Ewan C Goligher MD is an Intensivist at Toronto Western Hospital and a doctoral student in the Department of Physiology at the University of Toronto, Toronto, Ontario
Stephen W Hwang MD MPH is a General Internist at St. Michael’s Hospital and Professor of Medicine in the Department of Medicine at the University of Toronto, Toronto, Ontario.
The writing is on the wall. Physician-assisted death is very likely to soon be legal in Canada. Although legal decisions cannot put to rest ethical controversy, the winds of public opinion have shifted considerably, and policy changes will probably gain rapid and widespread acceptance in Canadian society. Requests for assisted death will become more frequent. Canadian physicians, of whom only a minority have indicated a willingness to provide or administer lethal doses of the drugs at their disposal, will therefore be faced with the serious personal ethical challenge of deciding whether to honour such requests and whether to refer patients to physicians willing to accommodate such requests.
The madman jumped into their midst and pierced them with his eyes. "Whither is God?" he cried; "I will tell you. We have killed him — you and I. All of us are his murderers. But how did we do this? How could we drink up the sea? Who gave us the sponge to wipe away the entire horizon? What were we doing when we unchained this earth from its sun? Whither is it moving now? Whither are we moving? Away from all suns? Are we not plunging continually? Backward, sideward, forward, in all directions? Is there still any up or down? Are we not straying, as through an infinite nothing?...God is dead. God remains dead. And we have killed him."
—Friedrich Nietzsche, Parable of the Madman
The recent debate in Canada for and against physician-assisted death has mostly centered on the safety of euthanasia as public policy, in contrast to past debate that has traditionally focused on arguments over the inviolability of human life. This shift may in fact determine the outcome of the debate: during clinical encounters with patients who make a properly autonomous request for physician-assisted death, ethical concerns about the inviolability of human life are far more likely to hold firm than somewhat abstract concerns about the safety of vulnerable populations.
The argument against physician-assisted death based on the inviolability of life may have fallen by the wayside for two reasons. First, it seems difficult to sustain this argument upon purely secular grounds: the lucid and comprehensive Royal Society of Canada Expert Panel Report found secular arguments against PAD based on human dignity wanting for lack of normative grounding. Second, it is now widely held that the arguments for or against physician-assisted death must be made upon secular grounds—theistic grounds are inadmissible. Two reasons are given for this stipulation: first, Canada is a pluralistic society and public policy must be formulated upon “neutral” secular grounds. Second, religious beliefs are not subject to the constraints of reason; it is therefore not possible to engage such beliefs in rigorous ethical pro/con debate (Sumner LW. Assisted Death. Oxford University Press; 2011). For all intents and purposes, Nietzsche’s madman was prophetic: God has virtually no meaningful role to play in guiding human behavior in contemporary secular society.
Physicians and healthcare institutions committed to theistic belief systems therefore face an important challenge: is it reasonable to base conscientious objection to physician-assisted death upon belief in God? This question has become critical in light of recent proposals to curtail physician autonomy and conscience rights in Ontario by requiring physicians to make referrals for procedures in violation of their ethical commitments. We argue that it is eminently reasonable to base such objections on belief in God, because theism is a rationally defensible belief system that provides coherent grounds for upholding the ethical values central to this debate, namely human autonomy, well-being and the incalculable worth of human life.
Proponents of secular and theistic frameworks uphold a remarkably similar set of ethical values. Both emphasize the value of life, respect for autonomy, the priority of compassion and relief of suffering, and the importance of protecting the vulnerable. In the debate over physician-assisted death, both frameworks agree that it would be wrong to put vulnerable populations at risk of harm — they simply disagree on whether legalizing physician-assisted death will entail such risk. The central difference between these frameworks lies in the priority assigned to the ethical values they hold in common. Advocates of physician-assisted death hold autonomy to be the primary value; for them, the wrongness of killing depends entirely on one’s autonomous preference for life or death (Sumner LW. Assisted Death. Oxford University Press; 2011). Theists hold the worth of the person’s life to be the primary value; respect for autonomy derives from the intrinsic worth of human life (Meilaender G. Bioethics. Wm. B. Eerdmans Publishing; 2013). This critical difference in the ranking of the core ethical values gives rise to very different views of physician-assisted death.
Is the theistic ethical framework a viable alternative to the secular framework? As the primary function of ethics is to "guide our actions and to provide justifications for the guidance given," one might first inquire whether each approach provides an adequate moral foundation for core ethical values. For example, both frameworks must viably respond to the question "Why ought we respect human autonomy?" Theism functions very effectively on this front. Theists understand that humans derive their value from their Creator; their autonomy and freedom of will are capacities supplied to them by God (Meilaender G. Bioethics. Wm. B. Eerdmans Publishing; 2013). Life is “sacred” in an absolute sense because humans ultimately belong to God. Value and autonomy are thus understood to be objective features of human nature independent of subjective human perspective or thought. Viewed in this light, human suffering commands our devotion to compassionate care and relief of suffering by every available means within the constraints of life’s incalculable worth.
By contrast, from a secular perspective, it is not exactly clear just why human life is of any value or why our autonomy ought to be respected. Canadian advocates of physician-assisted death have sought to ground respect for autonomy in observations about Canadian political and constitutional order. Such observations constitute evidence of our society’s high regard for the principle of autonomy, but fail to supply the moral basis for why it ought to be highly regarded. In fact, an argument can readily be constructed on similar grounds in support of the inviolability of human life. Even those attempting an explicit case in support of autonomy’s pre-eminence seem to take it as a presumptive good. In any case, by taking respect for autonomy to be the fundamental ethical value, secular attempts to advance universal ethical values become rather arbitrary — an outcome foreseen by Nietzsche’s madman. The ethics of compassion and care thus depend on our subjective preference, rather than the intrinsic value of the suffering patient.
As stipulated by the Royal Society Expert Panel, ethically relevant beliefs must be grounded in reason and evidence. Physicians must be responsible decision-makers, and rationality is a minimum criterion for responsible thinking. This raises a central and controversial question: can theistic beliefs be evaluated and supported rationally? We believe so. That theism is susceptible to rational refutation is clearly suggested by the fact that many have undertaken serious attempts at such a refutation (Martin M. The Cambridge Companion to Atheism. Cambridge University Press; 2006. ). That many contemporary philosophers and scientists offer rigorous and reasoned arguments in support of theism suggests that theism is rationally defensible. Regardless of one’s view for or against theism, one must acknowledge that reason is clearly engaged in the debate. Accordingly, to base one’s ethical decision-making upon theism is firmly responsible.
In sum, we argue that Canadian physicians may legitimately base their conscientious objections to requests for physician-assisted death upon their theistic beliefs, because theism provides a coherent and rationally supportable framework for belief in the core ethical values of respect for autonomy, compassion and the incalculable worth of human life. For many physicians in Canada, God is still very much alive. Upholding their right to conscientious objection to physician-assisted death on theistic grounds will be an important test of our society’s true commitment to pluralism and tolerance.