Earlier this year the Supreme Court of Canada legalized physician-assisted death (PAD)—a ruling that will take effect in February 2016. Overturning by unanimous decision its 1993 ruling that denied a patient’s right to die, the Court defined the “sanctity of life” to include determining one's “passage into death”—even if the patient isn’t terminally ill. Though Canadian policymakers are working to minimize potential abuses of PAD, the legal language is broadly permissive.
Of additional concern to Christian doctors in Canada is the College of Physicians and Surgeons in Ontario’s recent vote to restrict a doctor's right to conscience protection. A revision to their Professional and Human Rights Policy now mandates that all doctors—even ones with moral and religious objections to procedures like PAD and abortion—must provide referrals to other healthcare providers.
In the United States, PAD is legal in Washington and Oregon, and there are bills before many state legislatures in favor of legalizing it. I spoke with Dr. Ewan Goligher, an intensive care physician at Mount Sinai Hospital in Toronto, about the implications on both sides of the border.
Dr. Goligher, what changed in Canada's ethical landscape to make the legalization of PAD possible now?
What has shifted, both within the medical community and in society more generally, is the rising importance of individual autonomy. Autonomy (the right to self-determination) has always been a central consideration in bioethical decision-making, but it is now treated as the pre-eminent ethical value. In 1993, the Supreme Court of Canada upheld the sanctity of life over and against patient autonomy. In its recent ruling, however, the Court prioritized patient autonomy. Citing Canadians' constitutional right to “life, liberty and security of the person,” the Court equated “autonomy” with “security.” In Canada, we now value—as a matter of personal autonomy—a patient’s right to determine how and when he dies above the intrinsic worth of human life, which some ethicists view as a dubious concept anyway.
Aside from using patient autonomy to defend PAD, what particularly troubles you, as a physician, about this as a framework for medical decision-making? Shouldn't patients be granted the right to manage their own care?
Patient autonomy is one of many factors in making medical decisions. But in the debate around PAD, the concept of autonomy extends beyond simply allowing patients to make their own decisions about whether to accept proposed treatments for their medical conditions. For PAD advocates, it includes allowing patients to decide what counts as a benefit—even death itself. In this proposed framework, it’s not hard to imagine being required to accede to demands for lesser “benefits”—from the right to use prescription medications purely for a pleasurable “high” to the right to demand medical interventions that would not otherwise be offered. When death itself can be considered as a medical benefit, the sky seems to be the unfortunate limit for patient autonomy, and it introduces a level of subjectivity into medicine that we wouldn’t otherwise tolerate.
Why do you think there is public support in Canada for PAD?
It's true that public polls show that the majority of Canadians support PAD. It's less clear, however, that a majority of Canadian doctors support it. Many physicians who advocate for PAD seem to be personally unwilling to prescribe or administer lethal medication. To me, that speaks volumes.
The PAD lobby has been successful at arguing that many people suffer from irremediable, intractable pain. The argument for compassion is compelling, and both advocates and opponents of PAD seek a common goal and a shared desire—the relief of suffering. Doctors on both sides of the issue want to provide the best, most compassionate care for their patients, and there’s a definite consensus in the medical community that our current resources and training in end-of-life care are inadequate.
Nevertheless, published research clearly demonstrates that the vast majority of patients who seek PAD aren’t driven by their uncontrolled pain, but by their desire to be in control of their dying process. Ultimately, widespread public support for PAD reflects a deep sense of hopelessness and meaninglessness around suffering and dying in our society.
How do you approach this conversation with colleagues who don't share your Christian worldview and approach the ethics of PAD differently?
When faced with skeptical interlocutors, Jesus often asked pointed questions to help his opponents identify their own basic assumptions. In discussions around PAD, I've often found it effective to ask people simply, “Why should I respect patient autonomy?” As a Christian doctor, I know why I ought to respect it, but I find that most people fail to provide any sound ethical argument; it’s just something they take for granted. Another question I like to ask is, “How do you know that the patient is better off dead?” These questions force people to examine their own basic assumptions, and their responses reveal a great deal about their personal worldview.
Can physicians in Canada exercise the legal right to “conscientiously object” to providing services they deem morally objectionable?
Until quite recently, doctors were guaranteed conscience protection in Canada. They did not have to provide a service (such as abortion) to patients, nor did they have to provide a referral to another service provider. The medical community has usually considered it reasonable to respect conscientious objections, and this system has functioned well in Canada for decades.
The College of Physicians and Surgeons on Ontario, which governs medical practice in Ontario and disciplines doctors who fail to meet professional standards, however, has recently restricted this right. The college now insists that doctors refusing to provide a service must provide a referral in good faith to a physician willing to offer services. By February 2016, PAD will be one of those services. It’s likely that other provinces in Canada will follow suit on this policy.
Is it a betrayal of conscience to provide a medical referral to another physician for these services?
Yes, absolutely—although many of my secular colleagues find it hard to understand that point. I explain it like this: imagine that a mother came to you, insisting that she could no longer deal with her 1-year-old, and asking for a referral to the local infanticide clinic. My colleagues, of course, recoil at the thought of offering a referral under that scenario. I explain to them that, for those of us who believe in the intrinsic worth of human life, we feel this same horror at abortion and PAD. A referral is instrumental in providing access to treatment, even if the doctor doesn't provide the service herself.
If Christian doctors are not guaranteed conscience protection in Canada, what does this mean for them?
Christian physicians of conscience will simply not be able to practice in certain areas of medicine. Primary care will essentially be off-limits, as will palliative care (since palliative physicians are most likely to receive such requests). I'm saddened because these are highly relational areas of medical practice, where Christian values such as servanthood, love, and compassion are of such direct value.
Additionally, it may become harder for Christians to get into medicine. There may even come a time when we can no longer be a part of the medical community in Canada because we can no longer function according to the consensus values of that community. (Wesley Smith, senior fellow at the Discovery Institute's Center on Human Exceptionalism, makes some ominous predictions in this regard.)
What are the potential implications of the legalization of PAD for the United States? Is American medical practice headed in the same direction as Canada?
I think the United States will follow Canada in short order. From my perspective, I see considerable social momentum on this in the United States, and I know that many of my American colleagues are very worried about this possibility.
The American public might perceive Canadian physicians as public servants (making us more bound to public policy), but in reality most of us are independent and self-employed, just like American physicians. The important difference is that the Canadian government is the exclusive insurer that we bill for our services. Though we are paid differently, the consensus philosophical framework underpinning bioethical reasoning and the pre-eminence of personal autonomy is shared on both sides of the border. That points to the inevitability of a similar outcome.
What can Christians do to support medical professionals in Canada?
Christians in Canada can write to their government officials, speaking out on these issues. But because this is a worldview issue, even more than a policy issue, it's important that Christians be ready to make a cogent, coherent defense of their faith and worldview. When Christians in their workplaces and neighborhoods and cities can communicate the gospel in ways that make it plausible and appealing, our clear thinking, compassion, and Christlikeness can be instrumental in shifting society's opinions about Christian values.
We also need to faithfully teach the Scriptures so that the church can gain a clearer grasp of the normality of suffering in the Christian life, which is obviously front and center in this issue. And if we are asked to suffer and to make sacrifices (professionally), we must recognize that this is a part of what it means to be a disciple of Jesus.
In an effort to help Christians communicate the gospel in the context of this and other contemporary issues, we’re holding a conference on apologetics and evangelism in Toronto in June. The conference, organized by a group of Christian academics at the University of Toronto in partnership with my local church and Apologetics Canada, is geared to help Christians address a range of challenges to belief in Christ. I’d strongly encourage anyone in the area to attend. Additionally, Christians can donate to CMDS (Christian Medical and Dental Society), which is fighting the legal battle for conscience protection.
Are you optimistic for the future of Christians in Canadian health care?
Truthfully, not really. Modern Canadian society (and American society too, I suspect) is deeply committed to the supremacy of personal autonomy. I don't see this cultural mindset changing in the near future apart from the grace of God. But I trust that God is sovereign, and the debate around PAD provides us with a valuable opportunity to raise important existential questions, not only about end-of-life issues, but also about the “ends” of life.
Only the meta-narrative of the gospel can make sense of the meaning of life—and death.