Margaret Cottle
In the place where you hear the sound of the trumpet, rally to us there. Our God will fight for us. (Nehemiah 4:20)
Although the description of this presentation was “Advocating for end of life issues in the public square”, in reality, unless our efforts are rooted in a solid faith foundation our advocacy will be doomed. In most of the jurisdictions where euthanasia and assisted suicide are already legal, many Christians have either voted in favour of those measures or stayed out of the discussion altogether because they had only a superficial understanding of their responsibilities and the implications of the issues. The serious dangers that result from the legalization of state-administered death have been largely suppressed by the media and underestimated by the Christian church. In addition to imparting important information, I pray that you will hear our call for help and be inspired to join your medical colleagues in their positions on the wall.
Medicine, as it has been practiced for centuries, is under threat. Respect for life and traditional Hippocratic Medicine have been radically eroded. The ethos of our society is now similar to Roman times when the government largely ignored private worship, but meted out unmerciful punishments to those who did not bow down to the emperor. Today, this private/public dichotomy is less openly violent, but just as real. Licensing bodies for physicians and other health care professionals are mandating that we “check our morality at the door” and provide, or at least refer for, any legal service that the patient wants — even if we have reasonable evidence that the so-called “service” might harm our patient.
Editorials in academic journals declare that students should be refused admission to medical schools unless they are explicitly willing to perform (not just refer for or tolerate) any legal procedure. (Savulescu, J & Schuklenk, U, “Doctors Have no Right to Refuse Medical Assistance in Dying, Abortion or Contraception”, Bioethics Vol 31 issue 3. https://doi.org/10.1111/bioe.12288) Questions are included in current medical school applications and admission interviews that appear to be specifically designed to identify and disqualify students who might not support the prevailing views on contentious societal issues. Once students enter medical school, if their personal beliefs are flagged as “deficient” their “lack of professionalism” is remediated. At every level, dissenting voices are actively suppressed and differing views are misrepresented and demeaned. Belief in God is regularly disparaged and often identified as a handicap that might hurt patients and cause problems for the medical system. Very few physicians or professors with divergent views teach the students and these individuals are often at a disadvantage for promotion or other leadership opportunities. Idealistic, Christian medical students are steeped in this toxic swamp from day one of medical school. My husband Robin is a medical school classmate of mine and an ophthalmologist. Together we have been hosting Christian medical and dental students in our home every week for 25 years for dinners, Bible studies and discussions. In our experience, most students are woefully unprepared for the denigration and vilification of principles that they have simply taken for granted. Once they have begun their medical studies, they are usually too busy just surviving to take time to think deeply and carefully about ethical or theological issues. Furthermore, they have rarely had any experience with what healthy civil discourse might entail.
There is an obvious but unacknowledged irony in suggesting that it is possible, much less desirable, to remain “morally neutral” in a profession where every patient interaction is related to what the patient “should” or “ought” to do or not do. (You should stop smoking; you ought to take this medication…) As one of our colleagues, Dr. Dan Reilly says, “When they say that they want us to ‘check our morality at the door’, they don’t mean all our morality—they still want us not to cheat, lie, or seduce our patients, all of which are also expressions of our morality — they mean that they do not want us to act upon certain moral opinions that are not in alignment with their own.”
In addition, medical students and residents are often legitimately concerned that they may be excluded from certain career opportunities if their views are revealed. Younger physicians feel vulnerable as well. Having invested their hearts and minds, years of their lives and tens of thousands of dollars, the possibility that they may be shut out from practicing medicine is daunting. They “signed up” to cure and to care, not to kill. They are literally asking, “Will there still be a place for me?”
We face not only reasoned arguments from those who hold different views, but deception, outright lies, and personal attacks which are sometimes quite vicious. How absurd that those of us who do the genuine hard work of accompanying — being radically present with — our patients in the midst of their suffering without taking their lives are the ones accused of lacking compassion, and with “abandoning” our patients or “obstructing” their “right” to euthanasia.
However, I refuse to despair. Our God is still on the throne and will never leave us or forsake us. Challenges such as these are not new. The Apostle Paul always urged his followers to expect many difficulties and hardships and to stay strong, and the same message is in the letters to the churches in Revelation. The Lord’s charge to Joshua and the Israelites resonates today: “Have I not commanded you? Be strong and courageous. Do not be frightened, and do not be dismayed, for the LORD your God is with you wherever you go.” Daniel, too, from his post as an exile in a hostile culture, declares, “but the people who know their God shall stand firm and take action.” “And those who are wise shall shine like the brightness of the sky above; and those who turn many to righteousness, like the stars forever and ever.” Staying strong in the full armor of God must indeed be possible since it is commanded! Nevertheless, grieving and wounded health care professionals are in urgent need of well-trained, skillful reinforcements. We are already working with our weapons in our hands and are sounding the trumpet at our section of the wall.
How can the church help us? In my opinion, the most important thing that churches can do in the battle against this present darkness is to thoroughly catechize the members of their congregations about the basics of the faith.
Many otherwise strong Christians are led astray on crucial issues because their feelings are swayed by tragic stories and misplaced compassion. They have not yet come to understand — and to accept completely — that if the Lord says that something is wrong, it can never bring joy or peace, but only death in every sense of the word. Essential areas for universal competence include: a nuanced, Christian response to suffering that is infused with kindness and compassion; a well-rounded and solid understanding of the respect for life based on the imago Dei in each one of us; a clearly defined Scriptural view of autonomy and interdependence; the affirmation of robust conscience protection; and expertise in practical ways to support every member of the human family in loving community. There are many excellent arguments about why euthanasia is wrong and dangerous, but they will be lost on anyone who has a “sandy” foundation in these basic areas. Comprehensive, well-planned strategies that are diligently implemented are vital. A student who arrives at medical school without this training is already a casualty.
A few specifics about the issue of euthanasia. Language matters! I try to use the more precise terms of euthanasia (where the provider gives the lethal injection or performs the action to take the patient’s life) and assisted suicide (where the means are provided to the patient, but the patient takes the final action himself). I am heartened that in May 2018, the American Medical Association’s ethics committee has decided to retain this more accurate terminology and to continue its opposition to physician assisted suicide and euthanasia. How their general assembly will proceed is still unclear, however. As a palliative care physician, I vehemently object to the euphemistic term MAiD (Medical Aid in Dying). I have been “aiding” patients to ease their dying for decades without hastening death or killing a single one. The language has been intentionally hijacked to give the procedure a medical gloss of acceptability. I strongly urge you to use the more accurate terms whenever possible. In Canada, most of our terminations (as the Dutch more honestly call them) are by euthanasia, with very few assisted suicides. Most jurisdictions in Europe practice euthanasia, but in the US solely assisted suicide has been legalized and only in certain states. It should also be noted what does not fall under this umbrella: withholding or withdrawing medical treatment that is no longer useful, is harmful or extra-ordinary; the appropriate, skillful use of large doses of pain killing medications; and the use of proportional sedation within an approved protocol of medications. Decisions about food and fluids depend upon the individual situation and how close to death the patient is judged to be. There is no “one size fits all” in this area and intention is the most important factor. Is the intention to stop something that is giving disproportionate distress to the patient, or to cause the death of the patient? Discernment about intention can help to bring some clarity into the process and show the proper next steps.
Another note on language: those of us who address these issues in the public square have learned that using terms that have any religious connotations makes our message harder for some to hear. Preston Manning reminded us that public policy making is the art of the possible, and encouraged us to be “wise as serpents and gentle as doves,” not “mean as snakes and stupid as pigeons”. In the spirit of gentleness and wisdom, I always pray for “Pentecostal” communication — that when I speak in my own “language” the Lord will enable others to hear His voice in their own “languages.” Genuine discussion about these difficult issues is usually a very lengthy process grounded in meaningful relationships and needing an extended period of interaction before minds or hearts are open to change. Another important suggestion is to use the term “professional” and not “provider” to refer to health care professionals. This minimizes the idea of consumerism in the context of euthanasia.
There is also danger for palliative care units and hospices across Canada. Part of the World Health Organization official definition of palliative care is that neither hastens nor prolongs natural death. There is a tremendous effort across Canada to force palliative care units and hospices to “allow” euthanasia and assisted suicide on their premises. This has already been mandated in the Fraser Health Authority (just east of Vancouver) against the strong objections of many palliative care professionals.
The vast majority of patients — who are also tax-paying citizens — want nothing to do with euthanasia and should have the right to be treated in facilities where they can rest assured that euthanasia never occurs. In addition, it is not abandonment to move a patient. Patients are moved all the time for specialized treatments or tests and without compromising their comfort. When patients no longer require or desire specialized care, they are moved elsewhere — even against their wishes at times. This is not discrimination.
Euthanasia supporters often use the catchy slogan: “My life, my death, my choice.” They promote the notion that any limit to personal autonomy is a Charter violation and use this to justify state supported euthanasia. But no one lives — or dies — in isolation. We limit autonomy continuously for the common good — no smoking, no impaired driving, etc. We are all interconnected and what one person does always affects everyone else. Environmental activists never stop hammering home this message. Our society seems to be willfully blind to the fact that our metaphysical environment is every bit as delicate and interrelated as our physical one. For example, it is almost humorous that smoking outdoors on a public beach in Vancouver is against the law due to the possible negative effects of second hand smoke, but we refuse to acknowledge that government sanctioned intentional killing — even at the patients’ request — will undoubtedly have some negative consequences and some unintended victims. Canadians understood these potential dangers when we rejected capital punishment.There is also no acknowledgement of the blatant double standard of suicide prevention for some lives and suicide facilitation for other lives.
This was thrown into bold relief by the events surrounding the adoption of Bill C-14 legalizing euthanasia in Canada in June 2016. Even as the bill was being debated and passed, teams of mental health experts were being sent to Attawapistkat, a small First Nations’ community in northern Ontario, to try to address a disturbing epidemic of suicides in the youth of this vulnerable community. It is of interest that while no expense has been spared and strong-arm tactics have even been used to ensure that every single person who “qualifies for” euthanasia has immediate and unfettered access to it, the youth who so desperately need the resources were still without the help they needed a full year later.
Futhermore, who decides which lives are worth living and which are not? If it is all based on the individual’s subjective experience of suffering, how can there possibly be any reasonable, objective determination about whose deaths to prevent and whose to facilitate? A good question to ask a euthanasia supporter is, “Is there anyone to whom you would deny euthanasia?” (Or “Would you say yes to everyone? If not, please give me an example of someone you would say no to.”) Once the person gives that example, ask, “On what basis are you denying this person’s right to self-determination?” Where does it stop once we accept the concept that death is ever a “solution” to a problem? Also, if we codify in law that there are lives that are not worth living, what does this communicate to those who are currently living in that way or who may later find themselves in that situation—people living with disabilities or serious illnesses?
If euthanasia gives a person a “death with dignity”, does that mean that someone who chooses to live to a natural end, despite limitations and disabilities, is living an undignified life by definition? Former CBC producer and disability rights activist Ing Wong-Ward has been outspoken about her decision not to pursue euthanasia in her recent fight against colon cancer:
The term ‘dying with dignity’ implies that death is a better option, Wong-Ward said. ‘When your body starts to fall apart, when you start to lose function, when you need incontinence care, when you can’t eat anymore.’ […] ‘I know so many people with disabilities […] who are not defined by how they go to the bathroom, or how they eat or how they communicate.’ […] ‘So what is this whole notion […] that dying is the only way to deal with this?’
As Ms. Wong-Ward has identified, the rationale for euthanasia often has to do with disability — either long term or acquired due to illness. The fear of the “not yet disabled” about what living with a disability might mean to them has led to the passage of laws that allow euthanasia — “I’d rather be dead that to live like that.” Governor Jerry Brown publically admitted that he signed the California bill legalizing assisted suicide because “I might want it someday myself,” — even though he had worked with Mother Teresa and knew of the alternatives and the dangers of hastening death, and even though he knew that the bill had passed under procedural irregularities. Sinister.
And how long will it be before the “choice” to die becomes the duty to die? A broad-based coalition of people and groups who are concerned about this has united under the banner of the Vulnerable Persons Standard. The group has accepted that euthanasia and assisted suicide are now legal in Canada and has focused its efforts on harm reduction.
Sadly, no government has implemented either the excellent, scholarly, measurable safeguards or the guidelines for the appropriate monitoring needed to prevent as much abuse as possible. A recent case in Ontario has highlighted these concerns as a young man with a disability has sued the government because it explicitly gave him only two choices: either euthanasia or to live at home with an unsafe home care system (he had food poisoning more than once and numerous falls due to the incompetent home care staff supplied by the government). He is suing to try to obtain enough support to live with dignity instead. The Vulnerable Persons Standard will be even more important as Canada is on the verge of approving euthanasia for children, for those with solely psychological suffering and by advanced directive for people who are not medically competent at the time of their deaths.
Hastening death is not a “solution” for suffering. Jewish holocaust survivor and Austrian psychiatrist, Dr. Viktor Frankl, explored the issue of suffering very eloquently in his remarkable small book, Man’s Search for Meaning. He reminded us that the last of the human freedoms is the freedom to choose how we respond to our circumstances. Dr. Frankl noted that although the guards in the Nazi camps were cruel, they could not “make” the prisoners hate them. The prisoners could still choose how to respond. He also observed that people can endure almost any “how” of suffering if there is a “why”. It is suffering without meaning that leads to despair. While this does not necessarily mean that the suffering itself always has an inherent meaning, it does mean, however, that there may be ways to put the suffering into a context where meaning might be extracted or refined at some point. Dr. Timothy Keller provides some wonderful narratives from those who have undergone tremendous personal suffering in his excellent, highly-recommended book, Walking with God through Pain and Suffering.
Working hard to ease the suffering and to respond graciously in the context of its mystery is a unique calling for Christians and Christian communities. One of the characters in Stephen Lawhead’s book Byzantium makes this profound observation as he accounts for his conversion to Christianity: “This hanging God is unlike any of the others; this god suffers, too, just like his people…so he knows how it is with me.” And when Corrie ten Boom asked her sister Betsie why God had allowed them to be prisoners in a Nazi concentration camp, Betsie answered, “We are here to show that there is no pit so deep that He is not deeper still. They will believe us, because we have been here.”
Emotional pain, feeling like a “burden” and feeling “useless” are problems more for our communities than they are for individuals. We are stewed or “baptized” into our society’s lie that independence is a virtue, but independence is not a Christian virtue — interdependence is. If members of our human family are feeling distressed, burdensome or useless, it is our privilege and our duty to come alongside them and welcome them into a community where they are loved and valuable simply because they are made in the image of God. There is nothing that is more deeply human than to accompany each other in the midst of darkness. And God is no one’s debtor. Although this service is often difficult, the incredible richness that is poured into our lives as a result is available in no other way —it is our silver refined seven times in the fire. As I have said many times in media interviews, Canadians are resourceful. We learned how to fish in the North Atlantic and farm on the prairies, we can figure out loving ways to care for each other in difficult situations.
The late Dame Dr. Cicely Saunders of Britain was the founder of the modern hospice movement. She developed the concept of total pain which includes not only physical pain, but psychological, social and spiritual pain as well. We are whole people and it is often difficult to control pain unless all its aspects are addressed. A patient I cared for many years ago illustrates the concept of “total pain”. I have changed many of the details to protect her privacy. I shall call her Jen. Jen was a young woman in her 30’s with an aggressive gynecological cancer. She had severe physical pain that was difficult to control. She finally admitted to us that she believed that her pain was the result of a “curse from God” due to her “promiscuous lifestyle” as she termed it, and that she deserved to have it. Assurance from us and a visit from her pastor soon ended her spiritual pain, and her physical pain was under much better control after that. However, it was still stubbornly present despite our best efforts. After several days, I visited her specifically to ask if there was something else that was bothering her that we should know. “Do you really want to know?” she asked. “Yes! I really do want to know!” I replied. “Well, I’m just worried that when I die, no one will be able to redeem the rewards points I’ve saved at our local department store.” I was stunned. “Your rewards points?!?” “Yes. I’ve been saving for several years in order to get a bicycle for my little boy, and I’m afraid the points will go to waste when I die, and he won’t get his bike.” Miracles sometimes do happen in palliative care, and thanks to a donation from our foundation to top up the points, her son was joyfully riding his new bicycle up and down the halls of our palliative care unit by the next afternoon. And Jen’s pain? It was soon well controlled on less than half the dose of pain medication that had been used unsuccessfully for days. We are whole people and every part of us affects the whole.
In addressing the fear of a bad death, Stephanie Gray refers to Dr. B J Miller of San Francisco, a palliative care physician who lost both legs and one arm in an electrical accident many years ago when he was a student at Princeton University. In his TED talk, Dr. Miller challenges us to make health care “about making life more wonderful not just less horrible” and to “make space to allow life to play itself all the way out, so that rather than just getting out of the way, aging and dying can become a process of crescendo through to the end.” He reminds us that we “can always find a shock of beauty or meaning in what life you have left. If we love such moments ferociously, then maybe we can learn to live well, not in spite of death, but because of it. Let death be what takes us, not lack of imagination.” Dr. Margaret Somerville, formerly director of the McGill Centre for Law and Medicine, concurs with Dr. Miller. She writes that euthanasia represents a failure of our collective human memory and imagination. As Christians, we have access by the Holy Spirit to infinite stores of creativity and imagination to bring shalom — peace with order — to every aspect of our living and our dying. Are we committed to finding ways to bring beauty for ashes and the oil of gladness instead of mourning? This will mean investing the time, space and energy in our church families to provide meaningful, sustainable support for people who are lonely, ill, disabled (mentally or physically) and marginalized.
This is not easy — there can be very obvious reasons why people are lonely or marginalized! We may even need to become involved in civic policy-making or legislative efforts.
In Matthew 26:38 Jesus said to Peter James and John, “My soul is very sorrowful, even to death; remain here, and watch with me.” At the moment, those of us on the medical part of the wall are uncertain and truthfully a little frightened about what the future may hold. We would be so very grateful if our church families will watch with us! The early Christians, fearless and empowered after Pentecost, were characterized as people who had “turned the world upside down.” Perhaps the Lord is calling us, together, to start turning it upside down again!
“Therefore encourage one another and build one another up, just as you are doing… Now may the God of peace himself sanctify you completely and may your whole spirit and soul and body be kept blameless at the coming of our Lord Jesus Christ. He who calls you is faithful; he will surely do it.”