Quebecers will almost certainly find themselves facing the legalization of euthanasia and assisted suicide as early as June 2013. It would be a fatal mistake for other Canadians to believe it will happen only in Quebec. The eminent writer, thinker, activist and Holocaust survivor, Elie Wiesel, has given us some painful historical insight into past medical behaviour in this regard.
In 2005, writing in The New England Journal of Medicine, Wiesel wrote a profound essay examining how deeply learned, highly cultured, compassionate medical professionals lost their consciences—if not their minds—and became complicit in the horrors of Naziism.
" One day, Hitler and Himmler’s health minister made it known to leaders in the medical field that, according to a secret decision made at the highest level, it was necessary to get rid of ‘useless mouths’—the insane, the terminally ill, children, and elderly people who were condemned to misfortune by nature and to suffering and fear by God," Wiesel wrote. "Few in the German medical profession believed it worthy or good to refuse…
"Nazi doctors did their work without any crisis of conscience."
Rereading Wiesel’s essay as the euthanasia and assisted suicide debate swirls around me in Quebec, I feel absolutely no temptation to compare my colleagues on the other side of the question to Nazis. To feel such a temptation, never mind succumb to it, would be odious.
But then neither was Wiesel writing about what makes a Nazi. He was writing about what enables otherwise admirable human beings to convince themselves that atrocities are acts worthy of approbation. We are all familiar with the theological question of why bad things happen to good people. We may be less familiar with how good people can consider unspeakable evil to be an attainable good. So, while my medical colleagues who support euthanasia and doctor-assisted suicide are certainly not Nazi monsters, most Nazi-era doctors were not monsters, either. Indeed, it seems they were not very different from us.
For the past several years, Quebecers have been subjected to a propaganda campaign to persuade them—and the doctors who provide them with medical care—that euthanasia and assisted suicide are a natural and favourable social evolution whose time has come. And this despite the fact that good palliative care undermines the euthanasia propaganda. Nevertheless, as under a light anesthetic, the propaganda operation has proceeded and the very terms euthanasia and assisted suicide have slipped, like a grandmother with an overdose of sedatives injected into her arm, mysteriously away. We have entered the foggy-bottomed swamp of euphemism replacing euphemism. "Medical aid in dying" (MAID) is the new phrase du jour.
MAID has been particularly helpful to legal expert Jean-Pierre Ménard, who was mandated by the Quebec justice ministry to undertake a legal review to determine whether the province has constitutional jurisdiction over the termination of patients’ lives. Under normal circumstances, of course, it clearly does not. Euthanasia and assisted suicide are prohibited by the Criminal Code, which is federal jurisdiction.
Mr. Ménard, however, advised the government in early 2013 that a simple change in terminology would overcome the jurisdictional quagmire. Euthanasia, itself a euphemism, would ever so helpfully become MAID. He carefully muddied the waters by proposing a new law to grant patients what they already have: the right to refuse treatment. He proposed to regulate what doesn’t need regulation, namely, terminal sedation.
Currently in Quebec hospitals, patients are asked to assist in identifying their level of treatment on a scale of one to four. One choice is full, active, aggressive treatment where appropriate (meaning most acute illnesses). Another choice is treatment with limitations (for example, no attempts at cardiac resuscitation or chemotherapy in situations where they would be useless). Lastly, there is palliative care when, for example, a cancer cannot be stopped.
Naturally, doctors will encourage patients to choose the appropriate level of care or aggressiveness. Patients, normally, have the last word. What Ménard proposes is adding another level of care—or uncare. What he and others call "medical aid in dying" is, purely and simply, killing. It would mean every seriously ill patient admitted to a Quebec hospital realizing, at some point, that their doctor might well recommend medical aid in dying (e.g. a lethal injection). The question must be asked: how many fragile patients will be able to resist an expert physician’s advice?
It is a question particularly pertinent to Ménard not only in his role as advisor to the provincial government but in his capacity as a highprofile legal advocate for patient claims of mistreatment and malpractice at the hands of Quebec’s medical system. He is, after all, renowned as a lawyer who has sued thousands of doctors and hospitals for negligence and incompetence.
So how does this legal mind, keenly aware of every imaginable flaw and dysfunction in the health care system, respond to the prospect of euthanasia and doctor-assisted suicide being fraught with similar perils? He does not.
He simply paints a happy picture of fully autonomous patients—as if they are sitting serenely in a lawyer’s office, carefully dictating their wills, uninfluenced by family and social pressures. He never addresses the reality of being a patient in an overflowing emergency room when the hospital budget is spent and the chronic-care beds are full. He gives no guidance on how you or I at our most vulnerable—old, useless and expensive to boot—might assert our autonomy by simply refusing to get out of the way.
This last image is reality, not mere rhetorical flourish. While writing this article, I was called to the hospital to see an elderly, demented patient who had just broken her hip falling out of bed at her residence. As an orthopaedic surgeon, I fix bones for a living. I happen to be one of the last doctors to have taken the oath of Hippocrates under which I declared that I would put my patient before my pocketbook and that I would not kill my patients.
The patient I was called to see was very near the end of her life. Hovering close by were two of her adult children. They were worried. They were concerned.
I pointed out that we normally recommend an operation to fix the fracture, reduce pain, permit walking and allow for ordinary hygiene. I thought it normal, in front of this fearful son and daughter, to discuss why surgery would be appropriate or not, to raise the question of whether their mother would survive it.
As the discussion went on in the vastly overcrowded and noisy ER, it became troubling for me to see the fearful looks from both son and daughter. Was I imagining it or were they both thinking that my main concern was to get rid of their dear mother, my burdensome patient, as quickly as possible? Was this the way elderly patients would look at me in the future: with fear?
The patients might want to live. But what if the family and the doctor and the minister of finance and the taxpayer want otherwise? What then? Why do I think all the safeguards Ménard can dream up are illusions? We are assured that medical aid in dying will fill a real need. It will expand human rights and autonomy. There will be no pressure put on people to submit to euthanasia. There are no real abuses where euthanasia has been introduced. Only fanatics have reported such abuses.
But even if all of the above were unequivocally true—and it certainly is not—the stark question remains: are doctors to kill their patients? The question is appalling but not without precedent. Elie Wiesel has asked it in the voice of lived experience.
"Inspired by Nazi ideology and implemented by its apostles, eugenics and euthanasia in the late 1930s and early 1940s served no social necessity and had no scientific justification," he writes. "Like a poison, they ultimately contaminated all intellectual activity in Germany. But the doctors were the precursors. How can we explain their betrayal? What made them forget or eclipse the Hippocratic oath? What gagged their conscience? What happened to their humanity?"
Wiesel sees the loss of conscience as key to loss of humanity. The ordinary men and women who became Nazi-era doctors remained ordinary men and women minus the key component of their humanity: conscience. So, too, the ordinary men and women in Quebec—including ordinary doctors and lawyers—who support euthanasia and assisted suicide are not suddenly evil caricatures from history. They are not even the evil banalities of Hannah Arendt’s famous formulation. They are simply ordinary goodness hollowed out, evacuated, emptied of its essence. It is this emptying that prompts Wiesel, in describing the past, to throw down the gauntlet to today.
For what is conscience if not the law inscribed in the heart (Psalm 40:8) or, in Cardinal Newman’s wonderful words, "a messenger from Him, who, both in nature and in grace, speaks to us behind a veil." J.S. Bach wrote his last great choral composition, the Mass in B minor (BWV 232), to express the alternating emotions that arise as conscience reflects on a departed human life. (If only for the latter, I am happy that conscience exists.)
Well, according to a prevalent scientific view, conscience is actually nothing much at all. It is simply a function of the brain that has evolved to facilitate altruism within societies. Extrapolating from that, free will also goes out the scientific—or at last scientistic—window. Without conscience as the law inscribed in the heart, free will is an illusion. As Harvard scientist and former Montrealer Steven Pinker has written, we behave according to our genes and our enormously complex, unpredictable environment. Every thought, desire and action has a molecular substrate and no molecules are free. Freedom? We have no more than does a goldfish in a bowl.
As one who rejects religious influence on the law, and insists human life is not sacred, Ménard should be a happy prophet of such scientism. Yet it is precisely this dogma that drops his claims for legalized euthanasia and assisted suicide—excuse me, medical aid in dying—between two chairs.
In place of the Judeo-Christian foundations of our law and our life, Ménard proposes the image of the autonomous patient reflecting on his or her own subjective dignity and deciding freely and legally to end his or her life when that dignity begins to fade. For the time being, this autonomy will be limited to patients who are intelligent, conscious, insistent and definitively terminally ill. Even Ménard recognizes such limitations are unrealistic and allows that, over time, they will be extended to allow for authorization by living wills, patient representatives or, in the case of handicapped children, parents.
But where, exactly, is this autonomy upon which he relies supposed to come from? After all, the very anti-religious scientism on which he also relies insists that such human autonomy does not exist. Can it possibly be that the best case to be made by one of Quebec’s finest legal minds for having doctors kill their patients is based on terminating existence by appealing to the non-existent?
We are purportedly mere organisms entirely determined by genes, chemistry and environment, yet the decision to destroy the organism, void the genes, shut down the chemistry and vacate the environment will be made as a pure act of rational free will. The logic begins to swirl. However unwittingly bidden, the shadows of "useless mouths" begin to hover over the scene.
As Elie Wiesel reminds us in his essay, this is the devastating confusion and darkness that is left when a people is cut off—or cuts itself off—from the Judeo-Christian tradition through which their conscience has been given voice. It is what happens when we are filled with intellectual poison that leaves us as empty as a Nazi-era doctor’s conscience. It is, in its way, a kind of moral and social euthanasia.
It has happened before. It is happening right now in Quebec. And no one reading this should be under any illusion that it won’t soon be happening much closer to home.