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Skiing down euthanasia’s slippery slope

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From the Macdonald Laurier Institute

By John Keown

Canada is on track to surpass the Netherlands.

When the Canadian Parliament legalized voluntary euthanasia (VE) and physician-assisted suicide (PAS) in 2016, at the behest of the Supreme Court, supporters of legalization doubtless hoped the new law and its operation would prove something of a poster child for the compassionate and controlled medical ending of life. Its critics, however, might now describe it as less like a poster child and more like the picture of Dorian Gray.

Whether the law should permit VE and PAS is one of the most important questions of social policy in developed countries. Here we will eschew the tendentious and misleading euphemisms “assisted dying” and “medical assistance in dying.” The law and professional medical ethics have always allowed doctors and nurses to “help people to die” by palliating symptoms, even if so doing foreseeably shortens life. What the new law permits is radically different: the intentional killing of patients and intentionally assisting them to kill themselves.

Moreover, the euthanasia law does not require that patients be “dying” or “terminally ill” in order (to employ further euphemisms) to be given the “medication” for such “treatment.” Policy makers should not disguise, or be complicit in disguising, the foundational nature of this moral, legal, medical, and social paradigm shift.

The Canadian experience with VE and PAS is of major relevance to the international debate. Does it support the assurances of legalization campaigners that these practices can be effectively controlled by the law and provide a “last resort” in the sort of “hard cases” involving patients who are (or who fear) dying in severe pain or discomfort – patients who are so regularly paraded before us by the mass media?

Or does it support the counter-argument that the appropriate answer to such pain and discomfort is the wider availability of quality palliative care, and that a relaxed law would not only fail to prevent mistake or abuse but would also prove a first step on a precipitous “slippery slope” to VE and PAS in an ever-widening range of cases?

The best body of evidence concerning the effects of legalization comes from the Netherlands, whose experience I have studied for 35 years.

The Dutch Supreme Court declared VE and PAS lawful in 1984. To justify this change, the Dutch invoked the doctor’s duty to relieve suffering, and the focus of discussion was the physical suffering of the dying. However, in 1994 the same court held that the requirement of “unbearable suffering” could be satisfied by an illness that was neither terminal nor even physical and was solely mental. (Whether the patient’s suffering was “unbearable” remains very largely a subjective matter decided by the patient.)

In 2016 the Dutch government proposed a further legal extension: to elderly folk with a “completed” life. And, if some patients still do not manage to meet the lax legal criteria for VE and PAS their doctors can, and do, advise them that there is the option of being medically palliated while they dehydrate themselves to death.

Lethal injections have even been extended to patients who are incapable of making a request. In 1996 the Dutch courts declared it lawful intentionally to kill disabled infants, such as those with spina bifida. And only last year, the government announced that euthanasia would be allowed for children between one and 12. In short, over the past 40 years the Dutch have clearly tumbled down euthanasia’s slippery slope. Their Belgian neighbours, who followed them in 2002 (the same year that Dutch legislation enshrining the pre-existing legal criteria came into force) are also on the skids.

Why does this happen? There are two explanations, one empirical, the other logical. The empirical explanation is that relaxed laws cannot effectively control VE and PAS in practice because the challenges of formulating, drafting, and enforcing proper safeguards are intractable. Common media references to “strict safeguards” in places like the Netherlands and Canada reflect journalistic ignorance rather than social reality.

The second explanation is logical. VE and PAS are, campaigners tell us, justified by (i) respect for patient autonomy and (ii) by the duty to relieve suffering. But if one buys their argument, euthanasia is also justified for competent patients who are suffering from chronic, not merely terminal, illness, and whether their suffering is physical or mental. Suffering is suffering, whether from terminal cancer or chronic arthritis or depression. Indeed, suffering from chronic illness, physical or mental, may last a lifetime, not merely a few weeks or months. And why exclude the perduring existential suffering that tragically blights the lives of so many lonely, elderly folk?

Why, moreover, exclude euthanasia for suffering patients such as infants who are incapable of requesting death (non-voluntary euthanasia or NVE)? The absence of patient autonomy does not cancel the doctor’s duty of beneficence.

The Dutch have, then, proved nothing if not logical, and it is surely only a matter of time until their law is formally extended to embrace the elderly who are “tired of life.”

And so, to Canada. It leaped onto the slope as a result of the Supreme Court’s ruling in Carter v. Canada in 2015, in which the court overruled its previous decision in Rodriguez v. British Columbia in 1993. Rodriguez was soundly reasoned, and its reasoning remains in line with the rejection of a right to VE and PAS by the highest courts in other common law jurisdictions including the United States, the United Kingdom, and Ireland. By contrast (as I explain in Euthanasia, Ethics and Public Policy), Carter may strike some as reading more like rationalization than reasoning and as an exercise in judicial activism that stains Canadian jurisprudence.

Here we will mention just one of its flaws: its endorsement of the crucial finding of the trial judge that the evidence from jurisdictions with VE and/or PAS showed that the risks of legalization can be very largely avoided by carefully designed, well-monitored safeguards. This finding bristled with problems, not least of which was that no jurisdiction had (or has) carefully designed, well-monitored safeguards.

In a subsequent and similar case in Ireland, three senior judges carefully reviewed the judgment of the trial judge in Carter. They unanimously rejected her finding, not least in view of the (undisputed) evidence from the Netherlands and Belgium of the striking extent of medical euthanasia without any explicit request from the patient.

I was called as an expert witness in Carter by the Attorney General of Canada. At the end of my day-long cross-examination in Vancouver by the late Joseph Arvay, Q.C., counsel for those challenging the law against VE and PAS, the judge asked me to reprise both the practical and logical slippery slope arguments that I have outlined above. I did so, using the evidence from the Netherlands, Belgium, and Oregon to demonstrate the lack of effective legal control, and the Dutch endorsement of infanticide to illustrate the logical slippery slope. (Indeed, the two leading ethics experts called by Mr Arvay had endorsed both voluntary and non-voluntary euthanasia in their published work.)

The judge nevertheless concluded that the evidence showed that VE and PAS could safely be legalized. As for the logical argument, she dismissed it as involving “speculation” and because the legal challenge was only to the legal prohibition as it affected competent patients! Her failure to join the dots was noteworthy. (My 2022 paper in the Cambridge Law Journal confirms the real, not speculative, nature of the logical argument.) The Supreme Court endorsed the judge’s several errors. It did so, moreover, without even the fig leaf of a single dissenting judgment.

And what have we (all too predictably) witnessed since 2016, when legislation accommodated the Supreme Court’s ruling? Even leaving aside the steep yearly increases in the number of medical killings, we have seen that the statutory requirement that the patient’s death be “reasonably foreseeable” need no longer be met; that euthanasia where the sole cause of suffering is mental illness has been approved (though its implementation has been delayed until 2027 to allow preparations to be made), and that further expansion of the law to include “mature” minors, and requests for euthanasia written in advance of incompetence, is on the cards. Not to mention the several reported cases involving vulnerable patients that raise unsettling questions about the operation of the law.

In 1994 a distinguished House of Lords Select Committee on Medical Ethics unanimously concluded that English law should not permit VE or PAS. The committee observed that the criminal law’s prohibition on intentional killing was the “cornerstone of law and of social relationships” that “protects each one of us impartially, embodying the belief that all are equal.”

The experience in Canada uncomfortably confirms what happens once a society abandons that historic, bright-line prohibition in favour of the competing and arbitrary notion that whereas some people have lives that are “worth living,” others would be “better off dead” and it is right to grant their request to be killed or to help them kill themselves.

It is surely only a matter of time until calls are made for the “benefit” of a hastened death to be conferred on people who are incapable of requesting it. Why “discriminate” against people who are suffering with, say, advanced dementia merely because they are incapable of requesting a lethal injection? Why deny them their rights under the Canadian Charter of Rights and Freedoms? The enormous cost savings will lurk supportively behind the argument, like a gangster’s heavy.

In the Netherlands, euthanasia has been normalized to a significant degree. Far from being an exceptional practice in “hard cases” of “last resort,” it has come to be regarded largely as another healthcare option. Canada appears to be following suit. Professor Trudo Lemmens, the eminent Canadian health lawyer, has noted the “troubling normalization” of euthanasia in Canada where, he adds, “rights rhetoric” surrounding the issue has replaced evidence-based debate.

Thankfully, the concerning developments in Canada are now being ventilated in the public domain: in the media, both in Canada and abroad; in journals of lawmedicine and bioethics, and by the UN rapporteur on the rights of people with disabilities. It is telling that in the UK even campaigners for legalization are straining to distance themselves from the Canadian precedent.

In 40 years, the Dutch have slid down the slippery slope. In fewer than 10, Canada appears to be veritably skiing.

John Keown DCL (Oxon) is the Rose F. Kennedy Professor of Christian Ethics in the Kennedy Institute of Ethics at Georgetown University in Washington, DC. He previously taught medical law at the University of Cambridge. The second edition of his book Euthanasia, Ethics and Public Policy: An Argument Against Legalisation, described as “magisterial” by Lord Judge, the former Lord Chief Justice of England and Wales, was published by Cambridge University Press in 2018.

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MAiD

Even Canadian leftists are starting to recognize the ‘dystopian’ nature of MAiD

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From LifeSiteNews

By Alex Schadenberg

Euthanasia based on poverty or disability is rarely based on personal choice and autonomy, it is horrifying, it is profane, it is the outcome of a failed social welfare system, and it is indefensible.

David Moscrop wrote an excellent article that was published by Jacobin Magazine on May 2, 2024. Jacobin is an ideologically left magazine, which is concerned about Canada killing people with disabilities and the poor by euthanasia, known as MAiD (Medical Assistance in Dying).

The article begins with this quote:

Canada boasts one of the world’s highest assisted-death rates, supposedly enabling the terminally ill to die with dignity. However, this suicide program increasingly resembles a dystopian replacement for care services, exchanging social welfare for euthanasia.

Moscrop tells the story of Normand Meunier, the quadriplegic man in Québec who died by euthanasia after suffering from horrific neglect. Moscrop writes:

For want of a mattress, a man is dead. That’s the story, in sum, of a quadriplegic man who chose to end his life in January through medically assisted death. Normand Meunier’s story, as reported by the CBC, began with a visit to a Quebec hospital due to a respiratory virus. Meunier subsequently developed a painful bedsore after being left without access to a mattress to accommodate his needs. Thereafter, he applied to Canada’s Medical Assistance in Dying (MAiD) program.

As Rachel Watts writes in her report, Meunier spent ninety-five hours on a stretcher in the emergency room – just hours short of four days. The bedsore he developed ‘eventually worsened to the point where bone and muscle were exposed and visible – making his recovery and prognosis bleak.’ The man who ‘didn’t want to be a burden’ chose to die at home. An internal investigation into the matter is underway.

I find it interesting that the article states that Meunier chose to die by euthanasia when in fact he was put into an untenable situation. Moscrop then reinforces the concerns of the disability community:

Disability and other advocates have been warning us for years that MAiD puts people at risk. They warned that the risk of people choosing death – because it’s easier than fighting to survive in a system that impoverishes people, and disproportionately does so to those who are disabled – is real. Underinvestment in medical care will push people up to and beyond the brink, which means some will choose to die instead of ‘burden’ their loved ones or society at large. They were right.

Moscrop comments on how euthanasia is the outcome of a failed social welfare state:

A libertarian ethos partially underwrote the fact that not many people blinked when MAiD was initially rolled out. Taking a more expansive view of rights, many of those not swayed by rote libertarianism were convinced that concerns over bodily autonomy and compassion were reason enough to adopt MAiD. However, in the absence of a robust welfare state, and in the face of structural poverty and discrimination, particularly toward disabled people, there is no world in which the MAiD program can be understood to be ‘progressive.’

Indeed, last year, Jeremy Appel argued that MAiD was ‘beginning to look like a dystopian end run around the cost of providing social welfare.’ Initially supportive, he changed his mind on MAiD as he considered that the decisions people make are not strictly speaking individual but are instead collectively shaped and sometimes ‘the product of social circumstances, which are outside of their control.’ When we don’t care for one another, what do we end up with?

‘I’ve come to realize,’ wrote Appel, ‘that euthanasia in Canada represents the cynical endgame of social provisioning with the brutal logic of late-stage capitalism – we’ll starve you of the funding you need to live a dignified life [. . .] and if you don’t like it, why don’t you just kill yourself?’

READ: Young, healthy women being euthanized in the Netherlands should be a warning for Canada

Moscrop then comments on that euthanasia for psychiatric reasons has been delayed in Canada based on the lack of mental health care. He refers to the reality as grotesque and writes that this is the stuff of nightmarish science fiction. Moscrop comments on the broken social welfare system in Canada.

In Canada’s most populous province, Ontario, a recipient of disability support receives about $1,300 a month – a pittance they’re meant to stretch to cover food, shelter, and other basic needs. Ontario Works – the province’s welfare program – pays a current maximum of $733 a month. Meanwhile, rental costs for a one bedroom apartment routinely push toward an average of $2,000 a month in many cities. In April, in Toronto, a one bedroom apartment averaged almost $2,500 a month.

Moscrop challenges a statement by euthanasia activists James Downer and Susan MacDonald who stated:

Despite fears that availability of MAiD for people with terminal illness would lead to requests for MAiD driven by socioeconomic deprivation or poor service availability (e.g., palliative care), available evidence consistently indicates that MAiD is most commonly received by people of high socioeconomic status and lower support needs, and those with high involvement of palliative care.

By their own admission, the data on this matter is imperfect. But even if it were, the fact that ‘most’ patients who choose MAiD are better off socioeconomically is beside the point. Some are not – and those ‘some’ are important. That includes a man living with Amyotrophic Lateral Sclerosis who, in 2019, chose medically assisted death because he couldn’t find adequate medical care that would also allow him to be with his son. It also includes a man whose application listed only ‘hearing loss,’ and whose brother says he was ‘basically put to death.’ This story came a year after experts raised the concern that the country’s MAiD regime was in violation of the Universal Declaration of Human Rights.

In 2022, Global News said the quiet part out loud: poverty is driving disabled Canadians to consider MAiD. Those ‘some’ who are driven to assisted death because of poverty or an inability to access adequate care deserve to live with dignity and with the resources they need to live as they wish. They should never, ever feel the pressure to choose to die because our social welfare institutions are starved and our health care system has been vandalized through years of austerity and poor management.

Moscrop then states that Canada has the resources to prevent endemic poverty and provide adequate care, that poor people being euthanized by the state is profane.

Moscrop then refers to a recent article by professor Trudo Lemmens who is a critic of Canada’s euthanasia law.

In a February piece for the Globe and Mail, University of Toronto law professor Trudo Lemmens wrote, ‘The results of our MAiD regime’s promotion of access to death as a benefit, and the trivialization of death as a harm to be protected against, are increasingly clear.’ In critiquing MAiD’s second track, which allows physician-assisted death for those who do not face ‘a reasonably foreseeable death,’ Lemmens points out that within two years of its adoption, ‘“track two”’ MAiD providers had ended already the lives of close to seven hundred disabled people, most of whom likely had years of life left.’

In raising concerns about expanding MAiD to cover mental illness, Lemmens added that ‘there are growing concerns that inadequate social and mental health care, and a failure to provide housing supports, push people to request MAiD,’ noting that ‘[a]dding mental illness as a basis for MAiD will only increase the number of people exposed to higher risks of premature death.’

Moscrop continues by referring to a commentary from disability leader Gabrielle Peters.

In 2021, Gabrielle Peters warned in Maclean’s that extending MAiD to cover those who weren’t facing an immediately foreseeable death was ‘dangerous, unsettling and deeply flawed.’ She traced the various ways in which a broader MAiD law could lead to people choosing to die in the face of austerity, adding an intersectional lens that is often missing from our discussions and debates over the issue.

She warned that we were failing to consider ‘how poverty and racism intersect with disability to create greater risk of harm, more institutional bias and barriers, additional layers of othering and dehumanization, and fewer resources for addressing any of these.’ And now here we are. We should have listened more carefully.

Moscrop ends his article by suggesting that euthanasia may be OK based on personal choice but it is indefensible when it is based on poverty.

While MAiD may be defensible as a means for individuals to exercise personal choice in how they live and how they die when facing illness and pain, it is plainly indefensible when state-induced austerity and mismanagement leads to people choosing to end their lives that have been made unnecessarily miserable. In short, we are killing people for being poor and disabled, which is horrifying.

It thus falls to proponents of MAiD to show how such deaths can be avoided, just as it falls to policymakers to build or rebuild institutions that ensure no one ever opts to end their life for lack of resources or support, which we could provide in abundance if we choose to.

I agree with most of Moscrop’s comments but I disagree with his statement that euthanasia is possibly defensible as a means of individuals exercising personal choice. Even though people with disabilities experience social devaluation in Canada, they may be still exercising personal choice when they ask to be killed.

The problem with modern writers is that they miss the fact that euthanasia is about killing people. Even if Canada had a greater level of equality, there would be people who ask to be killed based on their poverty or their concerns about homelessness.

The real concern is that Canada has given medical professionals the right in law to kill their patients. This is about people killing people.

Nonetheless Moscrop is right that euthanasia based on poverty or disability is rarely based on personal choice and autonomy, it is horrifying, it is profane, it is the outcome of a failed social welfare system, and it is indefensible.

Reprinted with permission from the Euthanasia Prevention Coalition.

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28-year-old Dutch woman to be killed by assisted suicide after doctors deem her autism ‘untreatable’

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28-year-old Dutch woman Zoraya ter Beek (YouTube Screenshot)

From LifeSiteNews

By Louis Knuffke

28-year-old Zoraya ter Beek plans to die by assisted suicide over her struggles with depression and mental illness, a trend which is increasing in The Netherlands.

A 28-year-old autistic woman is scheduled to die by assisted suicide in May in The Netherlands after struggling with depression and mental illness, with her psychiatrist telling her that her condition is untreatable and will never improve. 

Zoraya ter Beek, who does not suffer from any physical illness, has decided to end her life by assisted suicide after psychiatrists said they had exhausted any means of helping her deal with her mental illnesses, which includes borderline personality disorder, according to The Free Press. 

Her struggles with mental illness have prevented her from being able to finish school or start a career. 

READ: Canadian judge blocks imminent euthanasia death of 27-year-old autistic woman 

In testimony to the nihilistic attitude adopted in the choice to end her own life on account of suffering, Ter Beek has decided that after she has been killed, her body will be cremated without a funeral and her ashes scattered in the woods. 

Ter Beek’s choice to take her own life comes despite her admitted fear of death arising from the uncertainty of what happens after death. 

“I’m a little afraid of dying, because it’s the ultimate unknown,” she said. “We don’t really know what’s next – or is there nothing? That’s the scary part.” 

The diagnosis of autism and mental illness as “untreatable” and “unbearable” has become an increasing trend in The Netherlands, with a study published in June 2023 revealing 40 cases over a 10-year period from 2012 to 2021. In a third of those cases, those with autism or intellectual disabilities were told there was no hope of improving their lives, and so their condition was deemed “untreatable.” 

Irene Tuffrey-Wijne, a palliative care physician at Britain’s Kingston University, who led the study  which examined 900 cases, said, “There’s no doubt in my mind these people were suffering. But is society really OK with sending this message, that there’s no other way to help them and it’s just better to be dead?” 

Tim Stainton, director of the Canadian Institute for Inclusion and Citizenship at the University of British Columbia, added, “Helping people with autism and intellectual disabilities to die is essentially eugenics.” 

The scheduled killing of the 28-year-old autistic woman comes as The Netherlands continues to expand the scope of what legally qualifies for euthanasia, with a new law effective February 1 allowing the killing of terminally ill children aged 1 through 12 who are deemed to be “suffering hopelessly and unbearably.” 

The law allows parents to decide to kill their child even if the child is unwilling or unable to consent. 

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