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Pulse
17 July 2023

On 14 January 2023, the BBC reported that Canada is preparing to expand its controversial medical assistance in dying programme (known by its acronym MAID), to include people with mental illness.

When MAID was launched in 2016, it was made available to adult patients with terminal illness, whose death was ‘reasonably foreseeable’. However, the criteria for patients who are eligible for this assisted dying programme were very quickly liberalised.

On 17 March, 2021, the Canadian government announced that changes will be made to the law which will remove ‘the requirement for a person’s natural death to be reasonably foreseeable in order to be eligible for MAID’. This means that adult patients whose condition is ‘serious and incurable’ but not terminal could apply.

From March 2024, adult patients suffering from a psychiatric condition such as depression, schizophrenia or bipolar disorder could seek MAID if their condition is deemed ‘irremediable’. Many commentators fear that soon MAID will be extended to ‘mature minors’ – children over the age of 12 who are deemed capable of making responsible decisions.

There have also been disturbing reports which suggest that some Canadians have opted for MAID because they are unable to afford adequate housing. Authorities have also launched an investigation after four veterans were allegedly prompted by their Veterans Affairs case worker to consider applying for MAID.

As the BBC article states, this has ‘prompted fears it could be used as a solution for societal changes – that someone may seek out MAID because of poverty, lack of housing, or extreme loneliness’.

In the year MAID was launched (2016), over 1,000 people received assisted death. By 2021, figures showed that there were 10,064 MAID cases. MAID deaths account for 3.3 percent of all deaths in Canada.

Three United Nations human rights experts have criticised the expansion of MAID to include mentally disabled persons. They argued that such a policy would devalue the lives of people with disabilities by tacitly suggesting that death is preferable to living with certain forms of disabilities.

But the most vocal and vociferous objections to Canada’s ultra-liberal assisted suicide laws came from organisations representing people with disabilities. In January 2023, a number of disability groups sent an open letter to Prime Minister Justin Trudeau, Justice Minister David Lametti and Leader of the Opposition Pierre Poilievre stating unequivocally that:

We, the undersigned disability and human rights organisations are writing to express our concern and opposition to the legalisation of Medical Assistance in Dying (MAID) for mental illness and to the already-legal practice of euthanising people with disabilities who are not terminally ill.

Defenders of MAID such as Dr Stefanie Green, president of the Canadian Association of MAID Assessors and Providers, present the programme as a humane effort to help suffering patients. Green even states that ‘it is objectively therapeutic to give someone the option’.

AUTONOMY, UTILITY AND DIGNITY

The justifications for such a radical policy of medically assisted dying are usually based on a mixture of liberal philosophical and ethical assumptions and premises. They include the cardinal liberal virtues such as personal autonomy and rights which are usually wedded to a utilitarian approach to ethics.

According to Jukka Varelius, ‘Personal autonomy is, at minimum, self-rule that is free from both controlling interference by others and from limitations, such as adequate understanding, that prevent meaningful choice’. ‘The autonomous individual’, he adds, ‘acts freely in accordance with a self-chosen plan …’

Autonomy has a special place in medical ethics, including Christian medical ethics. However, while Christian ethics insists that personal autonomy must always be governed by objective principles and values, secular and liberal accounts of autonomy seem to accord the self with unmitigated sovereignty.

The influential Dying with Dignity lobby in Canada not only valorises personal choice and autonomy, it has also linked it with dignity. As Todd Statham has perceptively pointed out, this implies that ‘to not have free control over your body, mind and destiny due to illness or injury robs you of your dignity’.

The autonomy-dignity argument has also been used with regard to the patient’s ability to independently pursue and achieve his life goals. Thus, to become overly dependent on others financially and medically due to one’s illness or disability is seen as the loss of freedom and self-determination, and therefore, a loss of dignity.

All this is set within the framework of a utilitarian ethics. Utilitarianism (which is also known as consequentialism) simply states that the most ethical choice is the one which will produce the greatest good for the greatest number.

From the utilitarian perspective, in electing to end his life, the person with serious and lifelong illness or disability and who is heavily dependent on others, can be said to have chosen a course of action that will produce ‘the greatest good for the greatest number’.

Put differently, in choosing to end his life by means of medically-assisted suicide, the patient has acted for the benefit of the ‘greater good’ – he has relieved both family and society from bearing the financial and psychological burden of supporting him.

Statham explains how proponents justify MAID by employing the autonomy-dignity argument set within a utilitarian ethical framework thus:

The logic of autonomy and choice is also clear in how Canadians are now thinking about mental illness in reference to MAID. People suffering from depression, PTSD or a psychiatric disorder have (often) lifelong and incurable afflictions from which they are not dying. Rather, their affliction leaves them dependent upon their spouses, friends, therapists, nurses, and others. Apart from whatever suffering they experience due to their psychiatric affliction, a major justification for permitting assisted death in these cases appear to be the perception that irremediable dependence has diminished their dignity.

From the standpoint of Christian ethics, a concept of autonomy that is developed apart from moral values and limits is fundamentally flawed. Some ethicists have described this misguided concept as ‘erroneous autonomy’, which is inspired by the radical individualism of our times.

An erroneous autonomy can never preserve and uphold human dignity or serve the common good.

Rather it will pervert society’s understanding of human worth, and sacrifice human life on the altar of expediency. It sees the life and death of a human being only as a means to the end which it cryptically describes as ‘the greater good’.

However, ‘the greater good’ is in fact is nothing more than a euphemism for what society deems to be convenient and advantageous for the majority of its members.

CULTURE OF DEATH

In 2008, Singapore’s then health minister Khaw Boon Wan toyed with the idea of legalising euthanasia in the nation-state which sparked intense discussion. The National Council of Churches of Singapore issued a statement which expressed its opposition to the practice and legalisation of euthanasia and all forms of physician assisted suicide.

The fundamental reason why the Council is opposed to medically assisted dying is its belief that ‘human life is a gift from God the Creator. God alone, from whom all life derives, has the authority in matters of life and death’. The doctrine of the sanctity of human life is consistently taught by the Church throughout history because it is based on the clear testimony of Scriptures.

But the Council was also worried that the legalisation of euthanasia and physician-assisted suicide would radically change society’s attitude to human life. ‘The legalisation and acceptance of euthanasia’, it asserts, ‘would result in the “euthanasia mentality” that sees death as the only solution when faced with terminal illness and which does not consider other alternatives.’

‘Death’, the statement adds baldly, ‘becomes the “solution” to many social ills.’

To be sure, the Council is here addressing the utilitarian ethics that we have been discussing and which undergirds Canada’s radical end-of-life policies. But in speaking of the ‘euthanasia mentality’, the Council is also pointing to the subtle but significant changes that the legalisation of assisted suicide could bring about to our cultural sensibilities towards human life.

Put differently, the legalisation and normalisation of assisted suicide will cultivate what the late Pope John Paul II has called the ‘culture of death’. In his 1995 encyclical Evangelium Vitae (‘The Gospel of Life’), the pontiff describes the culture of death thus:

[The culture of death] is actively fostered by powerful cultural, economic and political currents which encourage an idea of society excessively concerned with efficiency … [I]t is possible to speak in a certain sense of a war of the powerful against the weak: a life which would require greater acceptance, love and care is considered useless, or held to be an intolerable burden, and is therefore rejected in one way or another. A person who, because of illness, handicap or, more simply, just by existing, compromises the well-being or lifestyle of those who are more favoured tends to be looked upon as an enemy to be resisted or eliminated.

The culture of death tramples upon human life, especially the life which is weak, vulnerable and compromised – because it deems such a life to be useless and a burden. It uses lofty concepts such as freedom, rights, dignity, mercy to justify the taking of such lives.

The culture of death conditions society to be impatient towards human suffering, and to price the quality of life (of the patient and those around him) above the sanctity of life. It says that the most expedient way of eliminating human suffering is by terminating the life of the sufferer. And it insists that this kind of killing is justified because it is ‘mercy-killing’, an act of true compassion.

As Richard Doerflinger, the Associate Director for Policy Development, Secretariat for Pro-Life Activities, National Conference of Catholic Bishops (U.S.A.) has starkly put it:

In this ideology, sick and elderly patients may be members of our common humanity, but what really matters is their inability to live up to the standards for meaningful life that we – the strong, the intelligent, the healthy – have defined as the norm. Instead of care, comfort and moral support, they should receive society’s encouragement to recognise their own lives as worthless. By ending those lives they will free up more resources for those of us who can make good use of them – in much the same way that defenseless embryos serve the common good by giving their vital cells and organs we need for our own health and vitality.

The culture of death must be recognised for what it really is: a demonic deception which says that the greater good and flourishing of society can only be achieved if its weakest members are killed and discarded.


Dr Roland Chia is Chew Hock Hin Professor at Trinity Theological College (Singapore) and Theological and Research Advisor of the Ethos Institute for Public Christianity.