“Club Sandwich Mayonnaise” a play about Quèbec euthanasia.

All the World's a Stage! 

By Gordon Friesen
President: Euthanasia Prevention Coalition

We have some very good news to report, from the cultural front, in the Province of Quebec.

This good news concerns the recent production of a stage play which might not actually condemn --but does seriously criticize-- the practice of medical homicide in that Province.

The arrival of “Club Sandwich Mayonnaise”, by Manuelle Legare, is encouraging for a number of reasons.

First of all, this is not a marginal production.

Mme. Legare is the daughter of local performance icon Pierre Legare, and was thus born into the Quebec cultural aristocracy, a status which she has successfully built upon through her own efforts in television and documentary cinema.

Furthermore, the participating dramatic production company, Porte Parole, was the first group to pioneer what has become the dominant Quebec stage formula, of 'dramatic documentary', and remains a leading reference in this style.

For these reasons, the Quebec opinion establishment have had no choice but to take this phenomenon seriously. And they have done so in spades. For after each (sold out) performance from April 8 to 18, leading authorities were on hand to participate in audience question and answer sessions, beginning, on opening night, with none less than Véronique Hivon, herself, the veritable Queen of euthanasia in Quebec, political Godmother, and author, of the original “Law Concerning End of Life Care”.

In terms of Quebec politics and society, this is a big deal.

Quebec does not have the same sort of litigious, political division seen elsewhere. All Quebec politicians, journalists, and influencers share certain crucial positions which they consider as universal social "consensus", and which it is assumed that no "serious" thinker might oppose. These currently include: an eternal resentment for Quebec's previous conquered status within the British Empire, certain extreme views on religion (or fossil energy) and most recently: an unfailing support of medical homicide.

Indeed, author Manuelle Legare states that the dramatic stage has become the only remaining public space in which any questioning of the medical homicide consensus might still be permitted.

However, as history shows, apparent (and rigorously enforced) unanimity of opinion often blocks the evolution of real and necessary criticisms, which subsequently explode in peoples faces. And it is this fact which explains the enthusiasm of both pro, and anti, medical homicide factions in embracing Club Sandwich Mayonnaise along with the indirect opportunity of discussion which it provides.

For the first time, after ten years of lockstep support, it would appear that there is at least some political willingness to entertain the thought that mistakes might have been made, or failing that, to concede that some small improvements might be desirable to limit unforeseen harms.

Returning to the author's description of her own intentions: Mme Legare lends official credence to the consensus belief in medical homicide as "social progress", but then speaks of "blind spots in the mirror", which in her case meant the profound psychological distress of hearing her father joke, one day, that he could order up his death as easily as "a club sandwich with mayonnaise", and then actually seeing his corpse laid on a slab, 48 hours later.

This, in short, is the sort of personal experience --implying enormous social rupture-- that no political "consensus" may prevent its partisans from questioning. And it is also a glimpse into the bottomless social abyss that so many of us have been warning against from the beginning.

To be realistic, of course, there is no scenario, whatever, in which one might imagine Quebec decision-makers ever showing sufficient humility to actually admit that they were simply wrong about the practice of medical homicide. And it may well be that pro-euthanasia forces will succeed in co-opting this first criticism as a positive opportunity of "healthy" adjustment. However, a definite breach in messaging unanimity has indeed been made.

As our ally Catherine Ferrier, President of the Physicians Alliance Against Euthanasia has described it:

"... all came out in the play. Rushed assessments, lack of access to other options, psychosocial suffering, priority of MAID over palliative care, etc. It mentioned the opposition of disability groups and the UN recommendation against MAID for people not at the end of life."

In short, the public airing of such concerns, in the undisputed ‘Belly of the Beast’ of Canadian euthanasia, can only be a good thing. And although the wheels turn slowly, and although no open admission of error will ever be made: Quebec politicians have also shown themselves to be extremely adroit in making 180 degree policy changes while firmly pretending to stay the course.

Let us all hope that we will eventually see that skill masterfully displayed, with regards to medical homicide.

Euthanasia: No Evidence Base for Futility and Irremediability in Psychiatric Disorders

This commentary was published by The Psychiatric Times on April 6, 2026.

By Dr's Mark Komrad and Catherine Ferrier

Dr Mark Komrad

As Canada approaches the planned implementation of their medical euthanasia program—or medical aid in dying (MAID)—for patients with sole psychiatric illnesses in March 2027, the Canadian Parliament is again studying the advisability of this decision. Here, we make an argument as to why these practices should remain closed to individuals with psychiatric disorders.

Unlike many other kinds of illnesses, futility or irremediability cannot be reliably resolved by clinicians in cases of psychiatric disorders, especially for any one particular individual. As Sonu Gaind, MD, past president of the Canadian Psychiatric Association and chair of the Toronto Expert Advisory Group on MAID for mental illness, wrote, “An extensive review of the literature shows that we cannot predict irremediability when it comes to mental illness. . . There is a big difference between being able to predict the declining course of a well-known medical ailment with understood biology, even if not with 100% certainty, versus making unpredictable assessments about the course of mental illnesses.”1 Some reasons for this follow.

Diagnosis and Prognosis of Mental Disorders Are Unreliable

Prognosis, the ability to predict the course of any illness—with or without treatment—depends on accurate identification of what the illness is, so that we can mine scientific evidence about the course of that illness. Because psychiatric conditions are based on patient’s history and clinical observation of the individual (rather than other kinds of validations, like blood tests, imaging studies, etc) the reliability of psychiatric diagnosis is limited. Studies have shown that clinicians agree on a patient’s formal psychiatric diagnosis between 66% to 75% of the time.2 Also, over time, psychiatric diagnoses are liable to be changed, much more than diagnoses of somatic illnesses. So, the unreliability and instability of psychiatric diagnoses mean that predicting the course of a patient’s condition, the prospect of its remission, and its response to any or all treatment, are too elusive to declare any one case “untreatable” or “futile.” The level of uncertainty in the science of psychiatric prognosis is very high.3

Inability to Know Which Suicides to Prevent and Which to Provide

Because of these unpredictable aspects, allowing MAID for some psychiatric patients, but not for all, poses a profound and irresolvable clinical conundrum—how to distinguish those patients for whom suicide should be prevented from those for whom it should be provided. The chairs of all 17 academic departments of psychiatry in Canada expressed profound concern about allowing MAID for mental disorders for this reason.4 Imagine a likely scenario if MAID were legalized for psychiatric disorders: a psychiatric inpatient ward where some patients are being treated for suicidal thinking or behavior, perhaps involuntarily, but others on the same ward might be deemed eligible to receive MAID. Besides the moral injury to the clinicians, how confusing it would be for the patients in that milieu! Now scale up this conundrum to the general population where, nationally, some suicides for mental disorders are not prevented, but provided. That will impact the taboo against suicide—a vital component of suicide prevention in general. A taboo (“it is not good to commit suicide”) is different than stigma (“you should be ashamed if you try it”). Indeed, because of MAID’s dampening taboo, there is growing evidence that the rates of “ordinary suicide” in jurisdictions that have MAID (specifically Oregon, Switzerland Netherlands, Belgium5 and Australia6) have risen much faster after it was legalized than before, strongly suggesting the emergence of “suicide contagion”—a well-known public health phenomenon. The mixed messages of the provided vs the prevented suicides are profoundly impactful, particularly on those with mental illness, who already struggle with impairment in rational reflection about suicide as an option.

Enormous and Nonspecific Variety of Treatments for Mental Disorders

The breadth of treatments for psychiatric illnesses is wider than for somatic treatments. There is much less specificity for any one medication, therapy, or procedure for a mental disorder. Treatments for psychiatric disorders are much less precise than for somatic disorders.7 For example, a medication that might be effective for schizophrenia will also be effective for bipolar disorder, anxiety, posttraumatic stress disorder, insomnia, eating disorder, and others. Psychiatric treatments come in many modalities from over 100 pharmaceuticals of different actions to several hundred bona fide methods of talk therapy and physical treatments,8 like electroconvulsive therapy, transcranial magnetic stimulation, and many others. The response of several patients with a similar psychiatric condition can be highly variable,9 more so than for nonpsychiatric conditions, requiring a much more robust trial-and-error approach. Patients typically require more than one kind of treatment for optimal benefit. There is not widespread availability for so many of these various treatments, particularly some cutting-edge treatments like psilocybin, clozapine, ketamine, and dialectical behavior therapy. Some are available only in academic centers and some are wielded primarily by subspecialists in a certain condition, who may be difficult to access, as they are scarce, with long waiting lists to see them. Waiting lists for such specialists in Canada can be far longer than the 90-day wait for Track 2 MAID.10 Off-label treatments are especially common in psychiatry, even when there is a good evidence base, so they may be difficult to get approved.11 Therefore, not every treatment is available to every psychiatrist, and indeed, not every psychiatrist is even aware of the full scope of treatment options, or is trained in them.12

The Challenge of Evaluating Capacity to Consent to MAID

Capacity to consent to treatment is more elusive in the setting of mental illness. The most respected bioethics textbook in the world, Principles of Biomedical Ethics, written by Beauchamp and Childress, defines autonomy as: “Self-rule that is free from both controlling interference by others and from inner limitations.”13 Mental illnesses and their associated cognitive and emotional distortions are the quintessential inner limitations. The state-of-the-art of capacity assessment is a highly complex one, which was developed for far less serious existential issues than to make the decision to end one’s life. It was developed for capacity to stand trial, write a will, consent to surgery, etc. Even at that level, capacity assessment requires specialized training that even most psychiatrists do not have. It is a skill that is provided mostly by certain psychiatric subspecialists—forensic psychiatrists and consultation-liaison psychiatrists who work on medical and surgical wards. Even in the Netherlands, a country that has had 2 decades to develop experience with psychiatric MAID, one study showed that 92% of psychiatric patients receiving euthanasia had inadequate capacity assessment,14 because there were no agreed upon standards for such an assessment for approving a suicidal wish in that cohort where suicidal feelings are particularly endemic.

Those With Mental Illness Are More Marginalized and More Vulnerable

Family physician Ramona Coelho has written: “When feeling like a burden, or when loneliness, depression, or fear of prolonged suffering are the factors driving the decision, the choices for MAID are not made in true freedom but are borne of anguish and desperation... Suffering can distort autonomy.”15 Mental illness can indeed cause severe suffering. One might even consider it the “most human” form of suffering. That marginalization makes individuals more vulnerable to requesting MAID, which has been widely documented in Canada. Those with chronic and severe mental illnesses are among the most marginalized citizens of all. They are overrepresented in the lowest socioeconomic quintile of the population.16 They are more likely to be underresourced, disabled, unhoused, and stigmatized than people with other medical conditions. Franklin Roosevelt famously said, “necessitous men are not free men.” Those with mental illness are disproportionally necessitous.

MAID Inverts the Fundamental Ethos of Mental Health Professions

It is already challenging for physicians to get out the way of death, and to refer patients for palliative care. Further, to administer the means to actively produce death is anathema to medical ethics, but particularly for psychiatrists, whose daily work and fundamental ethos is to prevent suicide. This is why the American Psychiatric Association is opposed to any intervention to produce death for those with mental illness.17 Mental health professionals typically have longer and more frequent encounters with individual patients than other physicians and health care professionals. Helping individuals deal with despair, demoralization, suffering, and hopelessness is a core mission in the mental health professions. Psychiatric clinicians address symptoms, but also build coping mechanisms, mobilize support systems, and even help people make meaning of unresolved suffering. Mental health experts are skilled at accompanying patients in their afflictions and have specific training and experience on how to avoid absorbing a patient’s hopelessness and nihilism, a skill set which is independent of any psychiatric diagnosis. To create a facilitated path to suicide by opening MAID in the setting of mental health treatment is a profound, indeed revolutionary, and perilous inversion of that professional ethos for individual patients, and for public mental health.

Dr Komrad is a psychiatrist on the teaching staff of Johns Hopkins Hospital in Baltimore, Maryland. He is also a clinical assistant professor of psychiatry at the University of Maryland in Baltimore and on the teaching faculty of psychiatry at Tulane University and Louisiana State University in New Orleans, Louisiana. He is also a founding member of the international physicians’ organization Doctors Say No.

Dr Ferrier is a family physician working in the Division of Geriatric Medicine of the McGill University Health Centre. She is an assistant professor in the Department of Family Medicine at McGill University in Montreal, Quebec, Canada, and is the president of the Physicians’ Alliance Against Euthanasia.

References are attained by linking to the original article (Article Link).

We mourn the death of Dr Balfour Mount

Alex Schadenberg
Executive Director, Euthanasia Prevention Coalition

Dr Balfour Mount

Katrine Desautels reported for the Canadian Press on September 30 that Dr Balfour Mount, the Father of Palliative Care in Canada, died on Thursday September 25 at the palliative care unit that bears his name at the Royal Victoria Hospital in Montreal. Mount was born on April 14, 1939. Desautels reported that:

Dr. Mount was born in Ottawa. He studied medicine at Queen’s University in Ontario, then specialized in urology at McGill University in Montreal and in surgical oncology at the Memorial Sloan Kettering Cancer Center in the United States.

Balfour Mount and Cicily Saunders

Desaults explains how he became the father of palliative care:

In the 1970s, Dr. Mount traveled to the United Kingdom to learn more about end-of-life care, notably from Dr. Cicely Saunders, who created the hospice movement, which is in some ways the basis of the palliative care we know today.

Upon his return in 1975, Dr. Mount founded the world’s first comprehensive palliative care unit at the Royal Victoria Hospital of the McGill University Health Centre.

The following year, he established the McGill University Biennial International Congress on Terminal Care, which he chaired until 2004.

He continued to be closely involved with McGill University in the 1990s, notably by becoming the Eric M. Flanders Chair in Palliative Medicine and then the founding director of McGill’s Holistic Care Program.

Today, his legacy in the field of palliative care is undeniable. According to the Canadian Medical Hall of Fame, in 2015, 67 per cent of acute care hospitals with more than 50 beds in North America had palliative care teams.

Balfour Mount Canada Post stamp

Balfour Mount commented on euthanasia (MAiD) in an interview for Palliative Care McGill. Devon Philips published the following:

Q: You have explained the demands and rewards in setting up palliative care services and how our healthcare system is currently failing to support the implementation of palliative care in many instances. Now the bill permitting medial aid in dying has been passed.  What would you say to people who support medical aid in dying?

A: The first thing I would say is that the very name of that intervention, “medical aid in dying”, is misleading rhetoric. Medical aid in dying is what I have been doing for 50 years. This bill is not talking about medical aid in dying really, it is not talking about ending the suffering, but instead, ending the sufferer. We are talking about legalizing killing people. We have to be clear what this is. I am totally in favour of medical aid in dying. I have spent my professional life working toward that end. But, I do not support euthanasia and assisted suicide.

Q: Can you talk about what you mean by medical aid in dying.

A: The chartered accountant that I admitted on the palliative care unit is an example that comes to mind. He came in with his wife. He had advanced cancer. They were lovely, articulate people and a devoted couple with two adult sons. She said, “I’ll speak for my husband because he has suffered terribly, he is so tired and we really want this to end.” I said, “I am glad you are here, give me a few days to get to know what this suffering is about and then let’s sit down again.” Later that afternoon, after his wife had left the PCU, I went to his bedside for a visit and after chatting for a while said “You know, I don’t see you as a person who wants to die. I see you as a person who wants to live but without the discomfort you have had”, and then this man in his late 50s started to cry. He said, “You are right but I don’t want to be a burden to my wife,” to which I responded, “It can be a big job to care for people at home, but that’s why we have a Palliative Care Unit. Your wife and your sons can come in when they feel up to it. You are not a burden for us. You are why we are here.” His comfort levels and quality of life were superb within a day or two. There was no more talk about his desire for death. There was talk about what interested him and the sources of his quality of life. We had removed his fear of being “a burden”.  Every time I see the words “medical aid in dying”, I think of him. Medical aid in dying was what this gentleman received, but it was certainly not euthanasia or assisted suicide.

Barbara Kay, in her article, Euthanasia is Killing, that was published in November 2014, commented on Balfour Mount's opposition to euthanasia by writing:

Dr. Mount’s passionate disdain for the medicalization of euthanasia remains undimmed. Calling euthanasia “medical aid in dying” is a “cowardly distortion of language,” he said. The dying do not want to be killed; they want an “easy death,” and “that is what palliative care gives them.”

CBC news reported Dr Mount as stating at a Physicians Alliance for the Total Refusal of Euthanasia conference in May 2013 that:

"Euthanasia and physician-assisted suicide makes it necessary for a society to legalize killing — ending life. It's a switch in goals," he told a crowd that gathered in downtown Montreal on Saturday to unite against the practice.

Dr Mount, in his reflections in Le Devoir on February 1, 2010 wrote:

The last weeks of life are "the most precious time of family life" because this is when people resolve the unresolved cases where we can say the love and attachment that is brought to the family. "This is an important moment of sharing that can soften the death of the person who is dying and who can make the next 40 years calmer and happier for those who survive. This time holds tremendous potential that is lost if the person were euthanized,"

Dr Ferrier, Balfour Mount award

I am fortunate to have had the opportunity to meet and speak with Dr Mount on a few occasions. The Euthanasia Prevention Coalition, several years ago, created the Balfour Mount award that we have given to many deserving people.

Balfour Mount was a sign of hope for our times. We need to listen to and learn from his wisdom and experience. 

We mourn his death, but we also mourn that our country did not follow his path of providing care and rejecting killing.

Québec expands euthanasia law. They already have the highest euthanasia rate in the world.

Alex Schadenberg
Executive Director, Euthanasia Prevention Coalition

On June 7, The Physicians’ Alliance against Euthanasia joined with the Living with Dignity citizen network to express their great disappointment that Bill 11, An Act to amend the Act respecting end-of-life care and other legislative provisions was passed in the Québec legislature.

Many people are not aware that Canada has two euthanasia laws, a Québec law that came into effect in December 2015 and a federal law that came into effect in June 2016. Bill 11 amended the Québec law.

The Physicians' Alliance and Living with Dignity reported that Bill 11 will expand euthanasia in Québec in the following ways:

• creating an obligation for palliative care homes to offer MAID (in 6 months);
• offering MAID in cases of serious physical disability* (in 9 months);
• offering MAID by advance request* (in a maximum of 24 months).

*together with the other criteria of the Act respecting end-of-life care.

The Canadian Press reported that Bill 11 "also allows Quebecers to receive a doctor-assisted death in places other than hospitals, such as funeral homes and long-term care facilities."

A CBC radio program (in french) program by Davide Gentile & Daniel Boily reported on February 16, 2023 that more than 7% of deaths were from medical assistance in dying in Quebec with more than 5,000 people who died by MAiD in 2022, compared to less than 1,000 MAid deaths five years ago.

I reported on February 20 that the Québec government Commission on End-of-Life Care launched a consultation to learn why Québec has the highest euthanasia rate in the world.

Based on the passing of Bill 11, the euthanasia rate in Québec will only go up. As already stated, Bill 11 will force palliative care homes, that have refused to participate in MAiD, to provide it. Bill 11 expands the definition of eligibility to include people with serious disabilities and it expands euthanasia to be permissible by advanced request.

By forcing palliative care homes to provide euthanasia, some palliative care professionals will leave the profession. Defining euthanasia eligibility to specifically permit the killing of people with serious disabilities, who are not otherwise dying, confirms the eugenic nature of Québec's euthanasia program.

Pierre Luc Turcotte stated in his article published by the Montreal Gazette that:

In Germany, during the Second World War, "competent professionals" - doctors and nurses - participated in a euthanasia program that led to the deaths of 200,000 disabled persons. This eugenic policy was part of the Nazi's social cleansing efforts. But it was also seen and socially accepted as "medical care" based on the reasoning these lives were "not worth living." While a parallel with Bill 11 may seem far-fetched, eugenics similarly existed in Québec.

We must take every precaution to avoid repeating mistakes of the past.

I know that people will say that it is unacceptable to compare Canada and Québec's current euthanasia programs to the Nazi euthanasia program that began in 1939, but if they are different, then Turcotte is correct to urge that we avoid repeating the mistakes of the past.

Québec has the highest euthanasia rate in the world and it has now expanded it's euthanasia law. It seems to me that Québec, and much of Canada, have become dedicated to death.

The question is not - why does Québec have the highest euthanasia rate in the world, but rather, what can be done to reverse the killing trend in Québec and Canada?

I recently projected that there will be at least 13,500 Canadian euthanasia deaths in 2022 representing a 35% increase.

Gratitude and Concern - Québec Euthanasia Committee report.

For Immediate Release.

A joint reaction of Living with Dignity and the Physicians’ Alliance against Euthanasia to the report of the Quebec Select Committee on the Evolution of the Act respecting end-of-life care

Montreal, December 9, 2021 – The citizen network Living with Dignity and the Physicians' Alliance Against Euthanasia would like to jointly express their gratitude to the Quebec Select Committee on the Evolution of the Act respecting end-of-life care for having shown wisdom in recommending that access to medical aid in dying not be extended to people whose ‘only medical problem is a mental disorder’. At the same time, both groups would like to express their concern regarding the recommendations that facilitate access to medically assisted dying via advance medical directives, to individuals who are incapacitated.

The commissioners conclude in their report that individuals who are capable, who have neurocognitive disorders and "who will ultimately be incapacitated, should be able to make an advanced request for medical aid in dying following a diagnosis”. This recommendation is widely supported by a population convinced that a diagnosis of neurocognitive disorders inexorably leads to a loss of dignity that would make life no longer worth living. As one doctor points out in the report, "people do not die with dignity from Alzheimer's". Living with Dignity and the Physicians’ Alliance Against Euthanasia strongly oppose this perception of dementia, as do many medical specialists (geriatricians and others) who work on a daily basis with individuals with dementia, who objectively, never lose their dignity. The incredible vulnerability of those living with neurocognitive disorders must be emphasised - vulnerability due to their condition and due to the societal view. The State has a duty to protect them. Charity takes precedence over self-determination.

It should be remembered that there are still many voices decrying the serious ethical problems associated with an extension of MAiD by advance directives. Many of these issues have already been described in the submissions of Living with Dignity and the Physicians’ Alliance against Euthanasia (please see below), as well as other experts in the field, including Dr. Félix Pageau and Dr. Pierre Durand. The consultations during the examination of a possible bill will be an opportunity to express our concerns about this extended accessibility favored by the Select Committee.

In closing, Living with Dignity and the Physicians’ Alliance Against Euthanasia hope that the committee responsible for the parliamentary review of the federal law on medical aid in dying will take note of the cautious choice made by the Quebec Select Committee on the Evolution of the Act respecting end-of-life care with regard to individuals whose only medical problem is a mental disorder. There is still time to act so that March 17, 2023 does not mark the opening of the door to medical aid in dying (under Bill C-7).

Video series to reflect on the issues surrounding the expansion of assisted dying

In conjunction with the tabling of the report, Living with Dignity has commenced publishing a series of seven videos (currently available only in French) to reflect on the issues surrounding the expansion of access to medical aid in dying. It gives the floor to Mr. Louis-André Richard. A professor of philosophy, he participated in the development of Bill 52 (Quebec law concerning end-of-life care) from 2010. An expert in ethical and political philosophy, he has been providing training in palliative care in Quebec and France for over 15 years. He holds a doctorate in philosophy, palliative culture and society.

Three of these videos are already available in an abridged version on the Facebook page of Living with Dignity (direct link) and in a long version on its YouTube page (direct link).

Contribution of Living with Dignity and the Physicians’ Alliance against Euthanasia to the work of the Select Committee on the Evolution of the Act respecting end-of-life care:

Click here for the testimony and brief of the citizen network Living with Dignity.

Click the following links for the testimony and the brief of the Physicians’ Alliance against Euthanasia.

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Media contact: (438) 938-9410

Jasmin Lemieux-Lefebvre

Coordinator

Living with Dignity

directionVDD@gmail.com

Charmine Francis

Coordinator

Physicians’Alliance against Euthanasia

info@collectifmedecins.org

What is the "good" of euthanasia, Part III: A true system of choice

Gordon Friesen

By Gordon Friesen, EPC Board Member.

Necessary comparisons 

I have stated, on many occasions, that I am categorically opposed to euthanasia and assisted suicide and I will continue to struggle, on the most fundamental level, for a complete prohibition thereof. However, this article is based on being faced with the necessity of choosing some rational framework, to accommodate assisted death as a fait accompli.

Some time around 2013, approximately two years after I first decided that my various writings in opposition to medically assisted death should be organized into an actual book (still incomplete to this day), I attended a public meeting, in Montreal, of the Physician's Alliance Against Euthanasia. Many very valuable things were said about the dangers of what was then mainly feared as "physician assisted suicide". In the post-presentation question period, I had the opportunity of advancing an unconditional right-to-die position according to which any rational person should be allowed to choose the time, and the manner, of their own death, with no medical criteria and in fact: with no criteria of any kind, other than a true ability to choose.

I didn't take this position because I wished to see assisted suicide legalized in Canada. Quite the contrary. However, I had become convinced that the principle of choice would inevitably prevail (as it subsequently has done), and that frankly embracing choice is the only possible way of preventing that much, much worse alternative, which consists of inaugurating a scheme of euthanasia, normalized as benign medical care (such as that which we see in Canada today).

I realize, of course, that this is counter to all intuition; and that most readers would naturally assume that assisted death, restricted by medical criteria, must still be preferable to a full-on right-to-die. And yet most sincerely, after multiple decades of considering these questions, I would wish to argue that this is not logically the case; or at least, I would wish to invite the reader to undertake a comparison of relative harms in each case (right-to-die, versus medical euthanasia), according to a very simple standard ("What is the worst that can happen ?"), applied fairly to each.

A summary quantitative analysis

Unfortunately, from the moment we accept any form of assisted death, people are going to die. That is the inescapable fact. Therefore, In order to choose our poison (that is: to choose any form of assisted death), we must mainly consider the effects of those deaths on the rest of society.

The first and simplest measure, of social impact, would be quantitative: for more deaths must produce more effect. And on this score, we see that the very permissive Swiss system, of largely choice-based assisted suicide, produces only about half as many deaths as the heavily medicalized euthanasia system of neighbouring Netherlands; and also, the number of physician assisted suicides in the relevant American States, is truly trivial in comparison with the volume of euthanasia, per capita, as already performed in Canada, only five years after legalization (2016).

And yet there is a deeper measure of harm involving the damage wreaked upon the moral compass of individuals, and indeed, upon the moral fabric of society. And it is upon these injuries that I would wish to insist in what follows.

The German example : Moral implications of a free choice of death

On February 26, 2020, the German Federal Constitutional Court struck down a recently passed law which had been intended to prevent private organizations from offering assisted suicide as a quasi-commercial service. The logic was simple : people have a (constitutional) right to commit suicide and to seek aid in so doing; but to stop the operation of organizations offering such assistance, would be to effectively nullify that right; and therefore, such organized (and presumably even commercial) activity must be allowed.

As far as the underlying moral case is concerned, it is simply recognized, in this ruling, that different moral opinions exist in a pluralist society; that it is not the role of the High Court (of a constitutional state) to make judgments of a moral nature; that such a role must be limited to ensuring the constitutionality of legislation.

Simply stated then: despite enabling assisted suicide, the German State will not affirm that assisted suicide is "good" (either in general, or in any particular case). And above all: there is no suggestion, explicit or implied, that the German government, German society, individual German citizens, or any professional group, in Germany, have the slightest obligation to provide assisted death.

Free assisted death, and protection of the sick and disabled

In keeping with this general approach there are a number of especially significant elements in the actual judgment, and in particular the following (quoted from the official translation):

"The right to a self-determined death is not limited to situations defined by external causes like serious or incurable illnesses, nor does it only apply in certain stages of life or illness. Rather, this right is guaranteed in all stages of a person’s existence. Restricting the scope of protection to specific causes or motives would essentially amount to a substantive evaluation, and thereby predetermination, of the motives of the person seeking to end their own life, which is alien to the Basic Law’s notion of freedom."

In other words, Germany does not opine on the value of motives. There is no limit on the personal freedom to die, medical or otherwise. And this, paradoxically, is precisely what protects others, in such a system, from "death by association". For to state that a person "should" be allowed to die in situation "A" (but not situation "B"), is the same thing as saying that it is "right" for "A" to die. And thus, to affirm, for instance, that only a person with a grave medical condition "should" be allowed to die, is functionally the same as saying that it is "good" for such a person to die (in a way it is not for others); which, to be sure, is only a hairsbreadth away from simply stating that such a person "should", in fact, die. The German model, however, avoids these grossly discriminatory implications entirely; and thus avoids placing a significant moral pressure towards precocious death (backed by the full authority of the State) upon particular vulnerable groups, which is to say: upon the ill and disabled.

Freely assisted death and the medical profession

To judge the independent and pluralist nature of medical ethics in Germany (and the freedom of individual doctors to practice as they wish) we note that in spite of the assumed constitutional right to die, the following were actually given as reasons for why independent suicide services are indeed necessary:

"Without (assisted suicide services) the individual is reliant on physicians ... at least in prescribing substances. ... willingness of a physician can only be expected in exceptional cases. ... physicians have shown little willingness ... and cannot be obligated... The prohibition of suicide assistance from physicians... has been incorporated into the professional codes of most State Chambers of Physicians,... (and this) guides the actions of physicians in practice even where the relevant codes are not considered legally binding."

Quite clearly, also, there is no expectation that any of this will (or should) change. For under this paradigm of mutual freedom, it is simply assumed that the protection of assisted suicide services in no way places any obligation, or demand, upon individual doctors, upon doctors' regulating bodies, or upon the medical profession as a whole.

Assisted suicide and the State

Because the German State has declined to recognize any moral validity to the constitutionally protected right to die, that State retains its own right (and assumed obligation) to do the following:

"taking measures of general suicide prevention. ... establishing that the individual’s resolution to commit suicide is sincere and final ... expanding and strengthening palliative care ... counter dangers arising from current and foreseeable living conditions capable of influencing the individual to choose suicide ... preventing assisted suicide becoming recognized as a normal way of ending life... counteract developments that create social expectations pressuring individuals to take their own life, e.g. based on considerations of usefulness."

The very last sentence, of this historic judgement protecting the operation of independent assisted suicide organizations in Germany, is the following detached statement:

Regardless (editor's italics), there can never be an obligation, on anyone, to assist in another person’s suicide.

Standing as a paragraph all of its own, this statement apparently means "regardless" of any consideration whatsoever, and the term "anyone", would logically include individuals, professions, and the State itself.

In conclusion

The measure of the value of any moral system lies in its internal coherence. The coherent implications of a free right to die (including the right to seek assistance in dying) lead logically to a position such as that of the German Federal Constitutional Court described above: with no explicit discrimination against the ill and disabled; no obligation of the medical profession; no moral association of the state; and thus, providing an optimal environment for positive regulation, and for the development of countervailing measures.

I have stated, on many occasions, that I am categorically opposed to assisted suicide and I will continue to struggle, on the most fundamental level, for a complete prohibition thereof. However, faced with the necessity of choosing some rational framework, to accommodate assisted death as a fait accompli, I find the non-medical right-to-die interpretation comparatively appealing. In a future continuation of this text, I hope to analyze, also, the rational implications (and practical results) of the medical euthanasia system, as adopted in Canada. I will then invite the reader to look, dispassionately, at the respective advantages of these two models, when laid side by side.

One might suggest, of course, that we Canadians no longer have the leisure of choosing between these paradigms. For, as a practical matter, we are already saddled with both. However, I would argue that this actually makes it all the more important to clearly distinguish between the two, in the hopes of preventing the worst properties, of one, from enabling (and enhancing) those of the other.

Gordon Friesen, Montreal, September 20, 2021

http://www.euthanasiediscussion.net/ (français)
http://euthanasiadiscussion.com/ (english site in development)
http://hopeandfree.com/ (personal philosophical musings)

Doctors (world-wide) are being invited to sign this open letter: Doctors Want No Part in Euthanasia and Assisted Suicide.

An open letter from doctors around the world to medical ethicists and lawmakers

Link for doctors to sign the open letter (Link).

Doctors Want No Part in Euthanasia and Assisted Suicide

Euthanasia and Assisted Suicide are not part of Medicine

As medical doctors, we are committed to supporting people to both live and die with dignity and comfort.

We are determined that state-of-the-art care should be available for people who are dying and also for people suffering from chronic disease, disability or mental illness.

We believe that universal and equitable access to effective pain and symptom management, including mental healthcare and palliative care, is a fundamental human right.

We fully support the right of a person with decision-making capacity to decline a treatment offered to them.

We support clinicians and patients agreeing to withdraw or withhold burdensome and ineffective treatment in favour of supportive and palliative care.

We believe that doctors have the training and skill to promote and maintain a caring doctor-patient relationship.

It is our view that skilful and effective pain management neither requires nor uses lethal doses of drugs.

We believe neither assisted suicide nor euthanasia is a medical procedure. Doctors should play no role in the regulation, or practice, of euthanasia and assisted suicide.

We are especially concerned with protecting vulnerable people who can feel they have become a burden to others, and we are committed to supporting those who find their own life situations a heavy burden.

We endorse the views of Medical Associations around the world which hold that physician assisted suicide and euthanasia are unethical, even if they are made legal.

“Leave doctors to focus on advocating for patients – to cure sometimes, to relieve often and to comfort always.”

Join us

If you are a registered doctor and would like to add your name to this Open Letter, complete the form below. These details are required to confirm that you are a medical doctor.

Declaration of good faith and disclaimer

The organisers have sought, and continue to seek, support for this open letter from currently practicing medical doctors within participating countries, and every reasonable effort is made to verify that they hold a valid practicing certificate or licence. The list of supporting doctors is published in good faith with a commitment to correct any errors, but the organisers disclaim any liability for published names found to be ineligible.

Link for doctors to sign the open letter (Link).