Wednesday, December 14, 2011

Euthanasia: Thinly Veiled Propaganda Disguised as a Report

Margaret Somerville | Wednesday, 14 December 2011 
Tipping the scales towards euthanasia
A widely publicized report published by the Royal Society of Canada presents a thoroughly one-sided view.

The Royal Society of Canada Expert Panel on End-of-Life Decision Making recently released its Report to much media attention. The parts of that report we can all agree on, for instance, the need for much better access to palliative care and pain management for terminally ill patients, was not the media’s focus. The panel’s recommendation that euthanasia and physician-assisted suicide (PAS) should be legalized was.

It has generated many calls for a national debate in Canada on these latter issues – mainly, I would guess, if not entirely, from people advocating the legalization of euthanasia. In entering such a debate and deciding whether they agree with this recommendation, it’s important for Canadians to understand the weaknesses of the Report.

The Panel’s mandate included the following direction: “The public would… benefit greatly from having a careful, balanced review of various pros and cons of decriminalization of physician-assisted death from well-reasoned ethical and legal standpoints.” The Report comes nowhere near fulfilling this mandate. It’s a pro-euthanasia manifesto – to paraphrase an advocate for disabled people speaking in another context, it’s “thinly veiled euthanasia and assisted suicide propaganda disguised as an expert report”.

This is not surprising in view of who the authors are. Many are well-known pro-euthanasia advocates and, as the Report is unanimous, one can assume all agree with this stance. The people I know whom the Panel lists as consulting to them are, likewise, pro-euthanasia -- three of them world-leading advocates.

It’s important to understand this is not a Report of the Royal Society of Canada, as many have mistakenly assumed, as that gives it an unmerited credibility. It’s a Report of an expert panel (only one member of which is a fellow of the Royal Society) set up by the Royal Society. The fairness and wisdom of the Royal Society’s choice of panel members must, however, be questioned.

The Report is very far from being a “balanced review” or adequately comprehensive. The arguments against the legalization of euthanasia and PAS are almost entirely absent. Issues are considered almost entirely at the level of the individual. There is almost no discussion of the impact of legalizing euthanasia and PAS at the institutional level -- in particular, the impact on healthcare institutions and professions, and the law – or at the societal level, in particular, on important shared values, such as respect for life. In fact, this value is not discussed, an extraordinary omission considering the topic of the report.

Discussion of abuses is deficient and selective
The discussion of the practices in jurisdictions that have legalized or allow euthanasia and assisted-suicide are seriously deficient and very selective so as to minimize the Report’s coverage of abuses, expansions of justifications for the practices, and other problems or controversies.

For example, the Report indicates there has been one case of the use of euthanasia on disabled babies in the Netherlands. This is probably correct in the short time since the Groningen protocol allowing such euthanasia was formally accepted. But, prior to that, an article in the New England Journal of Medicine documents 22 cases of babies with spina bifida being euthanized, which is not mentioned. Such “pro-euthanasia presentations” of the facts are concerning and misleading. Likewise, the availability in the Netherlands of euthanasia for children is not mentioned. The combination of euthanasia and donation of organs for transplant in Belgium and the recent case in Flanders of “joint euthanasia” of a terminally ill man and his healthy wife are ignored. And a survey of Belgian physicians who had carried out euthanasia, published in the Canadian Medical Association Journal, which showed 32 percent of those physicians had carried out euthanasia without the patient’s request or consent is never mentioned.

The system set up under the Oregon Death with Dignity Act is presented as largely problem-free. The literature describing problems, for instance, articles and book chapters by renowned pain specialist and head of palliative care at Memorial Sloane Kettering, Dr Kathleen Foley, and Dr Herbert Hendin, a New York psychiatrist specializing in suicide prevention, is likewise totally ignored.

And although Canadian psychiatrist Dr Harvey Max Chochinov’s research is referenced, his ground-breaking work in the psychiatry of dying people, what helps them and what they want, is not discussed.

Through the lens of individual autonomy
The authors make an assumption that individual autonomy, implemented through “informed choice”, is always the prevailing value and construct their case for euthanasia and PAS from there. They do not consider that for many people some other value might prevail – for example, respect for human life which requires that we don’t kill each other, except when unavoidable to save life -- and what line of argument and decision outcomes that would result in.

In short, the authors have adopted a basic assumption, from which, as they state, everything else they accept and recommend flows, without adequately justifying doing so and not even mentioning the possible alternatives.

The essential difference between the pro and anti euthanasia positions is that the former gives priority to individual autonomy over respect for life, the latter does the opposite. We should keep in mind, here, that we are not just talking about the value of respect for each individual human life, important as that is, but also, respect for human life in general. The authors refer to the Charter as the primary source of our shared values: Apart from any other claims on behalf of the value of respect for life, it is one of the values enshrined in the Charter.

There is a strong emphasis in the Report on the burden and healthcare costs of an aging population and the Report gives the impression that euthanasia and PAS will help to resolve this “problem”. The authors note that euthanizing people “in advanced stages of dementia” will be an issue to be addressed in the future. In other words, they don’t reject the possibility that this might be acceptable.

The Report doesn’t mention survey results, such as those from an Environics poll, which last year (2010) asked over 2000 Canadians what the government priority should be - legalizing euthanasia or improving end-of-life care, or both. Seventy-one percent said improving end-of-life care and 19 percent said legalizing euthanasia, and 5 percent said both (the remainder were Did not know/Neither).

What about elder abuse?
Because the Report seems to have a special focus on aging, I note that the Environics polls also showed Canadians are very concerned about elder abuse if euthanasia or PAS is legalized. The 2011 poll expressly asked about "elder abuse" and 76 percent of respondents said they were concerned about it, if euthanasia were legalized. The 2010 poll did not expressly ask about "elder abuse", but did ask a question where 78 percent of respondents said they were concerned that elderly persons (disabled and sick persons too) would be euthanized without consent. To another 2010 question, 63 percent said they were concerned elderly persons could be pressured to accept euthanasia in order to reduce health care costs.

The authors recognize their position involves an inconsistency in that they champion individual autonomy as the prevailing value, but clearly will place limits on its exercise and not recognize the validity of the choice to die of all autonomous, competent adults.

But, if individual autonomy trumps all other considerations, then why is there a need any other justification for euthanasia? Simply wanting to be dead and consenting to it should be sufficient: “Over 70 and tired of life”, as proposed in The Netherlands, would suffice. And why, even, does the person need to be “over 70”? What about the broken hearted 18-year-old whose first love has abandoned her; why can’t she exercise her autonomy to have assistance committing suicide?
And if there’s a right to commit suicide, then there is a duty not to interfere with people exercising that right. How then can we justify treating people brought to an emergency room who have attempted suicide?

The usual “confusions” used to promote the case for euthanasia are all present in the Report: equating all acts and omissions; arguing there is no difference between killing and allowing to die; conflating intention and motive in relation to desired and unwanted consequences of pain relief treatment; and so on. The opposite arguments are not presented. And the fact that courts and others rely on these distinctions daily in making legal and ethical decisions is ignored.

The section on dignity, which the authors recognize is a prominent concept in the euthanasia debate, is especially biased to the pro-euthanasia arguments and inadequate. In particular, a 2008 major and very comprehensive research report on the concept by the US President’s Commission on Bioethics is not even mentioned.

The above criticisms are not comprehensive, many more could be articulated. Fortunately, in my view, there is a wealth of grounds on which the Report can be easily dismissed.

Margaret Somerville is founding director of the Centre for Medicine, Ethics and Law at McGill University.
Retrieved December 14, 2011 from


  1. Hey, Paul! Why is Al Qaeda more compassionate than pro-lifers?

    The 9/11 hijackers got to die instantly.

    1. So murder is compassionate if it's quick? Physicians who violate the Hippocratic Oath and kill their patients are being compassionate if they do it quickly? Are those who favor euthanasia as a treatment for depression (as in the Netherlands) being compassionate? There are good ways to treat depression or to relieve severe pain that do not involve killing the patient. And deliberately killing people is never compassionate.

    2. But the basic moral confusion is in equating direct and deliberate killing (whichAl Qaeda and practitioners of euthanasia both practice) with abstaining from killing, which is a fundamental moral duty.

  2. It's the lesser of two evils. Cancer isn't usually quick and painless, Paul. Why is informed consent meaningless to you?

  3. Informed consent may justify some things, like surgery to heal a medical condition, but not others, like removing a healthy limb because the patient requests it. As public policy, it puts the vulnerable - the disabled, the marginalized, the poor and the elderly - at risk. See this comment by Carter Snead on Gov. Brown's bad decision in California:

    The lesser of two evils is a very dangerous argument that can justify the second worst evil act in the world if some tyrant credibly threatens the MOST evil action if you don't do it. For example, a concentration camp guard orders you to kill ten people or he will kill 100. Are there no actions you consider intrinsically evil no matter what? For me, there are and among them is the deliberate, intentional killing of an innocent person at any stage or condition of life.

    1. No, your position is short-sighted. It ignores the vast quantities of euthanasia cases that occur RIGHT NOW, without consent.

      And yes, I would kill ten to save a hundred. That was the exact logic behind US policies after 9/11. If they knew a plane was hijacked, they would authorise the military to shoot it down. Better to spare those who would certainly die than let a greater number die.

      It sucks, but it's still the best option available. Just because it's the best option under the circumstances doesn't make it a good option or an easy decision.

  4. Deliberately killing an innocent person is always wrong. The aim in shooting down a hijacked plane is not to kill the innocent people aboard. That is a foreseen but unintended consequence. The intent is to stop the plane being used an enemy missile, as happened in 9/11. The intent in euthanasia, as in abortion, is always to kill an innocent human life as a means to some other end (end suffering, end a burden on the mother or family members, etc.). It is deliberately to commit evil to further good, treating the innocent person's life as a means to another end, one which involves the person's death.

    How far would you take your willingness to kill ten to save a hundred? Let's say you knew that with ten healthy bodies, with body parts duly removed and implanted in others, you could save a hundred patients who would otherwise die? Would that justify your finding ten suitable people who were passing the hospital, apprehending them, cutting them up for parts, and so saving a hundred lives? This is an evil doctrine, justifying grave evil in the service of some good you deem worth it, i.e., consequentialism, i.e., the doctrine that anything goes if the price is right. It is morally corrupt to the core.

    1. If it is foreseen, then it is intended. It may not be *desired*, but it is still intended. The difference is subtle but important. Civilian casualties in war are likewise foreseen but not desired. It does nothing to absolve the responsibility borne by those who carry out the acts in question.

      I wouldn't kill a homeless person just so their organs could be used. That would lead into a society where no one is safe from organ harvesting without consent. That, and we have alternatives to organ transplantation in most cases. Take artificial hearts, for instance.

    2. "if it is foreseen, then it is intended." In all wars, civilians get killed, but there is a world of moral difference between deliberately targeting civilians in order to kill them (say, because you want to demoralize or terrorize the enemy) and, on the other hand, hitting a military target foreseeing but not intending that some civilians who live in the vicinity will be killed. The first is wrong and blameworthy because the terrorist foresees and intends the deaths that result from his actions. The wartime bomber who hits a legitimate military target foresees that some civilian deaths will result but does not intend them. If he could avoid all civilian deaths while taking out his target, he would do so. Proportionality reflects intent and makes a moral difference here - carpet bombing a large city with the claimed intent of taking out a munitions factory would not be proportional or legitimate. Hitting the plant directly, foreseeing but not intending that some civilians living nearby would be killed would, other things being equal, be a legitimate act of war.

      Does a dentist who foresees that his procedure will cause some pain and discomfort thereby intend the pain and discomfort his effort to help the patient will cause? Only if he intends to hurt the patient (say because he doesn't like her). Otherwise, the pain is foreseen but not intended.

      The work of Elizabeth Anscombe offers a profound critique of the prevalent consequentialist or utilitarian view (including the rule-utilitarianism you rely on in your last paragraph), while also affirming that intentions are not mental acts but observable by others, e.g., a referee calling an intentional foul. So just telling yourself you don't really intend to kill an innocent person doesn't make it so. Failing the kind of distinction I want to make between foreseen and unintended consequences and actions with consequences that are both foreseen and intended, it is not clear to me how you can distinguish in morally relevant terms between the dentist who intentionally causes pain and the one who does so foreseeing it but without intending it.
      Search Anscombe on this blog or see this article:

    3. Now you're splitting hairs again in an attempt to remove responsibility for collateral damage. Individuals are responsible for the foreseen consequences of their actions.

      The dentist in your intention intends the pain. The crucial difference here is the informed consent of the patient and the greater good that comes from having clean teeth and gums.

  5. It is absurd to maintain that the dentist intends to inflict pain in this example. His aim is to treat the dental disease, not to cause pain. The question is one of the meaning of intention, a complicated matter. The greatest philosopher to have studied the matter in depth, Elizabeth Anscombe, uses the example of man sawing a plank. In sawing the plank his action is intentional under one description, that of ‘sawing the plank,’ though not under the description ‘making noise.’ So, he is intentionally sawing the plank, though not intentionally making noise since he has no intention to make the noise (his reasons for performing the action have nothing to do with making noise).

    The responsibility for collateral damage is not a matter of the foreseeing in itself entailing that the damage is intended. A responsible actor (say in the bombing case) must assure himself that the damage is proportional and unavoidable in the circumstances, among other things. The bomber in this case does not intentionally kill civilians. He foresees that their deaths will happen but their deaths are NO part of his intent. If he could avoid them, he would. He would not say he had failed to do what he intended to do if it turned out that all the nearby civilians had evacuated to a safer area. Why? Because he never had any intention to kill them in the first place. In the same way, would the dentist say that his intent had been thwarted if a new way was developed to avoid pain while curing the condition? Would he look for another way to inflict pain on the patient and so achieve his purpose? That is absurd.

  6. That's still a red herring, Paul. How can you not understand this? Dentists and doctors KNOW that there will be negative consequences to surgery. And as I have said before, there is a considerable distinction between *desiring* to do something and *intending* to do it.

    Surgery, in many cases, is the lesser of two evils. It doesn't matter what the individual actor's "primary" intention is. All forseeable consequences are intended. If the bomber wanted to avoid all civilian casualties, then the only reasonable option is to not drop any bombs and send in snipers to target only the terrorists.

  7. Yes, of course, they know that surgery has negative consequences (side effects), they foresee them but do not intend them, anymore than the man sawing a plank of wood, intending to do just that, also intends the noise he foresees but does not intend.

    Please explain the distinction you draw between desiring and intending and how it is relevant. I don't understand what you are getting at.

    The lesser of two evils phrase implies that it is sometimes permissible to do evil. That is the consequentialist view I reject for the reason I gave above. It is never permissible to do evil. If it is the right thing to do, it is good.

    It is never "necessary" to do a moral evil. If it is right to do, it is not a moral evil.

    If I save a drowning man but realize that another one I could have saved will drown in consequence, I foresee the latter's death but do not intend it. Are you saying I am responsible for one man's death because I saved another's life, realizing I could only save one but not both and so foreseeing that one of the men would drown?