A Glimpse into a Post-Christian Future: Public Support for Killing the Poor and Disabled

I find the term “medical aid in dying” (MAID) deeply pernicious. It is not only an assault on human dignity (which it implicitly claims to defend), but it also employs a rhetorical sleight of hand. The term conjures up an image of someone who is already dying of a painful and terrible disease, and the aid they receive seems good and possibly even heroic. So I will switch from the misleading term “medical aid in dying” and now speak of “physician-assisted killing,” or PAK.

These misleading ideas associated with MAID have taken a firm hold of the Canadian imagination. According to a poll from Research Co., a representative sample of Canadians were asked the following question: “At this point, only an adult with a grievous and irremediable medical condition can seek medical assistance in dying in Canada. Do you agree or disagree with allowing adults in Canada to seek medical assistance in dying because of the following reasons?”

When asked about “Disability,” a full 50 percent of Canadians agreed that someone should be able to seek PAK. When breaking down the results by age groups, one might expect to find that younger folks, more attuned as they are to the nefarious effects of structural coercion, would be less likely to support PAK in the case of disability. But the opposite turned out to be the case: for 18- to 34-year-olds, support actually jumped ten points to 60 percent. In other words, 6 in 10 of young Canadians support PAK as a response to disability.

What about poverty? A lower number of Canadians—27 percent—think of it as a reason someone should be able to pursue PAK. But once again the numbers for young people are remarkable and disturbing: 41 percent of Canadians aged 18 to 34 believe it can be a legitimate reason to request PAK.

How did Canada get here? Is the United States headed down this same path? If so, how can Americans reverse course?

PAK in America vs. Canada

As families and local communities have frayed, we no longer have a ready-to-hand idea of what a good death might be apart from PAK. The dying process has been outsourced to massive, impersonal housing projects that build sterile nursing homes underwritten by vulture capitalists who discovered they can get rich on our inability to deal with death. So, to the extent that PAK gives both the dying and their families an alternative to the horror show of dying alone (except for maybe the company of a robot) in totally inadequate “care homes,” it becomes quite attractive, and pro-lifers face a serious challenge in resisting it.

Effective resistance to PAK in America has focused largely on slippery slope arguments that emphasize what happens after you open the door to this practice. If those with terminal illness can seek death, why not those with disabilities, or those suffering from severe mental illnesses? PAK opponents, in other words, are focusing on things that invoke discomfort and even anger. But will this be enough in the long run?

 

Nothing has bolstered this strategy for PAK opponents in the United States more than pointing to what is happening in Canada, whose program has expanded in ways that invoke less a slippery slope, and more a free fall accelerating at 9.8 meters per second squared. Consider that it was only five short years ago that Canada legalized PAK. And as we’ve seen, the law has recently enabled killing the poor and the disabled precisely because they are poor and disabled.

This gold-standard reporting from The New Atlantis earlier this year clearly demonstrates the extent of the horrors of Canada’s program. The program trains those who administer death to expect patients who “choose” PAK due to lacking the support they need. In a kicker that is difficult to get out of one’s mind, the article explains the message that Canada sends to its vulnerable populations:

Just a few years ago they would have been textbook candidates for what a just society would say: Your life has value. In Canada today they hear something else: Your death will be beautiful.

But what kinds of situations are we talking about? In what kinds of cases are the powers that be in Canada telling people that they might be better off dead? Well, how about a veteran who asked for PTSD treatment? Or another veteran who asked that a wheelchair ramp be built into her home? Though neither was dying, in both cases they were asked if PAK would be a better option for them.

In another case, a woman with very severe chemical sensitivities “chose” PAK after she was denied public housing that wouldn’t trigger those sensitivities. Or how about a 63-year-old man who had been waiting for spinal fusion surgery for eighteen years, and bearing terrible pain during that time, saying “I am fed opioids and left to kill myself.” He requested PAK and was approved. And then there was the 44-year-old woman with a degenerative disease who, after being denied home healthcare, decided to be as direct as she could about what actually killed her:

Ultimately it was not a genetic disease that took me out, it was a system. There is desperate need for change. That is the sickness that causes so much suffering. Vulnerable people need help to survive. I could have had more time if I had more help.

The Toronto Star, the largest and most progressive newspaper in Canada, described the move toward these practices as “Hunger Games style social Darwinism.”

PAK and Post-Christianity

Opponents of PAK in the United States have pointed to the dystopia to the north of us, and so far their strategy seems successful: even in many blue states (especially out east), PAK is not legal. Yet why has Canada gone so far with PAK? Returning to the polling figures cited at the beginning of this essay, what are we to make of these numbers in a progressive country that has adopted a position so antithetical to how Americans understand social justice?

 

One reason is that progressivism in the United States has retained aspects of its Christian inheritance—with its focus on nonviolence, inherent and inalienable human dignity, and preference for the most vulnerable. Progressivism in secular Canada, especially among young Canadians, is by now far removed from these commitments. Thus, in Canada, killing the most vulnerable human beings comports well with a society that values giving individuals what they ask for (autonomy), and a just distribution of resources (equity) in ways that allow the most people to derive the greatest benefit from them (utilitarianism).

It doesn’t take a genius to point out the tensions here: equity very often conflicts with utility calculations, and the poor and disabled are some of the least autonomous human beings in our communities. But that doesn’t stop the secular state, and even secular academic bioethicists in both Canada and the United States, from attempting to muddle their way through with these incoherent values in play.

The fact that increased cultural distance from Christianity may have helped pave the way for Canada’s PAK regime is further suggested by what’s happened—and what has not happened—in the much more religious United States. While Oregon and Washington (two of the least Christian states) have had legal PAK for decades, it has only recently become legal in states like California and New Jersey. And despite the best efforts of groups like Compassion and Choices (formerly the Hemlock Society), PAK is still illegal in most of the country—including in deep blue states like New York, Connecticut, and Massachusetts, as noted earlier.

The arguments that have won the day in deep blue USA are—you guessed it—about the slippery slope of such laws and the effect that they will have on the poor and disabled. Unsurprisingly, the most effective advocates against such laws are disability rights advocates (and especially disabled people themselves) who point to the disturbing data about why people seek PAK. When physical pain doesn’t even make the top five reasons people in Oregon request PAK—but fear of loss of autonomy, fear of loss of enjoyable activities, and fear of being a burden on others do make the top five—this sends a very clear message to the disabled: it’s reasonable that someone like you would want to kill yourself. And in Canada, they take the next step: we think someone like you might want to take advantage of the legal right to kill yourself.

Going on Offense

Happily, disability rights activists are still winning the day, again, even in deep blue places on the east coast. But playing a strictly defensive game of knocking down legalization attempts—especially as the United States secularizes and becomes more like Canada—seems like an untenable strategy for protecting the most vulnerable from this deadly violence. Locking in the dignity and radical equality of all human beings will require more. In short, it is time to go on offense.

A broad and diverse coalition of folks is doing exactly that: seeking to make PAK unconstitutional and therefore permanently off the books in this country. The Euthanasia Prevention Coalition in the United States recently reported on a lawsuit filed in the State of California by the United Spinal Association, Not Dead Yet, Institute for Patients’ Rights, Communities Actively Living Independent and Free, Lonnie VanHook, and Ingrid Tischer. These plaintiffs are all organizations with members who have disabilities, individual persons with disabilities, and/or organizations that advocate for persons with disabilities.

The lawsuit has the goal of reaching the Supreme Court and overturning California’s law protecting physician-assisted killing. They argue that this law is unconstitutional because it treats suicidal persons with disabilities (which according to the Americans with Disabilities Act includes those with a terminal disease) differently from other kinds of suicidal persons. If the suicidal person does not have a disability, then the state of California protects her and restricts her ability to kill herself. But if the person has a disability, then California has a special set of discriminatory rules that imply that her life is worth less and (like Canada) even refuses care and supportive services in favor of steering her toward her death. This, the plaintiffs argue, is a violation of the Fourteenth Amendment’s Equal Protection and Due Process clauses.

In my view, this a brilliant strategy on multiple levels, aligning “conservative” pro-life human dignity concerns with “progressive” disability rights concerns in a way (to this non-lawyer’s mind, at least) that makes a powerful legal, moral, and rhetorical case against legalized PAK. Again, it is long past time for us to go on offense in this battle. And the horror show we see unfolding with our secular neighbors to the north indicates just how much is at stake if we lose.

Even “Compassionate” Killing Is Wrong

Canada has recently been in the news due to its imminent legal expansion of assisted suicide to include the mentally ill, beginning in March 2023. The Canadian government specifies that an “expert panel” will be used to evaluate the requests of the mentally ill “in a safe and compassionate way.” The virtue of compassion, which the Canadian government here invokes on its own behalf, is concerned with the best interests of the sufferer. So the question naturally arises: is it really “compassionate” for the state to offer death as an aid to the sufferer? Is it just?

To answer these questions, one must consider the state’s duty to its citizens. On this topic, there are few better guides than the Roman statesman and philosopher Cicero. Some things he gets right (the state’s duty to preserve justice and protect the well-being of its citizens) and others he gets wrong (the occasional permissibility of suicide). But if Cicero’s teachings are supplemented with Christianity’s teachings on suicide, we get a clear understanding of why assisted suicide cannot be counted among the state’s duties to its citizens.

 

In Book 1 of On Duties, a truly indispensable landmark in the history of political ethics—and Cicero’s last philosophical composition—Cicero says this (all translations in what follows are my own):

Absolutely all those who intend to preside over the commonwealth must observe Plato’s two precepts: first, that they guard what is useful for the citizens in such a way that they refer all of their actions to it, having forgotten about what is advantageous to themselves. Second, that they care for the entire body of the commonwealth, lest, while they guard some part of it, they abandon the rest. (On Duties 1.85)

Prima facie, this perhaps lends some support to the Canadian government. After all, those who are seeking death certainly believe that that is what is most useful to them; the government is merely assisting them in obtaining what they find useful. This would appear to fulfill Plato’s first precept as Cicero describes it.

And indeed, when it comes to suicide, Cicero allows that it is sometimes licit when done for the sake of honor. In On Duties 1.112, he points to Cato the Younger’s preference of death to subjection to Julius Caesar—“since nature had bestowed unbelievable seriousness on him”—as an example of honorable suicide. So if the magistrate is responsible for safeguarding what is advantageous for citizens, perhaps virtuous suicide should be legal. In other words, can suicide be both honorable and useful?

To answer this question, we must consider how honor relates to expediency.

Cicero devotes the third and final book of On Duties to showing that the useful and the honorable are never in conflict. If they were, injustice might sometimes be advantageous, as Thrasymachus argues in Book 1 of Plato’s Republic. But Plato has Socrates argue that any such advantage is merely apparent, for acting unjustly harms both the perpetrator and the victim. Cicero stands in this broad Socratic tradition: the one who commits an injustice for the sake of advantage is prevented from being a good man (On Duties 3.76); his victim suffers the consequences in his life, his property, or his reputation. Furthermore, unjust actions destroy fellowship among human beings, and thus contradict our very nature as social creatures. Therefore, they can never be useful.

 

From the foregoing discussion, it becomes clear that the state cannot facilitate suicide without committing a grave injustice. Despite Cicero’s exemption for honorable suicide, even these are not just: all suicide is by definition the extrajudicial killing of a person who, in legal terms, is innocent. Cicero is right that the useful and just, ultimately, cannot conflict. Therefore, even if someone’s self-slaughter seems convenient and advantageous—perhaps because his suffering is great, or because his quality of life is low—it can never be so since it is unjust.

Here, Christianity’s tradition of political and moral reflection can provide further guidance. The late Roman church father Augustine takes up the question of suicide in the first book of his City of God in dealing with the question whether consecrated virgins who had been raped had justification for killing themselves. The question may strike modern ears as absurd, but it was not a crazy one at the time given that the Roman tradition answered questions like this in the affirmative, as the example of Lucretia shows.

But Augustine disagrees with his Roman forebears on the basis of the Ten Commandments of the Old Testament and the Two Great Commandments of the New Testament. He remarks,

For it is not for nothing that nowhere in the Holy Scriptures can we find God commanding or permitting us to inflict death upon ourselves either for the sake of gaining immortality or for the sake of keeping or freeing ourselves from any evil. For in fact it must be understood that we have been prohibited from doing this when the law says, “You shall not kill,” especially because it did not add, “your neighbor,” as it does when it forbids bearing false witness: “You shall not,” it says, “bear false witness against your neighbor.” Nevertheless, it does not provide grounds for someone to think himself innocent of this crime if he has borne false witness against himself, since he who loves has received the rule that guides the love of one’s neighbor from himself, since it has been written, “You shall love your neighbor as yourself.” (City of God 1.20)

In this passage, Augustine draws attention to two of the Ten Commandments: “You shall not kill” (or “murder”) and “You shall not bear false witness against your neighbor.” He notes that the latter includes a qualification that the former does not, and yet this does not mean that one can bear false witness against oneself; such dishonesty would obviously still be wrong.

Why? Because self-love—that is, the high regard in which we naturally hold ourselves—provides the standard for the love of one’s neighbor: “You shall love your neighbor as yourself.” If we are forbidden to tell lies about our neighbor, then we are by implication forbidden to tell lies about ourselves because of the necessary ethical link between treatment of self and treatment of neighbor.

 

In the same way, if we were explicitly forbidden to kill our neighbor, we would by implication also be forbidden to kill ourselves, and the latter prohibition would be the ethical and logical foundation of the former. But the commandment against killing does not even offer the kind of apparent grounds for casuistry that the commandment against bearing false witness does, because no qualification is made with respect to one’s neighbor. It simply states that all unjustified killing is wrong, with no exceptions—including killing oneself. Therefore, suicide violates the Ten Commandments. Not even Cato, says Augustine, is off the hook.

The Ten Commandments are especially helpful in this discussion because they are summaries of the moral or natural law. Human societies have generally acknowledged that unjustified killing is wrong. When they make exceptions for the sake of expediency, they need to be reminded of what the moral law requires. This is true regardless of whether the inquiry concerns the killing of others or of oneself: both involve the taking of an innocent human life, and thus the same standard should be applied to each.

What does such a suggestion yield, if we combine the insights of Cicero and Augustine? Cicero teaches us that the conflict between true expediency and justice is an illusion. Augustine reminds us that killing the innocent is wrong. Physician-assisted suicide is ultimately the killing of the innocent. Therefore, any attempt to justify such an action on the grounds of apparent utility—here represented by two impulses that are good in themselves, that is, compassion and a desire to alleviate suffering—must be found wanting. If suicide is an action that is unjust in itself, no utilitarian arguments in its favor, however rhetorically compelling or seemingly ethical, can transform it into a just action.

The first and most important purpose of the state’s laws is to establish justice, the most basic principle of which is the protection and preservation of life. Canada’s regulations regarding so-called “medical assistance in dying” are fundamentally contrary to this purpose. In a just political order they would be overturned.