David Falk is a palliative care physician working in Calgary, Alberta
Recently the president of one of the Quebec medical federations published a request to the public to give the medical profession some time to accept physician assisted death (or medical assistance in dying – MAiD) “because they do not like change.” I agree and disagree with him about this. Yes, physicians are slow to change without measured assurance that the change would be beneficial to their patients, but, when it comes to the matters of the heart, these changes may not be beneficial nor become mainstream. Suppression of visceral responses does lessen with repeat exposure, just as shoplifting becomes less traumatic the more often you do it, but whether continued suppression of the heart language is good is questionable.
I’m interested to read articles where medical professionals describe their experiences with MAiD – either through their direct participation or through having in-depth discussions on the topic. Visceral responses seem to range from giddy euphoria to shared-experience intimacy to feeling emotionally drained to profound mistrust in one’s own medical judgments for a length of time after. Responses I’ve heard about but not seen published include profound nausea, uncontrollable shaking and cold detachment. It seems that the law of the heart does not express itself in “rational” intellectual words, which is the common acceptable mode of expression for medical professionals. There are acts for which our whole bodily DNA is wired to respond! It seems like this act is one of them from reports I have read in the literature.
To help me comprehend what is happening in these visceral responses, I find myself harking back to a framework I read from Dr. J. Budziszewski. 1 The law of the heart is transcribed through what the Great Wisdom Traditions, ancient & modern philosophers, and even Darwin would call the conscience and so Budziszewski uses that word. How we respond to the conscience determines how effective we will become in discerning heart language in our patients and their families. We can:
- acknowledge that our visceral response is the expression of a transgression and confess it
- acknowledge that our visceral response should be recognized for the outcome it will have in my heart if ignored
- rectify the misdeed performed if possible, which in this case is difficult as the patient could be dead
- acknowledge that continued ignoring of a visceral response is wrong for the integrity of person
We can suppress our conscience by:
- advocating for changes to the law of the heart by advocating for changes to society’s perception and society’s laws to soften the heart’s response
- denying that these visceral responses are of any importance as professionals must maintain a respectable distance/aloofness
- recruiting others to join our belief system so there becomes a sense of shared guilt/shared responsibility/blaming other
- rationalizing our actions so our intellect is comforted from the heart language and quiets the visceral response (mind over matter – “It’s their choice” is the standard line I hear in these discussions).
During the debate over legalizing MAiD, I noted all of the above suppression modalities were expressed at one time or another. Social media, repeat public polls over the past 4-5 years and different agencies all expressed advocacy. Not that all advocacy is wrong, but when it denies the visceral responses of the heart, it should be questioned.
Medical professionals have written or verbally expressed their visceral responses, but conclude that these were of no importance using denial and rationalization to continue suppressing their conscience.
I’ve seen professional associations’ leaders asking that all become involved, physicians asking that all physicians should be involved in enabling MAiD, administrators slowly searching for willing people/institutions near vulnerable patients, and people shaming those who are against MAiD by stating “you should not impose your morals on others.”
Of course, we are all very good at rationalization. That is the only way we can gain some control over our emotions and fears. Sometimes this is good; sometimes it is detrimental. Again, the statement, “It’s their choice,” ignores the impact it has on them personally thus shifting ultimate responsibility to the patient, and hopefully protecting the professional from their own visceral responses, and providing emotional distance from their patient.
Yet maintaining the ability to hear the language of a patient’s heart is necessary if we in the medical profession are to continue being healers as opposed to technicians. The physician’s heart needs to be clear to fully hear the heart of a patient in distress beyond the physical but repeated suppression of the laws of the heart desensitizes them . As a palliative care physician, I have been approached a few times by colleagues who either state they are unable to explore spiritual (heart) issues or they feel they need to learn how to do this. They sense the need to become more complete healers for their patients.
A clear conscience is important for a professional’s integrity, and for effective healing of existential suffering.
Thank you Dr. Falk.
Dear Doctor Falk,
Thank you so much for highlighting this perspective.
It is my belief that no adequate attention — indeed very little serious attention at all – has been given to this question : not regarding the “conscience rights” of those morally opposed to the practice of euthanasia, but rather to the psychological effects upon those who should choose, with whatever varying enthusiasm or sense of duty, to participate in such practice.
The question, indeed, has two dimensions: firstly, the challenges to be anticipated in the lives of individual practitioners, and secondly, the aggregate changes to the state and quality of society-wide medical practice which are the cumulative result of those personal struggles.
Taking the life of a human being is not trivial act. Study of those professions in which people are called upon to take the lives of others, for whatever reason and regardless of the perceived sense of moral justification, demonstrates unambiguously that such professionals must inevitably suffer a high incidence of extreme psychological pressure and damage. We must, in these professions, anticipate rates of divorce, suicide, substance abuse, and other demonstrations of mental anguish, well beyond those of the general population. Doctors, obviously, will be no exception to this rule, and in fact, suffering as they already do from dangerous levels of stress-related pathology, the negative effect of adding a mandate to kill, should immediately call forth urgent questions about the social ethics of imposing such a burden. Only if we are fully convinced that such killing is absolutely necessary for the survival of our society, or for the protection of its ethical core, can we justify imposing such costs upon the individuals who are so mandated.
Passing, now, from individual concerns to those of the collectivity, we know that the medical professions are already chronically understaffed, presenting acute problems of recruitment and retention. The increased personal difficulties associated with the mandate to kill can only exacerbate those problems. In short, beginning with the small pool of sufficiently motivated and gifted talent from which our doctors must be chosen, (in competition with many other very satisfying career paths), then subtracting the number who, for whatever reason, will simply not wish to join a medical profession now transformed to operate upon these new principles, and finally, being forced to deal with the debilitating institutional effects of increased personal crisis among those who still elect to serve, I believe we can confidently predict that the loss in quality of service to the average patient/consumer/tax-payer will be significant.
Once again, only if we are absolutely convinced that it is necessary to employ our rare and precious (not to mention extremely costly) human medical resources in this fashion, can we justify the personal and collective costs incurred.
And this, of course, is the weakness of the whole program of state-sanctioned suicide. For historical reasons and by force of habit, we simply assume that this is a medical problem. It is not. Medicine is a science. The point of science is to provide an objective basis for decision making. Suicidal desire is not objective. Suicidal desire is entirely subjective. Different people in similar circumstances will express opposing desires. The rationale for permitting assisted suicide is based on an assumption that there is no universal moral value assigned to suicide. In this view, suicide, per se, is no more “right” or “wrong” than Polka Dots (or Solid Colors) are right or wrong. People who wish to wear polka dots must be allowed to do so, of course, and so then (goes the argument) must people who wish to commit suicide.
Buti if suicide has no moral attribute, it becomes silly to establish assisted suicide as “correct” medical practice, for we have just agreed that there IS no “correct” (ie objective) judgement to be made about suicide. And this logical confusion between the subjective and objective have lead us to the most horrendous consequences.
Apparently, those people who represent suicide as categorically “wrong”, in the hopes of preventing assisted suicide as a matter of absolute principle, would seem to have definitely lost this particular social contest. But neither is the contrary principle true : simply permitting assisted suicide does not establish it as morally “right”, any more than permitting Polka Dots establishes them as fashionably “right”. No one would think of legally imposing polka dots in all corners of the fashion industry. Dots are a choice. Unfortunately however, this same conceptual clarity does not obtain in regards to the subjective desire for suicide. Quite to the contrary, the persistent confusion surrounding the medical morality – as opposed to the mere legality — of assisted suicide, has indeed resulted in a misplaced zeal to impose the universal and obligatory presence of euthanasia throughout the entire medical industry, causing all sorts of unintended and unnecessary effects, including the personal damage to individuals decried by you, Dr. Falk, and also, as described above, by what I would identify as a collective frustration of the legitimate needs of the typical citizen/consumer/patient/taxpayer which must result from the abusive misuse of those fragile human resources urgently required for the delivery of general medical service.
And yet the solution is so simple: Should a patient wish to die (within whatever parameters we might find acceptable), he or she should first refuse further medical treatment, and then (subsequently, from a logical point of view, but simultaneously, as a practical matter) apply to the correctly constituted social authority for assistance in dying, outside the scope of the medical profession. For maximum clarity, it is also my belief that such a transfer of responsibility should be concretely reflected in the actual physical transfer of the eligible person from one (medical) facility to another (expressly non-medical) for the satisfaction of the suicidal desire.
In this way, medicine might remain unsullied by such considerations ; medical institutions would be spared the reputation of being places where people go, not merely to die, but actually to be killed ; talented young people, who cannot see themselves in the role of state mandated death providers, would continue to be drawn to the profession ; doctors, individually, would suffer lower rates of debilitating post traumatic pathologies ; doctors collectively, would be able to freely pursue the primary traditional goals of their profession : they would be encouraged to compete directly with the alternatively constituted providers of death and they would naturally do everything possible to develop a medical practice capable of eliminating the desire of patients to seek out such assistance in dying. Above all, as a final result, the typical non-suicidal patient would be enabled to feel a full sense of confidence — at his or her moment of greatest vulnerability — that whichever doctor they might see before them (that is to say, any and every doctor whatsoever) be unconditionally committed to his or her survival and well-being.
Suicide may be a morally neutral phenomenon. And society may have a responsibility, in fairness, to assist certain people in fulfilling their suicidal desires. But such activity should, for the reasons outlined above, be logically (and firmly) established outside the realm of medical practice.
Thank you again Dr Falk for your courage in exposing the vulnerability of the medical soul. It is, I believe, a factor that has not been sufficiently considered in this context.
Feel the Love,
Gordon Friesen, Montreal
You lost me at the Polka Dots.
Falk’s letter “confused” you, and now you have become “lost”, half way through mine.
Forgive me if I have the temerity to suggest that you are exhibiting no particular enthusiasm about engaging either his logical arguments or mine.
Perhaps a direct appeal to sentiment is more appropriate in your case:
It is a well known fact that the act of killing, entirely divorced from context, has the potential of producing extremely satisfying emotional responses. You even mention some such from your own experience.
Perhaps you might suspect, then, from your personal emotional response, how it might possibly seem prejudicial to the interests of society at large, that individual doctors — subject to the same psychological and emotional predispositions as any body else, while benefiting from a position of unparalleled trust and authority with regards to patients and their families — be placed in what amounts to an ideal situation for the development and and satisfaction of such macabre appetites.
How much simpler and safer, for all concerned, to remove the doctor from such a morally hazardous position by placing the mandate to kill outside of the limits of medical practice.
Feel the Love,
Gordon Friesen, Montreal
I do feel the love Gordon. That’s what it is all about.
I’m confused. Is this for or against assisted dying? From my perspective the issue is about the heart of the patient, not the heart of the physician. As to the terrible consequences to which the author refers I don’t get it. I honestly cannot think of another service (perhaps other than delivering a newborn after a long and protracted labor) which has provided more satisfaction and produced such peace for families and patients.