DISPUTES OVER DIGNITY:

THE ROLE OF DIGNITY IN THE EUTHANASIA DEBATE

MARGARET SOMERVILLE

AM, FRSC, A.u.A (pharm.), LL.B. (hons), D.C.L.,

LL.D. (hons. caus.), D.Sc.(hons. caus.), D.Hum.L (hons. caus.)

The Canadian Association for Spiritual Care (CASC) National Conference

DIGNITY AT THE CENTRE

Delta Hotel, Winnipeg

April 11th, 2014

Copyright © 2014 Margaret A. Somerville

Not to be copied or cited without permission of the author

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Abstract

DISPUTES OVER DIGNITY: THE ROLE OF DIGNITY IN THE EUTHANASIA DEBATE

Both the pro-euthanasia and anti-euthanasia sides in the debate over legalizing euthanasia rely on upholding respect for human dignity as supporting their position. This seeming paradox can be explained by the different definitions of dignity each side adopts.

Is human dignity intrinsic to all human beings, an innate characteristic that comes simply with being human, the primary purpose of which is to protect all human beings’ lives, as the anti-euthanasia side believes? This definition means that euthanasia – intentional killing - is a contravention of human dignity.

Or, as the pro-euthanasia side argues, is human dignity an extrinsic feature the presence of which depends on a person’s being autonomous and independent and on others seeing us as having dignity and, thereby, conferring it? This means that dignity and the protections it carries can be lost when a person lacks capacities for autonomy and independence or others refuse to confer it, and euthanasia can be characterized as upholding dignity by putting suffering people out of their undignified state.

What are the consequences which flow from each definition, especially with regard to the protection of the lives of vulnerable people, who include people with disabilities? How should we respond to the argument that legalizing euthanasia and physician-assisted suicide is required to uphold dignity? What arguments and strategies are those advocating euthanasia using to promote its legalization and what are the counter-arguments?

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PART I

EXPLORING THE CONCEPT OF DIGNITY

1. INTRODUCTION:

IS THE CONCEPT OF HUMAN DIGNITY USEFUL, USELESS OR DANGEROUS?

The lawyer’s answer: That depends!

It depends on

What we mean by human dignity – there is no consensus. How we use the concept – again, there is no consensus. What we see as its basis – in particular, secular or religious or both, and yet

again there is no consensus.

As to dangers of the concept of dignity, there is a saying in human rights:

“Nowhere are human rights more threatened than when we act purporting to do only good.”

Reason is that we don’t see the harms unavoidably involved.

Respect for human dignity is overwhelmingly perceived as doing only good.

Are we overlooking some accompanying harms?

If so, what are they?

2. USE OF THE CONCEPT OF HUMAN DIGNITY

INTERNATIONAL INSTRUMENTS

Three international instruments that rely heavily on the concept of human

dignity are the Universal Declaration of Human Rights (UDHR), the UNESCO

Declaration on Bioethics (UDB), and the Universal Declaration on the Human

Genome and Human Rights (UDHGHR).

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Messages about dignity that these documents deliver, expressly, include that

recognition of dignity means recognition of equal rights; respect for dignity

affirms the worth of the person, means all people are equal, requires respect for

cultural rights, and requires access to paid work.

Scientific advances can threaten dignity, therefore, in light of these advances, we

need to promote respect for dignity. We must improve health, but only within

the confines of respecting human dignity.

The human genome shows our unity and, as the common heritage of humankind,

our common inherent dignity.

We all have dignity no matter what our genetic differences or disabilities.

That dignity means, for example, that we are more than our genetic characteristics

- that is, genetic reductionism (“Genes R Us”, “Gene machines” theories) is

inconsistent with respect for human dignity – and genetic discrimination offends

human dignity.

Consider that 80 to 90 percent of Down’s syndrome children are aborted.

The human dignity of genetic research subjects must be respected;

respect for dignity prohibits practices such as reproductive cloning;

and research on the human genome must respect dignity.

States must defend human dignity; and breaches of human dignity need to be

identified.

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NOTE:

Human dignity is nowhere defined in these instruments.

Human dignity is distinguished from both human rights and fundamental freedoms.

The rule against redundancy indicates that it must mean something not encompassed by these terms, but what is that something?

Some interventions are expressly labeled as contrary to human dignity,

for example, “germ-line interventions” and “reproductive cloning of human

beings”. What is the basis for that labeling and could knowing that help us to

decide whether other interventions, actions or omissions, for example,

euthanasia, are contrary to human dignity?

In other words, what human dignity consists of or what respect for it, in general, requires we do or not do, is not spelt out in these documents.

Why?

One explanation focuses on the relation of dignity and human rights:

In effect, “human dignity” serves here as a placeholder for “whatever it is about human beings that entitles them to basic human rights and freedoms.”

Adam Schulman, Senior Research Consultant at the United States President’s Council on Bioethics

We can agree that dignity needs to be respected, while we don’t necessarily agree what that requires or what it is.

The late Sergio Vieira de Mello, a prominent human rights advocate, described the relation of dignity and human rights this way:

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We recognised, through the Universal Declaration of Human Rights, that "the inherent dignity and the equal and inalienable rights of all members of the human family is the foundation of freedom, justice and peace in the world".

De Mello proposes that “[w]e should nurture our sense of self as part of a common humanity” and “that our common humanity is an inclusive one, built on values such as tolerance and dignity”.

In a similar vein, physician-ethicist, Daniel Sulmasy describes the relation of dignity and human rights this way:

“Intrinsic dignity... can be understood as the foundation of all human rights. We respect the rights of an individual because we first recognize his or her intrinsic dignity. We do not bestow dignity because we first bestow rights. Human beings have rights that must be respected because of the value they have by virtue of being the kinds of things that they are.” (p.485)

In short, human rights are secondary to human dignity. Stated another way, human rights establish the conditions that are required if inherent human dignity is to be respected.

Most importantly these descriptions of the relation of dignity and human rights show that if everyone’s human rights are to be respected, then an inclusive definition of dignity is necessary, that is one that recognizes that all human beings have dignity that must be respected.

Let’s look now at how some commentators have defined dignity.

3. DEFINING DIGNITY

So how has dignity been defined?

Philosopher Daniel Brudney says dignity has a complex history in multiple religious and philosophical traditions, but that makes for conceptual richness, which has both advantages and disadvantages, as we will see.

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Political scientist Diana Schaub says “we no longer agree about the content of dignity, because we no longer share what Meilaender calls a ‘vision of what it means to be human’.”

She’s correct that the various interpretations of “what it means to be human” are at the core of our disagreements about the nature of dignity and what respect for it requires, and those disagreements are what I would like to explore with you today in this address.

Then, if we have time, I’ll look more explicitly at some of the disagreements between pro- and anti-euthanasia advocates in the context of that debate.

Dignity is a ubiquitous concept in bioethics, and in 2008 the United States President’s Council on Bioethics issued a report, “Human Dignity and Bioethics”.

Many of the eminent authors who contributed chapters and comments to that report were responding to American bioethicist Ruth Macklin’s proposal that dignity is a useless concept that should be abandoned, and that instead we should just use concepts of respect for persons and respect for autonomy.

So, let’s look at what some of the essayists who contributed to the President’s Council report had to say about human dignity. What are some of the questions we can ask our responses to which might help to give us insights into the nature, meaning and purpose of the concept of dignity?

i) Is dignity connected with morality?

American philosopher Holmes Rolston III sees dignity as the marker of the ethical and moral sense humans have, which he sees as distinguishing humans from animals, which also have consciousness.

He sees as a major value question “how to recognize and to respect human dignity” and says “much in our future depends on the answer.”

In the latter regard, lawyer and author, Wesley J. Smith, would concur.

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“The morality of the 21st century will depend on how we respond to this simple but profound question: Does every human life have equal moral value simply and merely because it is human? Answer yes, and we have a chance of achieving universal human rights. Answer no, and it means that we are merely another animal in the forest.”

A powerful warning that deciding about dignity is no insignificant issue or choice on our parts.

And nowhere is deciding about dignity more important than in relation to the question of whether or not we should legalize euthanasia.

Many secular humanists argue that dignity is necessarily connected with religion, which is the reason they label it a useless, at best, dangerous, at worst, concept.

But are they correct that it’s necessarily a religious concept?

ii) Is dignity connected with religion?

Robert Kraynak, a professor of political science, believes “human dignity is based on the mystery of the human soul”.

Most people regard “soul” as a religious concept with a theological base. But I’d like to suggest a broader concept linked to soul that might allow us to find a broader consensus about the values we should adopt if we are to respect human dignity.

I have spoken about what I call the human spirit in my book, The Ethical Imagination and its importance in dealing with ethical issues. Let me explain what I mean by the human spirit.

I adopt a very broad definition of spirituality and regard it as a natural, inherent characteristic common to all humans, which some people express through religious belief and practice, and others express in secular ways.

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We can call our capacity to experience that spirituality the “human spirit”.

Our longing for transcendence – the need to feel we belong to something larger than ourselves – I see as an expression of the human spirit.

Our human spirit is that which makes us human and enables us to experience amazement, wonder and awe at the mystery of life, and through it we search for meaning.

This search for meaning is of the essence of being human; we are meaning seeking beings and, as far as we know, uniquely so.

Human spirit is a term I use in a religiously neutral sense, so it's open to people who are not religious and those who are, and, if religious, no matter what their religion. In other words, a belief in the human spirit does not require a belief in the supernatural or any religious belief, but it is not antithetical to religious belief.

In short, we can all agree that we have a human spirit and having that shared starting point is very important in searching for some shared ethics in our contemporary, pluralistic, multicultural multi-religious secular societies.

Here’s how I define the human spirit:

It is the intangible, immeasurable, ineffable, numinous reality that all of us need to have access to find meaning in life and to make life worth living — a deeply intuitive sense of relatedness or connectedness to all life, especially other people, to the world, and to the universe in which we live; the metaphysical -- but not necessarily supernatural -- reality which we need to experience to live fully human lives.

iii) Is dignity connected with sacredness?

I believe that we need to enlist a concept of sacredness to protect and promote our human spirit.

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The Oxford English Dictionary defines sacred, inter alia, as “regarded with or entitled to respect or reverence”.

I will speak about what I mean by sacredness shortly.

And if dignity is connected with sacredness that would mean dignity is connected with protecting and promoting our human spirit.

British philosopher Roger Scruton provides an insight that is relevant to understanding the nature of dignity.

He says that what is left out of contemporary standard treatments of ethics is the requirement to “face the surrounding world with due reverence and humility” — a disposition he calls piety. I agree with him — although what he calls piety I’d call respect for the secular sacred.

In my book “The Ethical Canary”, I introduced a concept that I called the “secular sacred” – everyone disliked it.

Secular people thought I was trying to impose religion on them and that religion had no place in the public square or public policy, and religious people objected that I was denigrating the concept of the sacred.

One of my students said to me “ You know, Professor Somerville, when you have everyone mad at you, you are probably on to something important”, so I further explored the concept in my following book “The Ethical Imagination”.

In talking about the secular sacred, I am proposing that the sacred is not only a concept that applies in a religious or ritualized context, but also one that operates at a general societal — or secular — level.

I’m proposing it as a concept that, among other outcomes, might help us to find some shared ethics, including in relation to what respect for human dignity requires, in particular with respect to people who are dying, and that we can endorse this concept whether or not we are religious, and, if we are religious, no matter which religion we follow.

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I believe that each of us needs to experience a complex interaction of knowing ourselves, relating to others, appreciating our place in the great web of all life, and seeing ourselves as part of the earth, the stars, the universe, and the cosmos. The acute and continuous awareness of such a mind-blowing web of relationships is what I have already described to you as the “human spirit”.

In summary, I am proposing that linking the secular and the sacred, by adopting a concept of the secular sacred, can help to unite everyone who accepts that some things are sacred, whether they see the sacred’s source as religious or purely natural or secular.

If we accept the sacred, whether the religious sacred or the secular sacred, we will accept that certain aspects of life are sacrosanct; not everything that could be done to life, in particular, human life, may ethically be done to it and certain moral and ethical principles that should be respected and should govern our conduct flow from that.

The sacred, then, requires that we respect the integrity of the elements that allow us to fully experience being fully human; in doing so, we protect that experience.

The sacred is a concept that we should use to protect that which is most precious in human life, starting with life itself.

Could using a concept of the secular sacred help to promote human dignity in the context of euthanasia?

What would applying a concept of the secular sacred to human life tell us about whether legalizing euthanasia and physician-assisted suicide was a good idea?

I was debating an Australian politician who was in favour of euthanasia. He declared:

"As far as I’m concerned, when you are past your 'use by' or 'best before‘date, you should be checked out as quickly, cheaply and efficiently as possible.”

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This is the antithesis of seeing human life as having a secular sacred element which requires respect and protection.

It sees us as disposable products. But we are not products to be checked out of the supermarket of life and the values of materialism and consumerism are not the ones that should govern our dying.

Euthanasia fits with the idea that they should.

In considering whether a concept of the secular sacred could help to promote human dignity, an important question to ask is what are our present ethical obligations to future generations?

If we introduce euthanasia now how will our great-great-grandchildren die?

Might they find themselves in a world in which no reasonable person would want to live?

What must we regard as sacred and hold on trust for them in order not to leave them worse off than we are or with less choices or options than we have?

What do we owe them?

What does an ethics of responsibility — as compared with an ethics of rights — require of us?

I suggest that respect for human dignity requires that we see human beings as having an element of at least secular sacredness.

For some people, however, the natural essence of being human has no element of the sacred, and therefore contains nothing that must be protected and preserved through restricting what we can do in light of what we ought not to do in order to maintain the integrity of our humanness.

Moreover, the entities that need to be seen as secular sacred and held on trust must extend beyond physical realities to include important metaphysical realities, in particular, important shared societal values such as respect for all life.

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Just as we now realize our actions could destroy our physical ecosystem and we must hold it on trust for future generations, we must also hold our metaphysical ecosystem—the collection of values, principles, beliefs, attitudes, shared stories, and so on that bind us together as a society—likewise, on trust for them.

In the context of the euthanasia debate that requires that we always react to pain and suffering with deep compassion and assistance to relieve it, but that we kill the pain and suffering, not the person with the pain and suffering.

iv) What is the relation of dignity with respect and with justice?

Some philosophers have distinguished two different kinds of “respect.”

In “recognition respect” you respect something because of what it is, for instance, a human being.

I call this “intrinsic dignity” – humans have intrinsic value just because they are human.

In “appraisal respect” you confer respect on something – or withhold it – because of its qualities or lack thereof.

I call this “extrinsic dignity”. Humans have the value others – the valuers - attribute to them

Likewise, there are two different senses in which one might speak of human dignity.

For instance, the language of dignity might be used to mark a “floor,” a kind of respect and care beneath which our treatment of any human being should never fall.

Or it might be used to mark a “height” of human excellence, those qualities that distinguish some of us from others.

Dignity is like justice, often it’s easier to identify what constitutes a violation of it, than to define what it is.

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That probably explains why it is not uncommon to speak of something being “beneath human dignity” or sub-human, without defining what dignity is.

That tells us that what is involved does not respect human dignity, which might be a judgment informed in part by moral intuition or examined emotions, not just logical cognitive mentation or reason, important as the latter are.

v) Conclusions on defining dignity

To summarize, broadly speaking, it seems there are two basic concepts of human dignity that are mutually exclusive.

Intrinsic dignity means one has dignity simply because one is human.

Intrinsic dignity is status model - dignity comes simply with being a human being. Respect is for what one is.

Extrinsic dignity means that whether one has dignity depends on the circumstances in which one finds oneself and whether others see you as having dignity.

Dignity is conferred and can be taken away. Dignity depends on what one can and cannot do.

Extrinsic dignity is a functional or achievement model – dignity comes with being able to perform in a certain way and to not perform in other ways. Dignity comes with being a human doing. Respect is for what one does.

These two definitions provide very different answers as to what respect for dignity requires, for example, in order to respect the human dignity of people with disabilities or dying people and that matters in relation to euthanasia.

Under an inherent dignity approach dying people are still human beings whose lives must be respected. Euthanasia breaches respect for life and thereby contravenes their human dignity.

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Under an extrinsic dignity approach dying people are no longer human doings – that is, they have lost their dignity - and euthanasia is seen as remedying that situation and promoting their human dignity.

Deryck Beyleveld and Roger Brownsword have distinguished three different ways in which the concept of dignity has, they believe, been used in bioethics.

The first they term “human dignity as empowerment.”

The central idea here is that one’s dignity is violated if one’s autonomy is not respected, and this concept leads quite naturally to an emphasis upon informed consent. ...

This is the concept of dignity used by pro euthanasia advocates and the reason they see informed consent as justifying euthanasia.

The second concept of dignity Beyleveld and Brownsword call “human dignity as constraint”—that is, constraint on individual choices.

This is the concept of dignity used by opponents of euthanasia.

The idea of dignity as constraint of autonomy and self-determination of an individual person in order to preserve human dignity, in general, could be described as “dignity in fetters”, if one believes dignity is based on respect for freedom of choice, that is, respect for individual autonomy.

In that case, it is similar to “freedom in fetters”. Sometimes we have to restrict freedom in order to maintain the conditions that make freedom possible.

It merits noting, expressly, that informed consent of an individual does not mean that human dignity in general is not breached.

For example, dwarf throwing is prohibited as offending human dignity, even though the dwarfs consented.

A third concept, somewhat different from the first two, is that of “dignified conduct.” (pp.273-274)

4. DIGNITY AND DYING

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Pro-euthanasia advocates argue respect for human dignity requires that it be legalized and opponents of euthanasia argue exactly the opposite, that respect for human dignity requires it remain prohibited.

They are using different concepts of dignity.

Pro-euthanasia advocates argue respect for dignity requires the absence of suffering whether from disability, or illness or terminal illness and that requires euthanasia to be an option.

Relatedly, as explained previously, they also believe that respect for dignity requires respect for autonomy and self-determination.

The basic approach of pro-euthanasia advocates is that euthanasia is necessary to respect a dying person’s dignity: “You are in an undignified state and we will correct that by eliminating you.”

Opponents of euthanasia believe respect for human dignity requires respect for human life and, if there were a perceived conflict with respect for autonomy, the latter should take priority.

In fact, the original primary purpose of the concept of dignity was to ensure respect for life. It’s paradoxical that it’s been turned on its head to promote exactly the opposite outcome.

Dr Harvey Max Chochinov specializes in psychiatric care for dying people.

He and his co-authors identified the components of dignity and defined them and then looked at how they could be implemented to enhance dying people’s feelings of both dignity and being treated with respect for their dignity, which are two separate considerations.

He calls this approach “dignity therapy”.

What a contrast this approach is to a quick fix solution of a lethal injection being the best way to enhance a person’s dignity.

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One of the central questions in bioethics is whether only humans have dignity that must be respected or animals also have it?

I believe we should answer this question in one of two ways:

Either only humans have dignity (which is probably the traditional use and limitation of the concept of dignity and linked to a religious belief that only humans had a soul – a sharing in a Divine spark).

Or, if all creation has dignity (a concept that I like), then humans have special dignity – human dignity.

Another way to ask this same question, one that is at the heart of some of our most important current ethical debates, is: Are humans special?

Is there a discontinuity between humans and other animals?

Are humans and other animals different-in-kind or only different-in degree?

Depending on how we answer these questions, our answers to the question,

“Do humans deserve special respect?” will also vary

CONSIDER the argument there should be no difference humans and animals re euthanasia:

Euthanize your dog you love to stop suffering do same for humans you love.

We are not dogs

Is there an essence of our humanness that we must hold on trust for future generations?

Is respect for human dignity one way we can protect that essence and fulfill that trust?

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Do some utilitarians reject the concept of human dignity because it restricts what they want to do?

In short, I’m suggesting that we need a deep respect for the natural if we are to respect human dignity.

To implement that respect, I argue in my book The Ethical Imagination that especially in relation to interventions on life itself, in particular, in taking decisions that will affect our children and their descendants down the generations, we should start from a basic presumption in favour of respecting nature, the natural and life.

This presumption could be described as seeing the natural – whether it is we humans or other animals or our ecosystem - as having a certain dignity – as expressing the order of creation - and starting from a presumption of the need to respect that.

That does not mean that nature, the natural and life must not be altered; rather those altering them must justify doing so.

It is a precautionary principle or approach.

We must ask ourselves: What do we owe to future generations in terms of holding nature, the natural and life in trust for them?

Applying this approach in relation to what human dignity is and requires leads to the conclusion that we should adopt a concept that dignity should depend simply on being human, which means that all humans deserve respect and equal respect.

The concept of dignity must be used to maintain respect for the integrity and authenticity of each person, and respect for human life and for the essence of our humanness. The current danger is that it could be used to realize precisely the opposite outcomes.

Respect for the natural in relation to euthanasia means we must respect natural death.

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So to summarize to return to my three questions, “Is the concept of human dignity useful, useless or dangerous?”, I’d answer:

It’s useful when we can use it as a common starting point. Starting from where we can agree and moving to where we disagree is likely to help us find more agreement about ethics than would otherwise be possible.

The concept of human dignity is also useful when it helps us to identify what respect for individual human dignity and human

dignity in general require we do and do not do, if we are to act ethically.

It’s useless when it is of no assistance in the above respects, although we should keep in mind that just asking the question “What does respect for human dignity require?” can be a contribution to ensuring ethics prevails. It makes us aware that respect for dignity matters. The issue is not whether asking this question absolutely ensures that we will act ethically, but rather whether we are better off asking it than not asking it.

And asking “What does respect for human dignity require?” is dangerous when the concept of dignity is defined in such a way that it leads to unethical conclusions.

All of which means that in speaking of dignity we always need to proceed with great care.

PART IIEUTHANASIA

I turn now to a few more detailed comments on euthanasia.

Here’s the essential question:

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Should society change its laws to authorize physicians (most people think that physicians would be the “assisters” or “euthanizers”) to help people to kill themselves through suicide or to kill them with a lethal injection (euthanasia)?

My answer is a resounding “No” and I’d like to explain just some of the reasons I’ve come to that conclusion.

But, note that in my remarks, I’m using the word euthanasia to include assisted suicide, as these two interventions raise mostly the same ethical and legal issues.

1. INHERENTLY WRONG VS. MORAL RELATIVISM

First, I believe, it’s inherently wrong for one human being intentionally to kill another.

The only legally recognized exceptions have traditionally been when that is the only reasonably possible way to save human life, as in self-defence or “just war”.

Utilitarians and moral relativists disagree. For them nothing, including euthanasia, is inherently wrong, rather its rightness or wrongness depends on all the circumstances and the values and preferences of the individual who wants it.

They argue that euthanasia should be legal, when its benefits for individual persons outweigh its risks and harms to them and others.

2. SANITIZING LANGUAGE (CAUSES CONFUSION)

In order to get as many people as possible to agree with them they sanitize the language they use in advocating for euthanasia.

For instance, they don’t speak of killing or even suicide, but, as in the Quebec government reports recommending that euthanasia be allowed in certain situations, “medically assisted death” or “medical-aid- to-die” (Wanda Morris).

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It’s difficult to reject outright interventions described in that way: we all want medical assistance – good palliative care, especially pain management - when we are dying.

This language suppresses our moral intuition that it is wrong to kill another human and our appropriate emotional response. “Examined emotions” play a role in good ethical decision making.

This euphemistic, concealing use of language creates confusion about what euthanasia involves, confusion that is being used as a strategy to promote it.

After all, if euthanasia is not killing, what is it?

Consider: When place a medical cloak on euthanasia it’s not seen as killing but when have a lawyer administer the lethal injection it is seen as that.

3. “NO DIFFERENCE” ARGUMENT (LEGALIZING THROUGH CONFUSION)

Another confusion used intentionally to promote euthanasia is what I call the “no difference” argument.

The pro euthanasia line is that refusals of treatment, including of life support treatments that result in a shortening of the patient’s life, is recognition of a right to die.

Such refusals are ethical and are legal, and, they argue, euthanasia is no different from them.

Therefore, if we are to act consistently, that too should be seen as ethical and legal.

The further related argument is that euthanasia is just another form of medical treatment.

But the right to refuse treatment is not based on a right to die; and both the intention of the physician and the causation of death are radically different in

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those cases as compared with euthanasia; and most physicians do not regard killing as medical treatment.

i) Nature of the rights involved

In accepting patients’ refusals of treatment we are respecting their right to inviolability, their right not to be touched, including by medical treatment, without their informed consent.

We are not recognizing a right to die, let alone a right to be killed. At the very most, this is a right to be allowed to die naturally.

ii) Intention

And, in honouring refusals of treatment, the physician does not have a primary intention to kill the patient.

Pro-euthanasia advocates argue that intention is not a valid differentiating factor between euthanasia and, for instance, pain management, because it’s not possible to tell accurately what the physician’s intention is in relieving the patient’s pain and it could be to hasten the patient’s death.

But courts across Canada make determinations about accused persons’ intentions every day in deciding on criminal culpability, where intention is a central element.

In the medical context, intention can be assessed on the basis of whether the drugs a physician gives a patient were medically indicated as reasonable treatment for the patient, for instance, to relieve pain, and given in appropriate doses.

iii) Causation

Legal causation also differs in refusals of treatment as compared with euthanasia.

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When a patient refuses life support treatment they die a natural death from their underlying illness.

In euthanasia, they die from the lethal injection or drugs they ingest.

iv) Ends vs. means

The pro-euthanasia “no difference” argument focuses, as well, on the ultimate outcome, namely death, which occurs whether or not euthanasia is involved.

As Dr. Marcia Angell, formerly editor of the prestigious New England Journal of Medicine, who supports assisted suicide, recently wrote in an article, the patients who are provided with assisted suicide “are near death anyway”.

But the issue in the euthanasia debate is not if we die – we all die.

It’s how we die and whether there are valid ethical and legal distinctions between well-accepted medical practices at the end-of-life, on the one hand, and euthanasia, on the other. Anti-euthanasia people believe there are.

4. VALUES CONFLICT

Another difference between anti and pro euthanasia advocates is that the former give priority to the value of respect for life and the latter to respect for individual autonomy, when these values conflict, as they do in euthanasia.

Note that respect for life must be upheld at two levels:For each individual life and for human life in general in society.

i) Autonomy

Much could be said about the unbridled advocacy of “radical autonomy”, which is functioning as the cornerstone for many of the so-called “progressive values” stances, including euthanasia.

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Choice (the implementation of autonomy) is put forward by pro-euthanasia advocates as the overriding value. But choice is not moral or immoral in itself; it depends on what we choose.

It should be questioned whether dying people really can make free and informed (autonomous) decisions that they want to have “assistance to die” – which is not the same as “wanting to die”, which I believe many terminally ill people do want at the end of their lives. Consider also Dr Harvey Max Chochinov’s research which showed that terminally ill people who requested euthanasia changed their minds about it, on average, every twelve hours.

New concepts such as “relational autonomy” - the idea that a person is not an isolated being, but exists in a context that influences their decisions, and that this must be taken into account when judging the validity of those decisions - can operate as a restraint on individual autonomy gone wild.

ii) Respect for life

One way that pro-euthanasia advocates justify overriding the value of respect for life is to label it as religious – they usually refer to it as “sanctity of life” – and as passé in a secular society, such as Canada.

But all societies in which reasonable people would want to live need to uphold respect for life, respect for both each individual human life and human life, in general. The Canadian Charter of Rights and Freedoms affirms this for Canada.

5. LEVELS OF ANALYSIS

To focus on the individual person who wants euthanasia, as pro-euthanasia advocates do, is valid, but it is not sufficient in deciding whether to legalize euthanasia.

Euthanasia is not just a matter of personal decision-making, as they argue it is.

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What we, as both individuals and a society, decide about it will affect others, important institutions, and society, as a whole, now and in the future.

Implementing euthanasia requires changing the law to allow it and permitting physicians to carry it out.

How will this affect the value-carrying capacity of law and medicine, the two main institutions in a secular society which carry the value of respect for life?

Legalizing euthanasia also means that society becomes complicit in inflicting death on some of its members.

What long term effects might result from that complicity?

6. SLIPPERY SLOPES

Finally, pro-euthanasia advocates adamantly deny that there is any evidence in jurisdictions where euthanasia has been legalized - the main examples are the Netherlands and Belgium - that slippery slopes have resulted.

They deny there is a ‘logical’ slippery slope – that the situations in which euthanasia will be available will expand over time –

or a ‘practical’ slippery slope – that euthanasia will be used abusively.

The latter is an especially relevant concern in relation to vulnerable people, including those who are old, disabled or dying.

But the evidence for the existence of both practical and logical slippery slopes is very convincing.

In Fleming vs. Ireland and others, the High Court of Ireland recently affirmed the former after extensively reviewing the evidence. Here’s what they held:

“In that case [the Carter case], the Canadian court reviewed the available evidence from other jurisdictions with liberalised legislation and concluded that there was no evidence of abuse. This Court also reviewed the same

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evidence and has drawn exactly the opposite conclusions. The medical literature documents specific examples of abuse which, even if exceptional, are nonetheless deeply disturbing. Moreover, contrary to the views of the Canadian court, there is evidence from this literature that certain groups (such as disabled neonates and disabled or demented elderly persons) are vulnerable to abuse. Above all, the fact that the number of LAWER (“legally assisted deaths without explicit request”) cases remains strikingly high in jurisdictions which have liberalised their law on assisted suicide (Switzerland, Netherlands and Belgium) – ranging from 0.4% to over 1% of all deaths in these jurisdictions according to the latest figures - without any obvious official response speaks for itself as to the risks involved.”

A recent chilling example of the logical slippery slope is the euthanizing, in December 2012, of 45 year old twins in Belgium. Deaf since childhood, Marc and Eddy Verbessem were facing the additional disability of blindness. Accepting that they were irremediably suffering, their physician euthanized them.

In short, yet another reason not to legalize euthanasia, as shown by real life experience in the Netherlands and Belgium, is that neither the logical nor practical slippery slopes can be avoided or controlled.

CONCLUSION

Although referring to marital love, philosopher Roger Scruton’s words could be applied to explain the rise in calls to legalize euthanasia:

“The world of the 'consenting adult', the world remade in accordance with the 'social contract' of the enlightened liberal conscience, is, in the last analysis, a world too timid for love.” (Sexual Desire: A Philosophical Investigation, p. 358.)

Is euthanasia the outcome of our failure to be able to love those who are dying?

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In this regard, we should keep in mind that two of the main reasons people give for wanting euthanasia are dying alone and unloved (which seems to be a universal human fear), and being a burden on others. Feeling loved could address and negate both these reasons.

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