Friday, July 28, 2017

Euthanasia slippery slope: a failure of memory and imagination

This article was published by Mercatornet on July 28, 2017
When the splash of assisted-suicide and euthanasia blinds us to their far-reaching ripples.
Margaret Somerville
By Margaret Somerville

Very recently, two senior physicians who have championed the legalization of euthanasia in their jurisdictions, Dr Boudewijn Chabot in the Netherlands and Dr Guy Robert in Quebec, have rejected current “appalling” developments in euthanasia in their countries. Yet, these developments should have been anticipated. So, why weren’t they?

Pro-euthanasia advocates focus just on individuals and only in the present – a combination of radical autonomy/ intense individualism and “presentism” - which blocks out considering both lessons from the past and likely future developments. In other words, the pro-euthanasia stance rests on a failure of people’s individual and collective human memory and imagination.

Those opposing euthanasia look to human memory – history and what the past can teach us – and imagination – what the future might hold – as well as the present. They also look beyond euthanasia’s impact just on individuals to the wide-ranging and multitudinous major issues and consequences it raises for medicine and law, for practitioners of these two professions, and for all of us as families, communities and a society.

Human memory

Human memory warns us of the “slippery slopes” euthanasia opens up: The “logical slippery slope”, the situations where euthanasia is allowed constantly expands, and the “practical slippery slope”, euthanasia is undertaken not in compliance with the law.

Once euthanasia becomes normalized slippery slopes are unavoidable, because, as British moral philosopher Dame Mary Warnock explains, “You cannot successfully block a slippery slope except by a fixed and invariable obstacle”, in the case of euthanasia, the rule that we must not intentionally kill.

Pro-euthanasia advocates dismiss the nearly 2,500 year history of the Hippocratic Oath’s guidance of medicine – cure where possible, care always, never kill – and, especially, any lessons from the Nazi regime. No one believes euthanasia will lead to a second Holocaust, but as the distinguished Canadian historian, Margaret MacMillan, has said, without knowing the past, we deprive ourselves of an important source of understanding.

Renowned Canadian disability rights advocate Professor Catherine Frazee, who says that what happened to people with disabilities in Nazi Germany is “part of my history as a person with severe disabilities”, explains “that one key to tackling complex problems is to ask the right questions, and history, through its cautionary tales and analogues, is a rich vein of 'right questions'” to ask about euthanasia.

We can also look to indigenous people’s practice of looking to Elders past and present, to argue it is wrong and dangerous to exclude human memory from informing our important societal decisions, and legalizing euthanasia is clearly such a decision.

Psychiatrist Dr Boudewijn Chabot, a very prominent pro PAS-E advocate in the Netherlands, who has been called the “patron saint of euthanasia”, is horrified at what is currently happening in his country.

He’s not anti-euthanasia (he is prepared to accept tens of thousands of euthanasia cases) but aghast at the rapid rise in the number of people with psychiatric illness or dementia who have been euthanized.

Writing in a leading Dutch newspaper, Chabot says that “legal safeguards for euthanasia are slowly eroding away and that the law no longer protects people with psychiatric conditions and dementia.”

He recognizes “we are dealing with a morally problematic act: how do you kill someone who does not understand that he will be killed?”. And he concludes bitterly, “I don’t see how we can get the genie back in the bottle. It would already mean a lot if we’d acknowledge he’s out.”

Why did the Dutch not look to the past for warnings? Why did they fail to use their imaginations to foresee these future consequences?

We need to ask these questions in relation to vulnerable Australians, those who are elderly and fragile, especially those with dementia, people with disabilities, including newborn babies, who can also be euthanized in the Netherlands.

Human imagination


A failure to look to the future is resulting in an extreme example of calls for expansion of euthanasia unfolding in Quebec.

Dr Yves Robert, the registrar of the College of Physicians and Surgeons of Quebec (the provincial medical licensing authority) was a major proponent of legalizing euthanasia and in 2009 the College was one of the main instigators of the movement to do so. Euthanasia was legalized in December 2015.

Robert adamantly rejected claims that effective safeguards were not possible, that euthanasia was not a medical act, and that it should be kept out of medicine. He constantly referred to a “continuum of good end-of-life care”, which included euthanasia as part of palliative care.

As in Australia, the claim it would be rarely used (about 100 cases a year in the province) was made. The first year saw over 400 cases. (In the first 7 months, 21 of 262 cases did not meet legal requirements: in two the patient was not terminally ill and in one not seriously ill – she probably had a urinary infection.)

But none of that seemed to raise any questions for the College, or I assume Robert, about whether legalizing euthanasia had been a good idea.

Here is what has, as he explains in a letter dated 10 May 2017, on College letterhead, entitled “Death a la carte”. That is, instead of food choices, it’s a menu of options for how one wants to die.

There are now calls and possibly the launching of a court case to have “death on demand” declared a constitutional right. The claim is that having to fulfil certain conditions to have access to euthanasia is a breach of the right to control one’s life and body and legally actionable discrimination.

Claiming a right to “death on demand” is consistent with and just an extension of the autonomy arguments used to legalize euthanasia.

The discrimination claim is unusual: It’s discrimination against people who do not have disabilities because those who do have access to euthanasia and those without disabilities cannot.

Robert notes opinion leaders and the media have denounced cases where people who do not fulfil the conditions for access to euthanasia in Quebec have been refused it. Such denunciations and the refusals being characterized as 'cruelty' are familiar pro-euthanasia strategies.

Robert recognizes the “paradoxical discourse” that calls for safeguards to avoid abuse of “medical aid in dying” (euthanasia) which are meant to limit its availability, while asking doctors to act as if there were no such restrictions.

He continues that if euthanasia is an unfettered right, then it’s not within the scope of “medical aid to die”, but simply “assisting dying” and society must consider other options than involving the medical profession in that.

He explains it’s to transform “medical aid in dying” to “legally authorized aid in dying”, a form of assisted suicide which, he says, could be provided by private enterprise as in Switzerland.

Indeed, if society legalizes euthanasia, all euthanasia should be kept out of medicine. Specially trained technicians could provide it.

Robert notes that the Quebec law was “a major opening” to euthanasia and expresses surprise at how quickly public opinion seems to have judged the opening insufficient, when testing the law is still in the “apprenticeship phase and the application and consequences of its provisions are not fully assimilated.”

In short, euthanasia has become normalized with astonishing rapidity and that has caused calls for access to it to be expanded, indeed, calls to have no restrictions at all on access.

Robert concludes: “Let us take the time to reflect deeply before going any further. There is no urgency to die.” I totally agree but, to use a common saying, “it’s too late to lock the barn door after the horse has bolted.”

As for me, after being heavily involved in the euthanasia debate over many years in Quebec, to use another common saying, “you could have knocked me down with a feather” when I read what Robert wrote. That said, I applaud his honesty and integrity.

Why did so many doctors (and likewise lawyers) of goodwill and professional integrity, such as Dr Robert so adamantly disagree that such expansion would occur – although none of us expected a proposed expansion to this degree?

I believe it was a total failure of individual and collective memory and imagination, including professional memory and imagination, resulting in “intense individualism” and “intense presentism” governing the decision making and leading it astray. Let’s avoid that in Australia.

Margaret Somerville is Professor of Bioethics in the School of Medicine at the University of Notre Dame Australia.

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