MAiD in Canada: A road to hell?

The euphemism of euthanasia

Image Creator: a-poselenov

There is nothing either good or bad but thinking makes it so. - William Shakespeare

By Anonymed (an anonymous Canadian Doctor)

I dislike the term Medical Assistance in Dying (MAiD) for a variety of reasons. For starters, it’s highly euphemistic. We aren’t assisting death anymore than a surgeon assists his patients in removing their abdominal organs. We are given consent to perform a procedure and we alone do the doing. It also feels like the term is intended to obfuscate, since we already have a word for this kind of “assistance”: euthanasia. Perhaps MAiD’s proponents can find some daylight between traditional doctor-directed death and this new iteration, but I can’t. For me, theirs is a distinction without a difference - semantics used to avoid association with assisted dying’s controversial early years (in particular, the trial and subsequent imprisonment of Dr. Jack Kevorkian).

Christopher Hitchens used to say that if you want to know what’s going on beneath the surface of any political issue, always “look to the language.” Everything starts there. In this case, in order to grasp the true significance of MAiD, it is important to consider the terminology that it left behind.  

The most important distinction in the use of the outdated term euthanasia is between what are typically referred to as “active” and “passive” euthanasia. Active euthanasia, where the physician not only provides the means by which a patient ends their life, but actually administers the lethal doses, is akin to modern MAiD. It is this "active" component that the Supreme Court effectively ruled on and which remains illegal in most of the world. 

“Passive” euthanasia is something of a grey area, but is typically taken to mean the withholding of the basic necessities of life (such as food, fluids, ventilatory support) for reasons of compassion (or futility) at the end of life, with the knowledge that this will lead to death. It can also include (as in parts of America) the provision of the means of death while their administration is left up to the patient. 

There are other blurry lines as well. Controlling refractory pain with increasingly high doses of narcotics, to the point where death is hastened, tends to fall under passive euthanasia, even if it sounds decidedly active-like. The practice of palliative sedation - where a continuous sedative regimen is used to provide ongoing comfort to patients as they pass naturally (typically done within days of foreseeable death) sounds like passive euthanasia, but is usually offered under the “palliative care” umbrella where actions to hasten death are traditionally frowned upon. 

Some version of passive euthanasia has been accepted by many bioethicists for decades. But if passive euthanasia can in some circumstances be considered ethically permissible, there has also been a sense (irrespective of the legality) that active euthanasia was crossing a moral line.

In the wake of the 2015 Canadian Supreme Court decision, which permits active euthanasia in certain circumstances, Intelligence² (one of the internet's more high-brow discussion forums) hosted a debate with the motion: “Euthanasia should be legalized.” The arguments put forth highlight the fact that MAiD's proponents and skeptics aren’t just envisioning divergent policy agendas. Where medical ethics are concerned, they’re speaking different languages.

In this case, the "for" panel included famed philosopher Peter Singer, best known for his advocacy for animal rights and against “speciesism” (the tacit assumption that human lives are worth more than those of our animal kingdom kin). His argument, here and elsewhere, is essentially consequentialist in nature.

Simply put, consequentialists care about consequences (it’s in the name) to the general exclusion of intention or motive. In the context of assisted dying, this way of thinking suggests that if I treat someone's anxiety to the point of sedating them, thus ensuring eventual death, this is no different ethically than intentionally administering sufficient sedative to suppress their respiratory drive and bring about death, because the result is the same. This constitutes a rejection of what is called the doctrine of “double effect”, an ethical position endorsed even by some religious authorities that presupposes a moral distinction between doing something with good intent with the knowledge that it can also have a “bad” outcome, and doing that same thing but with the intent to bring about the negative outcome. 

I'm sure there is an unemployed philosophy major out there who will tell me that I'm missing fifty kinds of nuance here, but it appears this is the crux - if there is no difference in outcome between passively and actively doing the same thing, then why make one legal and the other not? 

For me this discounts far too much of human nature. Intentions matter to us in everything - from domestic disputes to war crimes. Perhaps Peter Singer, a supremely intelligent and ethical man, lives in a world we ought to aspire to, but I don't believe it's one that most people inhabit. In the same way that I don't think a panda's fluctuations in consciousness are of a piece with my own (however meager), I don't think intending to kill someone is inconsequentially different from letting them die (or even hastening their death).

The argument of the "for" side is that we are merely disputing semantics, while so much human autonomy is on the line. Those "against", of which (with some caveats) I would count myself a part, would say with little exaggeration that everything morally turns on that distinction. 

It is difficult to gauge how these debates are being absorbed by doctors on the ground, but a recent study of the attitudes of Canadian undergraduates provides some sense of what the future might hold. Published in the Journal of Palliative Care in 2022, the survey asked a cross section of students about their degree of support for MAiD. For those of us wary about where this all goes, the numbers are devastating. The most basic division of the data found 92.9% agreement for providing MAiD to older adults with terminal illness and 74.0% for older adults with severe mental illness. I still find this troubling, but here comes the kicker. The same question was asked about younger patients. While the authors made much of the fact that age was a key determinant of students’ opinion of the matter, it turns out that 77.7% think MAiD should be offered for terminal illness and 59.1% for mental illness even for those with decades of life ahead of them. Am I missing something? Sure, there is less enthusiasm when the patients are younger, but it still looks like a clear majority of our educated young people thinks it reasonable to actively kill otherwise healthy young people if they have poorly controlled mental health.

My concern as a relatively young physician is not simply that “right to die” advocates are winning (by and large, they have won) but that the next generation of Canadian physicians won’t even be having the conversation - that a concern about the ethics of intent and the life-oriented ethos of medicine will be dismissed as antiquated or, worse, won’t be brought up at all. I admit I’m pessimistic, but things are bleak. At the moment, there aren’t really two sides to this issue. There is simply the right to die, and those who would subvert it.  

All of this brings us back to the importance of language. Euthanasia had a history. Its nuances had to be grappled with and this, I would argue, ensured some clarity about what exactly we were asking the medical profession to do. Medical Assistance in Dying sounds like nothing more than a (rather finite) kind of physician bedside manner. It sounds soft - comforting even - and as a result brooks little argument. Was this intentional? If so, would that matter at all?

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Thanks for reading. For more from this author read, Manichean medicine: patient-saint, patient-sinner

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