthanasia unavoidably sends a message of not caring for vulnerable or fragile people. The “ethical tone” of a society is not set by how it treats its most privileged, powerful, or wealthy members, but by how it treats its weakest, most in need, most vulnerable ones.
  • We must articulate and fulfil our obligations to future generations, especially our responsibility not to leave them a society in which no reasonable person would want to live – including one in which respect for the life of each individual is no longer a fundamental value.
  • We must tell stories of real-life examples of the abuse of euthanasia that will cause people to rethink their acceptance of it. For example, a Canadian man facing homelessness, who qualified for euthanasia, said, when interviewed, that he did not want to die but even more strongly he did not want to be homeless. Likewise, we can bring to the public’s attention a proposal to carry out euthanasia by removal of a person’s vital organs for transplant, as the means of inflicting death. The organs would be more viable. This would be euthanasia by organ removal, as compared with organ removal after euthanasia.* Most people, including many of those who support euthanasia, find this a horrifying proposal. We can gain important insights by exploring why they have this instinctive reaction.

Finally, is there anything we can do about the MAiD/VAD legislation?

For hope regarding the future in the face of the current reality of euthanasia, we can look for precedents in both Canada and Australia for abolishing legislation that was once thought to be necessary, ethical, and beneficial but ended up doing great harm. Later revisited with wiser eyes, such legislation was ultimately repealed.

The “Sexual Sterilization Acts” of Alberta (1928) and British Columbia (1933), were part of the eugenics movement in North America, and they were repealed only in the early 1970s. They allowed institutionalised people, including children, to be sexually sterilised based on an administrative decision – and without the consent of the person, or, if they lacked capacity to provide consent, even their guardian.

An Australian example – and it is a chilling analogy to the VAD laws – is the legislation that facilitated the removal of Aboriginal children from their families. The Australian state laws, from 1869 onwards, that authorized separation of First Nations children from their families gave us “the Stolen Generations.” Like euthanasia legislation, laws were passed in each of the Australian states. They authorized the separation of indigenous children from their families in order to assimilate them into the dominant white Anglo-Celtic culture. Like the VAD Acts, these laws had euphemistic titles. For example, compare the “Victorian Aboriginal Protection Act 1869” with the innocuous sounding Tasmanian VAD Act: “End-of-Life Choices (Voluntary Assisted Dying) Act.” The acronym MAiD (Medical Aid in Dying) has this same characteristic: using an acronym desensitises us to what is really involved. (Imagine this title instead: “An Act to Legalise Physicians Killing their Patients.”)

Like the VAD legislation, the first of the “Aboriginal Protection” Acts originated in the state of Victoria. That state, like the province of British Columbia in Canada, tends to be a so-called “progressive values” jurisdiction. Likewise, the 2015 Supreme Court of Canada decision in Carter v. Canada, which resulted in the legalisation of MAiD in Canada, originated in BC – and its capital, Victoria, has recently been described as “the euthanasia capital of Canada.”

As with the VAD Acts, governing structures were established for implementation of the “Aboriginal Protection” laws in both Victoria and New South Wales; but that did not ensure that what those laws allowed was ethical. Both the Aboriginal Protection Acts and the VAD Acts bring to mind an aphorism: “Nowhere are human rights more threatened than when we act purporting to do only good.” In both areas of legislation, the good that we hoped to do blinded us to the risks and harms which were also unavoidably present.

The Victorian Aboriginal Protection Act stated that the government, through the board it established, had the power to arrange the “care, custody and education” of Aboriginal children. Amendments in 1915 to their Aborigines Protection Act 1909 gave the New South Wales Aborigines Protection Board a breathtakingly wide, almost unlimited discretionary power “to remove any Aboriginal child from their family at any time and for any reason.” The last of these so-called “Aboriginal Protection” laws was not repealed until 1969.

Work is not over

In conclusion, even though those who oppose euthanasia, as I do, might have lost the battle against legalizing it, our work is not over. We must now work to prevent its expansion and abuse. For all our sakes – that is, for both those who are dying now and those who are not yet dying, and for our descendants and their future societies – we must kill the pain and suffering of dying people, not the dying people with the pain and suffering. That means we must work to help people to choose life, not death by euthanasia, even though it is now legal in Canada and all Australian states. That will not be easy. On the contrary, it will require resolute dedication and hard work.

*Footnote: Somerville, M. (2019). “Does It Matter How We Die? Ethical and Legal Issues Raised by Combining Euthanasia and Organ Transplantation.” The Linacre Quarterly.

Acknowledgement: I am grateful to my colleague Dr Megan Best for clarifications of Australian state law on VAD.

This article was first published at


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