Not so long ago, the question of physician-assisted death was largely confined to ivory tower debate amongst moral philosophers. Over the last decade it has become an on-the-ground reality affecting an increasing number of patients and families in Canada. When I was in medical school at the University of British Columbia (2003–2007), euthanasia was regarded as something more or less taboo. There was no serious discussion of the idea of deliberately causing a patient’s death. And how quickly that changed. Between 2013 and 2015 a moral sea change swept through Canadian medicine, and those who once would have only timidly suggested that doctors might consider causing death out of “mercy” now vigorously and loudly advocated for it. Ending a patient’s life was no longer unthinkable; suddenly, it was the compassionate, caring thing to do. In short order, assisted death was embraced by the medical establishment in Canada, and every year since its legalization in 2015 an increasing percentage of Canadians have died by means of assisted death. Tragically, Canada has become a world leader in the administration of euthanasia, and those outside the ideological bubble have been shocked and grieved by the stories emerging of people receiving assisted death because of poverty, loneliness, and despair.[1]
The thing is, once death becomes accepted as a definitive remedy for suffering, it starts to seem as if there are many people who might benefit from death. Life is hard. Many of us live with irremediable suffering in some measure, whether that suffering is physical, psychological, or spiritual. Illness and frailty can rob us of our independence, our freedom, our pleasures, and our powers. In the face of such loss, some people experience intense existential suffering; life begins to feel absurd and pointless to them. Death beckons as a tempting way out and they grow impatient for it, determined to have death on their own terms.[2] From this standpoint, those who are willing to end the patient’s life are regarded as empathic moral heroes, dedicated to empowering patients by giving them the death they want. And those who refuse to cause death when it is in their power to do so are said to be cruelly forcing people to suffer. Such is the logic of assisted death, a logic embraced with enthusiasm by some and accepted with quiet reservation by many.
Are there lessons from the Canadian experience that could inform our efforts to understand and promote a Christian vision of bioethics in medical and nursing care for patients at or near the end of life? Allow me to suggest two.
First, we need to become skilled at showing that the sanctity of the patient’s life is rooted in nature, not merely in tradition. At the heart of the debate over physician-assisted death is a simple question—why and when is it wrong to kill? In our ahistorical cultural moment, the traditional prohibition on killing in medicine was easily overthrown. The radically atomistic vision of the human person recognized by Charles Taylor and others taught us to think of ourselves as the entire owner of our persons; the wrongness of killing therefore hinged only on our own desire to remain alive. The right to life could easily be waived if we wanted someone to end us. The force of tradition, both in society and in medicine, carried little weight against this logic because the traditional prohibition on killing no longer seemed comprehensible. And in all fairness, tradition for tradition’s sake is thin ice for moral claims. Only if we can show that the traditional position reflects a wise discernment of the way God made the world can we hope to rationally sustain the tradition.
Appeals grounded in nature carry weight because, irrespective of our tradition, we all inhabit the world God made. There are therefore truths about humanity that we “can’t not know”[3] regardless of our religious beliefs (or lack thereof), and these truths establish some basic common ground for moral deliberation. Refusal to recognize these truths is what differentiates folly from wisdom. This basic knowledge of the good is not entirely lost in the Fall, even if fallen man is quick to suppress and distort this knowledge. That the “requirements of the law are written on their hearts” (Rom 2:15, NIV) serves only to make fallen man culpable before God. To this knowledge we may and must appeal, praying that God’s Spirit would grant the common grace necessary to prevent our friends and neighbours from giving themselves completely over to folly. Even if valid rational arguments rooted in truths that we “can’t not know” fail to persuade, they serve to vindicate the wisdom of our convictions.
What then is it that we cannot not know about human persons? We know in our bones that people matter, that they ought to be valued in accordance with their true value. Even the proponents of physician-assisted death root their arguments in human dignity and respect (so-called) for human persons. Yet their notions of dignity and respect are easily shown to be distortions of true human value. If people matter, then it is good that they exist. And if it is good that they exist, then we ought not to end them. Causing a patient’s death doesn’t honor the patient’s value, it denies their value. Assisted death treats people as a mere means to an end, ending them for the “greater good” of ending suffering. Assisted death is thus deeply demeaning. It is an act of desecration. Paul Ramsey rightly spoke of “the indignity of ‘death with dignity.’”[4]
It’s striking to observe that very few Canadian physicians are willing to actually perform euthanasia. Most will “make an effective referral to a willing provider” (in the words of the physicians’ regulatory body in Ontario). “I can’t do it, but I know someone who will,” they say. But this is not the “can’t” of technical inability. Causing death is easy. Any MD can administer midazolam, propofol, rocuronium, and lidocaine in toxic doses. Rather it is the “can’t” of a constrained conscience; deep down they recognize the sacredness of the patient before them.
That the sanctity of persons is rooted in nature, in the way God made the world, may give us confidence that we are in the right, and strengthen our resolve to show others the way of wisdom.
Second, we need to defend the proper function of conscience in medical practice. Freedom of conscience is not the freedom to willfully reject our professional obligations; rather, it is the freedom to object to practices that contravene those professional obligations.
Regulators in some provinces tried to force physicians to refer patients to a “willing provider.” Canadian physicians who conscientiously objected to any form of participation including referral sued the Regulators in the name of religious freedom. We lost in court (and on appeal). While the court acknowledged that our constitutional rights were seriously infringed by the requirement to refer, it held that the rights of patients to access “medical care” was paramount.[5] In consequence, many objectors had to modify their practice to limit the chances of receiving requests for assisted death. Some retired early; some stopped practicing palliative care. Trainees sought out areas of practice with less direct patient contact. Primary care was especially affected. While the pressures on objectors have lessened to some extent over time, we remain moral outliers reliant on the good will and toleration of our colleagues to find space for our consciences.
Opposition to freedom of conscience in medicine is often grounded in concerns about physicians “running amok.”[6] Excessive respect for freedom of conscience, it is said, transforms medicine from an ordered and disciplined profession into a chaotic and individualistic practice governed by the personal scruples of the physician rather than the needs of the patient. Should a patient’s access to care depend on the subjective preferences of the physician? Such concerns raise seemingly legitimate questions about the role of individual conscience in medicine. By framing conscience as an issue prioritizing the physician’s personal sense of integrity and psychological well-being above the good of the patient, doctor is pitted against patient in a battle of wills. Respect for conscience becomes medical paternalism at its worst, a doctor’s selfish concern for his own values rather than for the welfare of the patient.
Unfortunately, issues of conscience in medicine are nearly always framed this way in the media.[7] Litigation over conscience issues turns on competing claims of rights of physicians as individual versus the rights of patients. This only reinforces the public perception of conscience in medicine as a matter of selfish concern on the part of very privileged physicians thinking only for their own rights and comfort.
But is there a way to more properly frame conscience in medicine? To be a physician is to profess to heal the sick. The physician devotes himself to the patient’s welfare with respect to bodily healing. Actions that promote healing are good, and actions that hinder healing are to be avoided. To draw on the language of the medievals, the conscience of the physician integrates a commitment to the good (synderesis) with rational judgments as to what actions conform to the good (conscientia) and emotional awareness of the quality of one’s actions.[8] To be faithful to one’s conscience is to be faithful to one’s moral obligations (as one understands them). Framed this way, conscience is essential to medicine, for this internal accountability mechanism is the only true guarantee that the physician’s actions will serve the welfare of the patient. To be a conscientious physician is to be a good physician.
Thus, issues of conscience are really questions about one’s professional moral obligations. Do I have a professional obligation to facilitate the ending of this patient’s life? Is the ending of a patient’s life good, bad, or indifferent? Is ending a patient’s life consistent with the practice of healing? Questions of conscience are not matters of private and arbitrary moral whim. They are tied to the essential nature of medicine. As we deliberate about good medicine, conscience gives us leverage to call on ourselves and others to conform to the practice of good medicine. A well-formed conscience is essential to promoting good medicine. And insofar as good medicine is a common good, society should maintain a high respect for conscience to promote the common good.
This vision of the patient as sacred and of medical practice as intrinsically conscientious is, at present, often lost from view. Beset by an anthropological crisis, medicine—and society more broadly—clings to the notion of person as atomised individual, disembodied, constituted merely by desires, whose fulfillment lies in nothing more than satisfaction of preference.[9] In faithfully and conscientiously devoting ourselves to the practice of healing, and in steadfastly refusing to participate in the deliberate ending of our patients, we bear witness to the intrinsic and incalculable value of the human creatures in our care and give glory to their Maker, the triune God, the source of all value and the end of our being.
References
[1] Alexander Raikin, “No Other Options: Newly Revealed Documents Depict a Canadian Euthanasia Regime That Efficiently Ushers the Vulnerable to a ‘Beautiful’ Death,” The New Atlantis, December 16, 2022. https://www.thenewatlantis.com/publications/no-other-options.
[2] Harvey Max Chochinov, Linda J. Kristjanson, William Breitbart, Susan McClement, Thomas F. Hack, Tom Hassard, and Mike Harlos, “Effect of Dignity Therapy on Distress and End-of-Life Experience in Terminally Ill Patients: A Randomised Controlled Trial,” Lancet Oncology 12, no. 8 (2011): 753–62, https://doi.org/10.1016/s1470-2045(11)70153-x.
[3] J. Budziszewski, What We Can’t Not Know: A Guide (Ignatius Press, 2011).
[4] Paul Ramsey, “The Indignity of ‘Death with Dignity,’” Hastings Center Studies 2, no. 2 (1974): 47–62.
[5] Christian Medical and Dental Society of Canada v. College of Physicians and Surgeons of Ontario, 2019 ONCA 393, https://www.ontariocourts.ca/decisions/2019/2019ONCA0393.htm.
[6] Mark R. Wicclair, “Preventing Conscientious Objection in Medicine from Running Amok: A Defense of Reasonable Accommodation,” Theoretical Medicine and Bioethics 40, no. 6 (2019): 539–64, https://doi.org/10.1007/s11017-019-09514-8; Douglas B. White and Mark Wicclair, “Navigating Clinicians’ Conscience-Based Refusals to Provide Lawful Medical Care,” The New England Journal of Medicine 391, no. 16 (2024): 1465–67, https://doi.org/10.1056/nejmp2403935.
[7] James Keller, “Alberta Conscience-Rights Bill Puts Doctor Objections to Abortion, Assisted Dying, Back in Focus,” The Globe and Mail, November 11, 2019, https://www.theglobeandmail.com/canada/alberta/article-alberta-conscience-rights-bill-puts-doctor-objections-to-abortion/.
[8] For more on the nature of conscience in medicine, see Lauris C. Kaldjian, “Understanding Conscience as Integrity: Why Some Physicians Will Not Refer Patients for Ethically Controversial Practices,” Perspectives in Biology and Medicine 62, no. 3 (2019): 383–400, https://doi.org/10.1353/pbm.2019.0022.
[9] Matthew Lee Anderson, “Bringing Body and Soul Together (Again): Robert P. George, Oliver O’Donovan, and the Place of Resurrection in Body Ethics,” in, Social Conservatism for the Common Good: A Protestant Engagement with Robert P. George, ed. Andrew T. Walker (Crossway, 2023), Kindle Edition, 195.